New Era of Cosmetic Enhancement

Soft tissue augmentation dates back centuries when defects from trauma or war injuries were treated by filling with en bloc fat transfer. The modern era of soft tissue augmentation began in 1981 with the U.S. FDA approval of Zyderm® I (Allergan, Irvine, CA), bovine collagen injectable material.

At that time, physicians began to develop techniques to improve the appearance of acne and trauma scars and to soften the nasolabial folds. Advances in techniques and procedures were preceded by the introduction of new materials. More robust materials led to longer duration of correction; finer materials allowed the treatment of lines such as crow's feet. All products were based on collagen, particularly bovine collagen.

The introduction of hyaluronic acid as a filling material, however, eliminated the requirement for skin testing for allergy. The reliability and smoothness of correction that could be obtained with this material and the ability to configure the polymers in various ways of cross-linking and molecular weight made it the logical choice of material for body contouring and deep contouring of the face.

In contrast to the many hyaluronic acid products on the market for facial injections, only a few have been developed (or are in the process of being developed) for body contouring. Prollenium Medical, Toronto, hopes to have its hyaluronic acid body contouring product receive approval and the CE mark in Europe in the next few months. Currently, the product most used for this indication is Macrolane®, from Q-med in Sweden. It was first used in Japan nearly four years ago and is approved for use in the United Kingdom, all of Western Europe, Singapore and Malaysia. The product is not approved, nor available, in the United States and Canada.

Addressing Variability

Two forms of Macrolane are available to address the significant degree of variability in the amount of tissue support in various areas of the body. Macrolane VRF (for volume restoration factor) 20 is particularly suited for areas of the body that do not have a significant degree of tissue support and cover. This material is injected into the superficial subcutaneous tissue and is intended for areas that

Macrolane VRF 30 is a thicker formulation suitable for areas of the body with substantial tissue support and cover. It is injected either very deep in the subcutaneous tissue or onto the periosteum. The areas intended for augmentation with this material must have sufficient tissue support to avoid implant palpability.

Required Knowledge

As is the case with all types of soft tissue augmentation, the physician must be thoroughly trained in the use of these materials and have a complete knowledge of the anatomy of the area that is to undergo treatment. Patient selection is of paramount importance; two tests have been devised to determine suitability and aid in the choice of material.

First, measurement with calipers of the distance between two points at rest and with stretch will determine if there is an excess of skin. If the distance increases by more than 50 percent, the patient has excess skin in that area and is not a candidate for soft tissue augmentation.

The pinch test also is used to determine the amount of tissue cover by pinching a double fold of skin in the area. If the double fold is less than two centimeters, the patient is not a candidate for treatment.

Injection Technique

The injection technique is nearly identical to the technique of fat injections. A stab incision is made after cleansing the area and obtaining sufficient local anesthesia. Using the appropriately sized blunt tip cannula, injections are made into the proper plane. The gel should be injected in small aliquots rather than using a bolus technique, as this allows for more controlled and deliberate shaping. Overcorrection should be avoided, taking the defect to 100 percent correction.

Discontinue injection prior to withdrawal to prevent forming a canal for leakage and massage the area to conform to the desired result. Two injection sessions should be scheduled to ensure the defect is corrected, smooth and attractive.

Potential Side Effects

Side effects of body contouring with hyaluronic acid are the same as those in the face-swelling, redness, bruising and tenderness for a short period of time. Limited daily activity is prudent for seven days or so after the treatment and the patient should avoid excessive heat or cold to the area for several days. Massage is contraindicated for at least two weeks following treatment.

One of the most common questions asked by patients is how long the correction will last. This will obviously vary with the areas treated, patient activity, etc., but most results last approximately one year.

Clinical Applications

Uneven surface contours due to trauma or surgery such as liposuction are the most popular clinical applications of soft tissue augmentation of the body. A recent study of 56 patients with these types of defects revealed that 80 percent of patients were improved three months after injection with Macrolane and 69 percent at six months.¹ Liposuction defects responded best in this study and remain one of the primary indications for body contouring of this type.

Studies have been conducted over the last five years investigating use of this technique in augmenting the female breast.^2,3 Improvements are continuing to be made in both the material for injection and techniques using these materials. Further studies are required to determine if there is any long-term interference with the detection of breast cancer.

Studies also are ongoing in Europe to determine the efficacy of the treatment for buttock augmentation.^4,5 Large volumes have not been adequately studied at this time and generally 240 cc is the upper limit of injection into a single site.

Looking Ahead

Although Macrolane is the first product for body contouring using hyaluronic acid, others are in development and in clinical trials. Contour, from Prollenium Medical Technologies in Toronto, is one example. Certainly, other materials will be introduced for body contouring based on substances other than hyaluronic acid.

As additional products emerge, procedures become more prevalent and new techniques are developed, the era of body contouring with soft tissue augmentation materials will become as prolific as facial correction has become over the years.

References

1. Johnson G. Body contouring by microinjection of autologous fat. Am J Cosmet Surg 4:103, 1987

2. Physiological function of connective tissue polysaccharides. Physiol Rev 58:255; 1978

3. Duranti F, Sali G,Bovani B et al. Injectable hyaluronic acid gel for soft tissue augmentation. A clinical and histologic study. Dermatol Surg 24:1317. 1998

4. Per Heden. The promising future of hyaluronic acid for body contouring. Presentation Anti-aging Medicine World Congress, Monaco. March 22-24, 2007

5. Macrolane Clinical Information Brochure. Q Med. Uppsula, Sweden. 2008.

Melvin L. Elson, MD, has carried out extensive research in the areas of aging, photoaging and the evaluation and treatment of related disorders, particularly in the areas of soft tissue augmentation and topical vitamins. He has taught and traveled extensively throughout the world, sharing his techniques in the use of soft tissue augmentation materials. He is a member the American Academy of Dermatology, the American Society for Dermatologic Surgery and the International Society for Dermatologic Surgery. He has authored more than 300 scientific papers and chapters and has written two books, a textbook on the aging face and a book for laymen on appearance. He is president and CEO of Global Cosmeceutical Innovations LLC in Nashville, Tenn. Disclosure: Dr. Elson indicates that he has no affiliations with any commercial entities directly or indirectly referenced in this article.