PEER-REVIEW | COMBINATIONAL AESTHETIC APPROACHES |
metabolised into calcium and phosphate. Radiesse is composed of microspheres of CaHA (25–45 μm) at 30% concentration suspended in a gel composed of water, glycerin and sodium carboxymethyl cellulose. This formulation provides a 1:1 volumetric correction without the need for overcorrection. Once injected, the gel is slowly absorbed over a period of months. During this interval, there is ingrowth of fibroblasts into the scaffold of microspheres that will gradually replace the carrier gel15
endogenous collagen synthesis, which will anchor the microspheres in place. The microspheres, stabilised at the injection site by new collagen formation, will then slowly be reabsorbed by macrophages over several months17
18 months18
. This filler remains in the tissue for 12– . It is indicated for correction of severe facial
Figure 2 (A) A 42-year old patient with significant elastosis. Originally seeking treatment for improvement of marionette folds. (B) After careful discussion of possible options (no treatment of melasma warranted) injection of hyaluronic acid (5 cc) both supraperiosteally and via fanning techniques (cannula) injections to restore the malar contour. The lifting effect (result one week later) was associated with diminution of nasolabial and marionette folds, thus no further treatment was warranted by the patient
folds and facial volume loss and/or lipoatrophy. It is also well suitable for the improvement of jawlines and hand rejuvenation. The incidence of associated complications is low with mostly material accumulation (nodules) when injected into the lips, and there are no reports of calcification or osteogenesis at injection sites. PLLA is a biodegradable, non-toxic, synthetic material
derived from corn starch, which induces a subclinical inflammatory response, followed by encapsulation, fibroplasia, and neocollagenesis2
. Patient counselling is
especially important when using PLLA due to its delayed effect. Each injection session with PLLA provides gradual improvements. Based on the current recommendations, three treatment sessions (approximately every 6 weeks) are generally required, but once the final correction is achieved, volumetric results may last up to 2–3 years19
.
The most common adverse effects are injection related. Small, palpable, subcutaneous nodules, as well as visible nodules may result from uneven distribution or superficial placement of the product12
. The true
inflammatory granulomata rate is reported to be between 0.01 and 0.1%2
. Consequently, this product concentrated HA and/or large particle products tend to
absorb more water, and may thus produce some tissue swelling after injection9
. HA placement provides
excellent results in treating temporal hollowing, cheek volume loss, nasolabial folds, lips, marionette lines, facial scars, and tear trough deformity2
. HA is degraded by
native hyaluronidase. This fact is widely used in treating complications linked to injected HA fillers and represents an additional reason for its popularity.
Fat transfer and biostimulation For larger volume restoration, fat transfer (lipomodelling) and biostimulatory agents are valuable alternatives2
. The
latter stimulate the body to produce its own collagen and mainly include CaHa and PLLA. CaHA is a mineral present in bone and teeth. As a naturally occurring substance, it is inherently biocompatible and is
46 ❚ March 2015 |
prime-journal.com
Figure 3 (A) A 60-year old patient seeking help for a fresher but very natural look. After discussion of possible approaches, associated downtime and costs, microneedling has been performed a total of 3 times every 4 weeks followed by thread lifting of the lower contour (4 sutures with 12 cones each). (B) 2 months later 4 cc’s of hyaluronic acid had been injected using bolus and fanning techniques to improve the cheek area and using the hydrophilic nature of the HA for further improvement of skin appearance. One additional cc of hyaluronic acid has been injected into lips and tear trough (off-label)
should be injected deep — into the hypodermis or deeper. When used correctly (appropriate concentration) its efficacy and safety has been shown for the treatment of facial and non-facial areas including the hands, neck, and chest providing convincing, natural and long-lasting results20
. Whereas HA, CaHA, and PLLA are temporary dermal
fillers, PMMA represents a non-resorbable, permanent filler. Composed of 20% PMMA microspheres in 3.5% bovine collagen, PMMA is FDA approved in the US for the treatment of nasolabial folds. Off-label use of PMMA has been reported for several other facial lines, including glabellar frown lines, upper lip lines, and mouth corners21
.
Even though the collagen component is degraded over time, the PMMA microspheres are permanent and cannot be reversed without excision22
. Complications
after permanent fillers are seen relatively frequently and may appear shortly after injection (contour irregularity or nodules) or may develop after many years (granulomatous reactions)3,12,23
. Coleman24
Facial re-contouring using lipotransfer as described by requires harvesting of fat, centrifugation of the
. As these cells replace the gel, they will increase
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