THE ABC’S OF SKIN FILLERS
Alloderm, Botox, Captique……and many others! What are they? How do they work? Where do you use them? What's best for a particular problem?
Here is a brief summary of some skin fillers. Please be advised that many of the cosmetic applications are OFF-LABEL.
This product stands alone as regards what it does. It is NOT a skin filler. It is injected in micro-doses into muscles in order to relax them. Once the muscles relax, the skin that is closely attached to the muscle will smooth out as well. This product can be used for facial lines that exist when the face is in repose and also to "tune down" over-active muscles and facial lines when the face is expressive. It is most often used to treat the vertical "worry" lines between the eyebrows, horizontal forehead lines and crow's feet. Other, more novel, uses include treating multiple fine lip lines (ie "smoker's lines"), lifting a "turned down" corner of the mouth, gently elevating the tip of the nose, softening the two prominent vertical neck bands (cords), treatment of "tension" headaches, etc. It is absolutely wonderful as treatment for excessive perspiration of the armpits, palms and soles of the feet. And, it is sometimes combined with other skin fillers at the same time for a multi-treatment effect (ie Botox and Restylane).
At present, this is the most commonly used and well-known of the skin fillers. It is made of hyaluronic acid gel, which is compatible with our own bodily tissues. Therefore, no skin or allergy testing is required. It comes as a clear, colorless gel which is injected through a tiny needle into the mid level of the dermis. It is well suited for deeper lines but not furrows or depressions. It is ideal for lip enlargement, providing a smooth, natural and soft feel to the lips. Restylane usually lasts approximately six months or more and then has to be repeated. Injections of Restylane can be uncomfortable but pre-treatment with ice or a nerve block can make it virtually pain free.
Other forms of Restylane, which have smaller and larger individual particle sizes (ie thicker and thinner versions) of the same hyaluronic acid, are Restylane FL, Perlane and Restylane Sub-Q. Perlane has recently been approved by the FDA but the other forms are pending approval from the FDA and are not yet available in the US. Restylane and its family are synthesized in a process which does not use animals so there is virtually no chance of allergy and hence no allergy testing is required.
Juvederm is also a hyualuronic acid gel and is very similar to Restylane. It too is a clear, colorless gel and is useful for many small to medium sized lines and depressions, including the lips. It has a slightly different chemical cross-linkage from Restylane and is said to last somewhat longer than Restylane. Juvederm comes in two forms: Juvederm Ultra (similar to Restylane) and Juvederm Ultra Plus (slightly thicker and longer lasting and similar to Perlane). Juvederm is chemically produced without the use of animals so no allergy testing is required.
This product is similar to Restylane (hyaluronic acid) except that it is produced from rooster combs - hence a slight chance of allergy. It is slightly less painful on injection than Restylane and it lasts approximately four months.
This product is virtually identical to Restylane (including its synthesis) - it is produced by another company.
The original injectable skin filler and a winner for over twenty years. Collagen requires skin testing because it is derived from cattle. It comes in various strengths, such as Zyderm I, Zyderm II and Zyplast, and is used to treat everything from fine lines to deeper depressions. Depending upon the site that is injected, it will last from 3-6 months. Collagen was the gold standard, to which all other new injectables were compared, for the past twenty years. The gold standard has now been passed to Restylane.
A human derived form of Collagen so that allergy testing is not required. It comes in several strengths: Cosmoderm I, Cosmoderm II and CosmoPlast. It is used in a manner identical to Collagen.
Technically dimethylpolysiloxane, this synthetic molecule of carbon, hydrogen, oxygen and silicon, is a clear, colorless, thick and "greasy" liquid which is injected into deep tissue in multiple micro-droplets. The body then forms collagen around each micro-droplet to hold it in place. Once injected, silicone is permanent and cannot be removed by any means. Problems such as migration or infection have occurred even with the best of injection technique. Silicone is currently being studied in the US under the names of Silskin (Richard-James Inc) and Silkon 1000 (Alcon Labs), but is not yet approved by the FDA for general distribution to physicians.
This versatile injectible is comprised of microspheres of calcium hydroxyapatite suspended in a cellulose gel. It is virtually identical in chemical composition to particles of bone and teeth so no allergy testing is required. Radiesse is a white, creamy substance which must be injected deeply (below the skin), at the dermal-subdermal junction. It is very useful for volume treatment of folds and depressions, such as the naso-labial fold, depressed areas of the cheek, marionette lines and for touch-ups near the eye. In volume, it can be used to enlarge a chin or cheekbone area. It should not be used for lip augmentation due to frequent "clumping" of the material within the lips.
Radiesse produces some pinkness of the skin for about 24 hours after injection and there is an "achy burning" feeling for about five minutes after injection. Results of injection are immediately apparent. It lasts approximately one year or longer and has a soft feel - virtually undetectable.
A polymer of poly-L-lactic acid, Sculptra is a different type of skin filler. Actually, it is a bio-activator, in that once injected it stimulates the body to form its own collagen in order to thicken and fill in a particular area. The resultant thickened skin is soft and natural to the touch. Sculptra is made from the same substance that has been used for absorbable sutures for over twenty years. It is safe and non-allergenic.
As compared to most other skin fillers, the results of Sculptra injections are not immediately seen. A vial of Sculptra powder must be reconstituted with sterile water several hours before injection. Once injected, an immediate "improvement" is seen, which is due to the water used in preparation. Within a few hours, the water is absorbed leaving only the particles of Sculptra. Then a slow process begins in which the body, in response to the presence of the Sculptra, is stimulated to produce its own natural collagen. It will take 4-6 weeks to fully evaluate the effects of treatment and oftentimes multiple treatments are necessary.
Sculptra is ideal for filling in large depressed areas of the face, such as hollow cheeks, hollow temples, nasolabial folds, etc. It can be used as a touchup for hollow eyes and to build up a chin or cheekbone. It is also being used for the treatment of thin, "veiny" hands. Once the desired results have been obtained, Sculptra should last for 18 months or more and may require only a brief touch-up injection to maintain the results.
This product consists of tiny microspheres of polymethylmethacrylate (PMMA), which is the same substance as Plexiglas. It is mixed with bovine collagen as a carrier. Proper injection technique requires placement deep to the skin and just above the fatty tissue. These microspheres are never absorbed and are considered permanent. It has been used for deep hollows and lines, such as nasolabial and marionette lines and for augmentation of the chin and cheekbones. There have been some reports of granuloma formation after its use.
Artefill has recently been FDA approved for release in the US. It is available only to plastic surgeons and dermatologists who have been trained in its usage. It is not available for general distribution to physicians.
Fat grafts require a minor surgical procedure to harvest and cleanse your own fat cells. Obviously, there is no question of allergy and for most patients there is an abundant supply of the basic ingredient-- FAT. Placement of the fat graft is done through injections within the deeper layers of the face - not within the skin layer itself. It is very useful for treatment of large areas of depression or folds such as the nasolabial fold, marionette lines, etc. Fat grafts are also used to augment cheekbones, chin lines, cheeks, eyebrows and other areas in order to increase the volume of the face. Frequently, multiple treatment sessions are required. There may be swelling and bruising at the site of fat harvest and the recipient site as well. Once healed, the results are soft and feel very natural to the touch.
The results of fat grafting are individual and variable - sometimes permanent and sometimes requiring additional treatment to deal with fat absorption.
There are many other skin fillers in the "pipeline." Their introduction to the US market is still years away. As they become generally available, we will be pleased to offer them to our patients.