Beyond Botox, Juvederm, Restylane and Perlane

by Mina J. Grasso, NP

With medspas sprouting in cities across the United States, terms like Botox, Juvederm, Restylane and Perlane are heard more often in all types of circles. Using a magical combination of these tissue fillers and botulinum toxin A, patients can look years younger within minutes to a few days, depending on the potion. Although the effects of some of these products can last up to a year, people who seek to more aggressively turn back the clock continue to ask for treatments with longer lasting effects. Collagen stimulators can help meet this goal.

As the face ages, it loses volume. This causes the youthful contours and prominent landmarks of the middle and upper face to shift. A common analogy is a plump grape turning into a raisin. Loss of facial fat, muscle and bone, as well as loss of skin elasticity, leads to the development of nasolabial folds, so-called marionette lines, jowls and wrinkles around the lips.

Dermal atrophy, decreased elastin fibers, decreased collagen and decreased hydration all contribute to the appearance of an aged face. Fat loss also plays a causative role.

Fat loss in the face redistributes maxillary and infraorbital fat pads. The infraorbital fat pads may herniate from beneath the eye, causing effects ranging from an uneven or lumpy appearance to bagginess. The facial muscles are actually losing muscular bulk, just as our biceps and pectorals lose the bulk they may have had in youth.

The complex array of muscles that support our facial dermis and adipose tissue are undergoing a similar reduction in size. Experts believe thinning sinewy facial muscles are more visible due to the aforementioned losses of overlying tissue and cause increased (hyperdynamic) facial expression due to increased radiation of expression lines with movement (dynamic expression lines).

A vivid example of this is the hint of a smile line on the lateral side of the eyes. With age, these degenerate to crow's feet lines radiating 2 to 3 inches up to the temples and equally down the cheeks, creating a "roadmap" on the face.

A more recently documented source of substantial volume loss is bone loss around the eyes, teeth, maxilla and jaw. The exact pattern and speed of bone recession is dictated by genetics.

Fillers such as collagen and hyaluronic acid (HA) can replace lost volume under wrinkles and lines in multiple areas of the face. For many years, bovine collagen was the only option for this. Allergy to bovine collagen, coupled with its 3-month duration of effect, prompted the development of alternatives. Aesthetics practice changed dramatically with the introduction of hyaluronic acid products.

Restylane, Juvederm and Perlane are the three most popular HAs due to increased stability with their cross-linking. These products attract water and cause the skin to appear and feel soft and smooth, a result of an even layer of hydration. The effect of HAs is immediate, and the duration of effect varies from 3 to 12 months, depending on the product used and the area treated.

Calcium hydroxylapatite (Radiesse) is a natural constituent of teeth and bone that acts as a collagen stimulator. Radiesse has proven to be versatile due to its ability to act as a kind of scaffold supporting the skin. It is used to augment the chin, cheeks, deep nasolabial folds and other areas where larger volume is required. After a few weeks, the injected material softens and acts as a framework for the skin to fill with its own collagen. Proper placement can provide natural-appearing cheek and chin augmentation. When the cheek is lifted, the nasolabial area gets a "lifting" effect, reducing the appearance of the fold. In addition, the back of the hands can be injected with Radiesse to replace lost volume.

Poly-L-lactic acid (Sculptra) is the most potent collagen stimulator, but it has no immediate filling properties when injected. Sculptra was initially used as a treatment for HIV-positive patients who took antiviral medication. These drugs cause gradual facial fat loss, or lipoatrophy, that results in sunken cheeks, indentations and hollow eyes.

With Sculptra, substantial improvement over baseline is still evident after 2 years. It is a safe, synthetic and biocompatible material that provides a gradual and significant increase in skin thickness, improving the appearance of folds and sunken areas. A series of three to six treatments is required, with each treatment spaced 4 weeks apart. The back of the hands can also be treated with Sculptra. In this area of the body, volume replacement occurs gradually over several months.

Mina Grasso is a nurse practitioner who owns Allure Image Enhancement, Inc. in Upland, Calif. She is a member of the ADVANCE for Nurse Practitioners editorial advisory board.

Filler or Stimulator?

Collagen Filler

Today's skin fillers typically contain harvested fat, collagen derived from bovine or human sources, hyaluronic acids or a type of calcium. Each of these fillers provides instant results with varying lengths of effect and specific area uses. Fillers are primarily designed to act as a substitute for collagen.

Collagen Stimulator

A collagen stimulator acts differently from a filler. It is not instant, and it is not designed to replace collagen. A collagen stimulator does just what its name implies — it stimulates the production of natural collagen.