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New Versions of Injectable Fillers keep coming…..and more are on the way!

Next to Botox coming out of a needle, the use of injectable fillers is only slightly less popular as a cosmetic injection method. While collagen was the only injectable filler for lines and wrinkles from 1981 to 2003, there has been a virtual explosion of new injectable fillers since then…..now numbering six commercially available fillers….and four of these have become available in the last year. And collagen as an injectable filler has now become of historic interest only.

The new revolution in injectable filler materials has been the change from collagen to hyaluronic acid. A natural sugar, hyaluronic acid (HA), lasts longer and has much less potential for adverse reactions than collagen. The battle amongst HA manufacturers revolves around the claim of which one is the longest lasting. Despite differing claims, conclusive proof that one type of HA lasts longer than the other remains lacking. Clinical trials for most manufacturers has compared their version of HA to collagen as the control. Few direct comparison studies have yet to be done. While the amount or concentration of HA per cc would suggest greater longevity, there are other issues of importance as well such as the degree of cross-linking. These issues will eventually sort themselves out but it is fair to tell patients that HA injections will last between 4 and 8 months on average, and some perhaps longer. One thing is for certain, however, and that is more variations of HA injectable fillers are coming….and such competition will drive the price of a syringe down. (which is more than can be said for Botox!)

Two non-HA injectable fillers also became commerically approved last year. I call these type of injectable fillers, particulated synthetic injectable fillers. The concept is that they contain a portion of non-resorbable beads or particles mixed in a carrier solution. Radiesse uses ceramic beads and ArteFill uses plastic beads. Either way, the beads do not go away and some percent of permanence remains. As a result, they last longer than the HA fillers even if 80 - 90% of the particulated filler does go away. Because they have the potential to become lumpy due to scarring around the beads, their use in the lips is not recommended. In theory, build-up of the beads can occur over time with multiple injections so that their effect may seem to last longer over time.

With such a wide selection of injectable fillers available today, it can be confusing to the patient. For the physician injector, it is important to use more than one of the available injectable fillers for different areas and different problems.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

The Science of Hyaluron Injectable Fillers in Indianapolis by Dr. Barry Eppley

The use of injectable materials for filling or plumping up facial lines and wrinkles dates back to 1981 in the U.S. when collagen injections became available. From 1981 to 2003, for over twenty years, injectable collagen was the only available facial filler. While the injection process was easy, the popularity of collagen injections was limited as its effects were very short-lived usually lasting around 6 weeks or so. Because the collagen material was bovine-derived (from cows), a skin test was required prior to injection and a small percent of patients had allergic reactions, thus not being capable of treatment. Since 2003, a new synthetic material has become commercially available and collagen is now ‘a material of historic interest’ primarily. This new material is hyaluron or hyaluronic acid.
Hyaluron (HA) is produced today by fermentation in cultures of equine streptococci. The fermented material is then stabilized via epoxidic cross-links of the glycosaminoglycan chains. As a result of this processing method, the HA material does not cause immunologic sensitization and virtually no risk of allergic reactions. Hyaluronan is a polysaccharide that is an essential component of the extracellular matrices in which all human tissues differentiate. In certain tissues, such as the vitreous cavity of the eye and synovial joint fluid, it is the major constituent. Unlike collagen, it is identical across all animal species and microbes. The largest amount of hyaluronan resides in skin, where it is present in both dermis and epidermis. Hyaluronan’s high capacity for holding water and high viscoelasticity give it some unique properties that are useful in various medical and pharmaceutical applications. Because it retains moisture, hyaluronan is used in some cosmetics to keep skin young and fresh-looking. As we age, the water-holding capacity of our skin decreases as hyaluronan depolymerizes. Therefore, the retention or insertion of hyaluronan into the skin is theoretically helpful in wrinkle reduction.
HA can be rather rapidly degraded and is ultimately metabolized in the liver. Modern processing methods have produced more stable forms of HA that have much longer in vivo retention times. As degradation occurs over time, water is attracted to the material at the site of implantation. As the HA concentration decreases, more water bonds to it thus helping with cosmetic persistence. This feature is what probably accounts for its longer volume retention effects than bovine collagen. (isovolemic degradation)
A variety of differing grades of transparent gels are available, based on the same type gel from highly concentrated (20mg/ml)stabilized HA, which varies in particle size and subsequent indication. Restylane has a particulate size of 100,000 gel particles/ml, flows through a 27 gauge needle, and is indicated for mid-dermal applications such as deeper wrinkle reduction, as well as lip augmentation, nasolabial folds, and glabellar creases. Restylane has even been successfully used in the treatment of tear trough deformities.14 Restylane Fine Lines has the highest concentration at 200,000 gel particles/ml, can be injected through a 30 gauge needle, and is indicated for thin superficial wrinkles. The lowest concentration gel is Perlane at 8,000 gel particles/ml which is injected through a 27 gauge needle and is intended for shaping facial contours, correcting deep folds, and for lip augmentation.15 Restylane was FDA-approved in December 2003, Perlane received its approval in 2007. There are numerous manufacturers of HA injectable fillers which, in addition to Restlane, includes Captique and Juvaderm.
The universal HA composition makes the need for pre-injection skin testing unnecessary as the risk for hypersensitivity reactions is minimal. It is easily injected and flows nicely through small-gauge needles. While not permanent, its persistence is reported to exceed bovine collagen with estimates of between 4 and 6 months post-injection.
Rare side effects, that I have not yet seen, include injection site inflammation at an incidence of 0.02% and local hypersensitivity reactions (swelling, erythema, and induration) at an incidence of 0.02% lasting a mean of 15 days.

As of today in 2008, HA injectable soft tissue fillers are the gold standard by which all
future injectable filler materials will be compared.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis