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Injectable fillers of some type have been available since the use of bovine collagen in the mid-80's. Many technical refinements have resulted in a spectrum of chemical substances with different properties and indications. The largest class of fillers is Hyaluronic Acid. This chemical is a naturally occurring polymer, and is common in human tissues. Synthetic HAs can vary according to various physical parameters such as viscosity and stiffness. This will tend to dictate the type and depth of tissues each is most suitable for. Furthermore, each of the different HAs has a range of time over which it is effective. One of the best facts about HAs to be aware of is that an enzyme called hyaluronidase can be used to dissolve all or part of a treatment. Hyaluronidase is, therefore, an eraser in that sense. Some brand names of HAs are: Restylane, Juvederm, Perlane, Hydrelle, and Belotero.
Calcium Hydroxylapatite has been used in other surgical fields for over 20 years. It is a mineral naturally occurring in bone. It was approved by the FDA in 2006 for nasolabial folds and lipoatrophy related to HIV infection. Used in thin skin or in certain areas such as the lips, tear trough, or labella, this material has commonly caused nodule formation. Unlike Hyaluronic acid, this material has no associated “eraser”. Direct surgical removal is the only way to remove the material, aside from waiting for its natural biodegradation over several year’s time. Its brand name is Radiesse.
Poly-L-Lactic acid is a synthetic polymer derived from alpha-hydroxy acids. It was FDA approved for HIV related facial atrophy in 2004 and for moderate to deep wrinkles in 2009. It can be used to fill in acne pits and other depressed scars. The material must be mixed with sterile water several hours before use to allow for complete hydration and minimize clumping. Serial injections spaced 3-4 weeks apart are recommended for best results. Biodegradation takes about two years. PLLA is not good for areas which undergo lots of movement, such as lips or periorbital tissues, as this potentiates clumping and nodule formation. Sculptra is PLLA’s brand name.
Polymethylmethacrylate microspheres in a carrier of bovine collagen, called Bellafill, is FDA approved for nasolabial folds and acne scars. For best results, and to avoid complications, multiple serial injections are required over a period of months. The result is permanent, that being Bellafill’s advantage and disadvantage.
Two other injectables deserve mention: autologous fat and platelet-rich plasma. Placement of a patient’s own fat cells by grafting from unwanted fat beds to areas that would benefit has been the dream of many plastic surgeons and the research or a few diligent and courageous ones. Sydney Coleman, MD persevered years of criticism to become the world’s expert on fat, not just as a volume filler, but as a tissue graft with rejuvenation capability. He has found that scars radiation wounds and burns appear to improve or even resolve with grafted fat placed into a bed that has lost its blood supply or ability to heal. Many of us now believe that fat grafting occupies an important place in our toolboxes. Not only is autologous fat an important facial filler, but it is now used for augmentation and recontouring of breasts and buttocks, rejuvenation of hands, and the cosmetic improvement of overlying skin. Lest we sound too enthusiastic, fat grafting does have potential drawbacks. If done with careful technique, it is permanent, not biodegradable. Unwanted grafting results must be removed by liposuction or other revisional surgery. The learning curve of fat grafting is arguably steeper than that of most commercial fillers. Successful living fat grafts are subject to all dynamic processes in the body, especially weight loss and weight gain.
Platelet-rich-plasma has been used in veterinary medicine for decades, and in some surgical specialities in humans for almost as long. Relatively new to plastic surgery, the idea of concentrating a patient’s own growth and other heating substances in their plasma is being actively researched. It may accelerate certain phases of heal thing, provide a favorable environment for fat grafts, and improve skin and hair texture and growth. With an, as yet, unknown upside, it is fortunate that PRP hasn’t much of a downside. It is concentrated from the patient’s own blood.
At Christopher Jones, MD, we have chosen to limit ourselves to those commercially available fillers which have a degree of reversibility, namely Hyaluronic acid. There are enough varieties of viscosity and durability that most needs a patient may have for a tissue filler are nicely met without having to accept the irreversibility and risk of palpable clumping of Poly-L-Lactic acid, Polymethylmethacrylate, or Calcium Hydroxylapatite. We do perform Fat Grafting, with and without PRP, preferring to use a patient’s own tissue solutions, if possible.
Both commercially available tissue fillers and Fat Grafting have ushered in a new era in plastic surgery, the era of Minimally Invasive. Expect to hear more on this subject as other new technologies come into use. Stay tuned to Christopher Jones, MD for this.
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