Filling in skin of colour
Prof Mukta Sachdev, Dr Keerthi Velugotla and Dr Archana Samynathan share their approach to using injectable dermal fillers in skin of colour
Volume replacement and soft tissue augmentation are the key components of anti-ageing procedures and hyaluronic acid fillers with lignocaine are the most commonly used. In India there is rapid increase in patients who are interested in minimally invasive aesthetic treatments. Filler injections comprise a significant number of these treatments, either alone or in combination with chemical peels, neuromodulatory toxin injections and lasers. Aesthetic treatments in skin of colour require expertise in foreseeing complications and managing specific issues.
When compared to the western population, knowledge of the cultural practices and local perception of traditional beauty and attractiveness are critical in deciding the technique and placement of filler injections. In a global community it is necessary to understand the aesthetic perception and cultural differences to manage and meet the patient’s expectations.
Indications of dermal fillers
Unlike toxin injections, which are treatment of choice for dynamic lines, the key indications of fillers are static lines, wrinkles and volume augmentation.
• Nasolabial folds
• Forehead lines
• Glabellar lines
• Tear trough rejuvenation
• Nose reshaping
• Augmentation of chin, cheek, breast, buttock, temporal fossa
• Marionette lines, perioral, periocular lines
• Prejowl sulcus
• Lip augmentation and reshaping
• Décolleté rejuvenation
• Hand, neck rejuvenation
• Ear lobe plumping, ear lobe ptosis
Therapeutic indications include improvement of scars—post acne, post traumatic; dermatological diseases—scleroderma, AIDS associated lipodystrophy etc, and cushioning effect to treat corns and calluses
Contraindications include having a history of hypersensitivity to filler or its components; keloidal tendency; patients with unrealistic expectations or body dysmorphic disorder; pregnancy, lactation; infection at the site of injection; patients with platelet or bleeding disorders, or taking anti-platelet medication; patients with auto-immune disorders and patients with herpes facialis.
Collagen forms the major structural protein of dermis and is responsible for the tensile property of skin. Loss of collagen as the skin ages, results in wrinkles. Degradation of collagen can be collagenase mediated, which is produced as a result of UV exposure and antioxidant stress. The available injectable forms of collagen are bovine collagen, bioengineered human collagen and cadaveric collagen. Concentration levels differ in each of these forms.
HA is the most commonly used filler agent worldwide. It forms the predominant component of the extracellular matrix. It has a very short life in human tissues as it is degraded by native hyaluronidase in tissues. To prevent this degradation and stabilise the molecule the chains must be cross-linked. The unique property of hyaluronic acid is it’s ability to absorb water—hence the volumising and hydrating property of it when injected in tissues. Based on cross linking it can be monophasic or biphasic.
Crosslinking can be further managed to manufacture particulate (based on the particle size to increase the volumetric lift and span) and non-particulate forms (higher degree of crosslinking to proportionately increasing the volume). Research is underway to determine the best possible level of crosslinking, where the hyaluronic acid molecule loses its biocompatibility and hydrophilic nature thereby leading to rejection, encapsulation and granuloma formulation. Trials proving the efficacy with the recently innovated 0.3% lidocaine addition to the filler have been done, concurrent end results and safety profiles with the added benefit of pain relief were observed.
Semi permanent fillers
Temporary fillers can be created from various sources—some natural, and some synthetically produced in a laboratory.
Using patient’s own fat for augmentation of defects elsewhere is the oldest method of soft tissue augmentation. Introduction of tumescent anaesthesia has enhanced the use of autologous fat transplantation. The most popular method of fat transplantation is microlipoinjection, which involves use of aspirated fat globules in augmentation of facial tissues.
Poly-L-lactic acid (Sculptra)
This promotes the production of new organised collagen in the dermis. It is utilised in the form of a sub dermal injection dispersed in sodium carboxymethylcellulose gel. PLA is approved by USFDA for the treatment of HIV associated lipoatrophy, however volume augmentation is it’s off label indication.
Calcium hydroxyapatite (Radiesse)
The advantage of this filler material is its availability as microspheres which are dissipated into the tissue for a long time slowly up to two years. The FDA approved indications being HIV associated lipoatrophy, facial rhytides, and vocal cord augmentation. It is not known to cause granuloma formation.
These are less commonly used and include polymethylmethacrylate (PMMA) (Artefill), silicone and polytetrafluoroethylene. Associated drawbacks include hypersensitivity, high incidence of immediate post treatment edema and bruising. The major drawback is the permanent nature of the fillers—as the patient ages there will be changes in the skin and the cosmetic acceptability of the filler may change.
Patient selection and counselling play a pivotal role in any aesthetic procedure. Detailed medical history including previous experience of the patient with fillers, drug intake history (eg. aspirin, thrombolytics, anti platelet drugs), keloidal tendency in the patient and family has to be taken. Counselling of patient is important regarding the procedure, expenditure, complications and aesthetic outcome. Detailed informed consent and pre-procedure photographs are mandatory for future reference. Ideally it is advisable to evaluate the patient, provide basic information to the patient regarding dermal fillers, and schedule the procedure on another day.
Injection of dermal fillers is a minimally invasive technique and anaesthesia is generally not required. However in apprehensive patients and in treatment of areas with high pain sensitivity (lips, periorbital) anaesthesia may be required. Anaesthesia may be topical (Lidocaine cream under occlusion or ice), nerve block (infraorbital or mental nerve block), or use of fillers that contain anaesthetic agents. Newer filler injections are being available in the market that contains local anaesthetic molecules that alleviate the pain.
Choice of technique is at the discretion of the clinician and will vary depending on the type of filler used and anatomical site to be injected. Techniques include:
• Linear threading technique
• Fanning technique
• Cross hatching technique
• Depot technique
• Serial puncture technique
• Push ahead technique
• Sandwich or layering technique
• Fern technique
Post procedure care
Application of ice immediately after the procedure and intermittently during the day is advised to alleviate the pain if any and to reduce the risk of bruising. Patients of skin of colour have a high risk of post inflammatory hyper-pigmentation. Therefore it is necessary to emphasise the importance of use of sunscreen. Other equally important instructions include:
• Avoid excessive massaging the area treated.
• Avoid strenuous activity the next six to eight hours.
• Avoid exposure to extreme cold or heat.
• Analgesics can be prescribed to alleviate pain and discomfort.
• Anti-bruising creams containing vitamin K can be prescribed.
• Adverse reactions, if any, should be reported immediately.
Complications of fillers vary in skin of colour. Though the high melanin content in the skin is protective against photo damaging, it may be responsible for complications like post-inflammatory hyper- or hypo-pigmentation. Due to the high level of dermal fibroblasts in individuals of skin of colour they are more prone to develop keloids or hypertrophic scars.
Complications may be immediate, such as pain, hypersensitivity or anaphylaxis. Other early complications include:
• Injection site reactions: erythema, odema, ecchymosis, pruritus, tenderness.
• Skin discolouration: erythema, cyanosis, blue appearing papules (Tyndall effect of superficially placed fillers), blanching of skin.
• Infection: erythema, edema, pain, fluctuant mass, systemic symptoms.
• Tissue necrosis and venous congestion secondary to vascular compromise.
• Nodules: Due to inappropriate placement of filler.
Late complications include:
• HSV activation: Itching, burning, erythema, edema, vesicles, pustules.
• Granuloma formation: palpable, visible nodules.
• Clumping and migration of filler.
• Aseptic abscess or biofilm reaction.
Permanent complications could include: scarring; persistent discolouration and hyper-pigmentation.
Though reversal of hyaluronic acid filler action is not an FDA approved indication of hyaluronidase, it is advisable to have it in office to deal with the over correction, to manage impending tissue necrosis and the Tyndall effect. Hyaluronidase must be reconstituted with normal saline before use. It’s application is contraindicated in patients with hypersensitivity to hyaluronidase or injection components. It is also contraindicated in patients with an allergy to hymenoptera stings and thiomersal.
Dermal fillers, both alone or in combination with other aesthetic procedures, have gained popularity and are the most commonly undertaken aesthetic procedure. Factors such as detailed understanding of facial anatomy, proper patient and product selection for the anatomical site, preparation and injection techniques determine the outcome. In view of the high risk of post inflammatory pigmentation in skin of colour it is better to undertake techniques such as linear threading to minimise the number of punctures. Coloured skin specific issues such as hypersensitivity, keloidal tendency, bad scarring, dyschromias have to be considered in patient selection as well as filler and technique selection.
Prof Mukta Sachdev, Dr Keerthi Velugotla and Dr Archana Samynathan Manipal Hospital, Bangalore, India and MS Skin Centre, Bangalore, India. Prof Sachdev Prof Sachdev has two decades of clinical experience in medical, aesthetic and cosmetic dermatology, and is a skin of colour expert.