Fillers

1. Fillers • Modern soft tissue augmentation dates back to the late 19th century when Neuber first used autologous fat to correct depressed facial defects. • In the early 1900s, injectable paraffin gained popularity until a high incidence of foreign body granuloma formation was discovered. • In the 1940s, the use of highly refined injectable silicone emerged as a dermal implant, with excellent cosmetic results. However, because of the high abuse potential and untoward adverse effects from adulterated compounds, its use as a cosmetic agent has been banned.

2. Fillers • Injectable bovine collagen was developed in the 1970s. Approved by the FDA in 1981, it has remained the industry criterion standard. • In the 1980s, Fibrel was introduced and then approved by the FDA for dermal augmentation. Fibrel works by forming a clot, which, in turn, stimulates collagen synthesis. In the face of the AIDS epidemic and a concern for blood-borne diseases, the company later pulled Fibrel off the market, considering the use of human serum for product reconstitution. • In the late 1980s, autologous collagen processed from harvested fat was first used for dermal augmentation. • And now we have Hyaluronic Acid

3. Biorevitalization System

4. Hyaluronic Acid (HA) Chemistry Discovered in 1934 by Karl Meyer and John Palmer Found in all vertebrate animals Naturally occurring linear polysaccharide composed of alternating residues of the monosaccharides D-glucuronic acid and N-acetyl-D-glucosamine

5. Hyaluronic Acid (HA) Chemistry Synthesized on cell membranes Extruded into the extracellular space, HA is the largest and most plentiful glycosaminoglycan (GAG) in the extracellular matrix of the dermis An average adult concentration of 200 mg/kg (0.02%) Binds enormous amounts of water (up to 1000 times its volume).

6. Hyaluronic Acid (HA) Chemistry Unlike collagen, it exhibits no species or tissue specificity; Chemical structure is uniform throughout nature, Thus has no potential for immunogenicity in its pure form. With age, the amount of hyaluronic acid decreases in the skin, Resulting in reduced dermal hydration and increased wrinkling.

7. Hyaluronic Acid (HA) Biology • Widely distributed in the extracellular matrix of : • Connective tissues, • Synovial fluid, • Aqueous and vitreous humor of the eye, and • Other tissues. • In the skin, it forms the elastoviscous fluid matrix in which collagen fibers, elastic fibers, and other intercellular structures are embedded.

8. Hyaluronic Acid (HA) Biology • HA interacts with other extracellular matrix components • Forms the backbone for the organisation of proteoglycans • Forms associations with collagen and fibrin • HA is highly hygroscopic • involved in tissue hydration • HA exhibits extraordinary rheological properties in solutions • shock absorption, lubrication • HA has free-radical scavenging properties

9. Hyaluronic Acid (HA) • 19 - 47 year-olds 0.330 % • 60 year-olds 0.015 % • 70 year-olds 0.007 % HA & Progressing age

10. HA & Progressing Skin Ageing skin characterised by Continuous decline in the skin‘s hyaluronic acid content – the natural element of the ECM is then missing A decrease in the skin’s hydration capacity An accompanying reduction in cell turnover A loss of elasticity and turgor Development of wrinkles

11. Hyaluronic Acid – as a Filler • HA gels work by enhancing your skin’s own stocks of hyaluronic acid, directly adding volume to either soften the signs of aging or enhance your features. • Small amount of the gel can be injected directly into the dermis, thereby pushing the skin crease/ depression up. • The procedure is quick. It usually takes less than 30 minutes. The benefits can be seen immediately. • Used mainly for wrinkles and folds, in particular the nasolabial folds that begin at both sides of the base of your nose and continue down horizontally to your upper lip.

12. Nasolabial Folds

13. Nasolabial folds

17. Hyaluronic Acid & Skin Ageing

18. HA in Cutaneous Biorevitalization From Moisturization To Elasticity To Microcirculation Therapeutic Action of HA improves various Dermo-epidermic Parameters

19. HA in Cutaneous Biorevitalization Moisturizing and Restructuring Action HA is responsible for the compactness of the tissue. Carries out an extremely important function in the 3D organization of the components of the ECM  It binds to itself enormous quantities of water, making it possible to maintain adequate and natural moisturizing of the skin, Giving it characteristics of turgidity and freshness clearly seen in young skin.

20. HA in Cutaneous Biorevitalization Action on Fibroblasts • Presence of HA in specific concentrations recreates an optimum physiological environment for : • Proliferation and migration of fibroblasts and • Neosynthesis of collagen, elastin and endogenous hyaluronic acid.

21. HA in Cutaneous Biorevitalization Scavenger Action on Free Radicals Protecting the fibroblasts from the cytotoxic action of free radicals This action increases with higher the concentration of HA

22. HA in Cutaneous Biorevitalization In Neo-angiogenesis HA from the Extracellular Matrix (ECM) has a crucial role in the regulation of angiogenic process. HA is potent regulators of vascular functions, stimulating Endothelial Cells (EC) * proliferation and migration. The modulation of EC behavior is performed by interaction between HA and its receptor. * Endothelial cells (ECs) constitute an inner lining (endothelium) of blood vessels able to regulate the interface between the blood and the vessel wall.

23. A medical system based on sodium salt Hyaluronic acid. Presented as an apyrogenous, viscoelastic and transparent solution in disposable syringes Hyaluronic acid is of bio-synthetic origin. Contains 20 mg HA in 1.1 ml – i.e. a concentration of 1.8% and a molecular weight of about a million Dalton

24. A 2% (20mg /1 ml) gel containing Hyaluronic acid’s Auto-crosslinked Polymer (ACP) Derivatives formulated for intra-dermal injection

25. Chain 1 Chain 2 Pure HA Internal cross-linking inter – intra molecular binding Ester binding between carboxyl and alcohol groups ACP® ACP: the only-one autocrosslinked HA-biopolymers No chemical entitiesother than “native” HA are used

26. Cross-linking in other HA based Fillers Crosslinking via bishydrazides Crosslinking through Biscarbodiimides (reaction performs in aqueous solution) Crosslinking via bis-epoxides (BDDE) in situ crosslinking by PEG-dialdeide reaction Crosslinking via divinylsulphone Involve crosslinking agents in order to achieve molecular bridges between HA chains Obtained by crosslinking reaction through chain-to-chain bridges Crosslinked by molecular bridges

27. Treatment Goal To increasing native hyaluronic acid levels to early adulthood levels.

28. Treatment Protocol Involves • First stage of intervention with 1 or 2 sessions with • Second Phase use of in the favourable environment rich in water

29. Stage I

30. Stage I

31. Stage II – Injection of IAL ACP in the dermis During DEGRADAtion it gradually releases “natural” HA fragments With different molecular weights

32. Degradation happens in 2 steps ACP® Hydrolysis processde-esterification 1st Natural hyaluronic acid release O H O C O C O H H2O Auto cross-link O H O H H2O H2O H2O Links breakage long natural HA chains release

33. Degradation happens in 2 steps ACP® 2nd Enzymatic degradation Natural hyaluronic acid release Hyaluronidases O H O C O C O H H2O O H O H H2O

35. New vasal synthesis - ICAM Fibroblast migration - activation Collagen fiber synthesis - CD44 Extracellular matrix Natural hyaluronic acid release undifferentiated cells H2O OH - H2O CD44 ICAM

36. Therapeutic Effects Skin tone ageing Skin turgidity, elasticity Cell viability & molecular integrity Synthesis of collagen, elastin, hyaluronic acid Organisation of the ECM Hydration, viscoelasticity Antioxidant activity Stimulation of fibroblasts

37. Treatment Results The physiological functioning of the skin is optimised: Increased intradermal hydration Increase in skin elasticity Optimum cell turnover, among other things, similar to the cell activity of younger adults Higher fibroblast activity that results in the new growth of collagen, elastin and endogenous hyaluronic acid.

38. Treatment Results The visible appearance of the skin is improved: More Compactness And Tautness Reduced Wrinkle Formation Improved Complexion Younger, Smoother And Natural Looking Skin Pleasant To The Touch

39. Treatment Areas Skin rejuvenation on specific areas: Cheekbones The area around the eyes can also be treated by injection into the zygomatic arch area Neck Back of the hand Cleavage Perioral region 39

40. Contraindications Not recommended in pregnant and lactating women Not recommended in patients with renal impairment or hepatic impairment Patients with ascertained individual hypersensitivity to the product components. Avoid application in anatomical sites with infections or inflammatory processes.

41. Undesirable Effects The treated area may show reactions commonly related to the injection- such as swelling, mild pain and erythema They spontaneously resolve within few hours after application. In rare instances, small ecchymosis * may be induced which spontaneously resolve within few days. * Ecchymosis = the purple or black-and-blue area resulting from a bruise

43. In Conclusion • The keys to a successful outcome in soft tissue augmentation are in knowing which implant best corrects a particular defect and in knowing how and when to intervene if adverse or unsatisfactory reactions occur. Of equal importance is the selection of a patient with reasonable expectations, with full disclosure of the risks. Consulting with the patient preoperatively is important and requires a thorough history and physical examination, to discuss risks and benefits, to identify contraindications, and to review expectations and limitations.

44. THANK YOUSimply Skin – Aesthetics Ma-Belle Mansion,Central Avenue,Chembur.Tel: 25284453 / 9821117136www.simplyskin.in