The dermal filler stronghold

Fillers have revolutionised treatments over the past 20 years, so what’s new on the horizon?

Maintaining its pole position as the most popular non-surgical procedure, botulinum toxin injections alone have grown by 7,500% since 1997 and show no sign of wavering. According to the 2016 statistics from the American Society for Aesthetic Plastic Surgery (ASAPS), botulinum injections are up 8% on 2015.

Number two on the list is HA fillers, with an increase of 16% on the preceding year.

However, there also has been steady growth of other non-surgical facial rejuvenation techniques such as biostimulators, fat grafting, PRP and stem cell technology. With the increasing popularity and sophistication of these alternatives, how do traditional dermal fillers measure up?

HA mainstay

Dermal fillers have come a long way over the past two decades and have become so advanced that they now offer suitable patients results that may have required surgery 10 years ago.

QLD plastic surgeon Dr Mark Magnusson says that injectables have pivotal and clearly defined roles in cosmetic medicine.

“Modern fillers are a versatile range of products – from skin boosters and superficial fillers for fine skin areas to more structural fillers for lines, lifting and volume. Most are non-permanent hyaluronic acid products. They give a stable and reliable result and are not affected by problems such as fluctuations in body weight. Although not the goal, they can be dissolved if required which is a substantial safety element,” says Dr Magnusson.

“There will be ongoing refinements and developments in injectable products. It is going to take a very significant disruptive development for fillers to lose market share,” he says.

Dubai dermatologist Dr Hassan Galadari says, “Even though fillers will be one of the most important mainstays in the field of cosmetic dermatology and plastic surgery, I believe we will see more improved materials that will feel natural and last even longer.”

“HA is a great filler, but it has its drawbacks in some ways as it simply just fills. Although, a study from the University of Michigan has shown that the stretching of the fibroblasts can lead to neocollagenesis – that being said, this process is not qualitative and that’s why HA fillers are simply just that: fillers. We have indeed reached the level of ‘naturalness’ of HA fillers that corresponds to different parts of the face – thicker fillers working well in the cheeks and the softer ones in the lips, for example,” explains Dr Galadari.

The buzz on biological rejuvenation

For many patients, the idea of using their own biological materials to rejuvenate their skin is appealing.

But do these procedures truly offer comparable results to existing modalities?

For years surgeons have used fat transfer to replace lost volume and fine-tune liposuction outcomes, but only in recent times has it become part of the public’s lexicon.

A growing body of experts worldwide hold that fat grafting brings enhancements to facial rejuvenation that were not previously possible. Successful fat grafting, however, is highly technique-dependant and imposes a significant learning curve.

“If we think about the volume component, fat grafting has been around for a long time but there are challenges. Once it has taken, it responds to body weight fluctuations, may be uneven and may leave lumps (in thin skin areas). In the right patient, fat can be great, but clearly it is not for everyone,” explains Dr Magnusson.

There has also been significant debate about optimal harvesting techniques. “Autologous fat may show a comeback if we learn how to properly harvest it,” says Dr Galadari. “Fat, which is the most abundant and natural filler, requires more than one session to achieve results. Perhaps in the future we will see a better way to be able to harvest and transfer the fat so that megadoses may not be needed to achieve satisfactory results for our patients. However, until then, HA fillers will remain the gold standard.”

The challenge with facial fat injection is that the patients who benefit the most tend to be the patients who need volume least. Fat is a great tool when used appropriately, but a high tolerance for ambiguity is essential. “Harvesting and injecting fat that is not from the same donor site can lead to repercussions,” he says. “If you inject belly fat in the face and gain weight in the belly, your face will also grow, giving you an overfilled unnatural look.”

Platelet-rich plasma is another modality gaining popularity. “One of the difficulties is standardising the products so the proper comparative studies can be performed,” says Dr Magnusson. “The science is coming and it will hopefully refine how these products are used.”

Dr Magnusson goes on to explain that adipose-derived stem cells are another similar area. “Clinically we see autologous fat graft improving the quality of skin after radiotherapy, and camouflaging volume differences and irregularities in breast and facial surgery, but definitive proof in properly conducted high-level research is scarce. However, there are certainly many potential benefits of cells with regenerative capacity.”

“I believe the wave of the future is a combination of HA fillers with PRP, however we should first prove that PRP does indeed work and how these synthetic and natural materials interact to help us achieve not only the most natural of results but also outcomes that are truly longer lasting,” adds Dr Galadari.

Today’s facial practice

Overall, living fat cells, biostimulators, PRP and stem cells are too fundamentally different, on multiple levels, to be considered ‘alternatives’ to traditional fillers in a simplistic fashion. Instead, each has its advantages and have individually become fundamental tools in cosmetic practice, often being used in conjunction rather than as stand-alone products.

“Each of these technologies works differently, so it isn’t one or the other. In many instances they are complementary and work on different elements of the ageing process. In other circumstances, one product may clearly be better for one patient but not the next,” explains Dr Magnusson.

“There are many devices now that alter skin quality such as LED, radiofrequency, ultrasound, IPL and laser. Some give reliable results backed by science and research that can be emulated by others. For other treatments, the results are less well understood, results are more subjective and not always repeatable in the hands of others.

I differentiate on the basis of: proof of results, reproducibility and safety,” he continues.

“I tend not to mix and match,” says Dr Galadari. “I treat patients according to what is necessary. If a patient has fat atrophy and deflated cheeks then I use a filler and I choose one kind. Fillers, however, do not change the texture of the skin, thus I would combine their use with another treatment modality such as a laser or chemical peel. It would be interesting to see whether stem cells and PRP increase the effects of fillers, however no study of such exists as of yet.”

The future of facial enhancement

With such a wide range of modalities on the market, for a wide variety of facial treatments and indications, it is interesting to consider how it will influence anti-ageing medicine in the future and if, in fact, it signals a change of direction.

“Hormone replacement, oral supplements, dietary advice, maintenance of bone and muscle mass, appearance medicine, even preventative medicine – the field of regenerative medicine is here and it’s growing,” says Dr Magnusson. “At present it is not quite mainstream; it’s a little in the shadows but momentum is building.”

“I feel that science will prevail to make beauty enhancement a much more learned artform,” says Dr Galadari. “We need to encourage this and, in addition, we have to police ourselves and educate our community about the dangers of doing things that have not yet been approved. Many people are having treatments just because they saw a certain celebrity promote it on social media. At the end of the day we are doctors and we have a responsibility to treat patients with respect and not offer them treatments they may not need or, even worse, that don’t work.”