• Primary goal: Fill in wrinkles and grooves caused by loss of natural dermal collagen and fat.
• Special anatomy: Used to fill out depressions around the eyes, between the brows, as well as on the rest of the face.
• Anesthesia: None for most
• Operative technique: A non-surgical technique. The filler is placed into a syringe and injected through a needle or cannula into the dermis in the area of the skin depression. Multiple passes into different tissue planes achieves a layering effect, after which gentle massage may smooth out any beading.
• Products (this lists grows almost monthly):
Zyderm and Zyplast are preparations of bovine (cow) collagen, while Dermalogen is of human origin (donor skin from cadaver tissue banks) and Autologen is derived from the patient's own tissues. Collagen disappears rapidly (sometimes in one or two months) and carries the risk of allergy.
CosmoDerm and CosmoPlast are bioengineered, human-derived collagen products. While there are few published clinical studies, they are assumed to be similar to the older bovine collagen in effect and longevity. Unlike the older bovine products, no skin test for allergy is required.
Restylane and Perlane (Q-Med Esthetics), Juvederm, and Hylaform consist of longer-lasting but absorbable hyaluronic acid gel of non-animal origin and do not require skin-testing for allergy (although allergy is possible). Clinical studies seem to indicate that such materials last about twice as long as injected collagen. While heavily promoted to those seeking the latest product, these new fillers share the same main disadvantages as collagen: temporary (4-12 months), expensive, limited ability to fill in larger furrows.
Fat is obtained by liposuction or direct excision from the patient's own tissues (see below).
Fascian is freeze-dried and irradaited fascia lata harvested from cadavers. Long-term studies are lacking.
Isolagen is produced by processing patient's own fibroblasts and is currently undergoing FDA trials.
Alloderm (LifeCell Corp.) is a commercially-available replacement tissue derived from human donor skin that has had all cells removed thus leaving behind only the matrix or scaffolding of the dermis. Alloderm (which is supplied as a sheet) may be used for grafts and implants. Cymetra is a particulate form of Alloderm and may be injected to fill in soft-tissue defects using a minimally-invasive procedure.
ArteFill (Artecoll in Europe) is a mixture of bovine collagen (75%) and tiny plastic PMMA spheres (25%); as the collagen is absorbed, the body surrounds the plastic spheres with its own connective tissue and collagen over 3-4 months resulting in a long-term and possibly permanent fix for wrinkles. Studies have indicated a low incidence of Persistent redness and granuloma (cyst) formation.
Radiesse (formerly known as Radiance) is a suspension of microparticles of calcium hydroxyapatite (similar to bone). It may last 12-18 months but cause lumpiness.
Liquid Silicone (Silikon 1000) - Despite its tarnished past reputation, liquid silicone (designed for use in eyeball surgery) appears to staging a mini-comeback as a possible permanent tissue filler. The new commercial versions of injectable silicone are reputed to be free of the impurities in previous versions that stimulated formation of foreign body granulomas, or bumps, below the skin surface. Considering its history of problems, liquid silicone injection remains controversial.
Newfill, a polylactic acid powder that is rehydrated to form a gel, had been approved to treat HIV-associated lipodystrophy.
Sculptra, synthetic polylactic acid in microspheres, may last up to two years but cause lumpiness.
SoftForm (McGhan Medical) Expanded polytetrafluoroethylene implants consist of a Teflon material resembling a piece of spaghetti with a hollow center that can be directed inserted into the deeper furrows between the brows to build up deeper depressions. Because the implants can show and be felt through thin skin, they may be surrounded by collagen or injected fat to provided camouflage.
• Limitations: A number of the preparations mentioned above are being used "off-label" (not as originally intended by the manufacturer) and have limited clinical track records. Marketing of new fillers tends to be extremely aggressive, making it difficult for a patient to separate valid claims from "hype." Costs are high and recurrent.
• Care and recovery: None, in most cases. With fat injection, oral antibiotics and ice compresses are often recommended.
• Comments:
Fat Grafting for Eyelid Hollowness - See Eyelid Hollowness, a resource on orbital-eyelid hollowing and fat grafting
Fat Transfer by Injection: Recently, there has been much interest in injection of fat removed during liposuction (or during a separate minor procedure) into areas of facial depression, such as into furrows between the brows, the tear trough, or into deeper grooves between the eyelids and upper cheek. One limitation with injecting liposuctioned aspirate is its highly unpredictable rate of disappearance, ranging from almost none to nearly 100%. Resorption tends to be high in the glabellar area (between the brows) and in the area around the mouth; the cheek and lower eyelid areas appear to have the highest retainment (although the correction is seldom permanent). Treated areas may stay bruised, swollen, or lumpy for weeks to months. Even in experienced hands, results can be unpredictable and the volume replacement is not always aesthetically acceptable. Multiple sessions (three to four over the period of a year) are often required. We have seen several patients who suffered objectionable inflammation and a hard and visible lumpiness in the thin lower eyelid skin from fat injected into the tear trough (Photo). Because the fat pellets were firmly incorporated, removal was difficult and required incisons from both sides of the eyelid. Nevertheless, fat injection is an interesting attempt to achieve a semi-permanent form of natural volume restoration. When it does work around the eyelids, patients can be very happy; when it doesn't, they can be just the opposite.
Some patients interested in periorbital fat transfer by injection are better served by eyelid fat repositioning if there is bulging fat in the lower eyelid located just above or next to the hollow. Excess eyelid fat reflected over the orbital rim of bone during blepharoplasty retains its natural blood supply, is "natural" eyelid fat (rather than abdominal or thigh fat, which is much different in consistency and composition), and is much less manipulated, all factors resulting in a better chance for long-term survival.
• A Word of Caution: Lately, we have encountered a rash of patients seeking surgical removal of permanent, non-biodegradable fillers (for example, silicone oil, polyacrylamide, liposuction aspirate, etc) that have been injected into the skin of the brow or sub-brow area only to then migrate into the deep eyelid where they have caused deformity and ptosis (a droopy eyelid). Since such fillers are permanent, so are their complications. Surgical removal may be extremely difficult because many of these materials are transparent and are able to infiltrate normal tissue layers that are vital to the proper functioning of the upper eyelid. In some cases, hours of surgery and unavoidable scarring are inescapable. While similar considerations also apply to the the lower eyelid (where removal is likewise challenging), gravity tends to favor migration towards the cheek, where problems are more related to appearance than function.
• Who Are the Experts? In our opinion, the experts in the use of filler agents and fat injection after liposuction are those dermatologists and cosmetic surgeons who emphasize "cosmetic dermatology." Eyelid and orbital fat grafting, on the other hand, are true surgical procedures best performed by an experienced eyelid surgeon.
