The consequences of skin aging are a matter of concern for millions of people, mainly in the developed world. To minimize the effects of aging on soft tissues, a variety of treatments are used, including the renowned prestigious Tissue Fillers.
Over the past decade our ability to understand and treat facial aging has suffered a radical turn. In the past, facial aging was almost based exclusively on surgical techniques, deeply acting to correct the laxity of tissues.
Faced with these aggressive techniques, a new tendency have been developed to treat facial aging with minimally invasive techniques such as botulinum toxin and injectable agents to fill furrows, wrinkles and face depressions.
Today we can assent that in the modern cosmetic world, the restoration of volume and facial contour has become the first line of treatment, before the surgical correction.
The concepts and standards of beauty differ or are interpreted differently according to cultural or racial factors, but there are certain qualities that appear to transcend these differences globally that determine what is to be considered attractive.
Aesthetic is derived from aisthesis or the ability to perceive beauty.
A convex smooth shape, symmetrical, with texture, even tone and homogeneous skin are acceptable aesthetical characteristics, which define attractive features.
These features can be destabilized by natural illness or environmental agents, stress, smoking and sun exposure or injuries, or just by the natural and inevitable process of aging.
One example of a currently aesthetics dejected case, can be seen on a secondary lipodystrophy, caused by a HIV infection.
As we have stated, we have gone to the surgical skin uprising and stretching to restitution of facial volume and contour.
Tissue fillers are those applied by injection to modify the anatomy, correct wrinkles and folds, as well as increase the volume of specific areas.
THE FILLING COMPONENTS CLASSIFICATION.
Facial fillers are those components which can be introduced into the body by injection. According to their biological origin are classified into (organic origin) and non-biological (of synthetic origin), and its duration according to: in short temporary, semi-permanent or long term and permanent.
Implants are considered permanent by those carried out on non-metabolizable or absorbable by the body, so that once injected, rightly or wrongly, will remain in the time and in some cases may not even be removed by surgery.
This is one of the requirements of an ideal component, usually becomes an esthetic problem for the patient and a legal matter for the specialist. Some of these products are approved, but be cautious, as the long-term results of most injectables solutions are unknown.
At Dr. Rafael Spagnuolo clinic we do not use these components.
In the search for long term components the polialquilamida has been used under the Bio-Alcamid denomination.
Being developed by Polymekon, Italy and marketed in Spain by Mediform. It is an injectable, recommended to correct defects and deformities of the body. Endoprosthesis is defined as a crosslinked synthetic polymer polialquilamida.
The polyacrylamide hydrogel, is approved for facial contour treatments in Europe and other countries. In Spain it is approved to use as a filling component.
It is said that Aquamid does not move, but during the first forty-eight hours it might, until it begins to set the revascularization process.
There is an increased risk of infection in the first few weeks until the fibrous support is formed. An infection occurs during injection but due to the slow growth in the gel, the symptoms may appear typically within two weeks. It is treated with oral antibiotics.
Antibiotic prophylaxis is recommended. If necessary, the product can be removed partially during the first month and drainage by suction and pressure. This is quite complicated and could only remove any excess product.
C- Injectable Liquid Silicone.
The term Silicone refers to artificial polymers containing silicon.
The injectable liquid silicone is a product of so-called permanent that increase the soft tissue. The component is permanent; the results are not, since the regressive process does not stop.
Should be noted that the silicone is an excellent product to increase soft tissues, but is a product which results dependent and require of a great technical expertise.
It is suitable in a number of problems and imperfections of soft tissues and it is affordable.
The Food and Drug Administration (FDA) has not approved its use for wrinkles and in Spain and Europe is prohibited the use of liquid silicone for cosmetic purposes.
2- SEMIPERMANENTS COMPONENTS
This group of components is between those biodegradable and permanent. Patients want a safe, long-term correction, in order to achieve this, the semi-permanent components were devised. These products are the result of merging one biodegradable or short-term and long-term degradable, the first carry the component and when dissolve the semipermanent stays until is being dissolve or replaced by the new autologous tissue.
The problem with these materials is to find those that can be jointed, which are easy to inject and resulting in little inflammatory reaction. So far, this has been achieved moderately.
The examples of these fillers are Dermalive and Dermadeep which are semi soft tissue implants with acrylic hydrogel components, convey in hyaluronic acid.
Currently, it use is not authorized in Spain.
3- TEMPORARY COMPONENTS OR BIODEGRADABLE
They are commonly used materials for tissue filling.
They are the most widely used due to their security and especially the reversibility of their results, among them are:
3.1- AUTOLOGOUS FAT
When we mention fat we always refer to autologous fat (patient’s own), it is not valid the heterogonous fat injection.
Autologous fat is available in most patients, is inexpensive, non-allergenic, it has no potential for cross-infection, unless contamination, and is secure for patients. Further, the process of “taking” is simultaneously done at the same time of the infiltration. The fat can also be apply for body remodeling.
Although experience is gained, regarding the use of fat, there are still some points to be defined as the lasting of the infiltrated fat.
Aims of treatment with autologous fat
The priority aims for fat rebalancing treatments are:
• Facebow reconstruction that beard the semblance.
• To restore the jawline.
• To refit the skin, away from the middle zone of the face.
• To create an interphase between the skin and underlying muscles
Secondary Aims are:
• Cheekbones enhance.
• To reduce face dark shadows due to “eye bags”.
• Replace the eyelid skin by direct infiltration of fat.
It is not an objective treatment with autologous fat.
▪ Changes resulting from photoaging.
▪ Hyperdynamic wrinkles
▪ Face skin excess.
Contraindications of the Autologous Fat Treatment.
Contraindication for this treatment is photoaging, it is important since there is the risk of aggravating the damaged of skin imperfections.
Other contraindications include, the lack of sufficient donor fat for extraction purposes or inadequate skin tone, which prevents the retraction of the area.
Also are contraindications, systemic pathology such as serious chronic medical condition, coagulation disorders or acute infections.
Medical history of DVT or pulmonary embolism must be evaluated carefully.
3.2- HYALURONIC ACID
In pursuit of the ideal component for soft tissue filler, back in the eighties, the hyaluronic acid was developed. The hyaluronic acid was previously used in other medical fields such as ophthalmology and rheumatology.
With this new material, collagen has gone into the background due to its allergy problems and the need for pretreatment testing. Hyaluronic acid or generic named: hyaluronan or hylan, are more biocompatible and remain longer than collagen.
Hyaluronic acid derivatives are classified according to their concentration, the method and the degree of crosslinking, as well as their origins.
The first derivatives of hyaluronic acid were obtained from cockscomb, umbilical cord, vitreous, tendons, skin and currently from biocultivation.
The main feature of this compound is that no chemical kind or tissue specificity is present, being identical throughout nature so that it is immunogenic in its pure form.
The hyaluronic acid in the skin is part of the extracellular matrix, arriving from the cell membrane where it is manufactured. The hyaluronic acid is the largest glycosaminoglycan, 50-kDa, and the most abundantly of the dermal extracellular matrix.
This glycosaminoglycan is not linked to other substances such as sulfate ions or proteins, is negatively charged and binds into a significant amounts of water.
When joining multiple strings of hyaluronic acid in wrinkles, the viscosity which gives the skin its elasticity and flexibility, increased. The hyaluronic acid dewrinkles with age and therefore reduces dermal hydration and increase wrinkling.
The results after treatment with hyaluronic acid are visible to 8 or 9 months according to several sources.
In the area where the duration of the treatment is longer, it is located in the glabellar zone (brow) and philtrum furrow, it is easily exceeds nine months, especially when associated with Botox.
When compared with the collagen, the duration is also higher and the amount necessary to achieve results is lower with the acid.
Hyaluronic acid derivatives are indicated in the treatment of:
• Static facial wrinkles in the forehead, periorbital corrugation (crow’s feet), in the perioral, upper lip and smile and glabellar furrows.
• Lips sculpture to enhance the volume, set the vermilion border, labial ridge and eliminate wrinkles expressions of the corners of the mouth.
• Perform a facial cheeks reassertion, chin, temporal region and nasojugal groove.
• Finally, is indicated on dilatable scars treatments.
Hyaluronic acid is not useful in the following conditions.
• Hyperdynamic wrinkles, which improve with botulinum toxin.
• Atrophic scars, no dilatable, in which these cases surgery is advisable.
• Postsurgical scars and atrophic marks where treatment can be performed with surgery or laser treatment.
• Lips actinic injuries are best treated with external use creams with chemotherapeutics or lasers.
• Facial wrinkles improve extensively with laser, chemical peeling or surgery.
Hyaluronic acid products
There are many products derived from hyaluronic acid and each day brings new ones. In general the products are used according to the preference of the specialist.
By way of introduction, to indicate that surface and thin wrinkles, respond better to low density fillings that are placed in the middle third and upper dermis.
Deeper wrinkles like the nasolabial folds require a denser filling, placed in the lower third of the dermis or joining with the subcutaneous tissue.
Sometimes is necessary to use both types of compounds in wrinkles with superficial and deep elements.
An example within the range of these products are Restylane and Juvéderm which posses several types of hylans, but there are many more.
Animal Hyaluronic Acid
Authorized in Spain since 1996.
The Hylaform trademark corresponds to a gel called Hylan B, and it was the first used on a large scale.
This form of hyaluronic acid is obtained from cockscomb.
The product is more elastic than the one mentioned before, Restylane with a hyaluronic acid concentration of 6mg/ml compared to 20mg/ml of Restylane.
Non-Animal Hyaluronic Acid NASHA:
The former group of products was of animal origin; this can have consequences in terms of disease transmission. The next group of products is produced without any traces of “animals” hence the name of NASHA (non-animal origin of hyaluronic acid).
The Restylane family is considered by many, to be the closest to the ideal filler for its clinical effects that persist for four to six months, even longer, before being reabsorbed.
Restylane is approved by the FDA for injection into the medium and deep dermis as correction of wrinkles and furrows of the face.
Restylane Vital: to rejuvenate the skin by moisturizing and improving elasticity and tone. Used in the “neckline” area to improve the appearance of aging.
Touch Restylane is the one with the smaller particles and is less viscous. Infiltrates with a 31G needle in the superficial dermis to correct wrinkles and surface imperfections of the forehead or around the eyes and mouth.
Restylane has an intermediate particle size. Is injected with a 30G needle in the reticular dermis to correct moderate defects in the philtrum area and add volume to the lips.
Restylane Perlane has the larger particles, is more viscous. Is injected with a 27G needle in the deep dermis and the subcutaneous tissue. It is used to correct deep folds and the face contour and it does achieve fuller lips.
Because it is larger, is associated with increased redness and swelling, compared to the other components from the same family. Such a procedure has not been fully tested.
Restylane Sub-Q: to model facial contours or enhance facial features, such as giving more volume to the chin or cheekbones.
Restylane lips: specifically designed for the treatment of lips.
Juvéderm 18 is used for fine lines such as crow’s feet or perioral area.
Juvéderm 24 for moderate wrinkles like the forehead, glabella area and nasal furrows.
Juvéderm 30 is used for lip enhancement, deep grooves fillings and increased volume in the cheeks.
Juvéderm 24 and 30 has been expanded as Juvéderm Ultra and Juvéderm 24HV or Juvéderm Ultra Plus or Juvederm 30HV. These two products have a higher degree of crosslinking and mixed with uncrosslinked acid molecules serving as lubricant. Juvéderm Ultra and Juvéderm Ultra Plus are administered in vials of 0.8 ml.
Juvéderm Ultra and Juvéderm Ultra Plus have been formulated to provide a better flow by injecting a controlled release and prolonged lasting effects.
Juvéderm Ultra and Juvéderm Ultra Plus are designed for the correction of superficial wrinkles and scars; it is place it in the medium and deep dermis.
Ultra Plus formula is placed in the deep dermis or placed as a supraperiosteal deposit material form, in case desired volume restoration is desired.
For lips, Juvéderm Ultra is often preferred because it is soft and malleable. Equally preferred in fine wrinkles or thin skin areas such as the periorbital area.
Juvéderm Ultra Plus is often used in the nasolabial folds, supraperiosteal injections or to restore cheeks volume.
3 – Other hyaluronic acid of non-animal origin:
Hyaluronic acid of non-animal origin has been developed by medical Prollenium Technologies and marketed in Spain by ELM health and beauty.
Phormae and Phormae Plus are cross-linked hyaluronic acid from non-animal origin.
Manufactured by Redephine and marketed by medical Aster
New hyaluronic acid gel that Pierre Fabre Laboratories marketed under a patent called BioActiPolyMatrix.
There are three forms:
Glytone 2, 3 and 4 for different indications.
Testing studies on nasolabial folds indicated durability for up to 24 months.
4- HIGH DENSITY HYALURONIC ACID
Macrolane is a hyaluronic acid gel, denser than Restylane, which remains longer in the treated area.
Macrolane is a hyaluronic acid gel of non-animal origin intended for body contour remodeling.
Developed by Q-Med is based on the technology of Restylane.
Is a non-permanent agent that it is gradually reabsorbable and eventually disappears. It lasts for about two years, but is variable.
Annual touch-ups is recommended to optimize results.
5- CALCIUM HYDROXYAPATITE: RADIESSE
The calcium hydroxyapatite has been used in medicine for laryngoplasty, urological treatments problems and craniofacial defects.
It is used as filler in cosmetic medicine to correct soft tissue defects. Its activity is due to its long duration in acting as scaffolding for osteoblasts and fibroblasts.
Radiesse, best known as a brand, has been used safely in other fields of medicine. In 2006 it was approved for the improvement of facial wrinkles and moderate or severe furrows, and for volume restoration caused by hypotrophy in HIV patients.
Radiesse is similar to a cream, has a soft and natural texture. It has a viscosity similar to hyaluronic acid and therefore, when injecting, presents a similar dynamic flow.
Important to point out it is radiopaque, ie: seen on x-ray. Usually it does not move because due to its structure, it gets absorbed by the tissue and sets it. Before degradation, it can move so it is advisable not to move excessively after treatment.
Once injected, the gel is dissolved and the hydroxylapatite remains, attracting surrounding cells. If injected into soft tissue, induces the fibroblast collagen production. If injected into the bone encourage new bone formation.
Preclinical tests have demonstrated histological progressive integration of collagen fibers around the microspheres beyond 78 weeks (about 2 years). For this reason it is not technically a filler but a collagen own generator, achieving natural effects, which is what the patient seeks from the cosmetic medicine, in return, the desired effect is not immediate, and requires two sessions, the second session is made 6 weeks after the first, and the results will be gradual, the final results can be seen after the third month. Of course, there is always an immediate result but the patient should know that the effects are moderate, an increase in the rate of own collagen generation can be achieved with radiofrequency.
The first indication that the patient must understand, is that this is a long-lasting filler and that the specialist must have experienced in the application if these products.
Although there is no labeled indication, it may be used in atrophy cars, deep nasolabial folds, marionette lines, lips and forehead wrinkles.
Dr Rafael Spagnuolo has developed extensive experience with this filling on both byoplasty practice, as well as the appliance of vector delivery system with excellent results in re-tightening facial and cervical. (See photo gallery)
There are no contraindications of any kind.
To date there are no tests that aim to a permanent duration. The cause is that hydroxyapatite degrades in calcium and phosphate as it is expel following the normal metabolic process. It has been found that the nasolabial folds may require further treatment to 6 or 9 months, but may reach more than one year.
In a study about HIV, the duration was verified further than 12 months, considering that the one hundred percent of patients fared beneficial.
The length is related to the injection technique, the material placement site, the patient’s age and metabolism, but can reach between 12 to 18 months.
6- BETA TRICALCIUM PHOSPHATE: ATLÉAN
A reabsorbable injectable gel comprising a combination of non-crosslinked hyaluronic acid and beta tricalcium phosphate.
Suitable for skin depressions and flaccidity.
An immediate firming effect is noticeable thanks to the ability to re-moisturize the dermis.
This effect usually lasts about two weeks, after which the particles of beta-tricalcium phosphate have already begun to stimulate the formation of the new collagen.
The effect lasts about a year.
What areas can be treated with fillings?
Facial fillings can correct the signs of aging at any age, as there is a specific product for the treatment of each type of wrinkle or volume replacement level:
• Lines and surface wrinkles such as crow’s feet and wrinkles around the mouth
• Filling and moisturizing of facial wrinkles when they are not too deep, around the mouth or marked nasolabial folds, low and intermediate.
• Filling deeper wrinkles of the face, such as nasolabial folds or marionette lines.
• Specially designed to restore facial volume, on cheeks, chin projection, uppermylohyoid
• groove, nasal remodeling, scars, earlobes, hands, post-subcision body depressions.
• Lip refine and volume increase, strengthening and moisturizing of lip corners.
Traditionally the face is divided into three parts.
In the upper third area of the face, degenerative changes are mostly related to chronic injuries due to sun exposure, facial expression muscles and gravitational changes cause by the lost of elasticity.
In the middle third area of the face degenerative changes affect the eyelids, peri orbital region, cheeks and nose. These changes are primarily due to photoaging, loss of subcutaneous fat, loss of skin elasticity and restructuring of the underlying bone and cartilage structures.
All this result in looseness of the eyelid skin, decreased tone of the eyelids and exposure of periorbital fat pads or on the contrary, sinks eyes. The cheeks become empty by the loss of the fat pad. The nose shows a fall tip and an apparent elongation of the middle third area of the face.
The bottom third area shows changes affecting the lips, chin and neck. These changes are due to the combination of chronic exposure to ultraviolet light, loss of subcutaneous fat, minor changes to expression facial muscles and remodeling of the underlying bone and cartilage structures. The changes in the absorption of dentition and the maxillary and mandibular bones may cause loss of height and overall volume.
Skin aging results in a loss of volume that is associated with a loss of elasticity of the skin and soft tissue ptosis. Bone resorption also influences the volume loss, but most of the loss thereof is attributable to the soft tissue atrophy. Most soft tissue loss is due to the fact of loss of fat as the muscle remains virtually unchanged over time.
The traditional skin lifting, flattens and thins the face rather than remodel or rebalance the volumes. The lifting acting on the aponeurotic muscle, improves the volume, repositioning the tissues but do not act on the tissues atrophy.
The loss of subcutaneous fat is being produced with age, which means the loss of fullness and roundness of the facial contours of youth, and leads to a flattened or sunken appearance of the facial structures.
What are the results?
The aims to be achieved by injecting the fillers to treat the signs of skin aging are:
• Decrease the depth of the furrows and folds that ply the face after a certain age.
• To restore the lost volume on atrophic tissues as a consequence of loss of tissue volume.
• To provide rebalancing facial volume, meaning the face as “a whole” and not treating isolated areas. The whole must be treated, with one or more techniques and with one or several agents.
For how long facial fillers lasts?
Facial fillers are of varying duration as we have seen; it will depend on the material used. Among the different length in absorption of synthetic materials, there are materials such as hyaluronic acid that lasts between 4-12 months, materials such as polylactic acid or calcium hydroxyapatite lasting almost two years (although they are not technically fillings).
Is required Anesthesia?
It is a minimally invasive technique which allows the patient to return to work and social life immediately. No anesthesia is required (except for filling and lip-shaped dimples and body filler) because usually it is tolerated very well and some fillers include anesthesia in their composition, and others are allocated at the time of use if the patient still might prefer , local anesthesia or cold can be placed.
Facial fillers techniques
In the case of facial fillers, with only a slight puncture we can achieve amazing results. To inject the substances, a very fine needle is used into the treatment areas or where possible by filling the treatment area and Dr. Rafael Spagnuolo uses a cannula that prevents bruising and allows to introduce the filling by a single orifice.
With regard to the application technique, in the case of calcium hydroxyapatite, Dr. Rafael Spagnuolo uses the technique of linear vectors which originate the corresponding lines of collagen in the dermis, obtaining the retightening of the skin that we sought.
The results depend on the material utilized, some are immediate and others gradual.
Are compatible the facial fillers and the Botulinum Toxin?
Not only they are compatible but also they act solving problems that cannot be treated only with facial fillers.
In the next picture we see the result of the remodeling of the lower third part of the face with calcium hydroxyapatite, and the treatment of perioral wrinkles with hyaluronic acid.
Search for more pictures in the gallery