Dr. Little’s Philosophies
Injectables in Facial Rejuvenation: Fillers and Botox™
A popular and non-surgical option in facial rejuvenation entails the injection (usually in the office) of dermal fillers (such as Restylane™) and/or botulinum toxins (such as Botox™). While these injections can be especially helpful in combating the earlier signs of aging, they become increasingly less so in the face of established structural aging with soft-tissue descent, jowl formation, and neck deterioration. Also, both offer only a limited period of effectiveness and, therefore, require repeated reinjection for prolonged results. While many regard such temporary effectiveness as a major drawback in their use, Dr. Little finds that it also presents a “blessing in disguise;” when either product produces an unnatural or unwanted result, this negative effect usually corrects itself, as the injections themselves wear off.
Modern fillers such as Restylane™ (and an increasing variety of other products) offer another way to add volume to areas of the face. Dr. Little approves of such fillers, so long as they do not contain permanent particles (which may develop later serious problems in a small number of patients). But while he considers them a practical alternative to fat grafting, he does not condsider them the equivalent of living fat grafts. He believes, however, that plastic surgery is a richer specialty for having both modalities to offer patients.
Fillers, of course, bring their own particular advantages. They do not require a harvesting procedure or donor site, for example, as they come prepackaged, “right out of the syringe.” And they are far easier to inject and place smoothly than are living fat grafts (without the long “learning curve” required for expertise in structural fat grafting). Also, they may perform as well as fat grafts in specific situations, such as correction of the etched nasolabial fold (along the lower nose and mouth) when facelift will not be performed. And if there are problems after their use, such as lumps or irregularities, these problems–as mentioned–most often disappear as the filler itself disappears (so long as there are no permanent components). Also, the HA fillers (hyaluronic acids, such as Restylane™) present the additional advantage of an available “eraser” (the enzyme hyaluronidase) that can be injected to break them down rapidly, without having to “wait them out.”
But this advantage, as cited, uncovers a key disadvantage of their use: their limited survival, which necessitates their ongoing, repeated reinjection. While efforts to extend the effective lifetime of certain products have met with some success, it is unlikely that fillers will ever approach the long-term, lasting nature of expertly-placed living fat grafts. Nothing lasts forever, of course, but Dr. Little has found that the results of his structural fat grafts have lasted at least as long as the suspensory effects of his facelifts (a decade or more). Also, fillers present foreign elements contrasted with a patient’s own living fat cells or “self” (against which the body will not react). Finally, fillers cannot provide the reparative benefits to the overlying skin that many believe accompany proper fat grafting (by way of mesenchymal stem cells).
Injectable paralytics derived from the Clostridium botulinum bacterium (such as Botox™) offer a safe and straightforward option to diminish facial creases and folds (rhytids) caused by excessive muscular tone and activity. Initially applied largely to the areas around the eyes (especially forehead creases, frown lines between the eyebrows, and crow’s feet), they have also been found useful throughout face, bringing improvements to such aging stimata as the bitterness fold, lip lines, and neck bands. They may also be used to treat muscular imbalances brought on by aging, thereby improving the position and shape of the eyebrow or corner of the mouth, for example. Over-use may produce a leaden, expressionless quality best avoided by a tasteful restraint on the part of the injector. Again, the duration of action is strictly limited, requiring reinjection to maintain the desired effect. While they remain effective against rhytids caused by muscle activity, however, they become progressively less effective in the face of aging, soft-tissue descent, where folds are increasingly the result of tissue laxity and flaccidity, as opposed to increased muscle tone.
Illustration: detail from Leonardo da Vinci, “Geometrical decorative drawings,” Codex Atlanticus, fol. 342v, Biblioteca Ambrosiana, Milan