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National report — The use of facial fillers to help counteract the effects of facial aging is becoming more widespread, with new techniques and products springing up regularly. In a recent seminar, Paul M. Friedman, M.D., comprehensively covered the topic of facial fillers, with a focus on the hyaluronic acid products.
Dr. Friedman is clinical assistant professor at the University of Texas Medical School. He focused on choosing safe and appropriate fillers as well as on proper technique.
"Sooner or later, people experience the facial manifestations of aging," Dr. Friedman says. "These include thinning of the dermis, greater visibility of bony landmarks, hollowing around the cheek and mouth, descent of facial fat pads and deepening of nasolabial folds, as well as thinning of lips, descent of the corners of the mouth and ptosis of the nasal tip. These are caused by volume loss, specifically decreased levels of collagen, hyaluronic acid and alteration in elastic tissue."
Choosing a filler
"Several questions have to be answered, such as whether the patient has received any prior treatments," he says. "Are there deep folds or superficial, etched-in lines? What about allergies? Can the patient tolerate pain? Are there potential sequelae? Then there are very basic, everyday considerations, such as whether the patient has any upcoming social engagements or cannot afford too much postoperative downtime."
Dr. Friedman emphasizes that effective patient comfort management techniques such as topical anesthesia, regional block anesthesia and psychological tools ("talkesthesia" and "handesthesia") are essential to the overall success of any aesthetic facial enhancement procedure. He notes that patients can benefit greatly from simply applying ice to the treatment area both before and after the procedure is completed.
Dr. Friedman says there is debate as to the long-term effects of permanent fillers and their appropriateness for esthetic facial enhancement.
"With permanent fillers, persistent lumps are a potential complication," he says, "and although they are used successfully to treat atrophic facial scars, permanent fillers can migrate if too large a volume is injected."
Focusing on non-permanent fillers, Dr. Friedman notes the categories:
"Injections of fat as a non-permanent filler have been happening for a century," he says. "Today, fat is harvested from the abdomen, buttocks or thighs, or during liposuction. Overcorrection is necessary, and the average longevity is three to six months. A new technique that's found favor is FAMI, or 'fat autograft muscle injection.' "
Dr. Friedman cites three types of bovine collagen.
As for bioengineered human collagen, Dr. Friedman says one type, CosmoDerm (Inamed), is injected into superficial dermis for correction of wrinkles or scars, while CosmoPlast (Inamed) is injected into mid-to-deep dermis to correct more profound wrinkles and scars. He says their advantage, as compared with bovine collagen, is that no skin test is required.