Filler Materials Medical Aspects

Filler MaterialsMedical Aspects

Prof. Dr. med. P. GrafMunich

Aesthetic Operations/Treatments

Aesthetic Operations/Treatments in the USA 2000-2012 (Source: ASPS)

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Breast Augmentation

Blepharoplasty

Liposuction

Rhinoplasty

Abdominoplasty

Botulinumtoxin

Operations versus Minimal invasive Treatments

Aesthetic/Reconstructice Operations/Treatments 2000-2012 in the USA (Source: ASPS)

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total, operative cosmetic

total minimal nivasive cosmetic

total cosmetic

total operative reconstructive

Filler-Material (Selection)

Silicon Polytetrafluoräthylen (PTFE) Collagen Hyaluronic Acid

Acryl (Plexiglas)

Polyacrylamid

Poly-L-lactic acid

Calcium-Hydroxylapatit

Autologous Tissue (Fat)

Filler Material (Composition)

Plastic Material Silikon PTFE PMMA

Organic Material Collagen Hyaluronic Acid Autologous Fat

Filler Material (Consistency)

hard Silicon PTFE Goldthreads

„ liquid“ Collagen Hyaluronic Acid Acryl Microspheres Autologous Fat

Silicon (Hard Consistency)

inert Material Nonresorbable No indication as filler material for wrinkles Deep positioning Indication for contour improvement (Breast, chin,

etc.)

Silicon (Chinaugmentation)

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Collagen

Low Immunogenicity (3%) Resorbable Superficial and deep Positioning Bovine spongiform encephalopathy (BSE)

Hyaluronic Acid I

No Immunogenicity Resorbable (6 Months) Superficial and deep positioning

Hyaluronic Acid IIPattern of Intercellular Space

The intercellular space of the skin is filled by collagen fibers which are located in a matrix of polysaccharides (=hyaluronic acid).

Hyaluronic Acid IIIMicrostructure, Properties

An important function of hyaluronic acid is its property of water retention.

Hyaluronic Acid IVIntradermal/Subdermal Positioning of Filler

Hyaluronic Acid VInjection Technique

Linear Injection technique

Serial step-by-stepInjection technique

Hyaluronic Acid VILip Augmentation

Nonresorbable Filler MaterialAcryl-derivates, Calcium-Hydroxylapatit, Poly-L-Lactic Acid, etc.

Non- / Low-Resorbable Deep Positioning Immunogenicity ? -Foreign Body reaction

-Inflammation-Infection-Fistula

Complications I Transdermal Migration of Acryl Microspheres (PMMA), (=Plexiglas)

Complications IIintravascular Injection

Skin necrosis after accidental intravascular injection of PMMA

Complications IIIBlindness

from:Complications of Injectable Fillers, Part 2: Vascular Complications Aesthetic Surgery Journal Claudio DeLorenziy 2014 34: 584-600

Bacterial Biofilm I

A biofilm is any group of microorganisms in which cells stick to each other on a surface. These adherent cells are frequently embedded within a self-produced matrix of extracellular polymeric substance (EPS). Biofilm extracellular polymeric substance, which is also referred to as slime (from: https://en.wikipedia.org/wiki/Biofilm)

from:https://en.wikipedia.org/wiki/BiofilmResp.from: Looking for Chinks in the Armor of Bacterial Biofilms Monroe D PLoS Biology Vol. 5, No. 11, e307 http://biology.plosjournals.org/perlserv/?request=slideshow&type=figure&doi=10.1371/journal.pbio.0050307&id=89595

Bacterial Biofilm II

“Biofilms are ubiquitous. Nearly every species of microorganism, not only bacteria have mechanisms by which they can adhere to surfaces and to each other. Biofilms will form on virtually every non-shedding surface in a non-sterile aqueous (or very humid) environment.”

“Biofilms can grow in showers, pipes, on teeths, catheters, contact lenses, heart valves, etc.”

https://en.wikipedia.org/wiki/Biofilm

Bacterial Biofilm IIIin Soft Tissue Fillers

Bacterial biofilm formation and treatment in soft tissue fillersMorten Alhede et al. April 2014Pathogens and Diseasedoi: 10.1111/2049-632X.12139

„…Evaluation of treatment strategies showed that once the bacteria had settled (into biofilms) within the gels, even successive treatments with high concentrations of relevant antibiotics were not effective. Our data substantiate bacteria as a cause of adverse reactions reported when using tissue fillers, and the sustainability of these infections appears to depend on longevity of the gel. Most importantly, the infections are resistant to antibiotics once established but can be prevented using prophylactic antibiotics. …“

ComplicationsInflammation, Foreign Body Reaction, Fistulas

Consequences

Think!

Would you like to have a permanent filler?

Do you inform your patients who ask for permanent fillers about foreign body reactions, inflammations, infections, fistulas?

Do you inform about alternatives (hyaluronic acid, fat transfer)? Antibiotic prophylaxis?

Fat Transplantation by E. Lexer in Munich

Autologous Fat TransplantationApplication

Neurosurgery Ophthalmology Urology Aesthetic Surgery etc.

Autologous Fat TransplantationLipofilling

No immunogenicity Resorption Deep positioning (subcutaneous) Operation

Autologous Fat TransplantationHealing Process

Autologous Fat TransferResorption

Causes of trauma to transplanted fat grafts By suction of fat (mechanical, high vacuum) By preparation of graft (mechanical, drying) By injection of fat graft (high pressure) By late ischemia within the body (high tissue pressure)

Rates of Resorption in Literatur 20 - 100%Own Investigations: 55,6% (47 - 68%)

Autologous Fat TransferMinimization of Resorption

Avoid potentially damaging substances (Adrenalin?) Gentle suction (diameter of canula, size of vacuum) Atraumatic preparation of fat graft Careful preparation („ Cleaning“) of aspirated fat Careful Injection (short, thick canula) Good dissemination of graft Avoid high tissue pressure

Atraumatic treatment is critical forRates of resorption (=success) of fat transfer

Autologous Fat Transfer Operative Technique

Autologue Fat Transfer “Cleaning“

Autologous Fat Transfer Injection

Autologous Fat Transfer nasolabial

Die Darstellung präoperativer Fotos in ärztlichen Internetseiten ist in Deutschland leider nicht erlaubt

Die Darstellung präoperativer Fotos in ärztlichen Internetseiten ist in Deutschland leider nicht erlaubt