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The Results-oriented Revolution

By Jeffery S. Dover, MD, and Amy Kamin
Posted: May 30, 2008

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Injectables’ past begins when German physician Franz Neuber used fat from patients’ arms to fill facial defects in 1893. Foreign substances, such as paraffin and silicone, were used throughout the early-to-mid 1990s. Paraffin induced foreign body reactions and its use as a filler was discontinued. Impure and adulterated silicone has been used quite extensively, resulting in allergic reactions, as well as foreign body responses. In the past few years, the U.S. Food and Drug Administration (FDA) approved two different pure medical-grade liquid silicone products for ophthalmic use. Although not yet approved as a filler substance for aesthetic procedures, clinical experience and results from unpublished studies are encouraging.

Neuromodulators

Neuromodulator is the generic name for a group of toxins that selectively block nerve innervations of skeletal muscles. Botulinum exotoxin A, known by the trade name Botox*, is, at this time, the only approved neuromodulator for cosmetic use in the United States. It was accepted by the FDA for cosmetic use in 2002. The year it was introduced, it became the No. 1 injected cosmetic material in use, and one of the most commonly performed cosmetic procedures by physicians and nurses. According to the ASAPS, more than three million people in the United States received a Botox injection in 2006. It is a highly diluted form of neurotoxin that selectively and temporarily paralyzes voluntary skeletal muscle function and it represents only one of a group of neuromodulators. They are designated as botulinum exotoxin A though F. Botox is one of the type A exotoxins. Reloxin**, a different type-A toxin, is presently under review in the United States and is awaiting approval by the FDA, which is expected to happen sometime in late 2008. See Neuromodulator Options for more information about the two types. Myobloc is a type-B botulinum toxin that is not yet approved for cosmetic use, is slightly more painful upon injection and has a shorter-term effect than that of Botox. Other exotoxins are under investigation in the United States and will likely be approved during the next several years.

Fillers

Fillers are biomaterials that can safely and effectively fill creases, lines and areas experiencing volume loss due to facial aging and skin conditions associated with tissue loss. These materials are best classified as either temporary, semi-permanent or permenant, which in turn is defined by the makeup of the substance.

Temporary fillers. Collagen was the first approved filler in the United States and has been in continuous use since the early 1970s. Because it doesn’t last very long, it has been mostly replaced by other longer-lasting, safe and effective fillers, such as hyaluronic acids. Approved collagens are either bovine or human in source. Currently, porcine collagen, derived from pigs, is awaiting imminent FDA approval. See Collagen Options for more information about the various types. The advantage of human and porcine collagen is the very low risk of allergic reactions when compared with bovine collagen, which requires a skin test to rule out allergy.

Hyaluronic acid. Hyaluronic acid, a normal constituent of the dermis, is a complex sugar that makes up a significant portion of the substance of the dermis where collagen and elastin fibers, vessels, nerves and apendageal structures lie. It makes for a versatile filler because allergic reactions are uncommon, it can be used to fill small, large, shallow and deep defects, and it lasts, on average, at least six months. It is effective as soft tissue filler for fine and moderately deep lines, wrinkles and for volume replacement in the face, cheeks and lips. The moldability of the products and natural look of the results make it an appealing filler, and, because allergic reactions are so uncommon, the patient can be treated on the same day as the initial consultation. See Hyaluronic Acid Options for more information about the different available products.