Fillers



Fillers


Kristina M. Price, MD



CLINICAL APPLICATIONS OF FILLERS



  • Reducing wrinkles, fine lines, folds, scars, dimples


  • Restoring volume loss and contour deficiencies (Figure 40.1A – H)



    • Brow


    • Temples


    • Infraorbital hollows


    • Cheeks


    • Lips


    • Chin


  • Addressing facial descent by providing lift and projection


  • Stimulating collagen synthesis






FIGURE 40.1. Common aging changes addressed by filler injection. A, Zygomatic arch. B, Temple. C, Infraorbital hollow. D, Malar hollow. E, Nasolabial fold. F, Mesolabial fold. G, Chin. H, Prejowl sulcus.



TYPES OF FILLERS


Hyaluronic Acid (HA) Fillers



  • Background



    • A naturally occurring glycosaminoglycan or linear polysaccharide


    • Found in connective tissues, epithelial tissues, and neural tissues


    • Present in all species and thus does not require allergy testing


    • Can bind 1000 times its volume in water — 1 g of HA can bind up to 6 L of water


    • Naturally occurring HA in body decreases over time, which results in decreased tissue elasticity and hydration with age — thus playing a critical role in the appearance of aging face and skin.


    • Natural HA is broken down by hyaluronidase and free radicals.


    • HA filler is absorbed gradually by the surrounding tissues. This process is called isovolumetric degradation.


    • HA filler can also be broken down rapidly by injecting hyaluronidase (brand names include Vitrase, Hydase, Hylenex, Amphadase, and Wydase)


    • HA fillers accounted for more than 92% of all filler treatments in the United States in 2015.


  • Mechanical properties of HA fillers



    • G prime



      • Describes how well a filler is able to maintain its shape when a force is applied to it.


      • Fillers with a higher G prime are less deformable and will provide superior lifting of tissues.



        • High G prime fillers are useful for deeper placement in the cheek and prejowl sulcus to give voluminization and projection.


        • Low G prime fillers are useful for smoothing and softening, and are better suited for use near the eyes and lips.


    • Cohesivity



      • Describes the capacity of the filler to not dissociate (how well the filler sticks together).


      • It is determined by the concentration of HA and the degree of cross-linking.



        • High cohesivity contributes to the filler’s ability to provide support and projection of overlying tissues.


        • Low cohesivity allows the filler to flow and fill more superficial lines and wrinkles (Figure 40.2).


  • Brand names of HA fillers



    • Restylane-L, Restylane Silk, Restylane Defyne, Restylane Refyne, Restylane Lyft, Restylane Kysse (Galderma, Fort Worth, TX)






      FIGURE 40.2. Illustration of how the cohesivity of a dermal filler affects its response to an external force. A greater concentration of hyaluronic acid and increased cross-linking yield higher cohesivity.



    • Juvederm XC, Juvederm Ultra XC, Juvederm Ultra, Juvederm Ultra Plus, Vollure, Volbella, and Voluma (Allergan, Irvine, CA)


    • Belotero Balance


    • Prevelle Silk


Non-HA Fillers



  • Sculptra (Sanofi-Aventis, Bridgewater, NJ) — consists of poly-L-lactic acid (PLLA), an absorbable polymer that stimulates both fibroblast production and generation of collagen. Small risk of nodule formation, but lasts 2 years


  • Radiesse (BioForm Medical, San Mateo, CA) — 30% calcium hydroxylapatite microspheres suspended in a 70% gel carrier. Lasts 12 to 18 months


  • Artefill (Artes, San Diego, CA) — polymethylmethacrylate (PMMA) microspheres in bovine collagen, which stimulate fibroblasts to encapsulate each microsphere subdermally, thus increasing tissue volume by fibroplasia. Permanent, can form granulomas, and requires allergy testing


  • Bellafill (Suneva Medical, San Diego, CA) — newer version of Artefill. Lasts 5 years


  • Adato Sil-OL Silicone Oil (Bausch & Lomb, Rochester, NY) — highly refined silicone oil approved for ophthalmic use (retinal detachment repair) used off-label on skin. Permanent


  • Autologous fat transfer — three-step process

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May 10, 2021 | Posted by in OPHTHALMOLOGY | Comments Off on Fillers

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