Hyaluronic acid derivatives are glycosaminoglycan biopolymers similar to the substance found in the intercellular layers of the dermis of the skin and are very biocompatible. They are used primarily for lip augmentation and fine wrinkles. Some recent uses of hyaluronic acid derivatives include use as a nonsurgical rhinoplasty and volumetric filler in senile earlobe repair. Rare cases of hypersensitivity have been reported, but preinjection skin testing is generally not advocated. Volume enhancement with hyaluronic acid derivatives lasts four to six months, with some reports of material lasting for up to 16 months.
Complications are relatively uncommon with hyaluronic acid derivatives. In cases of over-augmentation, hyaluronidase can be used to decrease the amount of dermal filling. Caution should be used when injecting superior to the Frankfort horizontal line. Peter describes a case of retinal artery occlusion through retrograde flow through a peripheral branch of the ophthalmic artery. Skin necrosis is rare with a report of two cases out of 400,000.
Poly-L-Lactic Acid (Sculptra)
Poly-L-lactic acid is volumetric filler currently FDA-approved for treatment of lipoatrophy in HIV patients. Lipoatrophy in HIV is due to a number of factors including reverse transcriptase inhibitors and the disease process itself. Recently, poly-L-lactic acid has been used in an off-label capacity as a non-HIV facial filler. The main complication is nodule formation which can be avoided by injecting deep to subcutaneous tissue and not in areas of significant muscle motion such as the lips. The duration of augmentation of poly-L-lactic acid is up to 3 years.
Calcium hydroxylapatite (Radiance FN, Bioform, Inc., Franksville, WI)
Calcium hydroxylapatite is a major mineral constituent of bone. It has an off-label use for soft tissue augmentation in the face, primarily for reduction of nasolabial folds. Calcium hydroxylapatite should be injected subdermally to avoid nodule formation. The true longevity of Radiance FN is currently not known.
Bovine collagen (Zyderm and Zyplast)(McGhan Medical Corporation, Fremont, CA)
Bovine collagen is comprised of 95% type I collagen and is most commonly used to augment lips and nasolabial folds. Zyplast is cross-linked with glutaraldehyde (creates a longer lasting effect) but must be injected into the deep dermis. Zyderm is injected into the superficial dermis. Hypersensitivity reactions occur in about 3% of patients, so skin testing and even secondary skin testing is advocated. Bovine collagen augmentation lasts two to six months.
Human derived collagen (Cosmoplast and Cosmoderm)
Human-derived collagen (Cosmoderm and Cosmoplast, Inamed Corporation, Santa Barbara, Calif.) is used for the treatment of facial rhytids and lip augmentation . In contrast to bovine-derived collagen, human-derived collagen carries essentially no risk of hypersensitivity reactions, obviating the necessity for pre-treatment skin testing. Typically, injections maintain augmentation similar to bovine collagen. Adverse reactions may occur in patients with known allergy to bovine collagen.
Fat transplantation has the advantage of being an autologous substance. Fat transplantation is used as a volumetric filler. The concept of loss of facial volume is recent, and surgeons will recontour the face, the nasolabial folds, temporal fossa, prejowl sulcus, and perioral and periorbital areas.
Most commonly fat is harvested from the lateral thigh or abdominal region. Fat is then either strained or centrifuged, and injected into areas requiring volume. Technique in handling fat is crucial in maintaining adipocyte viability. Fat transplantation often requires multiple treatment sessions and has variable degrees of resorption. Fat can be frozen with minimal loss in fat viability and reinjected at a future date.
Disadvantages of fat harvest include donor site morbidity, potential for prolonged facial swelling, and unpredictable resorption. In addition, fat can lead to granulomas that can be treated with trimacinolone injections or direct excision. Advantages of fat transplantation include a potentially permanent, natural facial filler which can serve as an adjunctive or stand-alone procedure.
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