Success with RESTYLANE^®, the new facial filler, requires in-depth knowledge and sophisticated technique.

An Article by Dr. John Q. Cook
FDA approval of Restylane® and other hyaluronic
injectibles opens a new era for facial soft tissue
augmentation in the United States. These versatile
fillers have significant advantages over materials
previously available for this purpose. The purpose
of this overview is to provide you with an under-
standing of the nature of hyalurionic injectibles, the
range of medical applications to date, their
characteristic advantages and disadvantages, and
the qualities you should look for in the clinician who
will treat you.

WHAT IS HYALURONIC ACID?

Hyaluronic acid (HA) is a natural material that is
found throughout the human body. It has a simple
hemical structure that is known as a glycoprotein;
in other words it is simply made of a sugar molecule
that is hooked to a small protein molecule.
The physical properties of various commercial forms
of hyaluronic acid are determined by the degree of
cross-linking between chains of these molecules hooked together. In general, the greater the degree of cross-linking, the thicker the material. This variation provides us with a useful range of materials, each suited for a different purpose. The thicker, more cross-linked forms are placed deeper, while the thinner, less cross-linked forms are placed closer to the surface of the skin.

Although HA is found in many tissues in the body, we will concern ourselves predominantly with the HA that is found in the skin. The skin can be viewed as having two main layers, an outer cellular layer (the epidermis) that protects us from the external environment and a deeper structural layer (the dermis) that provides resiliency, tone and support. The dermis is made up of bundles of collagen and elastic fibers that run through a squishy pudding of HA.

With each decade of aging, our skin loses about 10 percent of its hyaluronic acid content. This is one of the main reasons that aging skin deteriorates in quality. The skin actually becomes thinner and less resilient. It also becomes drier. This is largely due to the decreased HA content. Biochemists like to say that HA is remarkably hydrophilic; this means that it naturally draws water molecules to itself, in a ratio approaching 100 to 1. As we lose HA with the aging process, our skin becomes progressively dehydrated. The appeal of restoring the HA content to the skin and surrounding areas should be readily apparent.

WHAT MAKES HYALURONIC ACID SO USEFUL?

The clinician has quite a few choices available for soft tissue augmentation in the United States and an even greater range of options in other countries. This is one of the reasons I have spent significant time in recent years traveling to medical conferences and visiting clinicians in European countries. In Europe, an almost Darwinian struggle goes on between all of the possible materials that compete for a doctor’s limited attention. In many ways this is quite good; the beneficial and useful materials tend to gain market share, while the ones with problems or disadvantages tend to

fade away. Since medical materials and drugs come to market much quicker in Europe than in the United States, an American physician such as myself, who can speak some French or German, can monitor the Europeans and predict future developments in the United States. It’s hard for me to say which knowledge has been of greater benefit to my patients: knowing what will probably turn out to be useful or knowing what to avoid at all costs. I’ve certainly seen plenty of examples of both. What was readily apparent to me was that European doctors en masse were abandoning other injectibles and moving to HA products.

As I learned from my European colleagues and began to develop my own approach to injection technique, I was struck by certain advantages inherent in the hyaluronic products.

First of all, they are soft. There is less of a problem with lumpiness or palpability than in many of the other injectibles. A pair of lips may look beautiful, but if you feel a firm ridge when you kiss them, they lose much of their appeal.

A second advantage that springs from this softness is the remarkable versatility of HA injectibles. With many of the other materials the clinician is limited to a small number of sites where he can inject safely: lip borders, nasolabial creases, and other facial grooves and furrows. With HA injectibles, the highly experienced clinician can actually build up three-dimensional structures in certain facial zones, especially around the lips. This allows for more of a sculptural approach.

A third advantage is durability. HA injectibles persist for months longer than many other forms of soft tissue fillers. To the patient this means fewer trips to the doctor for restoration.

The fourth advantage, non-permanence, may at first seem paradoxical; why wouldn’t it be better just to inject something that will persist for years? After all, there are products out there that supposedly will do just that. There are two powerful reasons why non-permanence is a desirable characteristic. First of all, if the patient doesn’t care for the result, it will eventually melt away. To achieve their true potential HA injectibles require a highly skilled and visually sophisticated clinician on the other end of the syringe. If a patient is treated by someone who lacks these characteristics, at least there is no permanent problem.

An even more important advantage to non-durability came to me during a visit to one of the European medical congresses. I noticed that physicians with a high level of experience and skill who had used so-called permanent injectibles in the past were warning others not to do so in their lectures. In each case, the reason was the same: delayed granulomas. No matter what the material, the message was remarkably similar: at first the doctors loved using a type of injectible, but after several years they began to notice that in a certain percentage of patients changes began to appear in the skin above the area of injection. These changes consist of granulomas: itchy, raised, red bumps that do not go away. As I looked into the record of these injectible materials, I was struck by the similarity of the pattern. Stage I: the physician thought he or she had found a permanent injectible that didn’t cause long-term problems. Stage II: aggressive marketing on the part of the company that manufactures the injectible material and uncritical acceptance on the part of certain physicians. Stage III: several years later the physicians discovered delayed granulomas.

These problems shouldn’t happen in my practice, as we follow a simple principle: only use materials for facial soft tissue augmentation that nature put there in the first place. That means we use the patient’s own fat for deep volume restoration and collagen or hyaluronic products closer to the surface of the skin. These are the very things that thin out with the aging process, so why not simply put them back?

WHAT IS THE WORLD WIDE EXPERIENCE WITH HYALURONIC INJECTIBLES?

When it comes to facial injectibles, there truly is safety in numbers. The more patients who have been treated with a given material and the longer the treatment experience, the more intelligently one can talk about safety. If I were considering treatment with a facial filler, the first question I would ask is, “How many people have been treated with this material?” If the clinician who will be treating you cannot answer this question, I would think twice about their commitment to patient care.

It is reassuring that over one million facial soft tissue augmentations have been carried out with HA injectibles.

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