As we age, the changes that occur in our face are a manifestation of the effects of gravity, sun damage, hereditary influences, and loss of volume. The change in volume is due to loss and redistribution of fat within the face, thinning of the skin dermis (deep layer of the skin) and bone loss. All of these changes lead to descent of the forehead, the eyebrows and the cheeks, downward turning of the corners of the mouth, thinning of the lips, drooping of the nasal tip, prominence of the folds along the sides of the nose and mouth (nasolabial folds), greater visibility of the bony structures, and relaxation of the tissues seen as jowls and redundancy of the neck.
Injectable soft tissue fillers consist of a group of natural or synthetic substances that restore volume within the facial skin and the deeper tissues giving rise to a fuller more youthful appearance. As of 2009, there are 14 injectable soft tissue fillers that are FDA approved for cosmetic use in the United States. These include Zyderm, Zyplast, Cosmoderm, Cosmoplast, Restylane, Perlane, Hylaform, Hylaform Plus, Captique, Prevelle Silk, Juvederm Ultra, Juvederm Ultra Plus, Radiesse, and Sculptra Aesthetic. Zyderm and Zyplast are forms of bovine collagen while Cosmoderm and Cosmoplast are forms of human collagen. Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus, Hylaform, Hylaform Plus, Captique and Prevelle Silk (Captique with Lidocaine) are all forms of hyaluronic acid. Radiesse is a calcium-based product and Sculptra Aesthetic is a synthetic filler consisting mostly of Poly-L-Lactic acid.
Each of these soft tissue fillers will be addressed individually and in detail later in this chapter. There are other fillers available which are not FDA-approved. These will not be addressed. Caution must be exercised when considering treatment with any product or procedure that is not FDA-approved. Our FDA has strict guidelines to ensure the proper use of various therapeutic modalities. Improper or unapproved use may lead to significant complications. Patients must be very judicious in the treatment modalities they seek and the physicians they seek to perform them.
All currently available and FDA-approved soft tissue fillers are temporary in nature. They must be repeatedly injected into the tissues to maintain their effect. The length of time they remain in the soft tissues varies with the characteristics of the filler itself, the area of the face into which the filler is injected and the patient’s unique response to the filler.
Most patients who seek treatment with soft tissue fillers often wonder why there is not an FDA- approved injectable permanent filler. Although the concept of “permanent correction” of soft tissues may seem very attractive, it is important to remember that our specific facial features are not “permanent”. With aging and weight fluctuations, our facial features undergo significant change. As such, a soft tissue filler that may have appeared perfectly placed at one point in life may be very misplaced in the future as the facial features shift due to the natural forces of aging or weight change. Furthermore, permanent fillers may have long-term side effects such as migration, asymmetry, and lumpiness. In these situations, permanent fillers are very difficult to remove since they are not an implant but an injection. Consequently, it is much safer to use temporary soft tissue fillers.
The ideal filler is one that has a low risk of complications and relatively predictable as well as reproducible results. It would create a natural appearance with minimal down time and minimal side effects. It would be easily tolerated by the patient with a low risk for allergic reactions eliminating the need for a skin test. It would be cost effective and provide a long-lasting but not permanent result.
