Injection Based Treatments

Dermal Fillers

Facial lines may be softened or erased by injecting a substance into the skin to 'plump' out the line, scar or fold

Wrinkles, scars and even heavier expression lines can be improved with these filling agents. Lines of expression include frown lines, 'crow's feet', 'smile lines', and 'smoker's lines', and these are commonly treated. Cosmetic improvements such as the 'Paris Lip' are also popular. Injectable fillers provide temporary correction; as yet none offers a permanent solution to facial lines or augmentation.

Recently, a revolution in this type of treatment has seen its use extended enormously. Volume changes of the ageing face are now treated, as are textural problems both there and in other areas such as the hands, neck and décolletage: areas that have been very hard to treat in the past.

Natural polysaccharides are found in all tissues in the body and one of these is used in many dermal fillers. Because of its tissue-friendliness, it is currently used in many pharmaceutical products, and around 27 million people have been treated with the substance in its many forms. The product has a greatly decreased risk of allergic reaction and is an exciting development.

When this substance is injected into the dermis, it smoothes out facial wrinkles and can create larger, more accentuated lips. It can also be used to fill out scars where the scar is nor more than 4mm deep, and can be manually stretched to the point that it is at least 75% eliminated.

The following are some of the advantages of natural polysaccharides.

Being a non-animal substance, allergic reactions are very unlikely. This means that skin testing is not necessary, thus eliminating the delay before a patient may have the treatment. It is also a suitable filler for those patients who are allergic to animal-derived fillers.
It has a relatively long duration compared to other fillers. Overseas studies show it lasts around 8 months, 80% of the time. For this reason, it may be more economical than collagen replacement therapy.

Various natural polysaccharide products are available, each fulfilling a different function. These fillers can be used to:

soften fine superficial lines around the eyes and mouth;
help achieve smoother lifting of fine superficial lines;
temporarily soften the naso-labial area (the lines running from the nose to the corners of the mouth) and glabellar frown lines (the vertical lines running between the eyebrows) for medium depth lines and wrinkles. Restylane® is also used to give the outer lip more definition;
plump up the lips;
to eradicate deep folds, augment lips and/or adjust their contours.

Collagen replacement therapy involves the injection of another for the removal of lines, involves the injection of highly purified bovine collagen (extracted from cow hide). It is available in several strengths suitable for treating different areas of the face. Collagen has been used in various medical applications for over a century.

Human collagen fillers are purified from human dermal cells and manufactured in the strictest controlled environment. These natural products are used for the treatment of wrinkles, post-acne scars, lip enhancement and other soft tissue contour deficiencies. Unlike other collagen replacement therapy products, these do not require a pre-treatment skin test.

Synthetic polymers can be used to help lift and smooth sagging skin, severe wrinkles and creases and scars. Dark circles can also be treated.

Another synthetic polymer variant is otherwise used to treat wrinkles and deep creases.

With synthetic polymers, the risk of allergy associated with animal product use is averted.

The procedure

Irrespective of the filler used, anaesthetic cream may be applied to the area 30-40 minutes prior to the procedure to minimise discomfort, then the product is injected into the dermis. The results can be seen immediately and there is no need to overcorrect the line with this product. Make-up maybe applied following the procedure and a return to work may be made.

Muscle Relaxant Injections

Muscle relaxants are used to help erase, soften and prevent lines on the face, neck and chest.

About wrinkles

Wrinkles and facial lines may be induced by sun damage, ageing, or the recurrent action of strong facial muscles, and they may be fine or deep. Fine wrinkles often involve only the top layers of the skin and respond well to AHA creams and skin peels. Deeper wrinkles are best treated with filling agents such as collagen or fat injections, or by resurfacing the skin with laser or chemical peels.

Expression lines occur when we smile, laugh or frown and the delicate muscles underlying the skin contract producing 'crow's feet', 'laughter lines' frown lines and horizontal forehead lines. The gruff, unfriendly expression produced by these lines may interfere with the way a person relates to others in the workplace as well as socially. It is these dynamic wrinkles that may be erased with muscle relaxants.

What are muscle relaxants?

Muscle-relaxing substances that have been used safely in a variety of medial areas for over a decade. Thousands of injections are performed each year to treat conditions such as 'cross eyes', facial spasms and various forms of paralysis. It has recently been adapted for use with facial expression lines.

They work by weakening the tiny facial muscles very precisely. After treatment, the expression lines and excess movement are diminished; however, normal facial expression is unaffected.

The procedure

This treatment is both simple and safe. Small amounts are injected with a very fine needle into several locations in the face. Because the needle is so fine and only a small amount of liquid is used, discomfort is minimised. No sedation or anaesthetic is required and you may return to work or your usual activities immediately.

The results of the treatment are temporarty, lasting about 4-5 months. Most people have injections about twice a year, although the benefit seems to last longer after each treatment.

Treatments for Hyperhidrosis (Excessive Sweating)

Several relatively simple treatments are available for the treatment of excessive sweating.

Muscle relaxants

The injection of a muscle relaxant is now being used for the effective treatment of excessive sweating from the armpits (known as primary axillary hyperhidrosis) and hands (known as palmer hyperhidrosis). It targets sweating at its source, inhibiting the release of acetylcholine: the chemical in the body that is responsible for signaling perspiration. The advantages are that it is a safe and effective technique and solution; the disadvantages are that it is a temporary treatment lasting approximately 6-8 months with a possible compensatory increase in sweating at other sites.

Other options

Other options include 20% aluminium chloride hexahydrate, iontophoresis and oral medications.

The procedure

Muscle relaxants

A topical anaesthetic cream is usually applied half an hour prior to the treatment to help minimise any discomfort. The product is then administered via small injections and approximately 7-10 days later, sweating may be noted to have decreased.

A review is recommended approximately 2-3 weeks after the initial treatment. A further smaller treatment may be necessary to any areas where the product may not have been fully effective.

Hypertrophic and Keloid Scar Treatments

These scars are the result of the body's over-zealous attempt to heal and replace lost or damaged skin. The means of correcting such as a scar depends upon its specific characteristics.

Not all scars are alike. In fact, there is a wide range of different scar-types, some of which protrude above the skin. One such scar is the keloid scar: an overgrowth of fibrous tissue/collagen that the body produces in response to an injury. These scars may appear anywhere on the body. Keloid scars extend beyond the borders of the original wound and they do not regress spontaneously.

The cause of keloid scars is unknown, but they appear more frequently in darker-skinned people. They tend to occur primarily in people aged between 10 and 30 years of age.

Treatments

The treatment of keloid scars is complex. All scars are permanent and there is no single technique to remove them completely. However, with treatment, the keloid scars may become smaller, softer, less tender and less red in colour. Attempts to surgically remove keloids are fraught with danger as they tend to reform and become bigger than before. As no single therapeutic method has been demonstrated for all keloid scars, the type of therapy used will depend on several factors, some of which relate to the scar's characteristics (location, size, colour, etc.), and others to the patient herself (the person's age, and past response to treatment).

Several treatment modalities are available to treat these scars. These include:

intralesional cortisone or injections of other agents such as fluorouracil (5FU) or bleomycin;
laser therapy;
cryotherapy (liquid nitrogen);
topical creams and dressings.

Fat Transplantation

Fat is taken from an area where there is too much and is placed in other areas where there is too little, such as the ageing or post-acne-scarred face.

It is a useful procedure for:

severe acne scarring, where the fat layer under the skin is affected, causing the skin to sink in some areas;
fat loss in the face as part of the normal ageing process. This happens especially in the cheeks and temples. People with a gaunt face from birth often benefit from having their own fat transplanted into these depressed areas;
major expression lines may be attempted by fat transplant. These transplants are more likely to be temporary as these lines are strongly bound down to underlying tissues;
hand augmentation. This is quite a good treatment for ageing hands which tend to lose fat as ageing occurs. This may need to be repeated periodically to maintain the correction;
upper & lower lips. The upper and lower lip often loses volume with ageing and this may be supplemented by fat. A technique of lengthening the lower lip by fat injection tends to correct the droopy corners of the mouth. This is often temporary but may be long lasting.

The procedure

Some fat is removed from an area of plenty with a thin cannula. Local anaesthetic is used to remove the fat painlessly. The removed fat is washed to remove any broken cells, then re-injected into the area where it is required.

For how long does the fat last?

On average, 40-60% of the fat survives one year. In certain areas, such as the upper lip and cheek hollows, the long-term results are substantially better than this, however in scars and expression lines, the fat may need topping up to achieve the desired result. Usually 2-3 injections, 6-8 weeks apart are recommended for these areas. There is often some loss after each injection and a satisfactory result is gradually built up rather than produced in the first injection.

Sclerotherapy

Unwanted vessels, usually of the leg, are treated by injection. 'Spider veins', 'starbursts' and some larger blue veins are amenable to this procedure.

Heredity seems to be the main cause of leg vessel formation, and this pattern seems to start earlier if both parents are affected. This hereditary tendency is further provoked by increased pressure on the legs such as during pregnancy, or long frequent periods of standing. Facial blood vessels are mainly caused by hereditary tendency, rosacea and sun exposure.

The procedure

Sclerotherapy is a walk-in, walk-out procedure and no anaesthetic is required. A solution of Saline or Aetoxysclerol (polidocanol) is injected into the vessels with a very fine needle. The solution acts on the wall of the blood vessel to compel the vessel to close up (sclerose). The beauty of this technique is that many of the blood vessels communicate with each other, and thus, one injection may eradicate an entire interconnecting complex of vessels. A number of injections are usually placed in each complex of vessels to increase the success of the treatment. After a few weeks, the vessel disappears. Several treatments may be necessary to eliminate the vessels completely.

Other treatment options

Laser and fine wire diathermy are very effective techniques for the treatment of facial and upper body blood vessels but are rarely effective for leg vessels. This is probably because leg vessels are thicker-walled, and are under much greater pressure. Newer lasers are now being used in conjunction with sclerotherapy in an attempt to further improve its effectiveness. Sclerotherapy treatment to eliminate lower limb blood vessels has a success rate of around 95%. For facial and body blood vessels, success rates are probably similar. Sclerotherapy may be used in conjunction with laser for these areas.

Sundry Procedures

Minor and adjunct procedures that are also used in the practice

Fine wire diathermy

This treatment works by passing a small electric charge down a hair-like needle into an unwanted spot, causing the spot to shrivel and disappear. It does so over the following few days to weeks depending on the body part treated and the amount of current used. It should not be confused with the rather gross diathermy delivery systems of the past. Correctly used, this is a most elegant technique and one that gives uniformly good results.

Fine wire diathermy may be used in many situations. These include the treatment of dilated blood vessels on the face and any fine vessels on the upper limbs or trunk. It has a major role in the treatment of minor skin blemishes such as small skin tags, milia, syringomas, seborrhoeic warts and sunspots. In this role, it is similar to a CO2 laser in its effects (see page 00). It is also used effectively as part of a hair removal technique called epilation (see page 00).

The healing process

Wounds and scabbing. After the procedure with non-insulated needles, a scab forms after an initial sore. This wound is usually inconsequential, but if a larger area has been treated then a significant sore may be seen and this may need a night-time topical antibiotic or antiseptic ointment (preferably greasy) for seven to ten days on the face or longer if elsewhere.

Makeup and sunscreen are usually permissible after the procedure.

Sun avoidance. It is important to protect this treated area from the sun whilst the spot is healing. Otherwise the spot may preferentially tan and stay that way for weeks.

Side-effects

Scarring and other side effects are very unusual.

Hearing aid and pacemaker malfunction. Caution is usually advised for people who use these devices as some of the older diathermy units have been known to stop them from working. The newer diathermy machines, which we use, don't really have this problem and most modern pacemakers also protect the patient from this rather nasty situation.

Cautery

Hot cautery is similar to diathermy except instead of electricity this technique uses straight heat to remove lesions. A wire loop is heated to red hot and, usually with local anaesthetic, the spot is cooked and left to fall off over time. This is an effective technique for treatment of brown spots on hands or anything that is entirely growing on the surface of the skin.

Another very good use for the hot cautery is in the treatment of skin cysts. With this type of spot the cautery tip is inserted into the cyst centre and the contents of the cyst melted. The lining also comes away with this technique and the cyst is often able to be delivered through a very small cut which becomes virtually invisible.

Side-effects

White spots may be left behind when hot cautery is used upon darker-complexioned patients. It is considered a less useful procedure for this group.

Liquid nitrogen

This chemical is most natural: it is around us all the time and represents 80% of the air that we breathe. The only difference is that once made into a liquid it has an incredibly low temperature of close to -200ºC. This low temperature allows us to selectively destroy anything that we aim it at. It affects the top layer of skin much more than the second layer, and given that scars are formed from injury to the second layer of skin, this approach can successfully treat large surface spots without scarring if correctly applied.

Liquid nitrogen is a traditional dermatologist's tool and is used widely to remove all sorts of lesions but especially sunspots and seborrhoeic keratoses. It is also particularly good at treating brown age spots on the backs of hands and faces. It is either applied with a swab on a stick dunked into the liquid nitrogen or it is sprayed on or applied with a cold probe.

The healing process

Blistering and scabbing. Whichever delivery method is used, the end result is the same. It produces localised frostbite which readily forms a thick blister that may break or remain intact and slowly evolve into a scab. This scab lifts in a week on the face and longer if applied elsewhere or for a longer time.

Colour resolution. After the healing time, the patch is often transiently red then white and finally in most cases returns to its normal skin colour.

Side-effects

Pain. There is some discomfort with liquid nitrogen application; a peculiar sensation whereby the body can't quite work out if this substance is cold or hot or just painful. The pain, however, is fleeting.

Scarring and changed skin colour. These undesired effects are not common if the procedure is carefully performed.

Skin shaving, snipping

These are two extremely simple but very effective techniques used for skin lesions such as acrochordans, seborrhoeic warts, cherry angiomas and moles.

Skin shaving is a technique in which the skin is inflated a little with local anaesthetic and the razor bowed so that it takes off the spot with a minimum surround of normal skin. The level of control that one can exert using this simple but exquisitely sharp instrument is very fine indeed. The edges of the wound are sometimes further bevelled with fine wire diathermy if necessary and the result, if the removal is kept superficial, is excellent. This technique is particularly effective on the nose and on the concave areas of the face such as the temples, around the nose, eyes and ears.

The snipping procedure is appropriate for any spot that has begun to hang from the skin surface such as a mole or skin tag. It is often done without local anaesthetic as the snip is so swift that it is not felt. This painlessness is also attributed to the extreme sharpness and special design of the scissors.

Spot peeling

This technique uses strong caustic substances such as Trichloacetic acid and Phenol usually in relatively high concentrations. The substance may either be painted on the skin such in treating xanthelasma around the eyelids or it may be applied in point fashion down the centre of either a dilated oil gland (sebaceous hyperplasia) or down a dilated pore or deep ice pick scar.

The healing process

Time. If painted on, the resulting healing will generally follow the same time frame as that seen with the more general chemical cosmetic peeling process.

Scabbing. If point peeling is performed healing will produce a very small sometimes miniscule scabbing.

The painting is usually performed with a cotton swab after cleansing of all skin oils with acetone. The point peel is often done with a sharp instrument such as a toothpick dipped in the peeling solution.

Side-effects and complications

Side-effects are rare.

Scarring is occasionally seen with painting but such a small area is being done that this is not usually visually obvious even if it occurs.

A need for repetition. The main problem with point peeling is that it doesn't always work and it may need to be repeated.

Curettage

This instrument is very versatile despite being mainly used for skin cancer treatment. It has been used for acne cysts and its newer use is in lipoma removal. It gently scrapes away seborrhoeic warts and other surface lesions that have been loosened with glycolic acid or other peeling agents or after fine wire diathermy.

The curette can not be used in areas of loose or very thin skin such as around the eyelid. But correctly used in the treatment of non-cancerous spots, it is a very useful instrument.

Cortisone injections

This very simple technique is useful in the therapy of scars and cysts.

A dilute local mixture of local anaesthetic and cortisone is sufficient treatment for early scars after sugery or acne or other inflammatory cysts. More entrenched or thickened scars may require stronger concentrations of cortisone to settle these down.