What are injectable soft tissue fillers?
As we age, the changes that occur in our face are a manifestation of the effects of gravity, sun damage, hereditary influences, and loss of volume. The change in volume is due to loss and redistribution of fat within the face, thinning of the skin dermis (deep layer of the skin) and bone loss. All of these changes lead to descent of the forehead, the eyebrows and the cheeks, downward turning of the corners of the mouth, thinning of the lips, drooping of the nasal tip, prominence of the folds along the sides of the nose and mouth (nasolabial folds), greater visibility of the bony structures, and relaxation of the tissues seen as jowls and redundancy of the neck.
Injectable soft tissue fillers consist of a group of natural or synthetic substances that restore volume within the facial skin and the deeper tissues giving rise to a fuller more youthful appearance. As of 2009, there are 14 injectable soft tissue fillers that are FDA approved for cosmetic use in the United States. These include Zyderm, Zyplast, Cosmoderm, Cosmoplast, Restylane, Perlane, Hylaform, Hylaform Plus, Captique, Prevelle Silk, Juvederm Ultra, Juvederm Ultra Plus, Radiesse, and Sculptra Aesthetic. Zyderm and Zyplast are forms of bovine collagen while Cosmoderm and Cosmoplast are forms of human collagen. Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus, Hylaform, Hylaform Plus, Captique and Prevelle Silk (Captique with Lidocaine) are all forms of hyaluronic acid. Radiesse is a calcium-based product and Sculptra Aesthetic is a synthetic filler consisting mostly of Poly-L-Lactic acid.
Each of these soft tissue fillers will be addressed individually and in detail later in this chapter. There are other fillers available which are not FDA-approved. These will not be addressed. Caution must be exercised when considering treatment with any product or procedure that is not FDA-approved. Our FDA has strict guidelines to ensure the proper use of various therapeutic modalities. Improper or unapproved use may lead to significant complications. Patients must be very judicious in the treatment modalities they seek and the physicians they seek to perform them.
All currently available and FDA-approved soft tissue fillers are temporary in nature. They must be repeatedly injected into the tissues to maintain their effect. The length of time they remain in the soft tissues varies with the characteristics of the filler itself, the area of the face into which the filler is injected and the patient’s unique response to the filler.
Most patients who seek treatment with soft tissue fillers often wonder why there is not an FDA- approved injectable permanent filler. Although the concept of "permanent correction” of soft tissues may seem very attractive, it is important to remember that our specific facial features are not "permanent”. With aging and weight fluctuations, our facial features undergo significant change. As such, a soft tissue filler that may have appeared perfectly placed at one point in life may be very misplaced in the future as the facial features shift due to the natural forces of aging or weight change. Furthermore, permanent fillers may have long-term side effects such as migration, asymmetry, and lumpiness. In these situations, permanent fillers are very difficult to remove since they are not an implant but an injection. Consequently, it is much safer to use temporary soft tissue fillers.
The ideal filler is one that has a low risk of complications and relatively predictable as well as reproducible results. It would create a natural appearance with minimal down time and minimal side effects. It would be easily tolerated by the patient with a low risk for allergic reactions eliminating the need for a skin test. It would be cost effective and provide a long-lasting but not permanent result.
What do soft tissue filler injections accomplish?
- The objective of using soft tissue fillers is to soften wrinkles, improve depressions or add volume. These substances are used to fill in the fine or deep facial wrinkles, frown lines, smile lines, crow’s feet, acne scars, and depressed traumatic scars (Figs 16-1, 16-2). Some may also be used to enhance the lips by making them fuller.
- In adding volume to the soft tissues, the face becomes smoother and more youthful.
- With the exception of Sculptra Aesthetic, the results of these injections are immediate.
- Since all of the FDA-approved fillers are metabolized by our body, their effect is temporary. They are absorbed over a period that can vary from 3 months to 2 years. The rate at which they are metabolized depends upon the nature of the filler used, the area into which it is injected, and the individual’s response to the filler.
What can I expect during and after the soft tissue filler injection?
- All of the soft tissue filler treatments may be performed in an office setting with you fully awake.
Your face is cleansed and the area to be injected is further treated with rubbing alcohol to minimize the potential for infection.
- The majority of these injections are performed with you in an upright position. Lying down or holding the head backward often diminishes the wrinkles and depressions in the face. Maintaining an upright position improves visualization of the areas to be treated and consequently allows more accurate placement of the filler.
- You may experience slight bleeding at the needle site; this is easily controlled with mild pressure.
- You will see the effect of the soft tissue filler injections immediately.
- There is minimal recovery following the injections and you may wear make-up shortly after the procedure.
- You may experience some redness for the first few hours at the injection site.
- You may also have swelling and bruising. These symptoms are more likely to occur and tend to last longer with the hyaluronic acid injections than with the collagen injections. The swelling tends to be more noticeable and potentially more intense with injections in the lips than anywhere else in the face.
- If you have a tendency to bruise, ice is helpful during and after the procedure.
- If you are undergoing any kind of injection procedures, you should try to avoid products that increase bleeding the week prior to your procedure, as these will increase the risk of bruising.
- Some individuals may develop "bumpy areas” where the soft tissue filler was been injected. This may be a result of:
- The filler being injected too superficially
- Too much filler being placed in one area
- Migration of the filler to one region. This is especially true of areas such as the lips and marionette lines
- Inflammatory reaction to the injection
Is there treatment for the "bumpy areas”?
- Massage is helpful to soften these bumps. If severe, a topical steroid cream or a small steroid injection may be attempted.
- If hyaluronic acid fillers are the cause of the bumps, a hyaluronidase product may be used to quickly dissolve them.
- This is considered an "off-label” use of hyaluronidase products.
Often however, only the body’s natural metabolism of the injectable material over time will resolve the symptoms.
Do soft tissue filler injections hurt?
- All injections are associated with pain. The discomfort associated with soft tissue filler injections is transient and typically does not last beyond the treatment session.
- The degree of discomfort is dependant upon the type of filler used and the area into which it is injected.
- There are three types of discomfort associated with soft tissue filler injections. The first is from the actual needle itself as it penetrates the skin. The second is due to the distension of the soft tissue as the filler is being injected. The third pain is due to the burning sensation of the substance itself.
- Both human and bovine collagen have a local anesthetic (Lidocaine) mixed with them and consequently are associated with less pain than other soft tissue fillers.
- The hyaluronic acid soft tissue fillers and Radiesse do not have any local anesthetics mixed with them. As such, they are associated with a slightly greater degree of discomfort. Soft tissue injections using these substances are more easily tolerated by using a topical anesthetic or by using a local anesthetic injection (similar to those used by dentists when working on teeth).
Who is not a candidate for soft tissue filler therapy?
- Patients with active inflammatory skin reactions such as herpetic blisters, rashes, pimples, cysts or hives should postpone soft tissue filler injections until the condition has resolved.
- Patients with a strong history of herpetic blisters should undergo suppressive anti-herpetic treatment prior to undergoing soft tissue filler injections in the lips. However, this is considered an off-label use of anti-herpetic medications.
- Patients receiving immunosuppressive therapy should discuss obtaining soft tissue fillers with their physician to obtain clearance. At times, it is prudent to consider postponing these injections until patients are no longer receiving such treatment.
- Patients with connective tissue disorders may have increased susceptibility to hypersensitivity reactions making soft tissue filler therapy unpredictable and perhaps imprudent. There is no data on the effect of these soft tissue fillers in this patient population.
- Women who are pregnant, attempting to become pregnant or nursing should avoid soft tissue fillers since their safety during these conditions has not been established.
- The safety of soft tissue fillers has not been established in patients 12 years of age or younger.
Are certain fillers more suitable for certain conditions or for certain parts of the face?
- Soft tissue fillers vary in terms of type, concentration, molecular weight or degree of molecular cross linking.
- In general, fillers consisting of smaller molecules are more suitable for superficial lines and wrinkles, whereas those consisting of larger molecules are more appropriate for the deeper folds and wrinkles.
Can different fillers be used together in one area?
- It has become common practice to use multiple fillers in the face. Certain fillers are more appropriate for different parts of the face than others.
- Under some circumstances, physicians may combine two fillers in the same region of the face. For example, they may place Radiesse along the deep plane of the nasolabial folds and layer Juvederm or Restylane above it, along a more superficial level.
- We do not have data on how well these fillers mix together once injected into the same region. However, to date there have been no adverse reactions reported.