Peels, Fillers, Botox: fact or fiction?
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The public’s interest in acquiring a youthful appearance by rejuvenating their skin has popularized the use of an array of cosmetic procedures. Due to the advances in the field of cosmetics, physicians have many cosmetic products in their armamentarium from which to choose. Deciding which product and procedure will attain the most pleasing results requires in depth knowledge of the products themselves, their proper uses, and the patient’s wishes.

The ageing face shows signs of dryness, fine lines, wrinkles, actinic changes, dyspigmentation, and loss of subcutaneous tissue. Over time both collagen and elastin are degraded and when regenerated do so in a haphazard way leading to loss of resilience and tone of our skin leaving it more susceptible to gravities pull with formation of jowls and the double chin. Our facial expressions are solely dynamic early in life, but due to multiple factors over time, they begin having a static appearance which is accentuated by expressivity. Over time repetitive motion and changes in the skin and subcutaneous tissue can lead to deepening of the nasolabial folds and permanent rhytides of the glabella. Actinic damage leads to irregular maturation of the epidermis, hastening of dermal haphazardness, and dyspigmentation of the skin. Loss of subcutaneous fat of the face also occurs beginning from the cheeks and eventually affecting the temples. With loss of this tissue, more lines are noticeable both statically and with expression.

When evaluating a patient, two objectives must be met for excellence in care: the patient’s desires must be understood and the physician’s evaluation of the patient must be accurate. It is important that the physician understands what the patient perceives as their problem area which seems simple, but can take time. An effective method of conveying information efficiently is by having the patient create a “wish list” of five things they would change about their appearance with the most important feature first on the list. This list should be reviewed with the patient having them demonstrate in the mirror exactly what is meant by each topic on their list, and adding our own suggestions as appropriate. Asymmetries should be pointed out to the patient, recorded in the chart, and recorded photographically before any treatment if received. Changes in the skin due to inherent aging, actinic damage, and loss of subcutaneous tissue with respect to the patient’s skin should be reviewed with the patient. Sometimes this is best done while a patient is looking into a mirror. Rhytides caused by recurrent movement verses changes in the skin caused by increased laxity and gravity and the treatment for these separate issues should be distinguished. It is important that the patient have realistic expectations and are educated on which treatment would be best for their particular concern and why. Treatment options are then reviewed with the patient beginning with simple procedures and combined simple procedures with little down time and ending with more long lasting procedures requiring significant down time. Prior cosmetic procedures are reviewed with the patient. If the patient has not had augmentation procedures before, we typically recommend beginning with a product that lasts the least amount of time so that the patient can decide if augmentation if right for them and whether they would like a degradable or permanent filler. Although permanent fillers have the advantage of fewer injection sessions to maintain a desired affect, there is less of a margin of error when injected and the products can shift over time and with muscular movement. Also as the face ages, the site first injected may not be the ideal site for injection five or ten years later in life leaving an unnatural appearance to the area. The cost of each procedure is reviewed with the patient and written information is given to the patient. They can either proceed with treatment or can schedule a future appointment after considering their treatment options.

The ideal patient for any cosmetic procedure is one that understands the risks and benefits of the procedure and has realistic expectations. If a patient wants more improvement than soft tissue augmentation can offer or has a prominent cheek overhanging the nasolabial fold, a better option may be a face lift or a feather lift. On the other hand, a patient who has almost no perceivable signs of skin aging and wants augmentation may better be treated with a good skin care regimen and possibly a noninvasive laser or microdermabrasion procedure.

Analyzation of the patient with photoaging skin must include skin color and skin type as well as degree of photoaging. Evaluation of the skin needs to be done in a systematic manner. Various classification systems are available and a combination of three systems to help the physician define the right program or therapeutic procedure for the patient will be presented here. The Fitzpatrick skin type system classifies degrees of pigmentation and ability to tan. (Fitzpatrick TB. The validity and practicality of sunreactive skin types I through VI. Arch Dermatol 124:869-871, 1988) Graded I through VI, it prognosticates sun sensitivity, susceptibility to photodamage, and ability of facultative melanogenesis. In addition, this system classifies skin according to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin types I and II are pale white and freckled with a high degree of potential to burn with sun exposure. Skin types III and IV can burn but usually have an olive to brown coloration. Skin types V and VI are dark brown to black skin that rarely ever burn and usually do not need sunscreen protection. See Table 1

The Glogau system classifies severity of photodamage, taking into account the degree of epidermal and dermal degenerative effects. (Glogau RG. Chemical peeling and aging skin. J Geriatr Dermatol 2(1):30-35, 1994.) The categorization is I through IV, ranging from mild, moderate, advanced, and severe photodamaged skin. These categories are devised for therapeutic intervention. Category I or minimal-degree photodamage can be treated with light chemical peeling and medical treatment. Categories II and III would entail the above and medium-depth chemical peeling, soft tissue augmentation and /or Botox, and category IV would need those modalities listed plus cosmetic surgical intervention for gravitational changes including aptos threads. See Table 2.

Monheit has devised a system of quantitating photodamage, developing numerical scores that would fit into corresponding rejuvenation programs. In analyzing photodamage, the major categories include dermal with textural changes and epidermal with skin lesions. Dermal changes include both dynamic and static rhytides, fine lines, sallow color and dyschromia, leathery, thin and parchment-like, pebbly or nodular skin, and pore size and number. Epidermal changes incude number of freckles, lentigenes, telangiectasias, seborrheic keratosis, actinic keratosis, skin cancers, and senile comedones. Each section is given a score and the final score is tabulated. A score of 1-6 represents very mild damage and the patient would adequately respond to a skin care program including sunscreen protection, retinoic acid, glycolic acid peels, and selective lesion removal. A score of 7-11 would include all of the above plus a repetitive superficial peeling agents program such as glycolic acid, Jessner’s solution, or lactic acid peels and laser therapy for pigmented or vascular lesions. A score of 12-16 would include medium-depth chemical peeling with the addition of skin fillers and/or Botox when needed, and a score of 17 or more would include the above plus deep chemical peeling or laser resurfacing. (Figure X: Index of Photoaging)

Most patients have a skin care regimen in place having tried many over the counter products by the time they make an appointment with their physician and are ready for a “procedure”. In every patient seen, skin care should be reviewed and the importance of a daily sunscreen and sun avoidance techniques should be stressed. To avoid eventual deep furrowing of the skin, smoking should be ceased if applicable. When appropriate the strongest tolerated Retin-A product should be prescribed to the patient and glycolic acid skin care products can also be used to contribute towards a youthful appearance.

Need chart for surgery course for AAD per Monheit
The areas to be rejuvenated should then be reviewed with the patient. According to the patient’s desires and scores on the above scales, modalities of treatment should be selected. Table X (chart for surgery course for AAD per Monheit) When photoaging is the primary concern of the patient, lunchtime procedures including microdermabrasion, superficial peels, radiofrequency skin tightening, and intense pulsed light can be used. More aggressive forms of treatment with significant down-time include medium depth peeling, laser resurfacing, and dermabrasion. When dynamic rhytides are attaining permanency or Crow’s feet are of concern, chemodenervation methods such as with Botox or Dysport can be used with no down-time. When static rhytides have formed or folds have become deeper or more prominent or contour irregularities of aging are present, a filler substance can be used. Choosing a filler substance to best suit the patient is imperative. If the cheeks or marionette lines are prominent with gravitational pull, aptos threads or a lifting procedure would best suit the patient. A combination of procedures may increase the effectiveness and longevity of each procedure preformed. The amount of time to recover from the procedure is a trade-off of the procedures efficacy and may dictate which procedure or procedures are preformed. A realistic treatment goal should also be discussed with the patient.
Fillers:
Natural youthful contouring of the face can be achieved with soft tissue augmentation. The improvement achievable with soft tissue augmentation depends on the amount of the implant used, the type of implant, the frequency of implantation, and the intrinsic qualities of the contour defect. A single implant or multiple implants can be used to attain the desired affect. For example, if a patient presents with fine lines radiating from the nasolabial folds, the best treatment would be one utilizing an injectable filler specific for fine lines and filling the nasolabial folds with a more appropriate filler for deeper furrows. This method works best when a few of the fine lines are treated followed by filling of the folds, then returning to finish the filling of the fine lines. At times after filling the deeper folds, certain fine lines become more noticeable or new ones occur. Another injection method is to inject both collagen and hyaluronic acid at the same visit and into the same treatment sites. This method is best used to treat deeper furrows, and by layering the two, a synergistic affect may take place lengthening the time of degradation of the products compared to the time of degradation of individual injections. With some products benefits are noticeable the day they are injected, with others, 1-2 weeks are needed before the product has maximum benefit. Some products last for four-six months while others last six to nine months or are permanent. While the cosmetic benefits of filler substances have been proven, the risks and benefits ratio should be reviewed with the patient. Side effect profile of each injectable chosen should be presented to the patient who if sensitivity to the product occurs, will likely have the side effect till degradation of the product is complete.

A thorough medical history, family history, and physical exam should be done with each patient when considering treatment with a filler substance. Any history of collagen vascular diseases (CVD) should be noted. There have been conflicting studies associating injectable collagen to certain CVDs, however, no causal relationship between collagen injections and CVDs has been established. Bleeding disorders or anticoagulation medications should be noted. Bruising occurs more frequently when an anticoagulant is used and the patient should be aware of this possibility. Ice and pressure are good methods to decrease the amount of bruising and pain. Any asymmetries in the patient’s appearance should be noted and brought to the attention of the patient. Asymmetries should also be documented in the chart for legal purposes.

Injectable bovine collagen was developed in the 1970s. Today bovine collagen (Zyplast) remains the gold standard for which other filler products are compared. Permanent injectable collagen, Artecoll, was developed as a long lasting alternative to Zyplast. Recent advances in filler substances include human fibroblast derived collagen (Cosmoderm and Cosmoplast), hyaluronic acid derivatives (Restylane and Hylaform), calcium hydroxylapatite microspheres (Radiance FN), and polylactic acid microspheres (Sculptra). Autologous fat transfer leads to a more permanent result with no chance for allergy or hypersensitivity to one’s own fat, but with significant down-time.

In general, the collagen derivative filler substances last three to four months. The bovine collagen derivatives (Zyderm and Zyplast) require a test implantation before treatment and approximately 3% of the population are sensitive to the product with the sensitivity lasting the longevity of the product. (Elson ML. The role of skin testing in the use of collagen injectable materials. J Dermatol Surg Oncol 1989;15:301-3 and Watson W, Kay RL, Klein AW, et al. Injectable collagen: a clinical overview. Cutis 1983;31:543-6.) There have also been some reports of adverse events with bovine collagen even with a negative test implantation site including systemic hypersensitivity and granuloma formation at the injection site. ( Stegman SJ, Chu S, Armstrong RC: Adverse reactions to bovine collagen implant: Clinical and histologic features. J Dermtol Surg Oncol 14(Suppl):39-48, 1988
Labow TA, Silvers DN: Late reactionsat Zyderm skin test sites. Cutis35:154-158, 1985. Overhold MA, Tschen JA, Font RL: Granulomatous reaction to collagen implant, light and electron microscopic observations. Cutis 51:95-98, 1993.
Cucin RL, Barek D: Complications of injectable collagen implants .Plast Reconstr Surg 71:731, 1983.)

Artecoll consists of bovine collagen and purified polymethyl-methacrylate (PMMA) microspheres. In addition to adverse events similar to those of bovine collagen there is a low but true risk of allergenicity to the PMMA microspheres which can cause a prolonged allergic response due to the permanence of this product. (Lemperle G, Romano J, Busso M. Soft Tissue Augmentationwith Artecoll: 10-Year History, Indications, Techniques, and Complications. Dermatol Surg 2003;29:573-587.)

Nonbovine collagen (Cosmoderm and Cosmoplast) is also available. These collagen products are less antigenic than their bovine counterparts and safety tests have deemed them free of any pretreatment test sites.

Restylane and Hylaform are injectable hyaluronic acid derivatives. They were developed primarily as an alternative to collagen injections for soft tissue augmentation. One of the advantages to injectable hyaluronic acid derivatives versus collagen is the potential longevity of the product in tissue typically lasting 6-8 months. Another advantage is the increased biocompatibility. Although the injectable hyaluronic acids seem as though they should be free of side effects, reported sensitivity to the products have been published and therefore patients should be warned of these potential sensitivities.
Micheels P. Human anti-hyaluronic acid antibodies: is it possible? Dermatol Surg. 2001 Feb;27(2):185-91.
Lowe N, Maxwell CA, Lowe P, Duick M, Shah K. Hyaluronic acid skin fillers: adverse reactions to skin testing. JAAD 2001;45:930-3.
Friedman PM, Mayfong EA, Kauvar AN, Geronemus RG. Safety data of injectable nonamincal stabilized hyaluronic acid for soft tissue augmentation. Dermatol Surg. 2002 Jun;28(6):491-4.
Fernandez-Acenero MJ< Zamora E, Borbujo J. Granulomatours foreign body reaction against hyaluronic acid: resport of a case after lip augmentation. Dermatol Surg. 2003 Dec;29*12):1225-6.
Lupton JR, Alster TS. Cutaneous hypersensitivity reaction to injectable hyaluronic acid gel. Derm Surg 2000;26:135-7.
Raulin C, Greve B, Hartschuh W, Soegding K. Exudative granulomatous reaction to hyaluronic acid. Contact Dermatitis. 2000 Sep;43(3):178-9.

Calcium Hydroxylapatite (CaHA) is an inorganic substance that mimics the structure of bone. In the United States, it is marketed as Radiance where it is used off label for soft tissue augmentation. In its soft tissue injectable form, CaHA microspheres are suspended in a carboxycellulose absorbable gel, and it is injected into the dermis or subcutaneous tissue. As the gel is absorbed, collagen deposition into and around the microspheres causes collagen formation and enhances augmentation. It is expected to last between two to five years and its break down products include calcium and phosphorous.
Sklar JA, White SM. Radiance FN: a new soft tissue filler. Dermatol Surg. 2004 May;30(5):764-8.

Poly-L-lactic acid (PLLA) received conditional FDA approval for treatment of HIV-related lipoatrophy under the trade name Sculptra on March 2004. The FDA has not yet approved Sculptra for general cosmetic use in the United States, however, studies of this product are currently underway to gain FDA approval. Poly-L-lactic acid has been marketed as New-Fill in Europe since November 1999.

PLLA is a synthetic polymer which is resorbable, biocompatible, and biodegradable. It has been used for several years in multiple medical devices and is a component of vicryl suture. PLLA can be injected into the deep dermal tissue or subcutaneous tissue to correct generalized contour defects. The area to be filled should be undercorrected. After injection, gradual degradation takes place by hydrolysis while gradual deposition of collagen occurs.
Nayak, PL. Biodegradable polymers: opportunities and challenges. JMS Rev Macromol Chem Phys, 1999, C39(3):481-505

The initial apparent correction, due to implantation of the PLLA decreases over the next few days as the diluent is resorbed. The area treated with PLLA will then slowly refill as the tissue reacts to the implant. A gradual increase in the volume will continue to occur over the next few months.

The side effects of this material are similar to other injectables and include erythema, edema, and bruising at the injection site. Palpable but nonvisible subcutaneous nodules have been noted in some patients which can resolve spontaneously. These nodules may be due to over-correction. Massaging the treated area after injection may reduce the incidence of this side effect. Rare cases of sterile abscess, late granuloma formation and hypersensitivity reactions have been reported.
Moyle GJ, Lysakova L, Brown S, Sibtain N, Healy J, Priest C, Mandalia S, Barton SE. A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection.
Lombardi T, Samson J, Plantier F, Husson C, Kuffer R. Orofacial granulomas after injectionof cosmetic fillers. Histopathologic and clinical study of 11 cases. J Oral Pathol Med. 2004 Feb;33(2):115-20.
Valantin MA, Aubron-Olivier C, Ghosn J, Laglenne E. Pauchard M, Schoen H, Bousquet R, Ktz P, Costagliola D, Katlama C. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open label study VEGA. AIDS. 2003 Nov 21;17(17):2471-7.

Autologous fat transplantation can be an effective treatment for subcutaneous augmentation that may produce permanent results in some cases. Fat transplantation can be used to treat generalized contour defects of the face. Typically swelling, bruising, and soreness will last from 3-7 days after the procedure depending on how much and where the fat is injected. Fat is harvested from a donor site and different techniques can be used to inject the fat into the contour deficiencies. Four injection techniques are used: immediate injection into the subdermis, immediate injection into multiple tissue planes from the periostium upwards, freezing and storage of fat for monthly low-volume augmentation with or without immediate injection, and emulsifying of fat and injection into the dermis with or without immediate subdermis injection. Overcorrection is necessary as the unviable fat will be resorbed. Small and repeated implantation results in less down-time.
(Fournier PF. Fat Grafting: My Technique. Dermatol Surg 2000;26:1117-1128
Markey AC, Glogau RG. Autologous Fat Grafting: Comparison of Techniques. Dermatol Surg 2000;26:1135-1139.)

Injectable implants are typically as effective as the product packaging claims as long as the products are injected as directed on the package insert. Variables in efficacy can be noted if the material is injected into the subcutaneous tissue causing much less augmentation compared to when it is injected correctly into the dermis. If the injectable implants are injected too superficially, a beading look to the skin can occur. The beading will eventually decrease with time, decreasing fastest in areas with the most movement. At times when injecting into the dermis and inserting the needle in a forward fashion, the injectable material can be extruded into an area of the dermis that is not the ideal site. Firm massage of the injected sites can help to smooth the contour of the injectable filler and guide the filler to a more optimal location albeit minimally.

Injecting material can cause considerable discomfort in some patients especially when injecting into the nasolabial folds, with maximal discomfort occurring at the superior aspect of the nasolabial folds. Some injectables contain an anesthetic which helps with the pain of injection. Countermeasures to avoid pain include topical anesthetic, ice, infraorbital nerve block, or simultaneous stimulation with a massaging apparatus. While it may be tempting to inject an anesthetic into the area to be treated, this can distort normal contours and should be avoided. Topical anesthetics help to decrease the pain of the needle puncture, but help minimally with the injection itself or the forward motion of the needle through the dermis. Infraorbital nerve blocks or counter nerve stimulation have mixed results, but do help to lessen the pain.

Peeling and Resurfacing:
The Fitzpatrick type skin classification allows for easy identification of which patients may experience pigmentary abnormalities after a resurfacing procedure. The side effect profile increases both with depth of peel and darkness of skin. As with all patients receiving a peel or other resurfacing procedure, the patient with Fitzpatrick type I or II skin with significant photodamage needs regular sunscreen protection before and after resurfacing procedures. The patient does, however, have only a small risk for hypopigmentation or reactive hyperpigmentation after a chemical peeling or resurfacing procedure. The patient with type III through VI skin has a greater risk for pigmentary dyschromia-hyperpigmentation or hypopigmentation, after a chemical peel and may need post-treatment bleaching agents in addition to sun prevention to prevent these complications. Pigmentary risks are generally not a great problem with superficial chemical peeling but may become a significant problem with medium and deep chemical peeling. Chemical peeling can also be a significant risk when regional areas such as lips and eyelids are peeled with a resurfacing laser, creating a significant color change in these cosmetic units compared to the rest of the face. This has been classified as the “alabaster look” seen with taped deep chemical peels in regional areas. Avoidance can be achieved if a blending medium depth chemical peel is used in regions abutting the laser resurfaced area. The chemical peel should be preformed first as to not place the peeling agent into denuded skin leading to greater penetration. The physician must inform the patient of this potential problem, especially if the patient is of skin type III through VI; justify the benefits of the procedure; outweigh these risks; and plan for the appropriate techniques to prevent these unwanted changes in color.

Chemical peeling and a laser resurfacing can lead to accentuation or new development of telangiectasias. Dermabrasion is the only resurfacing method that can decrease the number of telangiectasias during treatment, however as the skin rejuvenates, telangiectasias can develop as a natural part of the healing process.

Significant healing time is needed after a medium or deep resurfacing procedure. The patients must be reliable and able to make follow-up appointments for evaluation of the healing process, follow the directions of topical wound care, and take antibiotics and antivirals as prescribed. Patients with current or history of neurotic excoriations or aggressive picking behaviors should be treated with caution if at all with a resurfacing procedure since during the healing time the epidermis should not be disturbed except when doing wound care to ensure proper healing. Picking of the skin and infection can both lead to scarring. Patients should be aware that during the healing process, pruritus is a common symptom and cool compresses can be used with an antihistamine for treatment. Occasionally candida has been cultured out of wounds and should be treated, however, a moderate amount of staphylococcus will colonize any wound.

To minimize edema, we treat our resurfacing patients with 40 mg IM Kenalog after the procedure. This does not seem to slow wound healing and in fact likely speeds healing to the decrease in inflammation and edema.

Botulinum toxin used in conjunction with resurfacing techniques may lead to greater collagen deposition and therefore better post-operative results. This could be do to the lack of movement of the injected areas causing less collagen resorption . Treatment with botulinum toxin should take place at least one week before the resurfacing procedure to ensure full effect of the toxin.

Botox:
For cosmetic use, Botox is most commonly injected in the upper face for smoothing out the glabella and forehead and lifting the brow. Evaluation of individuals for symmetry, brow ptosis, and underlying musculature is crucial when treating forehead rhytides and lifting the brow. If asymmetry is present, it should be brought to the attention of the patient. Photographs not only help to track objective changes with treatment but also help to remind the patient of their progress or prior asymmetries. In order to decrease the incidence of brow ptosis it is important to identify those patients who compensate for brow ptosis by recruiting the use of the frontalis muscle to subconsciously lift their brows to a natural level. In those patients who recruit the frontalis muscle to prevent brow ptosis, injection of low dose BOTOX approximately 2.5 cm above the brow lessens this potential side effect.(Goodman G: Botolinum toxin for the correction of hyperkinetic facial lines. Aust J Dermatol 39:158-163, 1998 and Carruthers and Carruthers; Seminars in Cutaneous med and surg. Botulinum Toxin Type A: History and Current Cosmetic Use in the Upper Face) Brow elevation occurs by contraction of the frontalis and/or relaxation of the brow depressor muscles. The goal of treatment of the forehead rhytides is to soften these lines without causing brow ptosis or complete loss of facial expression. There have been several studies done to determine optimal dosage and treatment sites.

When injecting the lower face, it is important to ask the patients if a weakness in their oral aperture will be acceptable as weakening of the orbicualris oris can lead to lessened ability to play a wind instrument, kiss, or enunciate certain sounds.
Botulinum Toxin typically last three to four months when injected. Upon repeat injections, muscular atrophy can occur and toxin tends to last approximately four to six months.

Redraping procedures:

Aptos:

Miniface lift:

Conclusions:

The key to successful cosmetic treatments include both the patient’s viewpoint and the clinician’s expertise. Many products are available and if used correctly lead to excellent cosmetic results. The recovery time and product cost allowed by the patient can dictate which procedures can be preformed. Synergism between products has been noted and multiple products can be used at the same or interval visits. Starting slow with short lasting products can allow the patient to evaluate a particular look without permanency allowing movement to longer lasting products and procedures as desired. In our youth driven society, cosmetic procedures will continue to thrive, and skilled, educated physicians can continue to develop and better the field of cosmetics.