Filler Materials
Medical Aspects
Prof. Dr. med. P. Graf
Munich
Aesthetic Operations/Treatments
Aesthetic Operations/Treatments in the USA 2000-2012 (Source: ASPS)
7000000
Breas t Augm entation
Blepharoplas ty
Lipos uction
Number of Operations/Applications
6000000
Rhinoplas ty
Abdom inoplas ty
Botulinum toxin
5000000
4000000
3000000
2000000
1000000
0
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Year
Operations versus Minimal invasive Treatments
Aesthetic/Reconstructice Operations/Treatm ents 2000-2012 in the USA (Source: ASPS)
total, operative cosmetic
16000000
total minimal nivasive cosmetic
total cosmetic
14000000
12000000
10000000
8000000
6000000
4000000
2000000
Year
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
0
2000
Number of Operations/Treatments
total operative reconstructive
Filler-Material (Selection)

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

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)
Die Darstellung
Die Darstellung
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Fotos
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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 II
Pattern 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 III
Microstructure, Properties
An important function of hyaluronic acid is its
property of water retention.
Hyaluronic Acid IV
Intradermal/Subdermal Positioning of Filler
Hyaluronic Acid V
Injection Technique
Linear
Injection technique
Serial step-by-step
Injection technique
Hyaluronic Acid VI
Lip Augmentation
Nonresorbable Filler Material
Acryl-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 II
intravascular Injection
Skin necrosis after accidental
intravascular injection of PMMA
Complications III
Blindness
from:
Complications of Injectable Fillers, Part 2: Vascular Complications Aesthetic Surgery Journal
Claudio DeLorenziy
2014 34: 584-600
Bacterial Biofilm I
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
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)
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 III
in Soft Tissue Fillers
Bacterial biofilm formation and treatment in soft tissue fillers
Morten Alhede et al. April 2014
Pathogens and Disease
doi: 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. …“
Complications
Inflammation, 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 Transplantation
Application




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Neurosurgery
Ophthalmology
Urology
Aesthetic Surgery
etc.
Autologous Fat Transplantation
Lipofilling




No immunogenicity
Resorption
Deep positioning (subcutaneous)
Operation
Autologous Fat Transplantation
Healing Process
Autologous Fat Transfer
Resorption
Rates of Resorption in Literatur 20 - 100%
Own Investigations: 55,6% (47 - 68%)
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)
Autologous Fat Transfer
Minimization of Resorption
Atraumatic treatment is critical for
Rates of resorption (=success) of fat transfer







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
Autologous Fat Transfer
Operative Technique
Autologue Fat Transfer
“Cleaning“
Autologous Fat Transfer
Injection
Autologous Fat Transfer nasolabial
Die
Darstellung
Die Darstellung
präoperativer
präoperativer Fotos
Fotos
in
in ärztlichen
ärztlichen
Internetseiten
Internetseiten ist
ist in
in
Deutschland
Deutschland leider
leider
nicht
nicht erlaubt
erlaubt