Youthful skin is firm and able to retain its own structure. It remains relatively plump and well hydrated. As we age, wrinkles, lines and folds begin to appear. The naturally occurring substances found in youthful skin, such as collagen, elastin and hyaluronic acid diminish over time and cause the skin to lose structure and volume. Dermal fillers can add youthful fullness and reduce wrinkles. Replacing these naturally occurring substances found in the skin is the basis for the use of collagen and the hyaluronic acid fillers.
Collagen was the first filler to be approved by the FDA. The primary problem with collagen was that it did not last very long. Since it was bovine (derived from cows), it required skin testing for possible allergy. A percentage of the population who were allergic to it could not be treated. So the race to discover a more permanent biocompatible filler began.
Today the market is virtually flooded with many different alternative filler materials that can be injected or inserted into the face. This has become a very confusing topic.
ANSWERS FROM DR. BINDER
Fillers can be used to improve the appearance of moderate to severe facial wrinkles. The most common areas are the smile lines around the nose and mouth, marionette lines at the corner of the mouth, frown lines between the eyes, and fine lines around the mouth.
One thing is for certain. There is no one ideal filler! Otherwise, physicians would be using only one filler. Since there are so many fillers and techniques available I have categorized them by clinical need. Some have certain advantages and disadvantages for lines that are superficial or deep, for different areas of the face, different skin types and different indications. It cannot be over-emphasized that fillers are not a substitute for surgical procedures and can, over time, become more costly than surgery.
Depending on the extent of the treatment the area may be anesthetized either with a dental block, regional block and/or numbing cream before each treatment. An ultra fine needle is used to inject small amounts of the filler into the mid to deep dermis. There is minimal discomfort and wrinkles and folds are plumped up instantaneously. Patients resume normal activity immediately. The cost varies, depending on how much filler is necessary.
TYPES OF FILLERS
- Restylane® Fine Line
The thinner or superficial fillers are used to treat the superficial and fine lines that are “etched” into skin. In order to eliminate these lines, the filler must be injected just under the surface of the skin. Although these fillers do not last as long as the thicker fillers they avoid the problem of producing lumps under the skin.
Zyderm® was the original collagen injectable. It is still an excellent compound for fine lines, but is a bovine derivative that requires allergy skin testing. Cosmoderm® was developed as a genetically engineered substance from human collagen and requires no allergy testing. Restylane Fine Line® is also used in this category. All were formulated to treat small or shallow wrinkles or scars. They can be particularly effective in smoothing delicate frown and smile lines, as well as the fine creases that develop at the corners of the eyes mouth and above and below the lips. They can also help correct certain kinds of shallow acne scars.
- Hyaluronic Acids:
Hyaluronic acid fillers are a significant advancement in fillers. They are naturally modified forms of hyaluronic acid, and no allergy testing is required. They have an enormous safety record and are a non-animal product. The advantage of hyaluronic acids is that they naturally attract water molecules and hydrate the skin by holding in water, acting as a cushioning agent. This is what gives a smoother, healthier glow to the skin and creates a filling effect long after the actual filler is injected. These fillers are placed deeper into the skin and because they are thicker and last longer. There are reports of Juvederm® lasting up to one year. Juvederm® and Restylane® require less volume to fill wrinkles and hard to treat skin folds. They are used for actual folds in the skin and deeper crevices, such as the nasolabial folds and marionette folds that extend downward from the corners of the mouth. They are also used for lip augmentation. (See Section on Lip Augmentation)
Collagen (Zyderm® or Cosmoderm®) and Juvederm® or Restylane® can be used simultaneously in a layering technique to treat both the fine lines and deeper wrinkles within the same location.
Cosmoplast® is a thicker collagen derivative designed to treat depressions requiring a stronger treatment material. It has similar indications as the hyaluronic acids.
This category of fillers is perhaps the most complicated since there are not only fillers, but other materials and methods of fat and dermal-fat transfer to consider. The thickest fillers are better for volume enhancement and are used to treat areas of the face that need to be plumped up.
The available options of the thicker fillers are:
- Juvederm® Ultra Plus
- Sculptra® (Poly-L-Lactic acid)
- Radiesse® (Calcium Hydroxyapatite)
Of all the available options for substituting deep soft tissue, the naturally occurring hyaluronic acid compounds are the most popular, offer the most advantages, and have the least amount of complications. Sculptra® is a volumetric enhancer that has been approved by the FDA to treat facial wasting syndrome due to the effects of HIV treatment. It works by producing a tissue reaction at the dermal-subcutaneous interface. It usually requires several treatments. It does not provide the instant filling effects of Juvederm Ultra Plus® or Perlane® and is also not permanent, but reports lasting up to 1 – 1 ½ years. Radiesse® is a calcium hydroxyapatite compound which is a substance normally found in bone. It can be used to fill defects over bone. Although Radiesse® claims to last longer, in my experience, it has a tendency to be “bulkier” when injected into the soft tissue without the more natural feel that the hyaluronic acids have to offer. When injected into soft tissue, Radiesse® causes a fibrous capsule to form around the material until it resorbs. It cannot be used in the lips since it produces white nodules which necessitate surgical removal.
Radiesse® has also recently been advertised as a substitute for facial implants; providing a “non-surgical approach for chin or cheek implants”. In my opinion, Radiesse or other fillers should not be used for this purpose. Fillers, as opposed to facial implants, do not support soft tissue or provide structure to the facial skeleton. When volumes exceed their intended use, they can cause problems of infection, lumpiness, nodules and soft tissue fibrosis which can only be permanently cured with surgery.
In all permanent types of materials, if incorrect placement of the material occurs, or a problem occurs necessitating removal, the problem then becomes a surgical issue. My philosophy is that there are currently no excellent permanent soft tissue filler or even fat or dermal grafting procedures that do not have their own set of problems and disadvantages. What might look good today might actually be noticeable years from now; particularly if the implant material remains and the soft tissue continues to atrophy around the permanent material.
1. Artefill® (PMMA): This has been recently approved in the U.S. by the FDA for soft tissue augmentation and is a compound that is composed of methymethacrylate beads immersed in collagen. Patients need to be allergy tested first. There is currently controversy and skepticism within the Dermatological community regarding the benefits of using this product.
2. Liquid Silicone Injections: This has a long term history of being injected into the face, but also has noted long-term complications. A great deal of controversy continues regarding the use of liquid silicone in soft tissue. Granulomas are known to appear many years later after the injection of silicone liquid into the dermis. The issue of autoimmune disease from silicone gel has largely been resolved with the FDA approval of silicone gel breast implants.
3. ePTFE: Commonly known as Goretex® and Softform®, these inert (nonreactive) tubes are inserted into the lips or other areas such as the nasolabial folds. The material can often be felt when pressing deeply and has problems with shrinkage, extrusion and infection. With the longer acting fillers now available, it has fallen out of favor with the majority of doctors.
Experience has taught us that there is no one procedure that is a panacea. Each one has its own set of problems. There are similar problems associated with soft tissue volume enhancement as there are with Artefill®, Radiesse® or Scultra®. Overcorrection can cause an excessive amount of fibrosis to occur which may form lumps to develop within soft tissue. These lumps or nodules remain as permanent irregularities within the skin, and sometimes may necessitate surgical removal. Another problem using large amounts of volumetric material is the difficulty in determining the amount that will resorb and the amount that will be left behind. Recently we have seen a new problem with large volume fillers. The media has referred to this as the over-stuffed or “fat face”. When trying to fill large volumetric areas the skin has a tendency to be filled out in an “amorphous way” without regard to normal 3-dimensional facial proportions and adhering to the principles of facial contouring. The normal, supple, youthful face has areas that are more prominent (such as the cheek bones and chin) producing the dimensional hallmarks of beauty. This can only be changed with skeletal rather than soft tissue augmentation.
1. Fat transfer (Fat Injection): There are advantages to using one’s own fat as an implant material. It is readily available, is a living tissue will not be rejected, feels natural and can be replenished. The fat is harvested via liposuction techniques, washed, and spun down in a centrifuge to concentrate the fat cells. The fat is then injected into the face incrementally in small amounts. In my experience, its longevity is totally variable in each patient, and each area of treatment. Several injections are often required in order to get the desired long term benefits.
2. Alloderm is “acellular” dermis derived and treated from human (cadaver) tissue and has a tendency to remain soft. It is non antigenic and is an excellent material that is used in reconstructive surgery. It has been used in the lips for long-term augmentation, but with the use of the newer fillers (Juvederm® and Restylane®) it has not proved to be a significant advantage.
3. Dermal and Fascial-Fat Grafts: Dermal grafts have been used for over 70 years for reconstructive purposes and to treat burn injuries. Fascial grafts (temporalis fascia) have been used as a plumping graft for lip augmentation and the nasolabial folds for many years. It is also well established that the fascia will dissolve and eventually turn to scar tissue. Large quantities of dermal fat grafts have to be harvested and have the disadvantage of leaving behind scars at the donor site which in some cases can be a worse disfigurement than the defect one is trying to correct.
Lip enhancement has become a significant part of the aesthetic surgical practice. The essentials of youth are a “fullness” of the midface and “full” lips. Soft, pouty lips are flaunted on the cover of most fashion magazines. As a result, many different types of facial plastic surgery procedures have been promoted to enhance lip fullness.
In the lips, the aging process should be thought of as a “lip deflator”. As we age, we lose volume in the lips. The lips not only lose their fullness, but there is also a tendency to lose the outer part of the lip thus reducing the horizontal dimension of the lip as well. With loss of volume, the lip literally shrinks, the cupid’s bow flattens and the vertical lip lines are formed. Some procedures such as laser resurfacing are designed to erase many of these lines. However, it is actually the loss of soft tissue that is the main cause of the line. By replacing the soft tissue, the deeper vertical lip grooves and lines are reduced and the droopy corners of the mouth are raised up.
Since lip enhancement has received so much attention, there have been many procedures and fillers used for augmentation and enhancement. They range from dermal fillers, fat injections, fat grafts, Alloderm®, dermis, fascia, dermal fat grafts, ePTFE and surgical lip lift or lip advancement procedures.
In general, all of the procedures are not indicated for all people. In older patients who have almost no vermillion left to the lip, a lip advancement procedure would be indicated. In younger patients, such as models or actors, a subtle augmentation of the lip with a small amount of filler – to follow the natural contours of the lip – would be the procedure of choice. The silhouette of the lip along the vermillion border is in most cases enhanced and preservation of the cupid’s bow is paramount in maintaining the natural-looking lip. A conservative plumping of the lip should be done as well for a fuller yet more natural shape.
Why Does Dr. Binder Like To Use Juvederm® or Restylane®?
His philosophy is that the lips should not be OVER-FILLED. The lip is actually a complicated structure that takes a good eye and requires an ability to refine the augmentation technique. With some of the larger volumetric fillers, it is not possible to fine-tune the augmentation thereby leaving the lips either too big or resulting in the loss of the lip’s normal anatomical architecture. In some patients who have an extremely long upper lip, a “lip lift” can be done. This is a procedure that places incisions around the base of the nose and removes skin within this area so that the lip can be advanced upward. The lip advancement procedure involves removing a strip of skin above the lip line and advancing the red border of the lip to a higher level.
Like so many areas in plastic surgery, there are many ways to effect change in the lip, from complex to simple. Most of my patients prefer the longer acting fillers to provide an optimal result which can be changed, enhanced, and is reversible. Fillers provide the flexibility to maximize results by refining the contours of the lips by varying the way the material is injected.
The lip can be made smaller by lip reduction for patients who have lips that are too full, or who had silicone placed in the lips years before. This is accomplished by removing an elliptical strip of mucosa and some deeper tissue from inside the lip.