Sculptra: An Old Filler Resurrected

 Sculptra is a unique filler that was first approved in the US in 2004, for treating facial lipoatrophy (fat loss) in AIDS patients. It consists of a suspension of particles of poly-L-lactic acid, a material that has long been used in the skin as an ingredient in absorbable sutures. Although it was legally used for cosmetic purposes immediately after its initial approval, it received official FDA approval for this indication in July 2009.

Pan-Facial Filling: The End of the Facelift?

As our understanding of what causes facial aging advances, our approaches to this problem are advancing as well. Gravity as an explanation for the aging changes in the face has been discredited. Three factors are now recognized as important in facial aging: changes in the skin quality, mostly due to insults from the environment, but also due to biological changes that are not fully understood; repeated folding of the skin and loss of volume of the underlying tissues that support the skin. It is the last of these changes that I will discuss here.

For a while we have recognized that the loss of facial soft tissue: fat, muscle and connective tissue, have played an important part in facial aging. More recently it has become clear that loss of bone also plays a very important role. The openngs for the eyes are much larger in the skull of a 50 year old, than in the skull of a 20 year old. The jaw bone of a 20 year old is thicker and wider than the jaw bone of a 50 year old. These changes not only cause deflation of the face, but change the proportions. In the young individual the upper lip occupies 1/3 of the distance from the bottom of the nose to the tip of the chin. In the elderly it takes up 1/2.

Fat Injections: A Boon or a Bust?

The popularity of fat injections has risen and fallen, and appears to be on the rise again. The realization that many of the facial changes of aging are due to the loss of volume of both soft tissue and bone, has dramatically increased the use of fillers. Because the commercially available fillers are relatively expensive, fat grafting has been attractive as a relatively inexpensive source of a large volume of filler material, material that is native to the patient and should not cause allergic reactions.

The "Wow" Effect

There are precious few procedures that we perform where, immediately after the procedure, we can hand the patient a mirror and their typical response is "wow". The injection of filler is the outstanding example of this phenomenon. The results are immediate and frequently very impressive. The final result, however, is more of an art, rather than a science. This is especially true now that filling has evolved from plumping up a specific groove to re-contouring the face, producing a more youthful facial structure. This is very operator dependent and it is unusual to see physicians who are not members of "core" cosmetic specialties (dermatology and plastic surgery) venture into this arena.

"I love you, Dr. Bock"

That is how I was greeted last week by a long time patient. She had undergone a number of noninvasive procedures in the past few years, but two weeks before I saw her I had, for the first time, injected filler in her cheeks. The aging of the mid-face has, with the development of better and linger fillers, become recognized as one of the primary events that makes a person look aged. The young face is full, with smooth, convex surfaces, while the aging face becomes concave, with the loss of deep tissue and other structures. This produces depressions such as the "tear trough", a groove that extends downward and sideways from the inner (medial) part of the eye. It was this area that was filled in my patient. She was smiling as she reported that even her teenage son, without knowing that anything had been done, told her that she looked good.

Volume Loss and the Aging Face

There are a number of factors that combine to make our faces look older with time, but the two most important factors are changes in the quality of the skin and the loss of volume. The skin quality changes, that are markedly worsened by factors such as sun exposure and smoking, have long been recognized, but the changes due to volume loss have come to be appreciated only recently.

The most underused cosmetic procedure

People come in to our office requesting a variety of procedures. Botox and fillers are among the most frequently requested procedures, but the newest use of fillers, what we call "facial Sculpting" is almost never the patient's initial request. Yet, when shown photographs of the results, many patients choose to have it performed at the time of the visit, or schedule a subsequent visit to have it done.

Fillers

Fillers are becoming an increasingly important tool in facial rejuvenation. It is interesting that most patients are unaware of the range of uses that fillers can be put to. Collagen was the first filler to find widespread acceptance, but, because of its short effective life, it is now used much less.