1. Filler Materials Medical Aspects Prof. Dr. med. P. Graf Munich

2. Aesthetic Operations/Treatments

3. Operations versus Minimal invasive Treatments

4. Filler-Material (Selection) u Silicon u Polytetrafluoräthylen (PTFE) u Collagen u Hyaluronic Acid u Acryl (Plexiglas) u Polyacrylamid u Poly-L-lactic acid u Calcium-Hydroxylapatit u Autologous Tissue (Fat)

5. Filler Material (Composition) Plastic Material u Silikon u PTFE u PMMA Organic Material u Collagen u Hyaluronic Acid u Autologous Fat

6. Filler Material (Consistency) hard u Silicon u PTFE u Goldthreads „ liquid“ u Collagen u Hyaluronic Acid u Acryl Microspheres u Autologous Fat

7. Silicon (Hard Consistency) u inert Material u Nonresorbable u No indication as filler material for wrinkles u Deep positioning u Indication for contour improvement (Breast, chin, etc.)

8. Silicon (Chinaugmentation) Die Darstellung präoperativer Fotos in ärztlichen Internetseiten ist in Deutschland leider nicht erlaubt Die Darstellung präoperativer Fotos in ärztlichen Internetseiten ist in Deutschland leider nicht erlaubt

9. Collagen u Low Immunogenicity (3%) u Resorbable u Superficial and deep Positioning u Bovine spongiform encephalopathy (BSE)

10. Hyaluronic Acid I u No Immunogenicity u Resorbable (6 Months) u Superficial and deep positioning

11. Hyaluronic Acid II Pattern of Intercellular Space The intercellular space of the skin is filled by collagen fibers which are located in a matrix of polysaccharides (=hyaluronic acid).

12. Hyaluronic Acid III Microstructure, Properties An important function of hyaluronic acid is its property of water retention.

13. Hyaluronic Acid IV Intradermal/Subdermal Positioning of Filler

14. Hyaluronic Acid V Injection Technique Linear Injection technique Serial step-by-step Injection technique

15. Hyaluronic Acid VI Lip Augmentation

16. Nonresorbable Filler Material Acryl-derivates, Calcium-Hydroxylapatit, Poly-L-Lactic Acid, etc. u Non- / Low-Resorbable u Deep Positioning u Immunogenicity ? -Foreign Body reaction -Inflammation -Infection -Fistula

17. Complications I Transdermal Migration of Acryl Microspheres (PMMA), (=Plexiglas)

18. Complications II intravascular Injection Skin necrosis after accidental intravascular injection of PMMA

19. Complications III Blindness from: Complications of Injectable Fillers, Part 2: Vascular Complications Aesthetic Surgery Journal Claudio DeLorenziy 2014 34: 584-600

20. Bacterial Biofilm I A biofilm is any group of microorganisms in which cells stick to each other on a surface. These adherent cells are frequently embedded within a self-produced matrix of extracellular polymeric substance (EPS). Biofilm extracellular polymeric substance, which is also referred to as slime (from: https ://en.wikipedia.org/wiki/Biofilm) from: https://en.wikipedia.org/wiki/BiofilmResp. from: Looking for Chinks in the Armor of Bacterial Biofilms Monroe D PLoS Biology Vol. 5, No. 11, e307 http://biology.plosjournals.org/perlserv/?request=slideshow&type=figure&doi=10.1371/journal.pbio.0050307&id=89595

21. Bacterial Biofilm II u “Biofilms are ubiquitous. Nearly every species of microorganism, not only bacteria have mechanisms by which they can adhere to surfaces and to each other. Biofilms will form on virtually every non-shedding surface in a non-sterile aqueous (or very humid) environment.” u “Biofilms can grow in showers, pipes, on teeths, catheters, contact lenses, heart valves, etc.” https://en.wikipedia.org/wiki/Biofilm

22. Bacterial Biofilm III in Soft Tissue Fillers Bacterial biofilm formation and treatment in soft tissue fillers Morten Alhede et al. April 2014 Pathogens and Disease doi: 10.1111/2049-632X.12139 „…Evaluation of treatment strategies showed that once the bacteria had settled (into biofilms) within the gels, even successive treatments with high concentrations of relevant antibiotics were not effective. Our data substantiate bacteria as a cause of adverse reactions reported when using tissue fillers, and the sustainability of these infections appears to depend on longevity of the gel. Most importantly, the infections are resistant to antibiotics once established but can be prevented using prophylactic antibiotics. …“

23. Complications Inflammation, Foreign Body Reaction, Fistulas

24. Consequences u Think! Would you like to have a permanent filler? u Do you inform your patients who ask for permanent fillers about foreign body reactions, inflammations, infections, fistulas? u Do you inform about alternatives (hyaluronic acid, fat transfer)? u Antibiotic prophylaxis?

25. Fat Transplantation by E. Lexer in Munich

26. Autologous Fat Transplantation Application u Neurosurgery u Ophthalmology u Urology u Aesthetic Surgery u etc.

27. Autologous Fat Transplantation Lipofilling u No immunogenicity u Resorption u Deep positioning (subcutaneous) u Operation

28. Autologous Fat Transplantation Healing Process

29. Autologous Fat Transfer Resorption Causes of trauma to transplanted fat grafts u By suction of fat (mechanical, high vacuum) u By preparation of graft (mechanical, drying) u By injection of fat graft (high pressure) u By late ischemia within the body (high tissue pressure) Rates of Resorption in Literatur 20 - 100% Own Investigations: 55,6% (47 - 68%)

30. Autologous Fat Transfer Minimization of Resorption u Avoid potentially damaging substances (Adrenalin?) u Gentle suction (diameter of canula, size of vacuum) u Atraumatic preparation of fat graft u Careful preparation („ Cleaning“) of aspirated fat u Careful Injection (short, thick canula) u Good dissemination of graft u Avoid high tissue pressure Atraumatic treatment is critical for Rates of resorption (=success) of fat transfer

31. Autologous Fat Transfer Operative Technique

32. Autologue Fat Transfer “Cleaning“

33. Autologous Fat Transfer Injection

34. Autologous Fat Transfer nasolabial Die Darstellung präoperativer Fotos in ärztlichen Internetseiten ist in Deutschland leider nicht erlaubt