Q: Dr. Eppley, I changed almost my entire face bone structure by Medpor inplants and osteotomies (high lateral cheek implants, sliding genioplasty, paranasal implants, lateral supraorbital rim implants and forehead reshaping) All in all I am happy with the results but there are a few things that can’t be addressed by implants. Although I got the largest Medpor cheek implants that were placed very high and lateral, I still would like a little bit more lateral projection. (I like faces with a very wide midface in the frontal view) I know this isn’t possible with additional implant placement. The only other option would be a soft tissue filler. I want a permanent result so I want to use a permanent filler. I would also like my lips and temples filled with the permanent filler.
My surgeon told me of two options; Bio-Alcamid gel and Silicone injections:
1. Bio-Alcamid: (I know that it is not FDA approved in the USA but I am from Germany)
He has experience with this filler for almost 10 years. It has the consistency of gummy bear gel and and can only be injected through a 14 G or larger cannula. It doesn’t get hard because it attracts water. When it is injected in larger depots a fine capsule forms around the Bio-Alcamid and it doesn´t infiltrate the surrounding tissue. He told me while most patients do very well with a Bio-Alcamid implant a Bio-Alcamid implant is more likely to become infected. Two of his patients got a Bio-Alcamid implant infection after they had a tooth root infection near the implant. The advantage of this implant is that in all two patients he could remove the Bio-Alcamid completely through a 3 mm incision by suction and irrigating it out and they didn’t look worse than before the Bio-Alcamid implantation. Because of this he thinks that Bio-Alcamid has a very high safety profile and although it is a permanent filler it doesn´t cause permanent problems. It is more like an implant because you can take it out again if problems should occur.
2. Liquid silicone oil injections with Silikon 1000 or PMS 350: He told me he would inject small amounts of silicone oil in micordroplet technique and after 5 weeks own tissue growth is induced by the injected silicone. The desired volume has to be built up very slowly over several month. Late infections are very rare and theoretically could be treated with antibiotics. A big advantage of silicone oil injections is, hat most of the volume is provided by your own tissue. But he warned me that despite of using medical grade silicone and the right injection technique, some patients develop little granulomas.
And of course silicone is irreversible.
I personally like the idea that Bio-alcamid is more like an implant and is reversible, but I also like the idea of tissue growth induced by silicone. Another advantage of silicone over Bio-Alcamid is, that it feels very soft and more like your own tissue. A friend of mine has Bio-Alcmaid in this naso-labial folds and it feels like an compact implant made of gummy bear.
I know, that there lies a very important facial nerve below the skin of my very lateral cheek bones. When a silicone granuloma should form and pushes on the nerve or silicone that sticks around the nerve gets inflamed, I could permanently look like I had a stroke (I already looked like this for a few weeks after my cheek implant surgery). Bio-Alcamid doesn’t´stick or “melt” with the tissue and because it is injected in a big deposit that becomes surrounded by a capsule, the formation of granulomas is very unlikely. Because of this I think that I am on the safer side with Bio-Alcamid. However I know that a dental infection could lead to the loss of the implant… fortunately I never had any problems with dental infection due to a consequent oral hygiene.
What would you use if Silikon 1000 and Bio-Alcamid were your only two options?
(I know there are other options, but they don´t seem to provide stable volume) Is it true that silicone can migrate even if it is injected in micro droplets and held in place by scar tissue and why can it migrate in spite of this? Have you seen patients at your office who have been injected with Silikon 1000 microdroplet technique and got complications from this injections? What do you think of the concept of Bio-Alcamid? I have searched the internet and the only problem that seems to occur with Bio-Alcamid is implant infection when the Bio-Alcamid pocket is contaminated due to trauma or dental work and sometimes it is a little bit harder but never impossible to remove the implant, if it hasn´t been injectet in depot technique.
Thank you in advance for your reply.
A:Thank you for your long and detailed history and questions. If I have learned one thing about implant materials in my entire surgical career it is that they all can cause problems, most have more problems with their use than are reported and if you live long some of these problems will appear in some patients. For this reason, I always think about reversibility with any implanted material. This is the one thing that bothers me about so-called permanent injectable fillers. That being said, the answers to your questions are:
1) There is no question that the use of the Bio-Alcamid filler would be preferable to silicone oil. While I have not used Bio-Alcamid I am very familiar with its composition, properties and the literature on it. I have seen numerous problems, however, with silicone injections as you have mentioned including migration, lumpiness and some foreign-body type reactions. As you have mentioned, once its is injected it is impossible to remove.
So while I think Bio-Alcamid injections are better, I would have some reservations about where you want to place it. I don’t think it matters what long-lasting/permanent injectable filler is used, the lips are just a bad place for particulated filler materials. Lip tissues are very different than the rest of the face and any particulated injectate is going to cause lumps and maybe even some foreign-body reactions. They are too thin and supple to tolerate particulated injections. I have seen lots of problems with other particulated materials in the lips such as Radiesse, Artefill etc. so I would not be enthusiatic about it. In addition, the temples are a potentially problematic area as well for such fillers. While it can be done into the soft tissues above the temporalis fascia, be aware that the frontal branch of the facial nerve lives there. That nerve has the potential to be injured during the injection process (low risk) as well as during removal of the material (high risk) if necessary.
In my patients for your concerns, I would take a different approach to permanent temple and lip augmentation. I would use new silicone temporal implants which are easy to underso, no real risks in doing it and produce an immediate and permanent change. They are placed under the deep temporal fascia on top of the muscle. For the lips I would consider either fat injections or Permalip silicone tapered tube implants which are easy to insert and are completely reversible.
As for more projection from your cheek implants, be aware that custom implants exist that offer enhanced dimensional changes over what stock cheek implants can create.
Dr. Barry Eppley