Arun K Garg - Dermal Fillers for Dental Professionals

FIG 1-2The effects of neurotoxin and dermal filler treatments are subtle and appear natural, unlike plastic surgery procedures.

Unlike surgical procedures, neurotoxin and dermal filler treatments are luxuries that fit many budgets. At an average cost of $397 and $682 per site for neurotoxin and dermal filler (eg, Juvéderm, Allergan) injections, respectively, these treatments are comparable to the cost of tooth whitening or a day at the spa. Compare those numbers to the average cost of a simple rhinoplasty ($5,350) or dermabrasion ($1,250). 1 The relative affordability of minimally invasive procedures makes them appealing to people at all income levels, including those who likely would never consider seeking surgical treatment to address their age-related esthetic concerns.

Based on popular stereotypes, many readers might assume that middle-aged women are the ones primarily driving this trend. Not so. The “daddy do-over” has been quietly gaining in popularity for several years, and the average age of patients skews younger all the time as more 20- and 30-somethings seek dermal filler treatment for acne scars, nose recontouring, lip augmentation, and other cosmetic enhancements. In 2018, individuals aged 20–39 made up 18% of all neurotoxin injections and 11% of dermal filler treatments. 1

Neurotoxins and Dermal Fillers: Understanding the Differences

Currently, there are approximately three neurotoxin procedures for every dermal filler procedure performed in the United States (7.4 million vs 2.6 million). 1 Botox, the first commercially available neurotoxin, was initially developed and gained FDA approval in 1989 as a therapeutic agent for the treatment of strabismus, an eye muscle disorder. Today, many dentists use Botox therapeutically to treat patients suffering from temporomandibular joint pain related to clenching and bruxing and to relax the upper lip in patients who have a gummy smile. Botox Cosmetic was not FDA approved until 2002, just shortly before the approval of the first hyaluronic acid dermal filler in 2003.

Dynamic versus static wrinkles

Although the aim of these injectable agents is the same—to smooth facial wrinkles—they use different mechanisms of action to achieve it. Cosmetic neurotoxin targets the dynamic lines of expression that result from repetitive facial movement (Fig 1-3). It is injected directly into the muscles that animate these types of wrinkles, including frown lines, crow’s feet, and forehead creases. The muscles become paralyzed, and within 2 to 3 days, the lines and wrinkles disappear. These effects last an average of 3 to 4 months.

FIG 1-3Neurotoxins target the dynamic lines and folds of facial expression.

Unlike neurotoxins, dermal fillers target static wrinkles, the ones we develop over time as we age (Fig 1-4). These static wrinkles are present regardless of facial expression and usually accompany other visible effects of aging, such as hollowed cheeks and eye sockets, irregular or blotchy pigmentation, skin laxity, and dryness. These facial manifestations of intrinsic aging are a result of reduced collagen production and slower cell turnover rates. (Their appearance can, however, be accelerated by extrinsic factors such as chronic sun exposure and smoking.) Intrinsic aging is a natural consequence of physiologic changes over time that occur at variable yet genetically determined rates. In some lucky people, these lines, wrinkles, and folds do not make an appearance until they reach 55 or 60 years old, whereas others begin to see them in their late 30s and 40s, but for all of us they are an inevitable effect of aging.

FIG 1-4Dermal fillers target the static lines and wrinkles that are manifestations of aging on skin.

Nevertheless, we spend billions of dollars each year on expensive elixirs and procedures in our never-ending quest to prevent and diminish the visible signs of aging on our skin. And every year, the industry expands with new agents and modalities added to the long list of topical medical products (vitamin A acid, α-hydroxy acids, antioxidants, and moisturizers) and procedures (glycolic acid peels, deep peels, dermabrasion, laser resurfacing, and plastic surgery) already available ( Table 1-2).

TABLE 1-2Costs and total expenditures of the multibillion-dollar industry to combat aging*

*Data from the American Society of Plastic Surgeons. 1

In this book, we focus exclusively on the treatment of static wrinkles associated with aging using FDA-approved commercial dermal fillers and autologous serum-derived agents. As detailed in chapter 3, choosing a dermal filler requires an understanding of how its constituent components interact with the body. Broadly speaking, dermal fillers achieve their effects by one of two mechanisms of action. A stimulator works to reverse the loss of hydration and elasticity in the skin by inducing the production of new collagen (Fig 1-5), whereas a volumizer provides immediate volume replacement to smooth the appearance of fine lines and wrinkles (Fig 1-6). Many products combine these mechanisms of action in one agent. With dozens of commercial products to choose from, it is incumbent on clinicians to understand how their physicochemical properties affect their performance in terms of biocompatibility, longevity, and other clinical considerations, all of which are discussed in chapter 3.