Injectables and Fillers
Botox®, although off label for many uses, is able to treat wrinkles by inhibiting release of acetylcholine which causes weakness of muscles that create wrinkles. Beneficial effects are seen within 1 to 3 days and can last for 4 to 6 months. Sequential treatments are necessary to maintain effect. It is most commonly used at the forehead, glabellar area (junction between the forehead and nose), the nasolabial crease (junction between the upper lip and cheek), the bunny lines (on the sides of the nose), the crow’s feet area (adjacent to the eyes), the dimpled chin, and neck bands. In mild to moderate cases, the entire forehead can be treated by injecting the lower central forehead (glabella) as these muscles are brow depressors and by relaxing them, the frontalis, a brow elevator, smooths out and raises the brows. If this fails to fully correct the forehead, additional Botox® can be injected into the frontalis muscle, but this decreases animation and may lead to descent of the brow.
Fat can be harvested from one area, prepared, and injected in other areas to treat deep wrinkles, depressions, skin folds, areas of fat atrophy, and thin lips. Some fat resorption occurs over the first year with fat injection and may lead to irregularities but with the appropriate techniques employed by Dr. Park using tiny aliquots of fat well distributed in multiple planes, this risk is minimized. Some fat stem cells are transplanted with fat grafting and remain viable long-term, reversing some of the damage done by other mechanisms, such as sun, radiation, aging, etc.
Hyaluronic Acidas a dermal filler has become a huge component of cosmetic surgery and skin care. There are a variety of products which come from different sources or have different preparations, with some variability in durability (Restylane®, Perlane®, Juvederm®, Hylaform®, Reviderm Intra®, AcHyal®). Hyaluronic acid is a glycosaminoglycan which is a normal component of skin and the human body and is important in skin hydration. Its presence attracts water, thickening skin in the area of injection. Since it is a naturally occurring substance, an allergic reaction to hyaluronic acid is not possible although it is possible to have an allergic reaction to a preservative in a particular product. Hyaluronic acids are thin liquids which are easy to inject and are ready off the shelf. Hyaluronic acid products are frequently used for fine wrinkles, perioral creases, lips, and smile lines by injecting in the mid-dermis. Topical anesthetic or field blocks are frequently used, but now this product is available pre-mixed with lidocaine. The major uses Dr. Park likes hyaluronic acid for are small wrinkle filling especially around the mouth, conservative lip filling to blunt wrinkles, and minor depressions.
Sculptra® is a biocompatible poly-L-lactic acid, FDA approved for the restoration of atrophy associated with the loss of fat in HIV, but is frequently used for aesthetics. The effects are not immediate and are cumulative. It is used deep to provide fullness rather than specific wrinkle filling. Typically 3–4 treatments are needed spaced out by 3-4 months to gradually increase the thickness of the skin and the face.
Radiesse®/Radiance® is a long-lasting (2-3 year) injectable filler made with calcium hydroxyapatite, a normal component of bone that stimulates new collagen growth. This is a biocompatible filler that does not require skin testing. Dr. Park prefers to use Radiesse® for deeper folds and troughs, such as the nasolabial folds.
The following treatment options are not favored by Dr. Park
- Collagen for many years was the main option for filling in wrinkles and other depressions. Sources include cow (bovine) skin, pig (porcine) skin, and human skin and allergy testing is often necessary and therefore is rarely used currently.
- Zyderm I® is 3.5% bovine collagen and is used for superficial wrinkles.
- Zyderm II® is 6.5% collagen and is used for medium wrinkles.
- Zyplast® is crosslinked with glutaraldehyde which makes it more resistant to breakdown, less immunogenic, and better for deep wrinkles and folds, as well as lip augmentation.
- Dermalogen® is a collagen matrix filler derived from cadaveric skin.
- Cosmoderm® and Cosmoplast® are collagen matrices harvested from neonatal foreskin.
- Autologen® is prepared from a patient’s own skin and processed prior to injection.
- Cymetra® is small particles of Alloderm®, which is a proprietary preparation of acellular cadaveric dermis. This product contains a dermal matrix in addition to collagen and promotes ingrowth of tissue.
- Fascian® is a particulate acellular fascial product harvested from the extremities of cadavers. It can be injected to correct wrinkles and grooves but is thick and difficult to inject.
- Silicone, an inert synthetic polymer of dimethysiloxanes comes in many different forms and viscosities and is long-term. Goretex® (Polytetrafluoroethylene: PTFE) causes no inflammatory response and is long-term.
- Artecoll® and Arteplast® are combinations of bovine collagen and polymethylmethacrylate used for deeper wrinkles and soft tissue deficiencies. The bovine collagen requires skin testing and the polymethylmethacrylate is the permanent component of the product as it is too large for the immune system to remove. Due to the larger particles, its use is recommended for deeper wrinkles and grooves.