Non-invasive soft-tissue augmentation.
The search for non-invasive facial contouring and skin rejuvenation has increased in the past few years and has led to a myriad of procedures and development of new products. Indications for the ideal filler are dependent on the patient’s situation and their expectation of long-term effectiveness. Very often there is also the indication of a combined use of different devices in facial rejuvenation, for example botox, and hyaluronic acids.
Durability of results is device dependent, even though there is always an individual patient reaction to each product. Collagens (with the exception of Evolence® and Evolence Breeze™) and hyaluronic acids offer short- to medium-term results, Semi-permanent results are given by poly -l -lactic acid, calcium hydroxylapatite and beta-TCP (tricalcium phosphate), devices containing polymethylmethaacrylate and silicone oils provide permanent results.
The choice should be based primarily on patient safety, achieving a good quality of correction and an acceptable degree of intrusion in the patient’s life in terms of time, finances and physical healing combined with achieving a relatively long-lasting result.
All patients presenting for rejuvenation should have a full and thorough evaluation. This should cover the patient’s concerns, different treatment options available and create a treatment plan. There should be understanding of facial aging, including lines and wrinkles, difference of dynamic or static defects, photodamage and skin laxity, and loss of volume of fat and bony atrophy. A solution for each individual defect should be discussed. An understanding patient is much easier to treat and will recognize and accept the results. Once the fillers of choice are determined, several alternatives should be discussed and the post-treatment sequelae such as bruising, swelling, redness, and the possibility of adverse events explained.
A complete medical history to exclude any allergies should follow the first part of the consultation, and there should be a discussion of any medications taken by the patient. As in every surgical procedure, any patient taking anti-inflammatory drugs, ASA or blood thinning agents should be avoided. Heavy smokers should be advised that the result may be compromised due to smoking, especially the durability of most devices is reduced. In cases of recurrent herpes infection, a preventive oral therapy is indicated with an agent such as valacyclovir. Finally, pre-treatment pictures should be taken, in order to discuss before and after differences in case of incomplete patient satisfaction.
Fillers have multiple indications as every facial defect can be treated with different devices. If we start in the upper third of the facial structure (excluding the use of botox) fillers can be used for the temporal depression in atrophy of the aging face, in the lateral third of the ptotic brow, for the glabellar folds, frontal folds and the periorbital region.
The fillers chosen for glabellar augmentation should have a low viscosity to avoid necrosis and the possibility of blindness in a worst case scenario. Also crows-feet require very smooth fillers like, for example, low cross linked hyaluronic acids or smooth collagen. The filling effect is also very effective in the lower eyelid region, correcting hollow folds, but care must be taken because of the rich vascularization and the high risk of intravascular injections in that area. Fillers also create a smoother transition from the upper to the middle third of the facial structure, correcting the higher zygomatic area in cases of atrophy and tear trough deformities. In the midface, a variety of fillers can be used for tissue contouring. The most requested correction is the nasolabial fold (NLF), followed by an augmentation of the entire zygomatic area. Scars from trauma and acne are also indicated.
The NLF is often present in young patients, and when corrected gives a relaxed and soft aspect rather than an angry or severe one. In the aging face, the NLFs are deeper, and their correction is indicated with stronger fillers (such as Radiesse® Perlane® and Juvéderm® Ultra). The correction technique also needs altered to include correction of the medial cheek.
The zygomatic area can be corrected very easily by filling up the whole cheek zone, giving an appearance of roundness and youth. In cases of lipoatrophy, cheek hollowing can also be treated with fillers. In this area, the most indicated devices are poly -l -lactic acid like Sculptra®, or radiance (Radiesse®) which are bioabsorbable, long lasting fillers, which are placed with deep injection techniques. In the midface, rhinoplasty defects are also easily corrected using filling products. In the lower face, lip correction, marionette lines and the mandibular contour are areas of concentration.
For lip augmentation, there are various hyaluronic acids in different cross-linked concentrations, varying for the vermilion and the mucosal correction. Fine rhytides in the upper lip need smoother fillers and the vermilion, which increases in length with aging, needs stronger fillers. Allergan has created a hyaluronic acid including lidocaine in three different concentrations (Juvéderm® I, II, III ), which gives a painless, all round correction. Q-Med manufactures a product called Restylane Lipp™ which is especially for lip augmentation.
Marionette lines are a combination of genetics and sagging tissue and are especially visible if bone contours are poor. Fillers are not easily used in this hyperdynamic area, so there should always be a correction of the whole defect, with extension in the jaw line and the chin area. Very often there is an indication of a combined use of fillers and neurotoxin relaxation, which, due to the high mobility of the area, gives a longer lasting result without wrinkling. A smooth jaw line can also be created with the proper use of fillers, correcting the loss of elasticity (due to gravity) and structural underlying bone absorption.
The pre-operative procedure requires taking a complete medical history including past allergic reactions, whether soft tissue fillers have been used previously, if the patient has a tendency to keloid scarring, their proposed activities for the next days and the final choice of filler to be used. Pre-procedure medications like herpes prevention or bruising prevention using arnica or vitamin K ointment should be discussed. There should also be a discussion of the patient’s concerns. Most of the time, patients desire a complete correction in only one session with only one product so there must be a good understanding of what can realistically be achieved with dermal fillers. It should also be made clear how many sessions are needed and what kind of material is indicated, in order to avoid disappointment. It should also be suggested to heavy smokers that they reduce their smoking. An explanation of post-treatment possibilities such as bruising, redness, pain, and swelling is also important.
The choice of filler for the desired tissue augmentation is most important. The European market offers a confusing number of different fillers. The initial choice between permanent or non-permanent is important. Permanent fillers are almost never used in Europe. Their use is limited to pathologic lipoatrophy or post-traumatic cases, which require a large amount of material as a very long-lasting effect is desired. Liquid silicone oils are not permitted, so the choice is a filler including permanent particles, such as Aquamid®, Artefill®, or Dermalife®. The main concerns are the possibility of late onset adverse events, such as foreign body granulomas or displacement of the material.
Non-permanent devices are the first choice in aesthetics, having a proven safety record. The disadvantage is the short-term effect of most fillers which is, on average, 1 year. Currently, the needs of the patients are respected and there is no recovery time after application. Future patient tastes regarding correction may change. The previous fashion of unnatural looking puffy lips, for example, is completely out of the question today.
Historically, the oldest available filler is autologous fat (not discussed in this chapter), followed by bovine collagen (Zyderm®, Zyplast®). This filler has the disadvantage of the necessity for allergic tests, with the possibility of late sensitivation. Recently, human collagen (CosmoDerm®, CosmoPlast®) has mostly displaced this optimal filler as an allergic test is not required. Both materials are very smooth, and they are indicated in lip contour correction or the periorbital area. In Europe, since 2007, Evolence® and the thinner Evolence Breeze™, a porcine source material broken down in pure collagen for the correction of fine wrinkles has been used with correction lasting up to 1 year.
For over 10 years, hyaluronic acids generated either by bacteria fermentation or from chicken combs have been the most common fillers in use in Europe. There is no need for allergy testing. These devices also seem to have a longer duration than collagen, depending on the cross-linkage of the substance. Thinner acids are for fine lines and wrinkles, highly cross-linked acids are for three-dimensional augmentation of the NLF and the zygomatic area. Q-Med (Restylane®, Perlane®), Allergan, Merck (Belotero®) and almost every large pharmaceutical producer offers different compositions for fine to deep wrinkles. The latest hyaluronic filler in Europe and the USA is used with lidocaine, which results in a less painful procedure, but requires taking a more detailed medical history to include possible allergies to local anaesthetics (Juvéderm®).
Since 2006, in Europe there has also been a combination material available of non-cross-linked hyaluronic acid and beta-tcp (tri-calcium-phosphate) called Atlean®. This product is injected like stronger collagen or hylans, and is best indicated in deep wrinkling of the cheek and jaw line or for minimal enhancement of the dermal layer in the periorbital region. It produces an immediate filling effect due to the hyaluronic acid, and later onset of tissue growth due to the biostimulation of beta–TCP. Sessions should be 2, 3 or 6 weeks apart and the correction can last up to 12 months or more, depending on the patient’s metabolism.
Semi-permanent fillers are long-lasting but the name is misleading as it indicates that part of the material is permanent. In reality, all the material will be absorbed over a period of 2–3 years. In Europe and in the USA, the two most popular semi-permanent fillers are calcium hydroxylpatite (Radiance®) and poly -l -lactic acid (Sculptra™). Both have been available for over 20 years and are used in general surgery as implants or suture material as their biocompatibility and bioabsorbility are well known. These fillers are used for long-lasting, three-dimensional corrections of the complete facial structure. Large volume defects can be corrected with deep injection techniques, repeated every 1–2 months until the necessary aesthetic result is reached. They require the user to be an expert at injecting, as errors, bolus or superficial infiltration can cause nodules and/or late onset foreign body granulomas ( Figure 1.1 ).