SELECTION OF SUITABLE CUTANEOUS FILLER
When we evaluate cutaneous fillers: in our country
in order of frequency in the first four rows as varieties; hyaluronic
acid, calcium hydroxy apatite, polycaprolactone and
hydrophilic gel is used.
HYALURONIC ACID
Hyaluronic acid naturally found in the human body
(HA) is viscoelastic by stabilizing intercellular structures.
creates a roof. Decreased amount of HA as you age
with a decrease in skin hydration and elasticity.
Thanks to its water binding capacity 1000 times its volume, it
When injected, it creates volume and provides hydration.
and increases the elasticity of the skin. All HA fillers
depth adjustment according to the types of dermis.
It is applied to the folds or subcutaneous adipose tissue.4-7
In its natural form, hyaluronic acid is rapidly absorbed
The life of hyaluronic acid in the dermis is 1 day. butanediol
diglycidyl ether (Restylane, Juvederm etc) or divinyl
Crosslinking such as sulfone (Prevelle Silk, Hylaform etc.)
preparations resistant to heat or enzymatic degradation as a result
obtained. The crosslinking process is in itself ‘particle’
and HA production in ‘non-particulate’ forms.
makes it possible. The particulate form contains a single cruciate link.
and because it contains uncrosslinked HA in its structure.
It is grouped as “biphasic filling”.
The effect of biphasic fillings (Restylane etc.)
Although the time is proportional to the particle size,
Particle size in the gel volume forming feature
is directly proportional to That is, the HA particles per milliliter
the smaller the number, the larger the particles
and its permanence and volumetric effect are higher.6-9
Filling the volume of non-particulate form (Juvederm etc.)
strength and permanence time are determined by the number of crosslinks it makes.
it depends. In addition, non-crosslinked HA
i.e. all cross-linked HA chains
It is grouped as “monophasic filling” because it is formed.
The ideal level of cross-linking is unknown.
However, excessive cross-linking makes hyaluronic acid hydrophilic.
has been reported to significantly reduce its properties.
1,3,4,6,7
As the particles of the biphasic form grow (the duration of
lengthening and increasing the volumetric effect) injection
gets more difficult. The monophasic form is homogeneous and
Since it has small particles, it can be injected more easily.
However, the reliability of the biphasic form according to the depth adjustment
it is better. Biphasic form particle size
single cross inside the dermis no matter how big
Since it is attached to it, it can be shaped by stretching with massage.
However, 3-4 cross-linked variants of the monophasic form are superficial.
due to excess cross-link in dermis applications
with massage as it is more stable than the biphasic form.
more difficult to stretch. That’s why it’s shaped like a “drop” from the outside.
can be seen and felt. This way of encapsulation
risk has also increased. So monophasic
depth adjustment is important in filling applications.1,4,6,7,10
Recently injected in monophasic HA fillers
ability to react with tissues in the area where it is applied
According to the concepts of monodensified and polydensified
has occurred. The tissue where an HA filler was injected
If it can cross-link with its matrix, it is polydensed.
This feature persistence and stabilization
It increases and needs to be reshaped after a period of application.
If desired, this situation has become more difficult.
11.12
Advantages of HA fillers over other filler types
it is too much. According to the types of HA fillers
have forms that can be applied to all parts of the face,
Reversal can be achieved with the use of hyaluronidase,
being natural and safe, immediately after application
obtaining cosmetic results and not showing antigenic properties
(no skin testing required) HA’s other fillers
advantages over the items. of HA
its advantages are much greater, its use in the USA
increased by 190% in the last ten years. Injected in the USA, in 2011
69% of all fillers used are HA fillers.
6,7,13
HA products that do not require skin testing
should not come into contact with high temperatures, in which case the resulting
monomers have the potential to promote inflammation.
In addition, for HA filling, the skin before use
Although it is stated that it is not necessary to apply the test,
associated with hyaluronin, which is present in varying amounts in
The protein theoretically carries a risk of hypersensitivity.
HA filler application; cancer patients, pregnant women,
lactating, children under 12 years of age, keloid development
in those with a predisposition, in the presence of bleeding diathesis,
It is contraindicated in the presence of active infection and inflammation.
13
CALCIUM HYDROXYAPATITE
In our country, it is most commonly sold under the brand of Radiesse® and is produced in milliliters.
‘Calcium hydroxylapatite’ found at the rate of 30%
spherules with mineral components in teeth and bone
is the same. for lipoatrophy in HIV patients and for
FDA-approved for severe wrinkles. Submucosal
lips and under eyes due to the risk of nodule formation.
It is not recommended for use in applications. an inert
Since it is a substance, it does not require a skin test. be radio-opaque
can be seen on direct radiographs. Completely
a synthetic substance of human or animal origin
not included. It is injected into the subcutaneous tissue. The product is usually
It is used by diluting with 0.5 cc lidocaine. This filler
in order to ensure long-term permanence.
can be preferred for 14-18
POLYCAPROLACTON
This product, which has just entered our country with the Ellanse® brand,
security parameters, long persistence
It is more reliable than other products. polycaprolactone
actually the raw material of absorbable surgical sutures
used as. Both longevity
as well as other products with a long permanence period.
popularity because it is more reliable to use
is increasing. According to the duration of
Models ranging from one year to four years are available.
Does not require skin testing. Application depth subcutaneous
must be in adipose tissue. This filler is more
It can be preferred for long-term use.
19.20
HYDROPHILIC GEL
2% available in our country as Aquafilling® and Aqualift®
synthetic linear polyamide and 98% saline
structure of the hydrophilic gel; between carbonyl and amine groups.
based on multiple hydrogen bonds. face and body
can be used in aesthetics (breast augmentation, hip augmentation)
it is a filler. In faceline and bodyline form
It is produced in 2 different forms. Application depth percent
It should be from the submucosa on the lip to the subcutaneous adipose tissue.
Does not require skin testing. This filler is more
may be preferred for long-term permanence.
21
Filling in direct proportion to the patient’s expectations
The choice of the type of substance depends more on the permanence expectations.
determined after evaluation.
What should be noted is how experienced the clinician is.
Regardless, the risk of complications increases as the permanence increases.
increases and complications become more difficult to manage.
PERMANENT PERIOD OF THE FILLER
Permanence and expectations of the patient before the application
After evaluation, the choice of filler should be made.
Frequency of use of permanence fillers permanence
is inversely proportional to the duration. The most commonly used
when fillers are evaluated; permanence
Hyaluronic acid, a natural product ranging from 6 months to 15 months
acid derivatives are the most preferred. Persistence
Calcium hydroxy apatite ranging from 15 months to 24 months
crystals are in second place. Permanence ranging from 1-4 years
While using polycaprolactone derivative in the third frequency,
hydrophilic gel with a permanence of 3-5 years
derivative is used in the least preferable way.
Application safety of the polycaprolactone derivative in this ranking
As it gets better, the frequency of use is gradually increasing.
The longer the persistence, the greater the side effects.
is too much. The patient’s expectation of a long retention period
side effects of the filler chosen to meet
The patient must be sure that there may be more
should be informed.6,14,19,21
THE VOLUMETRIC POWER OF THE FILLER
FACE REGION SUITABILITY
Upper Face
The most frequently intervened areas; by movement of the frontalis muscle
forehead wrinkles, depressor corrugator
vertical glabellar wrinkles formed by the complex
crowbar formed by the action of the orbicularis oculi muscle
are wrinkles. Horizontal forehead lines and in the middle of the eyebrows
the lines that appear are dynamic wrinkles and such wrinkles
respond very well to botulinum toxin treatment
In addition to botulinum toxin treatment in resistant cases
low cross-linked or small particulate HA.
intradermal application was found to be successful.10,22
Middle of the Face
Thinning of the adipose tissue on the malar prominence and
The collapse can be corrected with the use of fillers.
Largest particle or most cross-link
HA preparation should be used. duration of persistence
polycaprolactone, hydrophilic gel or calcium to prolong
subcutaneous/supraperiosteal derivatives of hydroxy apatite
application is good for midface augmentation.
is an alternative. During the treatment of ‘Tear Trough’ deformities
selected filler retrograde tunneling method
just outside the orbital rim and
low cross-linked or under the orbicularis oculi muscle
small-particle HA should be applied.4,23
Fronto-nasal angle to correct the nose line, nose
ridge and columella to medium-deep dermis, a medium-strength HA
filler should be used. To extend the retention time
Calcium hydroxy apatite filling is preferred to the subcutaneous region.
medical rhinoplasty can be performed. to the nasolabial angle
A strong HA filler to be medium deep dermis
should be used. subcutaneous to prolong persistence
polycaprolactone, hydrophilic gel, or calcium hydroxy
apatite filling can be applied. Nasolabial sulci
especially as a result of deepening during laughing
Many patients are disturbed by the bad image that occurs. Only
filling, since the overfilling shows the face swollen in the session.
should be done in several sessions.4,10,22
Lower Face
Mouth with collapse of soft tissues as a result of volume loss
their commissures face down and the depressor anguli oris muscle
As a result of excessive movement, marionette lines develop. Middle
A strong HA filler should be used in the deep dermis. Permanence
polycaprolactone subcutaneously to prolong its duration,
hydrophilic gel or calcium hydroxy apatite
filler can be applied. Volumetric lip filling
loss and perioral lines are in the foreground. plump up
middle of the dry/wet mucosal junction
Medium-strength with 1/3 submucosal injection
An HA filler should be applied. prolong retention time
A hydrophilic gel filler can be implanted for Lips
with a history of herpes simplex before filling procedures
Patients should be given antiviral drug prophylaxis. perioral
low crosslinking or small particulate for lines
Intradermal application of HA and combined with botox
was found to be successful.4,10,22
Changes in the jaw that occur with aging
large particle or at most cross-link
HA preparation can be applied. prolong retention time
polycaprolactone, hydrophilic gel or calcium
hydroxyapatite derivatives can be administered subcutaneously/supraperiosteally.
24
Atrophic disease, which can occur in every part of the face for various reasons.
scar before applying in the treatment of scars
in the scar after stretching the area with two fingers
If there is improvement, it is understood that the filling will be beneficial. Application
Subcutaneous fibrotic bands with subcutaneous subcutaneous
low cross-linked or small particulate after cutting
Intradermal application of HA was found to be successful.25
DEPTH ADJUSTMENT ACCORDING TO THE NEED OF THE APPLIED AREA
For what purpose will the filler be applied to the application area?
determining the variety according to
It is very important to set the depth correctly. Opposite
Otherwise, the risk of complications increases. polycaprolactone,
hydrophilic gel or derivatives of calcium hydroxy apatite
It should be applied between the subcutaneous adipose tissue and periosteum.
With these three derivatives, only the removal of deep wrinkles
and should be used to correct volume loss.
They are not suitable for superficial wrinkles.
Encapsulation formation in superficial dermis applications
serious complications may occur. HA derivatives
according to the particle size and the number of crosslinks.
It can be applied between dermis and periosteum. Number of cruciate ligaments
application to the superficial dermis as the particle decreases or the particle gets smaller
applications of this depth
its purpose is to open superficial wrinkles. The exact opposite
As the number of cross bonds increases or the particle gets larger, the medium
dermis, deep dermis, subcutaneous adipose tissue, and periosteum
until applicable. The purpose of these applications is deep
for the removal of wrinkles and volume losses.
are applications. Highly cross-linked products are more risky
However, products with large particles can also be superficial.
administration increases the risk of complications.
6,14,19,21
DISORDERS THAT MAY BE DUE TO THE PROCEDURE
GOOD TRANSFER TO THE PATIENT
The first thing that the physician should question in the first consultation
thing; the patient’s aesthetic concerns from the filling process
how much benefit can be obtained and the satisfaction of the patient
whether it is sufficient. If necessary, the patient
to different cosmetic procedures (resurfacing, recounturing,
relaxing) should be redirected. In the second stage, the patient’s detailed
medical history (for those with active infection)
The procedure should be postponed, those who use drugs such as aspirin and coumadin
if possible, they should interrupt the drug)
should be taken. In the third stage, possible infection to the patient
information about the risk of occurrence should be given. End
At this stage, the types of fillers, their advantages
and disadvantages, duration of effectiveness and local anesthesia
information is given to the selection of the filler material to be used.
The patient should also be included. All that can occur
legal procedure after the complications are explained to the patient
A signed consent form must be obtained.
26
A good physician, while applying fillers/
management of complications that may occur after
knowing well and managing this situation if complications occur.
knowing physician. To cope with complications
The best way is to make sure they don’t show up at all.
In the event of an undesirable effect, a treatment
The patient should be relieved by explaining that there is a plan and
tell the patient that the treatment plan may take several sessions.
information should be given.13,26
EVALUATION AND CONCLUSION
The patient’s expectations and the clinician’s choice in the selection of cutaneous fillers.
As a result of the patient’s assessment of his deficiencies
The filler to be used after the common denominator formed
should be determined as most appropriate. selected
Filling the patient’s need for atrophic areas or deep wrinkles
if it will be applied for the purpose of superficiation;
highly cross-linked or large particulate HA fillers
It should be used by applying to deep areas. atrophic area
If we want to extend the persistence period in applications
polycaprolactone, hydrophilic gel or calcium hydroxy apatite
We can use its derivatives in the form of deep application.
The patient’s need is for the correction of superficial wrinkles.
low cross-linked or small particulate
HA fillers should be used by applying to the superficial areas.
After application without installing big expectations
good transfer of the image to the patient,
well-being of all possible complications
Disclosure must be made prior to administration and must be signed by the patient.
consent should be obtained.
