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  • An Overview of Current Fillers

    Oculoplastics/Orbit
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    Introduction

    According to information published in 2007, the number of cosmetic procedures performed has increased 446% in the past decade. Nearly 3.2 million procedures were performed with botulinum toxin type A (BoNTA) and another 1.6 million procedures were performed with hyaluronic acid (HA) fillers, constituting about 81% of all procedures involving soft-tissue augmentation.1,2 Together, BoNTA and soft-tissue fillers comprise approximately 54% of all nonsurgical aesthetic procedures.

    Offering the full array of both surgical and noninvasive cosmetic procedures to the better-educated consumer is becoming increasingly important to the successful oculofacial cosmetic surgeon and ophthalmologist.

    Facial Volume Loss Is the Hallmark of Facial Aging

    Conceptually, oculofacial cosmetic surgeons have shifted from simply tightening looser facial skin; they now recognize that there is underlying depletion of facial fat pads and underlying facial bone.3 No longer is it adequate to simply redrape the skin-surgeons need to be able to think in 3 dimensions and to identify the need for volume restoration using multiple modalities.

    Clinical Implications

    All fillers are not the same (Table 1). One hears of such tragedies as 5 ml of silicone oil being injected into the patient's hand, the surgeon having been under the impression that the product is a hyaluronan (Personal written communication with Shu Min Peng, MD, October 31, 2007).

    Table 1. Fillers

    Jean Carruthers, MD, FRCSC, FRC(Ophth) and Alastair Carruthers, MA, BM, BCh, FRCPC, FRCP(Lon)
    Table 1. Fillers

    Before injecting fillers, the physician must understand facial anatomy and facial aesthetics. In addition, he or she must understand the aesthetic effect desired by the subject, as well as appreciate how differences between products of the same and different classes influence clinical use and outcomes. The most successful physicians use photographic documentation for every treatment session.

    Classification of Fillers  

    Shorter-acting biodegradable fillers
    Shorter-acting biodegradable fillers are the ideal starting point for the aesthetic ophthalmologist who is starting to introduce soft-tissue augmentation into his or her practice.

    The hyaluronans are already very familiar to ophthalmologists who have used them during cataract surgery. Unfortunately, Healon is not cross-linked and would have a mean tissue dwell time of only 1 or 2 days. However, the Restylane and Juvederm families of HA fillers are densely cross-linked and are very well studied, are FDA and Health Canada approved, and are remarkably effective and safe.4 In addition, if the novice injector should place the product too superficially into the skin, causing bluish discoloration (the Tyndall effect) or a lump in the lips, for example, hyaluronidase can be used to effectively "erase" the technical fault, thus almost immediately restoring patient satisfaction.5 The ISTA Pharmaceuticals product (Vitrase) contains no thiomerosal and is much less likely to cause allergic responses, and is also more reliable than compounded solutions.

    Injectable collagens are also safe and effective. Zyderm and Zyplast are of bovine origin, and a double skin test is required to rule out an allergy to the bovine-derived product. CosmoDerm and CosmoPlast use a human collagen source to avoid the inconvenience of skin testing. Both products are also FDA and Health Canada approved.6 Physicians should note that currently there is no collagenase available to use in the same manner as hyaluronidase.

    A third generation of collagen filler, Evolence, is derived from the porcine gastrocnemius tendon. It is currently awaiting FDA approval and is already approved by Health Canada.

    Fillers inducing collagen formation
    As the treating ophthalmologist becomes more familiar with the range of available fillers, using more robust and longer-lasting fillers is reasonable. There are 4 fillers whose effect is produced entirely or largely by inducing fibroplasias in the tissues: ArteFill, Radiesse, liquid injectable silicone (LIS), and Sculptra.7

    Radiesse is composed of smooth beads of calcium hydroxylapatite (CaHa) suspended in a vehicle of carboxymethylcellulose. Radiesse was approved for its cosmetic indications in 2006 by the FDA and in 2003 by Health Canada. Interestingly, the calcium does not interfere with the interpretation of CT scans or X-rays, although the radiologist should be informed of the presence of Radiesse. This filler induces new collagen formation around the beads; the beads appear to degrade and disappear from 6-18 months, and the induced fibroplasia lasts for an additional 6 months or longer. Radiesse is very helpful in restoring facial volume loss in the cheeks, nose, and chin, but it is not currently recommended for lip enhancement or the infraorbital hollows.

    ArteFill is composed of smoothly polished beads of polymethylmethacrylate (PMMA) suspended in a vehicle of atelomeric bovine collagen. It was approved by the FDA in 2006; a sister product, Artesense (formerly Artecoll), has approval by Health Canada. It is approved as a permanent implant, because the beads of PMMA stimulate new collagen formation, which appears to be permanent, like the PMMA beads. It is useful in treatment of the nasolabial folds, but it is not currently recommended by the FDA for lip enhancement.

    Liquid injectable silicone (LIS; the modern formulation is Silikon 1000) is approved for ophthalmologic use by the FDA and Health Canada. It is used off-label for facial volume enhancement and is injected using the microdroplet technique; each subdermal injection is of 1/100 ml. The individual silicone oil beads induce neocollagenesis, and the aesthetic effect is long-term. It has achieved particular success recently in the treatment of HIV-related facial lipoatrophy.

    Sculptra is approved by the FDA and Health Canada for treatment of facial lipoatrophy related to HIV infection. In Canada it is also approved for cosmetic indications. Although more a volumizer than a filler, it is composed of poly-L-lactic acid (PLLA) particles suspended in an aqueous vehicle. The PLLA particles stimulate neocollagenesis, and the effect can last for 2 years and occasionally longer. Currently it is under study for approval for cosmetic indications.

    Conclusion

    We believe that the rapid changes in the world of fillers should be of interest to many ophthalmologists. Fillers today are safer, last longer, and are easier to use than in the past. At the same time, as the public has become aware of the benefits of the current generation of fillers, patients should rely on the expertise of their ophthalmologists to guide them in making appropriate choices to address their specific concerns.

    References

    1. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank: 2006 Statistics. Available at: http://www.surgery.org/download/2006stats.pdf. Accessed February 4, 2008.

    2. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank: 2000 Statistics. Available at: http://www.surgery.org/download/2000stats.pdf. Accessed February 4, 2008.

    3. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219-2227; discussion 2228-2231.

    4. Narins R, Michaels J, Cohen J. Hylans and soft tissue augmentation. In: Carruthers J, Carruthers A, eds. Soft Tissue Augmentation. 2nd ed. Philadelphia: Elsevier; 2008:31-50.

    5. Hirsch RJ, Brody HJ, Carruthers JD. Hyaluronidase in the office: a necessity for every dermasurgeon that injects hyaluronic acid. J Cosmet Laser Ther. 2007;9(3):182-185.

    6. Matarasso S. Injectable collagens. In: Soft Tissue Augmentation. Carruthers J, Carruthers A, eds. Soft Tissue Augmentation. 2nd ed. Philadelphia: Elsevier; 2008:19-30.

    7. Carruthers A, Carruthers J, Prather C, Jones D, Mandy S. Fillers working by fibroplasia. In: Carruthers J, Carruthers A, eds. Soft Tissue Augmentation. 2nd ed. Philadelphia: Elsevier; 2008:83-101.

    Author Disclosure

    Dr. Jean Carruthers receives consulting fees from Allergan, Inc., Artes Medical, Inc., BioForm Medical, Inc., Lumenis, Ltd., Merz Pharmaceuticals, OrthoNeutrogena, and Solstice Neurosciences, Inc. She has contracted research funds from Allergan, Inc., BioForm Medical Inc., Merz Pharmaceuticals, OrthoNeutrogena, and she has ownership interest in Artes Medical, Inc., and BioForm Medical, Inc.

    Dr. Alastair Carruthers is on the advisory boards of Allergan, Inc., Artes Medical, Inc., Bioform Medical, Inc., and is a consultant for Allergan, Inc., Artes Medical, Inc., Bioform Medical, Inc., and Galderma, Inc. He has received honoraria from Allergan, Inc., Artes Medical, Inc., Bioform Medical, Inc., Galderma, Inc., Medicis Pharmaceutical Corp., and OrthoNeutrogena. He has ownership interest in Artes Medical, Inc., and BioForm Medical, Inc.