Role of New Fillers in Facial Rejuvenation:: A Cautious Outlook

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A major shift in facial rejuvenation is well under way. According to statistics published recently by the American Society of Plastic Surgeons, total cosmetic plastic surgery procedures increased 393 percent from 1992 to 2002. 1 There has been a nearly two-fold increase in the number of face lifts (from 40,077 to 73,562) and a nearly three-fold increase in the number of forehead lifts (from 13,501 to 37,199). There were also significant increases in nonsurgical procedures during the same time frame: a four-fold increase in fat injections (7,865 to 32,418), almost a two and one-half-fold increase in collagen injections (41,623 to 98,092), a four-fold increase in chemical peels (19,049 to 85,379), and 350,469 injections of botulinum toxin type A (no data are available from 1992, as few plastic surgeons were injecting botulinum toxin type A for cosmetic purposes before that time). The numbers reflect the shift in patients’ desires for facial rejuvenation: less invasiveness, less downtime, less pain.
Another shift in facial rejuvenation has come by way of what is considered the ideal facial aesthetic. We know that facial aging is caused by much more than mere descent from the effects of gravity. It is also caused by a loss of volume from fat, muscle, 2,3 and skeletal atrophy and by chronic animation. 4 Therefore, the use of fillers as an adjunct to both surgical and nonsurgical facial rejuvenation techniques is logical and effective in restoring a youthful appearance by helping to “lift and fill.” We have moved away from the pulled back “operated look” and toward one of conservative skin excision, deep fascial–superficial musculoaponeurotic system manipulation, 5 volume restoration, 6 and modification of facial animation (via chemodenervation). 4 Traditional face-lifting procedures alone cannot effectively reverse the atrophy of facial soft tissues that occurs naturally with aging.
Soft-tissue augmentation dates back more than 100 years, 7 and yet the search for the ideal filler continues. The most popular nonpermanent injectables in the United States at present are the bovine collagens and fat (Table I), primarily because of availability and limited options. Bovine collagens (i.e., Zyderm and Zyplast from Inamed Corporation, Santa Barbara, Calif.) have been the mainstay in the treatment of static facial rhytids 8,9 because of their generally forgiving nature, ease of injection, and reduced dependency upon accuracy (less sensitive to technique). With the use of these agents, facial lines are improved on the basis of low-grade focal inflammation. Procedures are usually performed in an office setting, where a diluted mixture of lidocaine is added to these agents to reduce the pain of injection that begins to take effect after several initial injections of bovine collagen into the target regions. Fat injections have also risen in popularity as an adjunctive procedure during plastic surgical procedures, as the injections are least painful when the patient is under anesthesia or sedation. However, both bovine collagens and fat have significant disadvantages that make them less appealing as fillers of choice, including the skin testing required for bovine collagens, the need for harvesting required of fat injections, and, of course, resorption in both. Several other recent filler candidates used worldwide, many of which are not approved for use in the United States, include Achyal (Meiji Seika, Tokyo, Japan), Alloderm (LifeCell Corporation, Branchburg, N.J.), Artecoll (Rifol Medical International, Breda, The Netherlands), 10 Arteplast (Artes Medical, Inc., San Diego, Calif.), Autologen (Collagen Matrix Technologies, Beverly, Mass.), Biocell Ultravital (Belleza Integral, Valencia, Venezuela), Bioplastique (Bioplasty, St. Paul, Minn.
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