One of the hot catch phrases in plastic surgery circles these days is “early intervention”. The emphasis is on less invasive procedures performed at an earlier age to put off the inevitable arrival of lines, folds, grooves, bags and pouches. Preventive maintenance is an appropriate description of this phenomenon, as more people are looking to plastic surgery to delay the aging process instead of reverse it.
Coupled with a need for reduced healing times and a rapid return to every day activities, the field has responded with several different products and procedures including Botox, Dermologen, Alloderm, Soft-form, hyularonic acid, endoscopy, lasers, vitamin C, polyhydroxy acid. But often little is known about these procedures until a consultation with a physician is made.
These new products are routinely injected in the doctor’s office. It only takes a few minutes and the healing time is minimal. While most injectibles are soft tissue fillers, designed to soften wrinkles, plump up the lips or fill out depressed scars, the product that has received the most attention of late is Botox.
Botox is not a filter, but rather a muscle weakener. Derived from the deadly toxin botulinum, Botox A is administered in safe doses for a variety of medical and cosmetic reasons.
Originally utilized for uncontrollable spasm of the eye muscles in facial paralysis patients, Botox has revolutionized the treatment of facial wrinkles. Dynamic facial lines caused by the continuous action of the muscles that create facial expressions — especially in the forehead and around the eyes — can be significantly softened with injections of Botox. Botox is not permanent and must be repeated every four to six months, depending on the individual, but nothing else can approach the safety and efficacy of this particular injectible. The typical cost of Botox A injectibles ranges from $400 to $600 per session.
While bovine Collagen remains the gold standard of soft tissue fillers, several new products have recently been introduced onto the market. Human derived collagen (Dermologen) is one such product that originally promised longer lasting result than bovine collagen with fewer allergic reactions. Unfortunately, the manufacturers claims have not held up well after clinical trials and it is still unclear whether Dermologen holds any advantage to Collagen.
Isologen, also a human derived product, still holds out much promise in the treatment of acne scars and other skin depressions, but is extremely laborious to use. The patient’s own skin is used to grow special cells called fibroblasts in the laboratory, which are then re-injected in the depths of a wrinkle or scar. Clinical result shave been good to excellent, but the harvesting, preparation and re-injection process precludes routine use by most practitioners.
Alloderm, a soft tissue replacement material, has been used in many areas of the face for augmentation and reconstructive purposes. Alloderm, which can be used to add fullness to the lip or smile lines, augment the nasal bridge or plump up a shallow scar, comes in sheets which are implanted during a short office procedure under local anesthesia. Injectible Alloderm is now available to a small number of physicians in this country and is undergoing further clinical trials to evaluate the longevity of this product.It is derived from cadaveric human skin and is stripped of all of its cellular components. It provides a dermal matrix which, once implanted, fully integrates with the patient’s own soft tissue.
Fascian, Artecol and hyaluronic acid are three additional injectibles, which have been used extensively in Europe, but have yet to gain popularity in this country. For completeness, I should mention the granddaddy of all injectibles, liquid silicone. Used with wild abandon in the seventies and eighties, silicone was taken off the market and its use in facial plastic surgery declined precipitously. There are still many physicians who swear by liquid silicone (and who still administer it), but for the most part the search for a safe, predictable, and permanent injectible continues. Although the price for each of these injectable products varies, one should expect to pay between $350 and $750 per session, which must be repeated at four to twelve months.
Although Alloderm is safe, easily obtained and reasonably priced, it is still unclear whether long-term results are obtainable. In an effort to overcome the transient nature of many injectables, permanent implants have been designed that can be threaded through the lips, placed in the nose, cheeks ad chin and tunneled under the grooves that represent the naso-labial folds (those lovely creases between your upper lip and cheek that tend to deepen with age). Along with permanency come some not so welcome bedfellows such as rejection, infection and altered sensation. These complications of permanent implants must be taken into consideration when choosing a method of facial augmentation and are especially troublesome when they occur in the lips.
Soft-form and S.A.M. are two such implants that are made of a substance known as Gore-tex. Yes, that Gore-tex, and the same attributes of durability and porosity that make it an ideal outer garment render it quite useful in facial augmentation and reconstruction. Although touted for use as a permanent lip enhancer, many physicians have been less than enthusiastic about the results seen in this area. More recently, these products have been used successfully in softening the naso-labial folds, and area that appears to be more receptive to implantation than the lips. Gore-tex implants are also used extensively in nasal, cheek and chin augmentation with reliable and satisfying results.
Finally, a discussion of facial injectibles and implants would not be complete without mentioning fat. Fat injections have inherent theoretical appeal in that excess fat from one area of the body can be used to augment a deficiency in another area of the body. Unfortunately, fat tends to dissolve when it is transplanted to a new home and therefore the promising early results are often transient and disappointing in the long run. There are some areas, such as the cheeks, that are more amiable? to fat grafting and there are several physicians who swear by that technique. And while safe and economical, it does require an additional procedure each time fat is to be obtained for re-injection. For this reason, and the inconsistent long-term results, it is not the implant of choice for most physicians when performing facial augmentation.
This article was originally published in August 2000. Jon B. Turk, M.D., is a Board Certified Facial Plastic Surgeon specializing in aesthetic surgery of the face.
By Jon B. Turk, M.D.