PEER-REVIEW | COMBINATIONAL AESTHETIC APPROACHES |
alterations of the ageing face has shifted the focus from treating individual wrinkles to a rather holistic paradigm. Thus, to date, filling materials are frequently used for volume enhancement such as cheek and chin augmentation, tear trough correction, nose reshaping, hand rejuvenation, and the correction of facial asymmetry9
different filling products are currently being manufactured worldwide9,10 by well-designed studies10
safety with fillers has clearly improved since the first published study in 199811
. It has been estimated that around 160
, with only a few supported . However, experience and
. The most frequently utilised
materials for facial augmentation include hyaluronic acid (HA), calcium hydroxylapatite (CaHa), collagen, poly- l-lactic acid (PLLA), polymethyl methacrylate (PMMA), and autologous fat12
.
Figure 1 (A) A 52 year old patient with deep folds due to significant sun damage. Filler treatments for singular wrinkles elsewhere have not been to the full satisfaction of the patient. (B) After pre- treatment with BoNTA for forehead wrinkles, glabellar lines, crow’s feet, and micro-injections in the lateral cheek area, a fractional CO2
modified. Although most clinical trials report results of
BoNTA treatment on single areas of the face, clinicians tend to treat multiple areas to provide a more natural, relaxed look4,5
. Importantly, BoNTA may also help in facial
line prevention if initiated at an earlier age and if regular treatments are sustained6
. Although results are usually
- laser full-face treatment has been performed with good results 2 months thereafter. Additional treatments with HA-fillers are currently considered by the patient.
excellent and treatment is associated with few (and transient) side-effects, expertise is essential when injecting the M. frontalis, M. orbicularis oculi, and peri- orally2,7,8
. With regards to the frontal
Hyaluronic acid Since its FDA approval in 2003, HA has become the ‘gold standard’ of safe injectable fillers. It represents the most important polysaccharide in the human extracellular matrix (ECM), which acts as a scaffold for collagen and elastin13
collagen formation14 The most frequently
area, particularly with older patients, a two-step procedure with moderate dosing at the first treatment might prevent unpleasant side-effects, such as eyebrow ptosis or a ‘feeling of heaviness’, followed by a touch up for optimal results. With regard to the peri-oral area and other areas of risk, such as the M. zygomaticus major, the use of higher diluted superficial ‘micro-injections’
(intradermal
microdroplets) of BoNTA may help optimise results and patient satisfaction. The latter technique may also be used for improvement of fine wrinkles around the jowls and may help optimise and sustain results when used prior to any ablative or non-ablative laser treatment.
Injectable soft tissue fillers for volume replacement
Soft tissue augmentation using dermal fillers in order to overcome the signs of ageing as an alternative to surgery has become a daily practice
44 ❚
for many dermatologists and plastic surgeons. In recent years, indications and the number of procedures performed is continuously increasing. Improved understanding of the complex anatomic
March 2015 |
prime-journal.com
used worldwide are derived from the fermentation of Streptococcus equi bacterium, which are referred to as non-animal stabilised HA or (NASHA)15
utilised materials for facial augmentation include
hyaluronic acid (HA), calcium hydroxylapatite (CaHa),
collagen, poly-l-lactic acid (PLLA), polymethyl
methacrylate (PMMA), and autologous fat.
. It has also been reported to stimulate new . Nowadays, most of the HA fillers
. The chemical
formula consists of linear polymeric dimers of N-acetyl-D- glucosamine and D-glucuronic acid cross-linked into a long unbranched chain15
. The
longevity of the respective product depends on the muscular activity, concentration of the product, and amount of cross-linking, usually lasting from 6 to 18 months. The process of crosslinking HA
molecules is usually achieved by using butanediol diglycidyl (BDDE). Its stability, biodegradability, and long- term safety has been demonstrated for more than 15 years16
. Cross-linking will also
. The degree of cross-linking enhances the
persistence of the HA filler, but excessive cross-linking may reduce its biocompatibility, causing foreign body reaction and encapsulation13
change the rheological properties of the gel. Depending on the grade of cross-linking, the filler’s persistence, elasticity, and resistance during injection is being influenced. The resulting strength of the gel mainly determines the clinical application of the filler. Strong gels have a higher lifting capacity and should be used for deep wrinkles and volume augmentation, whereas weak gels are characterised by a lower viscosity and should be used for fine wrinkles and mesotherapeutic approaches3
.
An important characteristic of the HA molecule is that it is hydrophilic, which has a major influence on hydration and turgor of the skin. While its hydrophilic nature may be used therapeutically, it should be noted that higher
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