Fillers and Injectables: A Historical Perspective
September 2014 | Volume 13 | Issue 9 | Editorials | 1010 | Copyright © 2014
Vivian W. Bucay MD FAAD
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As a dermatologist in private practice, I am honored and humbled by the opportunity to share my filler “journey” with esteemed colleagues and friends in the dermatology community. My first experience with dermal fillers dates back to 1988, while a dermatology resident at the University of Miami School of Medicine. Collagen injection workshops under the tutelage of Fredric Brandt, one of the true giants in the arena of cosmetic injectables, and a colleague to whom so many of us are indebted for his role in enhancing our understanding of facial aesthetics, were a far cry from what I had envisioned to be a part of my formal dermatology training.
From my perspective, our time and focus were best reserved for serious diseases such as AIDS and its many cutaneous manifestations, skin cancer, and incompletely understood diseases like psoriasis. With all due respect and deserved recognition to Arnold Klein, a pioneer and leader in the use of injectable collagen,1 intruders like the Paris Lip belonged elsewhere, not in the domain of the highly sought-after and competitive dermatology residency. After all, dermatology, with its roots in internal medicine, was real medicine, making dermatologists, real doctors. Fast forward to 2014, and although a minority may still hold on to the belief that aesthetics does not belong in the realm of dermatology and dermatology residency, a look at the program content of the many conferences sponsored by our specialty societies (eg, AAD and ASDS) in conjunction with the table of contents of any number of our journals, indicate otherwise. Aesthetic medicine is very real and a very real part of dermatology, a specialty so intricately linked to the visual and, as such, capable in its undeniable ability to impact our perceptions of self and others. After all, how many specialties are capable of affecting self esteem?
To that end, powerful medicine must be grounded in powerful science. As with anything, the quest for a deeper understanding inevitably leads to more questions. In her guest editorial for the JDD September 2012 Fillers issue, Amy F. Taub notes “In the United States we have a paltry number of filler brands compared with the rest of the world.”2 I would add that the relatively few filler brands that we have in the US each possess unique qualities that make them particularly suited for certain applications. In the same editorial, Amy Taub states “although not an overlooked area, the upper face/cheek area should have more primacy in the consultation on fillers.” The approval of Juvéderm Voluma® (Allergan) in the fall of 2013 has gone a long way not only to open the door to this important conversation with patients but to highlight the importance of addressing the cheek area when designing a facial rejuvenation treatment plan for patients who complain of nasolabial folds and under eye hollows/tear troughs.
My private practice experience with fillers begins in 1996 with Restylane®, introduced by QMed that year and available in Mexico City where I lived and practiced from 1991-1999. In truth, it was a patient who first told me about injections of hyaluronic acid, the latest treatment for unwanted facial lines. With the arrogance of a US-trained and board-certified dermatologist living abroad, I suggested that she was probably referring to collagen and informed her that hyaluronic acid was a sugar-derived compound capable of holding 1000 times its weight in water, a property that made it especially well suited for inclusion in topically applied cosmetics. Despite the absence of Google searches whether on the computer or smart phone, I somehow learned all about the hyaluronic acid (HA) filler Restylane® and rapidly incorporated it into my growing armamentarium of tools (that already included carbon dioxide ablative laser resurfacing and botulinumtoxinA) to address the aging face.
How had we managed to overlook volume as a critical piece of the puzzle? Even more fascinating is something else I recently learned while attending an advanced injectables workshop led by Brazilian plastic surgeon Mauricio Di Maio: the effect of adequate structural support on muscle function. I had never thought about this relationship, having compartmentalized the applications and indications of fillers and neuromodulators. Di Maio frequently reminds us to go “back to the basics,” referring to a thorough knowledge of facial anatomy and the interdependence of muscles, soft tissues, and bone. An invaluable resource is a brilliantly thought out and beautifully articulated discussion by Rebecca Fitzgerald and Danny Vleggaar in which they examine facial aging as the result of volume loss largely due to loss of craniofacial skeletal support of overlying soft tissue.3 Facial assessments, patient consultations, and injections now take me much longer than they did years ago during the days of blissful ignorance. The more I know, the slower I go.
As our knowledge and understanding of the complexities of facial aging improve, our initial approach of filling lines has been replaced by the more modern approach of volume replacement to restore facial contours. But what about those lines that patients bring to our attention? Do we really have to choose between lines and contouring? For example, in the notable absence