February 2010




Volumizing fillers, better than excising skin and fat

by Michelle Dalton EyeWorld Contributing Editor


The newer fillers can be readily integrated into cosmetic offerings

A recent aesthetic surgery article1 laments that excising excessive skin and fat from aging eyes (in addition to brow elevation) can sometimes lead to an increased definition of the orbit. Instead, adding volume in the periorbital area “may provide a better-looking result than traditional surgical alternatives,” the study said. A better understanding of how the skin and face react to aging has led to an increased shift toward volumizing fillers, said Kami Parsa, M.D., Beverly Hills, Calif. (For more on the topic, see “Update on oculoplastic surgery,” EyeWorld, November 2009, p. 34.) In addition to Botox Cosmetic (onabotulinumtoxinA, Allergan, Irvine, Calif.), oculofacial surgeons are using collagen implants and hyaluronic acid for volumizing (today’s answer to face lifts, Dr. Parsa has said). Since 2005, hyaluronic acid has been used to treat the brow and upper eyelid, in a technique similar to fat injections. In cases of brow volumizing, “contouring is easier,” said Val Lambros, M.D., author of the latest article. “Hyaluronic acid is less subject to variability than biologic fillers.”

According to Dr. Lambros, brow volumizing can have effects that last as long as two years.

Collagen implantation

Both Zyderm and Zyplast (Allergan) are comprised of highly purified bovine dermal collagen. Most collagen implants are used to treat superficial facial wrinkles. Zyderm has about 30% to 35% collagen, and has been used for more than 20 years.

Botulinum toxins

Botulinum toxins are neurotoxic proteins produced by specific bacteria, the Clostridium botulinum, a group of spore-forming, anaerobic, gram-positive bacilli. In late April 2009, the Food and Drug Administration granted regulatory approval for Dysport (abobotulinumtoxinA) to be jointly marketed by Medicis (Scottsdale, Ariz.) and Ipsen (Paris). According to Medicis, Dysport was evaluated for the treatment of glabellar lines in about 2,900 patients at more than 80 clinical study sites. Further, the drug has been used in patient care in the United Kingdom since 1991, and has marketing authorizations in 76 countries for therapeutic use and 27 countries for aesthetic use. Comparatively, Botox is approved for 20 different therapeutic indications in 80 countries worldwide, and Botox Cosmetic is approved in almost 60 countries.

Hyaluronic acid

There is no potential for immunologic reactions to hyaluronic acid since it occurs naturally, so the category is becoming more attractive as a cosmetic procedure.

In the United States, hyaluronic acid Restylane (Medicis) has been approved for the treatment of moderate to severe facial wrinkles and folds. A variation of Restylane—Perlane—is comprised of the same concentrated amount of hyaluronic acid (both are 20 mg/mL), but has a larger particle size. A different kind of hyaluronic acid, Hylaform (Genzyme, Cambridge, Mass.) is derived from a highly purified form of the acid naturally found in human skin. Restylane is derived from a biodegradable non-animal stabilized hyaluronic acid.

In general, hyaluronic acid is considered “better” for static rhytides while botulinum toxins are better for dynamic rhytides. Pain is also higher with the hyaluronic injections; use of an analgesic is usually recommended. Hyaluronic acid in solid form is being investigated outside of oculoplastics. Rabbit studies have shown solid hyaluronic acid film can significantly prevent adhesions after both conjunctival and sclera flaps after filtering surgery for glaucoma.2


1. Lambros V. Volumizing the brow with hyaluronic acid fillers. Aesthetic Surg J 2009;29:177–179.

2. Takeuchi K, Nakazawa M, Yamazaki H, et al. Solid hyaluronic acid film and the prevention of postoperative fibrous scar formation in experimental animal eyes. Arch Ophthalmol. 2009;127(4):460-464.

Volumizing fillers, better than excising skin and fat Volumizing fillers, better than excising skin and fat
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