A well recognized component of facial aging is loss of fat volume. This loss results in a sunken, hollow appearance to the face, which may be difficult to describe, but is easy to recognize. The face looses its round contours and sharp demarcations develop between different regions of the face. Volume augmentation is a large component of comprehensive facial rejuvenation.

Facial volume restoration can be achieved in several ways. There are many commercially available injectible fillers to augment the face. Products such as Restylane, Juvederm, Scupltra, and Radiesse are now a part of the popular culture lexicon. Although these fillers are easy to administer, they lack permanency. Fat grafting is a permanent technique for restoration of facial volume, and an attractive alternative to the commercially available facial fillers.

Dr. Khosh performs fat grafting in Manhattan, as an office based procedure. Small amounts of fat is gently harvested from the lower body, prepared carefully, and then meticulously injected into appropriately chosen areas of the face. Fat transfer can be used to enhance the appearance of the cheeks, brow, temple, and the orbital regions. Patients notice not only improved facial contours, but also more vibrant and healthier skin. A secondary benefit that has been postulated to be due to growth factors or stem cells present in the fat graft.

The Allergan company has introduced a new injectible facial filler to the market that addresses the main area of concern for most patients: pain during injection. The new formulation of Juvederm has lidocaine (an anesthetic) mixed with the hyaluronic acid (the active molecule that gives the cosmetic benefit).

Hyaluronic acid products are currently the most widely used form of dermal injectibles used for treatment of lines, wrinkles, and depressions in the face. The addition of anesthetic makes filler injections more comfortable. The suffix “XC” indicates xylocaine (lidocaine). Both formulations of Juvederm (Juvederm Ultra, and JuvedermUltra Plus) are available in the XC formulation. Juvederm Ultra and Juvederm Ultra Plus last an average of six and nine months respectively.

Hyaluronic acid products and other dermal fillers can be used for non surgical facial rejuvenation in areas such as the nasolabial folds, frown lines, and depression below the eyes, and marionette lines. These fillers can also be used to augment the cheeks and the jaw, and to camouflage jowls. Dermal fillers can also be used for non surgical rhinoplasty.

There is a plethora of products that are being used as dermal fillers to smooth lines, depressions, and/or wrinkles in the face. In the US, the FDA regulates sale and promotion of these substances. Many available injectable fillers are not sold in the US due to lack of FDA approval. Amongst the FDA approved filler agents, the major indication for use is correction of naso-labial folds. However, physicians are allowed to inject dermal fillers into other parts of the body following a thorough discussion with patients, as an off-label use of the filler. The fillers can be broadly classified to synthetic and natural. The synthetic products tend to last longer, but are considered to be at higher risk for lumping or migration.

It must be kept in mind that since the commonest indication for injectable fillers is cosmetic improvement of lines and wrinkles, as opposed to other medical drugs and devices that are developed to treat or prevent maladies or deformities. The safety profile of filler agents is therefore specially important. A list of most common dermal fillers is provided, with my own thoughts and conclusions reserved for the last paragraph.

Silicone Fluid:Dow Corning introduced medical grade silicone in the 1950’s for soft-tissue augmentation. The FDA banned the use of silicone as a soft-tissue filler in 1967 due adverse reactions. However, silicone continued to be approved by the FDA for use inside the eye, as treatment for treat retinal detachments. The FDA Modernization act of 1997 allows the off-label use of silicone to augment soft tissues. A new micro droplet injection technique has greatly reduced adverse reactions, such as migration and inflammation, seen earlier. Silicone is classified as a permenent filler.

Bovine Collage (Zyderm and Ayplast):Zyderm and Zyplast were introduced in 1981 and 1983 respectively. They are comprised of collagen fibers which have been extracted from the hide of specially designated cows. The clinical effect of bovine collagen lasts from three to four months. Bovine collagen is one of the safest fillers on the market. However, collagen use has waned due to availability of longer lasting alternatives. Collagen injections need to be preceded with a skin test, due to 3% risk of allergic reaction.

Hyaluronic Acid (Restylane, Juvaderm Ultra, Perlane, Juvaderm Ultra Plus):Hyaluronic acid is naturally found in all living beings as a polysacchride (a complex sugar) molecule that binds water in the space in between cells. In humans, the molecules in broken down and replaced within one to two days. The manufacturers have been able to prolong longevity of the hyaluronic fillers, through a process known as cross-linkage. Currently, hyaluronic acids are the standard of injectable dermal fillers. They last between six to nine months, and exhibit very few adverse effects. Hyaluronic acid fillers are the only fillers that can be immediately reversed by injection of an enzyme known as hyaluronidase.

Polylactic Acid Microspheres (New-Fill/Sculptra):Sculptra (formerly New-Fill) is a suspension of microspheres composed of poly-L-lactic acid (same as some absorbable sutures) suspended in methylcellulose. It was introduced in Europe in 1999, and in the US in 2004. The suspension in diluted with sterile water before injection into the face. Typically a series of 2 to 3 injections are necessary to achieve the desired effect. Results last up to two years. In the US, the FDA has approved the use of Sculptra for treatment of HIV related lipodystrophy (loss of facial fat in HIV patients secondary to anti-viral medications). Sculptra is utilized as a facial filler in non-HIV patients, as an off-label indication. There have been reports of palpable nodules with the use of Sculptra, but problems have diminished with newer injection techniques. Sculptra should not be used in the lips.

Calcium-Hydroxylapetite Microspheres (Radiesse):Radiesse is a white, paste-like suspension of calcium hydroxylapetite (the substance present in bone and tooth) which gained FDA approval for injection into the nasolabial folds in 2006. It is commonly used in off-label fashion to augment cheeks and enhance the midface. Radiesse dose NOT form bone when injected into skin. It usually lasts one year in the body. Use of Radiesse in the lips is discourage as it can form a lumps due to action of muscles.

Polyacrylamide Gels (Aquamid and Bio-Alcamid):Polyacrylmides are polymers of a water solulable crystal which is used in soft contact lenses, and Gro-Beast toys. Aquamid is approved in Europe and Bio-Alcamid is approved in Europe, Israel, and Mexico. Polyacrylmides are not approved by the FDA for use in the US. In Russia and China, Polyacrylmide gels have been injected in large quantities for breast, buttock, and calf augmentation, and in facial lipodystrophy. The duration has been variously reported as form one year to twenty years, depending on the injected volume. Its clinical behavior is similar to liquid silicone. There have been a relatively large percentage of complications with this filler. Complications such as migration, granuloma (swelling and nodule formation), and infection.

Polymethylmethacrylate Microspheres (Arteplast/Artecoll/Artefill):Artefill, formerly Artecoll, is a 20% suspension of polymethylmethacrylate microspheres (tiny glass beads) in bovine collagen. The bovine collagen is resorbed by the body after four months, but the polymethylmethacrylate microspheres persist and become encased by fibrous tissue to give a sustained result. Due to presence of bovine collagen, as a carrier for the microspheres, patients need to be pre-tested to ensure absence of allergy to bovine collagen. Artefill gained FDA approval as a dermal filler in October 2006. However, the company stopped production in November 2008, due to disappointing sales results. There had been concerns regarding complications such as granuloma (lump) formation or infection with this “permanent filler”.

Poly-Hydroxymthyl-Methacrylate Particles (Dermalive/DermaDeep):Dermalive is similar in its chemical structure to Artefill. Dermalive is a 40% suspension of resorbable poly-hyroxyethyl-methacrylate fragments mixed in hyaluronic acid. It was introduced in Europe in 1998. It is used only for deep injections, as superficial injections caused a high incidence of granuloma formation. This product is not FDA approved and not sold in the US. Some doctors have brought the product into this country and advertise its use.

Bottom Line: The long list above is still incomplete in regards to all the available options for injectable dermal fillers. Most products gain regulatory approval in Europe, Asia, or Canada before achieving FDA approval. This should give us a level of comfort to know that the FDA sets the bar very high for approving dermal fillers. I recommend that only products with FDA approval be considered for injection, as such products have passed a rigorous regulatory process. Although “permanent fillers” promise a lasting solution to wrinkles, the long term effects are not known for many such products. I, therefore, prefer long lasting but non-permanent fillers with proven track record such as hyaluronic acid products (Restylane, Perlane, Juvederm, or juvederm Ultra Plus) or calcium hyroxylapetite (Radiesse).

I recently came across an interesting posting about Olympic athlete and tennis star Lindsey Davenportdiscussing her experience with the dermal filler (Juvederm). She had very positive comments in regards to the procedure and how it has helped her look younger and well rested. She received her injections four months before her Olympic appearance. The area of treatment was the fold between the nose and the corner of the mouth (nasolabial fold). Although the posting made it obvious that she was acting as a spokes person for Juvederm, it has been my own experience that patients have very favorable comments about their experience with dermal fillers, such as Juvederm or Restylane.

Dermal fillers are easily injected during a consultation visit in the office. The area to be treated can be made numb with a cream or a small Novocaine injection. Patients can apply makeup immediately and return to work right away. Whereas surgery for total rejuvenation may be necessary for older patients with significant loose tissues, filler injections and Botox work wonderfully for younger patients. I’ll be rooting for Lindsey in Beijing!

Celebrity watchers are always looking for clues as to who may have had plastic surgery. Of course in someone like Michael Jackson or Pamela Anderson the evidence is hard to miss. Other times, it’s more difficult to figure out if a celebrity has had plastic surgery. Cosmetic treatments like Botox and Restylane injections are more subtle and harder to discern.

The recent pictures of Madonna seems to indicate she had some work done on her face. Although her body is extremely this, her cheeks and lips appear quite full. It is likely that she has had injection of fillers such as Restylane, Juvederm, or Radiesse into her cheeks. Alternatively, she may have had fat injection into her cheeks and filler injection into the lips. From this picture I would say the cheeks were overdone.

One wonders how a plastic surgeon would choose to overdo a cosmetic procedure in a high profile patient such as Madonna. This is probably due to a surgeons unwillingness to “just say no!”. There is a point when too much of a good thing can look un-natural.

The goal in plastic surgery should be a beautiful and natural result. That principle has guided me in my own practice, as demonstrated in my surgical results in the photo gallery.

The FDA has recently approved Evolence for use in the United States. Evolence is the newest product to reach an ever expanding list of dermal filling agents. Bovine collagen was the first such product to reach the market over 20 years ago.  In the last five years, hyaluronic acid fillers have become the most commonly used dermal fillers. Brand names such as Restylane and Juvederm are now well recognized products by consumers. Evolence is manufactured from pig tendon sheaths. The company states that a new technology has allowed manufacturing of the harvested collagen with numerous cross links in between the molecules. This cross linkage prolongs the longevity of the product within the skin. In contrast to bovine Collagen which typically lasts 3 to 4 months, Evolence is reported to last up to six months. The hyaluronic acid products tend to last six months as well.

The increasing number of products on the market, however, has not had an impact on the price! Manufacturing companies tend to price the newer products in the range of older, more popular ones. I belive that intense competition and research in this segment of medical cosmetic products will lead to safer and longer lasting products, which will ultimately benefit the consumers. Currently, the only permanent products for filling deep facial wrinkles are fat grafting from the patient, and a product known as Artefill. I recommend fat grafting to my patients who desire permanancy, since I find patients own fat a more natural and ultimately safer choice that a permanent filler made from polymer microspheres.

In minimally invasive facial rejuvenation, injectable skin fillers play an integral role. These fillers are injected into the skin to remove deep lines, correct contour irregularities, and plump various parts of the face. Most people who read Cosmo or Allure know about Collagen, Restylane, Juvederm, and Radiesse. The most commonly used class of fillers is Hyaluronic Acid (HA) gels which includes Restylane and Juvederm, and their related products: Perlane and Juvederm Ultra Plus. These products are popular due to their long lasting benefits (six months to a year), and their natural feel within the skin.

A potential drawback for Restylane and Juvederm has been pain during injection. In order to address this potential drawback, when I inject HA, I apply numbing skin creams and administer local anesthetic (Xylocaine/Novocaine). Earlier this year, the FDA approved a new form of HA gel (Prevelle Silk) that is produced by Mentor Corporation. Prevelle Silk is HA mixed with Xylocaine, so that as the skin is injected, the area of injection becomes numb. Thus far, Prevelle Silk has not captured a large market share both due to its late entry into this market segment, and its shorter duration within the skin. Restylane and Juvederm have higher concentrations of the HA molecules and tend to last longer.

Currently, new formulations of Retylane and Juvederm with Xylocaine, are available in Europe. It’s likely that they will soon be available in the US. The Mentor Corporation is working on developing another form of Prevelle with higher concentration of HA, with improved longevity. All this is good news for consumers and doctors as it indicates improved options for long lasting cosmetic results.