Dermal Fillers

With devices “resurfacing” the facial canvas and botulinum toxin A “relaxing” the mus­cles of facial expression, dermal fillers address the issue of loss of volume and complete the triad of procedural nonsurgical facial restoration. During the last five years, a myriad of dermal fillers have been approved by the FDA and the way fillers are now utilized are dra­matically different from the way they were used when the collagens were first introduced. Dermal fillers can be divided into temporary, mixed, and permanent. For many years, fillers were used to “fill in lines”. The trend in the twenty-first century is to address global volume loss, as opposed to “individual” rhytids. Regional volumetric restoration is the best way to utilize dermal fillers. Moreover, fillers can be used in combination with each other, based on the characteristics of the volume loss and the nature of rhytids, once again emphasizing the concept of combination therapy. With certain areas, combination of fillers and botuli­num toxin are essential—such as deep glabellar rhytids, droopy meilolabial folds, and perioral rhytids. It is safe to perform photofacials and fractional laser resurfacing over fill­ers. However, if a patient is considering multiple modalities, it is better to complete the light and laser procedures first, and introduce dermal fillers after the completion of device­based therapies. There is anecdotal evidence that the longevity of fillers may be enhanced after light and laser-based therapies, as these modalities induce neocollagenesis. Studies are underway to quantify these observations. In addition to the face, the hands are becom­ing an ever popular area for dermal fillers. Combination therapies for hand rejuvenation include using laser/light for lentigines, fractional lasers for resurfacing, and dermal fillers such as calcium hydroxyapatite and polylactic acid for volume loss (Fig. 13.5).