Faculty Bibliography

Our expanding understanding of the physiological and immunological conditions of the skin and, in particular, the aging face, has prompted a growing field of aesthetic technology. Restorative procedures are taking advantage of improved and refined biotechnology, which continues to evolve at a rapid pace. Whereas surgical correction of skin laxity was the norm in years past, there are now many topical options available to encourage healthy, youthful skin, and an ever-growing, increasingly perfected depot of minimally invasive, injectable dermal volumizers and stimulators, collectively referred to as dermal fillers. The growth indicators for this market are as striking as the science. However, successful use of dermal fillers is not only a function of the quality of science leading to improved biocompatibility but also the "art" of client selection, filler application and vigilant follow up. Even the "ideal" filler is subject to unique interactions with both the practitioner and the patient. This article presents a review of the safety and efficacy of the most commonly used dermal fillers with emphasis on those approved for facial aesthetics. The subtleties of improved filler technologies that impact tissue acceptance and reaction, measures of effectiveness and a comparison of wrinkle-reduction outcomes, the nature and incidence of acute and chronic tissue reaction, and a discussion of recommended or preferred filler applications are presented.

BACKGROUND: Nonanimal-stabilized hyaluronic acid (NASHA) fillers are frequently used for facial soft tissue augmentation. Their long-term efficacy and the effects of different retreatment schedules are not well established. OBJECTIVE: This is an 18-month interim analysis of a 30-month study to evaluate the efficacy and persistence of NASHA 100,000 gel particles/mL filler with two different retreatment schedules. METHODS: This multicenter, randomized, evaluator-blinded study enrolled 75 patients with moderate to severe nasolabial folds. Patients were randomized to retreatment of one nasolabial fold at 4.5 months and the contralateral fold at 9 months after correction of both folds at the initial visit. RESULTS: Wrinkle Severity Rating Scale scores improved significantly (p<.001) from baseline, with mean improvements ranging from 1.1 to 1.7 grades. Almost all patients (97%) responded satisfactorily, and the efficacy of the retreatment schedules did not differ significantly. Adverse events, primarily swelling and bruising, occurred in 33% of patients; none were serious. CONCLUSION: The improvements seen after initial treatment with NASHA 100,000 gel particles/mL filler persisted for up to 18 months with one retreatment. The response was equivalent for retreatment at 4.5 and 9 months

BACKGROUND: The porcine collagen-derived dermal filler Dermicol-P35 (Evolence, Colbar LifeScience Ltd, Herzliya, Israel) has low immunogenicity and the potential to provide a long-lasting corrective response for soft-tissue contour deficiencies and deformities. OBJECTIVE The objective was to assess the persistence of the corrective response with Dermicol-P35 up to 12 months after obtaining an optimal cosmetic result (OCR) in a randomized, multicenter study comparing the efficacy and safety of Dermicol-P35 with the hyaluronic acid (HA) filler Restylane (Medicis Pharmaceutical Co.). METHODS & MATERIALS: Subjects with moderate to deep nasolabial wrinkles (n=149) were randomized to injections of either Dermicol-P35 or HA on one side of the face and the alternative preparation on the contralateral side. If necessary, one touch-up injection could be given after 2 weeks to obtain an OCR. RESULTS: Although the mean Modified Fitzpatrick Wrinkle Scale score increased gradually after achieving the OCR with Dermicol-P35, 95.3 and 76.5% of subjects, respectively, met the criteria for persistence of the corrective response after 9 and 12 months. Persistency rates were similar regardless of the requirement for a touch-up injection at Week 2. No unexpected, severe, or serious injection-related adverse events were experienced. CONCLUSION: The effectiveness of Dermicol-P35 appears to be maintained for up to 1 year after achieving an OCR, both for touch-up and for non-touch-up subjects

BACKGROUND Injectable devices offer an attractive alternative to surgical cosmetic rejuvenation. Many injectable products are biocompatible but demonstrate varying levels of durability, ranging from temporary to permanent. Product duration is determined, in part, by its mode of operation. Passive fillers, such as collagen, generally add volume through mass, whereas other injectables, such as poly-L-latic acid (PLLA), rely on a foreign-body response in which endogenous collagen production by fibroblasts is thought to generate new volume. OBJECTIVE To review the use of injectable PLLA, specifically regarding optimal injection technique that can reduce adverse events (AEs) and enhance out comes. RESULTS PLLA has been used extensively to correct HIV-related facial lipoatrophy, with effects lasting for up to 2 years. The efficacy and safety of PLLA can be influenced by correct product reconstitution, dilution, and administration. Undesired AEs, such as papules and nodules, may result from incorrect reconstitution, uneven product distribution in the suspension, imprecise injection technique (superficial injection), or lack of posttreatment massage. CONCLUSION Administration of PLLA with optimal techniques can help enhance treatment effect while simultaneously minimizing AES

BACKGROUND: Non-animal-stabilized hyaluronic acid (NASHA) offers longer-lasting cosmetic improvement and reduced risk of hypersensitivity and requires less injection volume than bovine collagen-derived dermal fillers. Porcine collagen-derived Dermicol-P35 has low immunogenicity and has the potential to provide durability at least equivalent to that of NASHA. OBJECTIVE: The objective was to evaluate the efficacy and safety of Dermicol-P35 and NASHA for correction of nasolabial folds (NLFs). METHODS AND MATERIALS: A total of 149 subjects with moderate NLFs were randomized to receive Dermicol-P35 and NASHA on contralateral sides of the face. If needed, subjects could receive a repeat injection 2 weeks later to obtain an optimal cosmetic result (OCR). RESULTS: Significant (p<.001) improvement in the Modified Fitzpatrick Wrinkle Scale scores relative to screening was observed after treatment with Dermicol-P35 and NASHA. Relative to the OCR visit, mean scores increased (p<.001) over time, but there were no significant differences between treatments (+0.39 and +0.37 at 6 months; p=.626). Greater proportions of subjects experienced swelling, bruising, and pain at the NASHA site. Several subjects had more induration at the Dermicol-P35 site. There was no evidence of any adverse immunologic effect. CONCLUSION: The effectiveness of Dermicol-P35 is maintained for at least 6 months and is equivalent to NASHA for the correction of NLFs

Restoring volume in the middle and lower portions of the face is becoming an indispensable component of modern facial rejuvenation. Radiesse (BioForm Medical, San Mateo, Calif.) is an injectable filler material composed of synthetic calcium hydroxylapatite microspheres (30 percent) suspended in an aqueous carrier gel (70 percent). At present, Radiesse is indicated in the United States for correction of moderate to deep nasolabial folds and for correction of the signs of facial fat loss (lipoatrophy) in people with human immunodeficiency virus. Its off-label use in other facial aesthetic indications is widely reported in the literature. The ability of Radiesse to provide immediate and durable effects has fueled interest in its use for expanded aesthetic applications, particularly in the middle and lower face. The authors' consensus panel, consisting of a cross-section of experts in plastic surgery, facial plastic surgery, and dermatology, was convened to review the scientific literature and compare clinical experiences regarding the use of calcium hydroxylapatite. This report describes the characteristic effects of aging in the middle and lower face and reviews the composition of calcium hydroxylapatite, its safety and durability, and its appropriate use in a variety of facial applications, including nasolabial folds, correction of human immunodeficiency virus-associated lipoatrophy, augmentation of the malar, submalar, and zygomatic regions, and correction of oral commissure defects, marionette lines, and prejowl sulcus. Recommendations for Radiesse use in each area, including anesthesia, and injection techniques are provided. Measures for enhancing patient comfort, anticipating and minimizing potential complications, and optimizing aesthetic results are also discussed

For over five decades, liquid injectable silicone has been used for soft-tissue augmentation. Its use has engendered polarized reactions from the public and from physicians. Adherents of this product tout its inert chemical structure, ease of use, and low cost. Opponents of silicone cite the many reports of complications, including granulomas, pneumonitis, and disfiguring nodules that are usually the result of large-volume injection and/or industrial grade or adulterated material. Unfortunately, as recently as 2006, reports in The New England Journal of Medicine and The New York Times failed to distinguish between the use of medical grade silicone injected by physicians trained in the microdroplet technique and the use of large volumes of industrial grade products injected by unlicensed or unskilled practitioners. This review separates these two markedly different procedures. In addition, it provides an overview of the chemical structure of liquid injectable silicone, the immunology of silicone reactions within the body, treatment for cosmetic improvement including human immunodeficiency virus lipoatrophy, technical considerations for its injection, complications seen following injections, and some considerations of the future for silicone soft-tissue augmentation