EyeNet Magazine

Beyond Botox: Primer on Dermal Fillers

By Marianne Doran, Contributing Writer

Ophthalmologists who are considering expanding into facial aesthetics should feel comfortable in making the move, according to Stephen L. Bosniak, MD, an oculofacial surgeon affiliated with the Manhattan Eye, Ear and Throat Hospital in New York. Facial rejuvenation is a natural transition for physicians already skilled in performing delicate procedures in the periorbital area.

Now the availability of new injectable materials is making aesthetic procedures more accessible and more popular among ophthalmologists.

Dr. Bosniak pointed out that both botulinum toxin type A (Botox) and the newly approved hyaluronic acid dermal filler Restylane have their roots in ophthalmology. Although facial rejuvenation is performed by a variety of specialists, he contends that ophthalmologists are “probably some of the best suited for this kind of therapy because they are so meticulous and have to have such a light touch for ophthalmic surgery.”

Kathleen M. Duerksen, MD, an eye and facial plastic surgeon and clinical lecturer at the University of Arizona, agreed, noting that hyaluronic acid’s use as an intraocular filling agent for more than 20 years makes Restylane “particularly attractive to those of us with an ophthalmology background because we know it’s safe.”

Botox and More
Dermal filling agents are nothing new, but the approval of Restylane is seen as a major advance in terms of convenience, ease of use and durability.

Until now, the primary choices for minimizing the appearance of wrinkles were Botox, bovine collagen (Zyderm, Zyplast), human-derived collagen (CosmoDerm, CosmoPlast) and fat transplantation.

Here are some pros and cons of each procedure:

Botox. Although not a filler, Botox immobilizes the muscles that create lines and wrinkles. But it lasts only three to six months when used by itself. Dosage is critical: Injecting too little Botox will not achieve the desired effect, but too much of the substance can give the face an emotionless, mask-like appearance. Botox works well for “crow’s feet” and in adjusting the level of the eyebrows. Recently, Botox has been used in combination with Restylane for “frown lines” in the glabellar area.

Collagen. The main drawback to bovine collagen is that it requires skin testing first because of the risk of allergic reactions, which can cause scarring when they occur. Moreover, even though bovine collagen is obtained from a specially bred, highly monitored herd of cattle, skittishness over even a theoretical risk of transmitting bovine spongiform encephalopathy also makes it less desirable as a filler. Human collagen, derived from human fibroblast cell cultures, does not require skin testing, but it’s expensive. Both forms of collagen last only about three months.

Fat transplantation. Fat transplantation involves taking fat from a patient’s thigh, buttock or abdomen and injecting it into wrinkles. The advantages of fat injections are that they are potentially permanent (although their durability is unpredictable), and the material is virtually unlimited.

The disadvantages are that an additional procedure is required to harvest the fat and fat globules can be more challenging to inject. Moreover, transplanted fat has the potential to leave a lumpy appearance.

Restylane. Restylane is hyaluronic acid that has been biosynthesized from a nonanimal source, reworked and stabilized with relatively few cross-links. It is considered to be the most desirable dermal filling agent available in the United States.

“The nice thing about Restylane is that it comes in a vial, it’s a carbohydrate gel, and it’s a natural substance that doesn’t have to be skin-tested,” said Jane J. Olson, MD, an ophthalmic facial plastic and reconstructive surgeon and assistant clinical professor at Yale University who practices in Greenwich, Conn. “It also lasts longer and is very user-friendly in that it flows very nicely and it gives a nice contour.”

Restylane Makes Inroads
Restylane is being used primarily in the glabellar furrows, nasolabial folds, oral commissures (the so-called “marionette lines”) and lips. In the November 2004 Archives of Facial Plastic Surgery, Dr. Bosniak and his colleagues report on their six-year experience in using Restylane at these sites in more than 1,400 consecutive patients in an oculoplastic clinic in Rio de Janeiro, Brazil. Patient satisfaction and durability of the procedures were evaluated at three, six and nine months.

High patient satisfaction. For all treatment areas combined, at three months 88 percent of patients said they were satisfied or very satisfied with the procedure. The satisfaction rate was 73 percent at six months and 61 percent at nine months. Areas with both the most durable results and the highest patient satisfaction were the glabellar area and the nasolabial folds, with more than 80 percent of patients still happy with the results at nine months.

Patient satisfaction (as a single measure) was highest for lip and oral commissure procedures, but the results did not last as long as in other areas. At these two sites, touch-ups were needed by six months.

Patients who had injections into the glabellar area were pretreated with Botox to relax the corrugator muscles (which create the vertical “11” between the eyebrows) and the procerus muscle (which creates horizontal furrows on the bridge of the nose).

“The Botox relaxes the muscles and then any residual furrow is filled in,” Dr. Bosniak said. “By using both, we can get a result that lasts much longer than by using either one by itself.” About 20 percent of patients who had the two techniques together didn’t need the filler again and were maintained with only a couple of Botox injections a year.

Alternative to blepharoplasty. Some ophthalmologists are now injecting Restylane into the lower lid area as an alternative to lower-lid blepharoplasty. “One of the reasons we start to look older is that we lose the soft tissue from our face,” Dr. Duerksen said. “So more and more people are trying to get away from removing fat from around the eyes and are finding that injecting Restylane into the lower lid can be more helpful than blepharoplasty.”

Restylane also can be used around the orbital rim or even on the brow bone to give more shape and contour to the facial structure without having to do a face lift or brow lift, according to Dr. Olson.

“The other place I’ve used it is along the jaw line,” she said. “If you follow the marionette line down, there is an indentation in the jaw, and that’s where people look like they have jowls. You can actually inject just above the periosteum, and the Restylane acts like a sponge, swelling up and filling out that area so that you reestablish the jaw line without doing a face lift.”

Restylane also can be used at the corners of the lips. “Some people have a down-turned look to their lips, which makes them look old,” Dr. Duerksen noted. “So we can build up the corners of the lips, and that subtle elevation looks nice.”

More Fillers Expected
Several new fillers are expected to be available soon. These promise even greater flexibility and more creative combinations of techniques. Some products awaiting FDA approval include the following:

Perlane. This, from Q-Med, is another hyaluronic acid-based filler. It is more viscous than Restylane and is good for filling in deep furrows and contouring irregularities. Perlane lasts nine months or more.

Restylane Fine Lines. This, also from Q-Med, is a thinner version of Restylane and is designed to be injected into tiny wrinkles, such as the vertical lines above the vermilion border of the lip. It lasts three to four months.

Artecoll. This product, from Artes Medical and to be called Artefill when approved in the United States, is considered to be a permanent filler. It is made of PMMA beads and bovine collagen and is injected in small amounts into the subdermal fat.

Artecoll is used to fill the nasolabial folds and other large defects. CosmoPlast or Restylane may be layered on top of Artecoll.

Getting Started
Dr. Olson emphasizes that facial rejuvenation is not just filling in lines. “It’s important to train with someone who has an aesthetic point of view. You don’t just look at the patient. You have to be able to see what you want to achieve. Plus you have to understand facial structure and anatomy.”

“It’s about facial sculpting. That’s what makes it challenging but also what makes it so satisfying,” Dr. Bosniak said. “By combining these noninvasive techniques, you can do some great things that in the past were only possible with surgery. And these are all within the reach of ophthalmologists if they have the desire to pursue them.”

Dr. Bosniak is a consultant for Medicis and has received travel reimbursement from Allergan and Q-Med; Dr. Duerksen has no related financial interests; and Dr. Olson is a trainer for Allergan and Medicis.

Further Reading

Bosniak, Stephen L. and Marian Cantisano-Zilkha. Minimally Invasive Techniques of Oculofacial Rejuvenation (New York: Thieme Publishers, 2005).

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