Las Vegas — Determining which injectable filler is most suitable to use for a given cosmetic surgical procedure depends upon the indication, associated risks and patient preference, according to David A. F. Ellis, M.D., F.R.C.S.C., F.A.C.S., a professor in the department of otolaryngology at the University of Toronto and a surgeon in private practice at the Art of Facial Surgery in Toronto. Dr. Ellis presented an overview of the Canadian experience with injectable fillers at the Facial Cosmetic Surgery 2004 meeting here.
One of the first decisions is whether to use a temporary or permanent filler. Categories of temporary fillers include xenogenic fillers, such as Zyplast (bovine collagen, Inamed), Fibrel (porcine collagen, Mentor Corp.) and Hyalform (hyaluranon derived from rooster combs, Inamed); homogeneic fillers, derived from pooled cadaveric dermal tissue; autogeneic fillers such as fat derived from the patient's own cells; and synthetic fillers. A variety of synthetic fillers are available, ranging from hyaluronic acid derivatives such as Restylane (Q-Med) and Reviderm (Rofil Medical International) to preparations of calcium hydroxylapatite or polyglycolic acid in a matrix of carboxymethylcellulose or methylcellulose, such as Radiance FN (Bioform Inc.) and New-Fill (Biotech).
Temporary A temporary filler might be the best choice for patients who are uncertain about whether or not they will really enjoy the correction. Patients might feel uncomfortable about having a "foreign substance" left in their face permanently, or they might simply want a temporary correction.Hyaluronic acid gels such as Restylane, Juvaderm 24 + 30 and Hylaform are used as temporary fillers and are effective for lip augmentation or facial correction. The use of collagen as a temporary filler has decreased in Canada, according to Dr. Ellis.
Dermalive is a thick suspension of hyaluronic acid gel and acrylic micro-crystals in a buffered solution. Dermalive is recommended for treatment of deep wrinkles such as nasolabial folds and for augmentation.
Artecoll is described as an injectable microimplant consisting of Protein A-incorporated polymethylmethacrylate (PMMA) micro-beads, 3.5 percent bovine collagen and 0.3 percent lidocaine in a buffered solution. Artecoll can be an effective permanent filler for treatment of facial grooves, wrinkles and subcutaneous depressions and for augmentation. It is contraindicated for patients with allergies to lidocaine or collagen and is not recommended for patients undergoing systemic treatment with steroids or for patients with known autoimmune disease or systemic immune suppression.
Good technique Application of Artecoll requires a deep dermal injection using a linear threading technique. A 25-gauge needle is recommended. During the injection, the non-dominant fingers should be used to control needle placement and deposition of the permanent filler, and constant pressure should be maintained.
Complications arise with over-correction; in some cases, excess filler can be removed by needle aspiration or surgical excision. Blanching indicates that the injection was too superficial. A local reaction of slight redness and swelling within the first 48 hours is normal, but prolonged redness can indicate granuloma formation or chronic inflammation.
Artecoll is not currently approved for market in the United States, although it has been approved for market and is now widely used in Canada and Europe. "The FDA wants the collagen to be derived from American cattle because of concerns about BSE," Dr. Ellis says.