Aging is a fact of life. Wrinkles are a sign of aging but are also a function of several other factors. Strong facial musculature may produce deep furrows, sun exposure and cigarette smoke can produce fine wrinkles and genetic factors make each individual more or less likely to develop wrinkles at any given age. Loss of facial volume contribute to the development of facial wrinkles, analogous to the difference between a grape and a raisin.
Injectable fillers have been used for decades in an effort to rejuvenate the face, softening and minimizing the effects of aging. The fillers are, basically, a substance that is introduced under the skin to “fill in” areas where aging changes have occurred. These changes include wrinkles and folds as well as the volume loss associated with aging. Although most fillers are FDA approved for use in the correction of nasolabial folds, many physicians use them in an “off-label” fashion in a number of other areas.
The correction of deep facial wrinkles, particularly in areas that are resistant to other techniques (e.g., Botulinum toxin, facelifting, etc.) has been revolutionized by the development of reliable injectable fillers. Areas commonly treated include the nasolabial folds, marionette lines (below corners of mouth), “smokers lines” around the mouth, and fat loss in the cheeks.
History of Injectable Fillers
The use of injectable fillers was first introduced in the late 1800′s when paraffin wax was the first to be injected into the human body. The results were, as you might expect, not very good.
Silicone became popular as an injectable filler in the 1960s as more reliable results were able to be obtained for breast augmentation and aging facial changes. Over time, however multiple complications including unsightly reactions, migration of the filler, scarring and disfigurement were noted to occur. Due to these and other complications, silicone was eventually condemned for use as a injectable filler in the late 1970s by the FDA.
The experience with silicone led to a search for a material that would be ideal; this material would provide natural appearing results, would not produce an allergic or other sensitivity reaction, be potentially reversible and be long-lasting. Ideally, this would be quick and easy to use, inexpensive with minimal to no recovery period. The first step toward finding this material was collagen.
These products were revolutionary in that the injected material attempted to replicate the natural tissue found in the skin. Bovine/porcine (from cows and pigs), and human-based collagen products were popularized in the 1980s-1990s and reintroduced more recently but have largely been replaced by products with longer lasting results and few side effects. In addition, bovine-derived products required a skin test to rule out any allergy prior to injection, something more recent products do not require.
Examples: Xyderm™, Xyplast™, Evolence™
Hyaluronic Acid(HA)-Based Fillers
Currently the most popular injectable filler products used in the United States today, these products were the “next big thing” following collagen products. HA is a naturally occurring material in all vertebrate animals and can be produced by some bacteria as well. This non-cellular material does not produce an allergic reaction, therefore requires no skin test. It fits the need for a longer-acting material that is potentially reversible, has a favorable risk profile and provides natural appearing results. Generally, HA products offer 9-18 months of effect and the possibility of longer effects with repeat injections. Some products contain lidocaine, an anesthetic that may improve the experience of receiving the injections.
Examples: Restylane™, Juvederm™, Juvederm Voluma®, Prevelle Silk™, Hylaform™, Captique™, CosmoDerm™, CosmoPlast™, Elevess™
Multiple other materials have been developed with variability regarding duration of effect, risk of complication and overall natural-appearing results. Poly-L-Lactic Acid products (Sculptra™) offer longer-lasting results (up to 2 years) but are not potentially reversible during that time. Hydroxyapatite Products (Radiesse™)are also popular and produce results in excess of 12-18 months. Due to their larger particle size, they may not be the best option around the lips or eyes and are also irreversible once injected. Risk of bumps or irregularities are possible with all injectable fillers but many physicians feel they are less likely with the HA fillers than others.
The transfer of fat from one part of the body to the face for augmentation and filling of wrinkles is used by many experienced physicians and offers the benefit of long-lasting, natural augmentation. Int he past there were difficulties with the predictability of fat resorption after it was transplanted. In other words, sometimes it would last and others it would not. Fortunately the techniques have been refined in the last few years to greatly improve the predictability of fat transfer. This, combined with the advantage of (in many cases) larger amounts of material for injection (compared to other fillers), make this a powerful technique to correct the loss of volume commonly associated with the “aging face” appearance.
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