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Collagen and Fillers

Collagen and Fillers In-depth

‘Soften deep facial lines or Add Youthful Fullness to your face’

Introduction

Soft tissue filler procedures are minimally invasive cosmetic treatments used to correct signs of facial aging, or facial volume deficiency/volume loss. There are many different classes of soft tissue fillers, but they share the common characteristic of being injected under the skin. Older or younger patients alike use fillers for their cosmetic enhancements.

With age, injectable facial fillers treat the following changes:

  • Mild tissues sagging
  • Loss of youthful fullness of the face (cheeks, lips, eyelids, temples, etc…) and hands
  • Deepening of facial folds and lines (smile lines, frown lines, etc…)

With younger patients without significant signs of aging, injectable fillers enhance volume, such as for:

  • improving fullness and pout in the lips
  • enhancing the cheek bones
  • for a ‘non-surgical Rhinoplasty’

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What are the advantages of Soft Tissue fillers?

Soft tissue filler procedures have the advantage of

  • being minimally invasive
  • having little or no down time for the procedure
  • having little or no down time for the recovery
  • not requiring sedation
  • immediate results

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Types of Fillers Available

There are many types of filler on the market; they are categorized by their ‘active’ component.

The following fillers are the most popular on the market:

Filler Type: Brand Name:
Human Collagen CosmoDerm
CosmoPlast
Hyualronic acid based JUVÉDERM® Ultra, JUVÉDERM® Ultra Plus
Restylane®, Restylane® fine line
Perlane
Calcium hydroxyapatite based RADIESSE®
Platelet Rich Fibrin Matrix Sephyl
Poly-L-lactic acid Sculptra

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Categories of Soft Tissue Fillers

Collagen

Collagen was one of the first available FDA-approved soft tissue fillers. Initially, the collagen was derived from an animal source, and later on, human derived collagen became available on the market. The main disadvantages of collagen were its cost, and relatively short duration of result. These days, Collagen is seldom used, having been eclipsed by many newer products with better aesthetic properties, less cost, and longer lasting results.

Hyaluronic Acid Based Fillers:

Hyaluronic Acid (HA) based fillers are the most studied and frequently used of the injectable fillers. Hyaluronic acid is a substance found naturally as a component of the skin’s connective tissue. It has the general property of attracting water molecules; so it is able to plump-up an area, by absorbing water like a sponge. HA-fillers also stimulate natural collagen production to some extent, as another mechanism for increasing tissue volume. The duration of improvement after injection varies from 6-12 months, depending on the area of application and the product’s specific chemical properties. The different properties of various HA fillers are due to differing Hyaluronic Acid concentrations and degree of cross-linking. These differences make some HA products more suited for specific applications. The can be broadly characterized as Hyaluronic Acid fillers for volume, or Hyaluronic Acid fillers for delicate areas or fine lines.

Reversible Property of HA Fillers:

One unique aspect of Hyaluronic Acid fillers is that the result are ‘reversible’. Injecting an ‘antidote’ into an area previously injected with HA filler will ‘melt’ the filler away completely, usually within 24 hours. This is the only filler type that can be quickly reversed if the result is unsatisfactory.

Volumizing HA Fillers:

Some HA fillers are well suited for providing maximal volume enhancement. Examples include JUVÉDERM® Ultra Plus, JUVÉDERM VOLUMA™, and Perlane. Dr. Tong uses these fillers most commonly for lip augmentation, cheek augmentation, and correction of nasolabial folds and marionette lines.

HA Fillers Designed for Fine Lines or Delicate Areas:

Restylane® Fine Line and Juverderm Volbella are the HA fillers preferred for camouflaging the bags under the eye, and smoker’s lines around the lips.

Calcium Hydroxylapatite Fillers

Calcium hydroxylapatite (CaHA) is a mineral substance found in teeth and bones. When used in tissue fillers, it is synthesized as smooth microspheres, and is suspended in a gel carrier. As the gel dissolves, the CaHA remains, and induces collagen production which is thought to be the mechanism of its volume enhancement. The CaHa eventually is eventually broken down by the body. It is thus a filler and stimulatory agent. RADIESSE® is the only available CaHA based filler on the market.

Platelet Rich Fibrin Matrix Fillers (‘Vampire’ Facelift)

Platelet rich Fibrin Matrix fillers are soft tissue fillers that use a patient’s own blood as the principle active ingredient. It’s mechanism of action is thought to be due to the release of the abundant growth factors found within platelet cells. Selphyl is the only commercially available soft tissue filler that utilizes this technology.

Poly-L-lactic Acid

Poly-L-Lactic acid is a material used to make dissolvable stitches. In a different form, it can be utilized as a soft tissue filler. Unlike HA and CaHa fillers, the result is not immediately apparent. The Poly-L-Lactic acid works by stimulating collagen synthesis under the skin. Over a period of weeks, the result gradually emerges, and the treatment is repeated 2-3 times until the desired end result is achieved. The brand name for this filler is Sculptra.

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Specific Filler Brands and Their Use

JUVÉDERM®

JUVÉDERM® is a hyaluronic based injectble filler from Allergan. It comes in differing preparations that reflect varying degrees of volume enhancement. The HA concentration and crosslinking affects its volume enhancing properties. JUVÉDERM® Ultra provides moderate volume enhancement, while JUVÉDERM® Ultra Plus provides maximal volume enhancement. It is most commonly used in the nasolabial folds, lips, marionette lines, and cheeks.

JUVÉDERM VOLUMA™

Developed by Allergan, JUVÉDERM VOLUMA™ is the first, and currently the only, hyaluronic acid-based filler to be FDA-approved for midfacial volume enhancement in patients 21 and older. This injectable treatment is most commonly used to augment the cheeks and regions of the midface to achieve a fuller, more youthful contour. Additionally, it can also help smooth and fill out lines and wrinkles in the targeted treatment area. The volumizing effects of JUVÉDERM VOLUMA™ have been clinically-proven to last up to two years in several instances.

JUVÉDERM VOLBELLA™

Juvederm Volbella is the newest HA filler from Allergan. It has the unique property of looking very ‘smooth’ and is suitable for being injected very close to the skin’s surface. The result is that even very superficial fine lines can be treated with a low risk for looking bumpy or creating countour irregularites. The properties of Volbella lend it to be an excellent HA filler for natural augmentation of the lips, lip lines, and lower lid tear trough region.

Restylane®

Restylane® is a hyaluronic acid (HA) based injectble filler from Medicis. Restylane® provides a moderate degree of volume enhancement. It is most commonly used for enhancement of the lips, nasolabial folds, and marionette lines. Restylane® Fine Lines is filler that provides less volume enhancement than regular Restylane®. Its properties are more suited for delicate areas such as camouflaging bags in the lower lids, and fine lines around the mouth (commonly refered to as ‘smoker’s lines’, although non-smokers may also have these lines).

Perlane

Perlane can be thought of as the maximum volumizing version of Restylane®. Its chemical composition is formulated for improving fullness and correcting volume deficiency. It is most commonly used by Dr. Tong in the nasolabial folds, Marionette lines, cheeks and lips.

RADIESSE®

RADIESSE® is calcium hydroxylapatite based filler. RADIESSE® has the advertised advantage of longer lasting results over HA based fillers. The average duration of result varies between 9-12 months.

RADIESSE® is best used for increasing volume in the cheeks and filling the nasolabial folds or marionette lines. RADIESSE® should not be used in the lips or in the lower eyelid area. RADIESSE® tends to be slightly firmer in feel, when compared to other fillers, during the early recovery period. Dr. Tong uses RADIESSE® primarily for cheek augmentation, nasolabial folds, marionette lines, and general volume enhancement.

Selphyl (the’Vampire Facelift’)

Selphyl is a product that allows a patient to use a small amount of their own blood to create a filler used for treating wrinkles and folds in the face. Thus, it has been termed the ‘Vampire Facelift’. Despite its name, the treatment is not a Face Lifting procedure, but one that helps improve fine lines and skin quality. The appeal is that the filler is completely natural, using growth factors found naturally in the platelets (the clotting cells in your blood).

The procedure involves drawing blood from the patient, and preparing it immediately to form the filler, which is injected by Dr. Tong. These growth factors stimulate improvement in the injected areas. The enhancement tends to be more of a qualitative improvement of skin quality and fine lines, rather than strict volume enhancement.

Sculptra

Sculptra is a filler made from poly-L-lactic acid, the material is used in dissolvable stitches. Sculptra is injected as a liquid solution underneath the skin. Results are not immediate, and generally requires an average of 3 injection sessions over a period of months to achieve optimal correction. Following each injection, there is gradual collagen deposition, that results in increased facial volume and decreased facial lines, folds, and areas of depression. Sculptra is a very gradual treatment but the duration of results can last up to two years.

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With so many fillers out on the market, consumers can be confused with all of the choices (and hype) put out by the different manufacturers. In reality, differences between products within the same class (eg. HA fillers) are not as significant as they are marketed to be. Even differences between products of different classes may not be very dramatic when comparing aesthetic outcomes. Although the mechanisms of action and principal components may be quite different, the end result tend be comparable, assuming the products are designed for similar applications. For any one area to be treated, there is usually more than one soft tissue filler that could be used very appropriately.

Dr. Tong can make a recommendation regarding which soft tissue filler would be best suited to your needs. Some factors taken into account are location, depth of lines, required degree of augmentation, your skin quality, and skin thickness.

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The Procedure Details

The selection of the filler must be well suited for the patient’s needs Dr. Tong will make his recommendations when he sees you in consultation.

Anesthetic

Injections are usually supplemented with some form of local anesthetic. The local anesthetic helps to relieve discomfort that may occur during the injection procedure. Dr. Tong can administer the anesthetic just prior to the start of the procedure, or more commonly these days, the local anesthetic comes pre-mixed with the product so and is administered simultaneously with the product.

Injection

The areas to be treated are marked on you face by Dr. Tong in conjunction with your input. The areas are cleansed with alcohol or antibacterial soap to remove dirt, oils, and bacteria. If local anesthetic is to be administered before the procedure, it is performed at this point. The product is injected through a series of linear threads or puncture sites. There is no single method of soft tissue filler injection. Dr. Tong has specific configurations of injection for each specific area of the face.

Dr. Tong’s underlying principles regarding filler injections:

  • distribute the filler evenly and at the correct depth
  • assure symmetry
  • do not fill beyond accepted limits (to maintain naturalness)

Each area generally takes 15-20 minutes and Dr. Tong shows you the progressive result from time to time during the procedure.

Recovery from Soft Tissue Filler Injections

After the procedure, we will give you an ice pack, and recommend you ice the area for 20 minutes each hour as you are able, for the rest of the day. This helps to decrease any swelling of bruising that may occur with the injection. You may return to work or daily activities so long as they are not overly strenuous. You may begin exercise at 24 hours after the procedure, unless advised otherwise by Dr. Tong. Bruising is unusual, but if it occurs, it can be covered with make-up, and generally lasts a few days. There may be some swelling of the area, which tends to subside over the first 48 hours. Sometimes the product feels firm in the treated areas. This tends to be more common in some products than others. Patients may occasionally see some minor contour irregularities that are caused by the product, as well. These issues are temporary and any firmness or visible contour irregularities smooth out over the first number of days, as the product has some time to distribute itself.

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Common Areas for Soft Tissue Filler Injection

Soft Tissue Fillers in the Nasolabial Folds

The nasolabial folds (the smile lines) are the most common area for soft tissue fillers. Usually 1-3 syringes of the product are required to obtain the best correction. Dr. Tong typically utilizes volumizing HA fillers, or CaHA fillers for this area. Sephyl or micro fat grafting is an alternative for patients that seek a purely natural filler source.

Soft Tissue Fillers in the Marionette Lines

The marionette lines occur at the corners of the mouth. They are associated with downward drooping mouth corners. Fillers can lift the corners of the mouth and soften these lines. Volumizing HA fillers (eg. JUVÉDERM®, Restylane®) or CaHa fillers (eg. RADIESSE®) are used most often here.

Soft Tissue Fillers in the Lips (for increasing volume)

You may have thin lips due to age or genetics. Soft tissue fillers placed in your lips can enhance fullness, creating a youthful pout and shape. Dr. Tong generally recommends a volumizing HA filler (eg. JUVÉDERM® Ultra, Restylane®, Perlane) for lip augmentation.

Soft Tissue Fillers in the Lips (for Smoker’s lines)

Lines around the mouth makes a person looked aged. Women commonly complain about lipstick bleed into these lines. These lines may be caused by smoking, aging, weight loss, or sun exposure. Dr. Tong recommends the use of an HA filler for delicate areas (eg. Restylane® Fine lines or Juvederm Volbella) to help correct the appearance of the lines. Other options for ‘smoker’s line’ correction includes Dermabrasion (for more deep lines), and BOTOX® (for less deep lines).

Soft Tissue Fillers in the Cheeks

Sunken or flat cheekbones may be due to aging, weight loss, or are something you are born with. Enhancing the volume of the cheeks is a simple procedure using soft tissue fillers. Dr. Tong generally recommends a volumizing HA filler (eg. JUVÉDERM®, JUVÉDERM VOLUMA™, Perlane) or CaHa filler (RADIESSE®). Sculptra is recommended when there is a significant amount of volume restoration needed (i.e. gaunt looking faces). Selphyl works well for patients looking for a more moderate and gradual degree of enhancement, coupled with improvement to the quality of skin. Another options for a more permanent improvement is fat transfer to the cheeks.

Soft Tissue Fillers in the Frown Lines (Glabella)

The frown lines between the eyebrows are usually treated with BOTOX®. This is very effective when the lines are mild to moderately deep. If the lines are very deep or the lines have been present for a long time, they may be ‘etched’ into the skin. In these cases, using a soft tissue filler may be beneficial as an additional treatment to ‘fill in’ the depressed folds. A volumizing Hyaluronic acid (eg. JUVÉDERM®, Perlane) is recommended by Dr. Tong in these cases. Other surgical options for frown line treatment includes fat transfer, or Corrugator removal.

Soft Tissue Fillers for the Under the Eyes

A noticeable trough or line can form at the junction between the lower eyelid and cheek. Patients with either hollowness in the lower lids, or fat bags in the lower lids can have this condition. Lower lid Blepharoplasty is often the best way to correct this problem, but fillers can camoflauge the area by filling in this area so that there is a smooth transition from lid to cheek region. Dr. Tong uses a HA fillers specifically designed for filling delicate areas.

Soft Tissue Fillers for Jowls

If you have mild jowling, the appearance of the jowls can be camouflaged by placing soft tissue filler along the jaw line, directly in front of the jowls. This area is called the Pre-Jowl Sulcus. A volumizing HA filler (eg. Perlane, JUVÉDERM®) or CaHa filler (eg. RADIESSE®) is typically used with good results. Patients with moderate or severe degrees of jowling will likely require a Facelift or Extended Neck Lift in order to obtain optimal results in jowls correction.

Soft Tissue Fillers for Acne Scarring

Acne scars can be treated a number of ways, including fractionated laser therapy, surgical dermabrasion, and with soft tissue fillers. Soft tissue fillers are commonly used in conjunction with the other modalities mentioned. Dr. Tong uses a special technique called subcision to first release the scarred tissues, followed by injection of a volumizing Ha (eg, Perlane, JUVÉDERM®), CaHa filler (eg. RADIESSE®), or PRFM filler (eg, Selphyl)

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The Liquid Facelift

Liquid Facelift is the term used for facial rejuvenation done with a combination of minimally invasive techniques, without undergoing a traditional surgical procedure. In the right candidate, a significant degree of facial rejuvenation can be accomplished by only using Soft Tissue Fillers and BOTOX®.

This is an attractive option for patients who:

  • do not want to have surgery, or are not ready for surgery
  • cannot undergo surgery for medical reasons
  • do not have the time/resources to commit to surgery/recovery
  • want a ‘quick fix’

An example of a Typical Liquid Facelift would utilize:

  • BOTOX® in multiple areas of the face (eg. Glabella frown lines, crowsfeet, forehead lines)
  • Soft tissue fillers in multiple areas of the face (eg. the nasolabial folds, cheeks, marionette lines, under the eyes, wrinkles around the lips, etc..)

A Liquid Facelift does not produce the same improvement as a traditional surgical Facelift. This holds true in regards to the degree of correction, and the duration of the results. Despite this, patients are generally very satisfied with the degree of improvement obtained. The key to success is having an educated patient with the correct expectations for the procedure.

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Hand Rejuvenation with Soft Tissue Fillers

As we age, the hands can also appear aged. Soft tissue fillers can be used to camouflage veins, tendons, boniness, and general loss of soft tissue volume. Dr. Tong prefers to use volumizing HA fillers on the back of the hand to smooth out contours which become more apparent as you become older. A more permanent alternative to using a tissue filler is to use your own fat with a fat transfer procedure.

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