I thank Dr. Cuomo et al. for reading my Viewpoint article1 and for their useful comments. It seems that they have encountered similar clinical problems and investigated different solutions. I will respond as follows.
First, I agree that botulinum toxin can and should also be used with fillers where appropriate—and this was used in the patient with facial nerve dysfunction secondary to incomplete recovery after Bell palsy.
Second, I disagree with Cuomo et al. regarding longevity of hyaluronic acid fillers. It is well beyond 12 months for many fillers,2 especially when inserted where there is no or little tissue movement.
Third, although “permanent” fillers are attractive, the fact that there are many on the market suggests that there is no “ideal” permanent filler. Also, should a local complication3,4 occur, the problem is “permanent”—and may require an operative solution, thus explaining the attraction of hyaluronic acid fillers, which can be dissolved. Hydroxyapatite fillers are not available in my country.
Fourth, as a plastic surgeon, I love lipofilling and look forward to further advancements to reduce the rate of fat resorption. Their idea of mixing fat grafts combined with growth factors and the stromal vascular fraction is not new. There are suggestions that the latter improves fat survival,5 but resorption is still a problem.
Fifth, it appears that they have tried mixing hyaluronic acid fillers with the stromal vascular fraction emulsion, which is a novel concept, and I look forward to a large series with long-term results.
Sixth, there is a new concept in fillers—myomodulation—as advocated by de Maio6 that may be particularly useful in facial asymmetry, whether congenital or acquired. The concept presented is that fillers can be used to modulate muscle action and restore balance between agonists and antagonists. Fillers can be used to support weak muscle by injecting hyaluronic acid under the muscle, which enhances the fulcrum action of the muscle. Similarly, an overactive muscle can have its action reduced, by injecting hyaluronic acid superficial to the muscle. I think we will see more application of this in the future.
Plastic surgery is a technique-driven specialty that may require innovative solutions to difficult or uncommon clinical problems. This is part of the attraction of a wonderful profession.
The author has no financial interest to declare in relation to the content of this communication. No funding was received for this communication.
Don A. Hudson, F.R.C.S., F.C.S.(S.A.), M.Med.
University of Cape Town
Cape Town, South Africa
1. Hudson DA. Use of hyaluronic acid fillers for acquired contour deformities. Plast Reconstr Surg. 2018;142:244e–245e.
2. Hermann JL, Hoffmann RK, Ward CE, Schulman JM, Grekin RC. Biochemistry, physiology and tissue interactions of contemporary biodegradable injectable dermal fillers. Dermatol Surg. 2018;44(Suppl 1):S19–S31.
3. Ozturk CN, Yumeng L, Tung R, Parker L, Piliang MP, Zins JE. Complications following injection of soft-tissue fillers. Aesthet Surg J. 2013;33:862–877.
4. Cassuto D, Pignatti M, Pacchini L. Management of complications caused by permanent fillers in the face: A treatment algorithm. Plast Reconstr Surg. 2016:138:215–227.
5. Wei C, Li-dong Y, Xioawei T, Gan S. The stromal vascular fraction improves maintenance of the fat graft volume. Ann Plast Surg. 2018;81:367–371.
6. de Maio M. Myomodulation with injectable fillers: An innovative approach to addressing facial muscle movement. Aesthetic Plast Surg. 2018;42:798–814.
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