ABSTRACT
Besides the agents covered in other chapters, there are numerous products and techniques whose positions in the field of soft tissue augmentation have not yet been fully defined. The search for the perfect material to eradicate rhytides, smooth scars, and fill traumatic defects continues. New products appear, sometimes with great fanfare, but these sometimes fail to fulfill the promise of a better alternative to what we use. Fibrel, Autologen, Dermalogen, and Softform are no longer available. Isolagen was withdrawn from the market but is now undergoing clinical trials with the expectation that it will be reintroduced. Though no currently available implant fulfills the criteria for being the perfect material, many are adequate for a given task, satisfy patients, and offer excellent safety profiles; but efforts to develop the perfect soft tissue augmentation material continue. Permanent or temporary fillers lasting for many years are not necessarily ideal, however, because problems may persist indefinitely with such fillers. Additionally, the facial architecture with its delicate nuances changes over time and a filler placed in a certain location today may not be ideally placed years from now. Synthetic fillers are appearing in rapid succession, but thus far have failed to match the safety of hyaluronic acid fillers. Obviously, the techniques and substances used for soft tissue augmentation are increasing at an accelerated rate. The choice of implant material should be based on the location of the defect, potential for hypersensitivity reaction, desire for permanency, and the patient’s feelings about the need for a ‘‘natural feel’’ of the implant. Choosing an appropriate injectable implant requires a thorough understanding of the materials available and the etiology of the wrinkle. Fine, superficial
rhytides respond best to therapy at the intradermal level. Deeper, more substantial wrinkles typically have a subcutaneous component, with or without a facial-muscular element, and are best approached from the subcutaneous space. Often a wrinkle will have both a superficial and a deep component, such as the nasolabial fold, and both these components need to be addressed to obtain optimal results. Filler substances are essential tools to be used when treating the face either as stand-alone treatment or in conjunction with laser resurfacing, botulinum toxin, or chemical peels. The difficulty is in choosing the proper treatment techniques and in meeting patient expectations. As newer products develop, the methods of soft-tissue enhancement will continue to change, hopefully bringing improved results to patients. It is a fact that Europe is ahead of the United States in terms of filler availability. At the same time, the greater ease or approval for marketing of medical devices like fillers in Europe (the socalled CE mark), leaves a greater chance for unsafe fillers to be marketed there. While this means that Americans, to a degree, often have to wait for the latest fillers ‘‘to arrive’’ from Europe, this also means that we get the benefit of these products being tested overseas prior to their use here.
