Press Information Details for Cosmetic Plastic Surgery in the UK and USA

Today's injectable fillers may increase patient demand for nonsurgical procedures for a younger looking face.

In the past twenty years, nonsurgical treatment of the aging face was probably the most significant advancement in plastic surgery other then liposuction. The field is broad but essentially consists of two main categories. The first addresses lines and contour irregularities. The second addresses skin texture and color. Until recently, the former was treated with tissue fillers alone - either autologous or derived substances form animal or synthetic sources, which were injected into the dermis or sub dermis to correct rhytids and depressions. More recently, Botulinum toxin has been added to this category, although it works in an entirely different way by paralyzing the mimetic muscles that cause the lines of expression to become imprinted on the dermal architecture of the skin, during expression and eventually at rest.

Botox

The term "Botox-babes," coined by an English newspaper, may seem to be an oxymoron, but it promises to be the leitmotiv of the nonsurgical cosmetic revolution of the 21st century. Botox has become the craze of the baby-boomers, but now promises to hit younger groups, even the twenty-something as well. The reason is that facial lines can occur at even younger ages either because of childhood sun damage or because of a genetic and anatomical propensity to have lines fixed of expression. A deep frown line can make us look angry. Forehead lines can make us look worried or just prematurely aged. The decades of the twenties and early thirties have discovered Botox and the other soft-tissue fillers, not only as a means to correct rhytids, but also to improve certain features such as flat malar eminences and hypoplastic lips.

Types of Botox

Botulinum Toxin Type A is the most studied of the seven different serotypes of botulinum toxin (A, B, C, D, E, F, and G). Each serotype has different properties and actions, and no two are exactly alike. Botulinum Toxin Type A blocks the release of acetyclholine from the nerve endings preventing muscle contraction. The injection is administered by diluting a 100-unit vial of the toxin with 3 cc of nonpreservative containing saline and then injecting using a 1-cc syringe. The air in the syringe (0.05 cc) is expelled prior to injection. The 1-cc syringe is attached to a 31-gauge needle.

For about 20 minutes prior to the injection, 4% lidocaine is applied to the affected area, and the skin is prepped with a non-alcoholic based antiseptic. The injection is made into the muscle layer in 0.05- and 0.1-cc aliquots with the patient in the semi-sitting position. When injecting into the currugators, a gauze sponge is placed over the eye, and pressure is applied using the index finger at the orbital rim to concentrate the injection at the site. Then, 0.1 cc is injected into the lower part of the currugators and 0.05 cc into the upper currugators. Sometimes a lateral injection of 0.05 cc is placed into the currugators, when the muscle is particularly active. In the midline, a series of 0.05- and 0.1-cc injections are placed, depending on the strength of the procerus muscle. The injections should extend down to and include any horizontal lines over the nasion.

In the case of the forehead, 0.1 cc is injected in the midline above, below, and/or even in the lines of the upper forehead. Injections should not be made into the area immediately above the eyebrows, preserving the first transverse line. A series of two or three 0.05-cc injections are placed laterally above and below the upper forehead lines. A single injection of 0.05 cc is placed in the far lateral forehead. Occasionally, an injection of 0.05 cc is placed below the upper line of injections and about 1 cm above the eyebrow to prevent a hyperactive frontalis and prominent line forming in this area.

When performing injections in the crow's feet, two injections are often placed below the lateral third of the eyebrow to elevate it. A series of injections are placed along the lateral rim, and sometimes 0.1 cc is also injected laterally to further diminish the lines. In patients with lower eyelid dermatochalasis, care should be taken to not relax the lower eyelid as this will exacerbate the wrinkles in the lower lid. The index finger is always placed on the bony orbital rim to protect the globe when injecting.

All patients are counseled to animate the muscles after injection, keep their heads elevated, and not to massage the area.

Hyaluronic Acid

A synthetic form of Hyaluronic acid is currently available in Europe and Canada. Biosynthetically produced by bacterial fermentation, Hyaluronic acid comes from three molecular sizes.

Since there are no animal products, there is no risk of allergy, and testing is not required prior to treatment. The results appear more natural than animal-based collagen products and may last twice as long. Hyaluronic acid can be safely injected into the substance of the lip, unlike animal-based collagen. Degradation is iso-volemic. The injectable imbibes water and maintains volume as the Hyaluronic acid is absorbed, unlike collagen where absorption is arithmetic, resulting in progressive loss of volume.

Recommendations for injecting the three forms of Hyaluronic acid include: 1. Larger sized molecule- for deep folds, facial contours, and lip enhancement. Inject in the deep layer of the dermis and/or the surface layer of the subcutis.

2. Medium sized molecule - for moderate wrinkles and lip enhancement. Inject in the middle part of the dermis.

3. Smaller sized molecule - for the correction of very thin, superficial lines. Inject in the upper part of the dermis.

The products differ from each other only in terms of their particle sizes, and each is suited for injections into a specific layer of skin. I have used Hyaluronic acid in my London office for the past 4 years. I prefer to use the larger sized molecule for the nasal-labial lines and lips and the medium sized molecule for other fine lines. I have not used the smaller sized molecule fine lines with any great benefit. The larger sized molecule is injected with a 11/4-in 27-gauge needle and the medium sized molecule is injected with a ½-in 30-gauge needle. The area is numbed first with a topical application followed by spot injections of 2% lidocaine with 1:100,000 adrenaline for lip augmentation using the larger sized molecule. Ice is applied after injection, but bruising is always a risk, particularly in the lips. For lip augmentation, it may be best to split the treatment into two parts to avoid multiple punctures. The patient should avoid aspirin or nonsteroidal anti-inflammatory agents for 2 weeks prior to treatment.

Lip injections are placed in several locations beginning at the vermilion border and the philtral columns, then in the anterior part of the vermilion, and lastly in the mucosal aspect of the lip. The last location in close proximity to the coronal artery is the most likely to result in bleeding and subsequent bruising.

Since naso-labial folds often disappear when the patient is reclining even a few degrees, I prefer to sit them on the edge of the bed and inject them sitting completely upright. I find that I can judge the result more easily. I use a short 27-guage needle to fill the triangle between the naso-labial fold and the alar crease as well as the triangle between the mento-labial crease and the lower lip. An injection is made to elevate the oral commisure. The placement is at the junction of the wet and dry vermilion of the upper lip and 1 cm medial to the oral commisure.

A syringe contains 0.7 cc. One half to one syringe of the larger sized molecule is required for each nasal-labial fold, and one to two syringes for lip augmentation. The volume of the medium sized molecule required depends on the number of rhytids to be treated.

Polylactic Acid

One of the most recent and exciting products on the market is a polylactic acid (PLA) hydrogel not yet available in the United States. PLA is a synthetic polymer that is biocompatible, biodegradable, and immunologically alert. It is related to polydioaxanone suture. Treatment does not require any prior skin test. Polylactic acid is intended for the treatment of fine lines, wrinkles, marked furrows, or creases, as well as augmentation of the tissue volume in certain areas of the face, such as cheekbones, cheek depressions, lips, and chins.

The reconstituted solution is injected to a slight under correction and induces dermal fibrosis over the following 3 to 4 weeks. A minimum of two treatments are usually required 3 to 4 weeks apart. There are no special requirements for storage. The product can be stored indefinitely until it is reconstituted. The kit and reconstituted product should be kept at room temperature. Reconstitution product is ideally preformed the night before. Reconstituted product should be used within 24 hours to avoid the risk of bacterial contamination. A 1-cc thick-walled disposable syringe with a 26-gauge needle is used for injection.

Each vial is reconstituted with 4 cc sterile water or saline. The solution is frequently agitated to avoid separation of the colloidal suspension. It is extracted from the vial by using a 1 ½ inch needle so that the tip of the needle is below the level of the solution. Any air trapped proximally next to the plunger. During injection the needle may become blocked. The plunger is pulled back, the syringe shaken and the air and some solution is then squirted out to clear any blockage. Superficial injections must be avoided as they can form spherical deposits, which can become organized. The solution is injected in 0.1 cc aliquots through multiple injections into the area of the depression. The technique is radically different from Collagen and Hyaluronic acid. Instead of trying to fill a line or depression, the concept is to create a collagen build up in the entire area. Cheek bones and cheek furrows require about 2 cc per side. Lip margin augmentation requires approximately 0.5 cc.

Polylactic acid has been particularly useful for acne scars and facial atrophy secondary to AIDS. Two to three sessions are required spaced a month apart. The effects are claimed to last for 1-2 years. There is a definite learning curve with this product and it is advised that you practice with the company representative present for the first few patients.

Fire Away

Botulinum toxin and the other products on the horizon, such as Hyaluronic acid and Polylactic acid, promise to expand the indications and effectiveness of injectable fillers. Botulinum toxin already in use in patients in their 3rd and 4th decade. Hyaluronic acid has been useful in older patients for treatment of naso-labial lines and in the young and old for lip augmentation. Polylactic acid can treat areas of general atrophy which previously responded poorly to other treatments such as Hyaluronic acid.

The field of injectable fillers and nonsurgical treatments for the face continues to expand. Surgical alterations and rejuvenation still have their place in giving permanent and generally better results. However, the attraction of a syringe versus a knife continues to be compelling. Plastic surgeons and dermatologists will be firing away for some time to come.

Laurence Kirwan, MD, FRCS, is certified by the American Board of Plastic Surgery and is an active member of the American Society for Aesthetic Plastic Surgery. He practices Aesthetic Surgery in Norwalk, Conn, and London, England.

Reference

1. Hart-Davis A. Botox babes. Evening Standard. February 26, 2002

The latest weapon . . .

It isn't available in the US yet so, for once, the Brits have had first option on the latest anti-aging treatment - Perlane.

Developed in Sweden, Perlane is injected into your cheeks and lips to plump them out, giving you a more youthful appearance. The word is that US women are flying over in droves to have the treatment here.

The arrival of this new advance in cosmetic surgery is down to Dr. Jean-Louis Sebagh, one of the first doctors to use that other popular wrinkle remover, Botox.

'Perlane is a filter like collagen,' says Dr. Sebagh. 'I use it to create volume, so it is fantastic for the face and lips to plump out wrinkles. It is a transparent gel - based on hyaluronic acid -and, as it's a 100-per-cent safe, non-animal product, it's very popular.'

But the big question is: Does it hurt? 'The patient is numbed first,' says Dr. Sebagh, 'in the same way a dentist would numb your mouth. So, no, there isn't any pain.'

So what about the downside? Perlane lasts between nine months to a year, so you would need regualar injections - and it's not cheap. On syringe costs between £350 to £400 (one syringe would fill out your lips or smooth out two wrinkles).