GE introduction: Injectables—Dermal fillers part A

Dermal fillers, soft tissue fillers, volumizers, collagen stimulators; however, they are referred to, these innovative products have forever changed the landscape of aesthetic dermatology. In this issue of Dermatological Reviews, I have the distinct pleasure of presenting a carefully curated set of articles written beautifully by our guest authors. Dermal filler technology has continued to advance at a rapid pace since the 1980s when the first devices in this space gained approval in the United States. Dr. Pearlman et al. guides us through the rapid rise in filler use over the decades, how they have become integrated into practice and how popular culture has portrayed them over the years and provides us with a starting point from which to dive into the various products in use today. However, before you enter the realm of the filler world, if you are anything like me, you will want to know how we got here and where it all began. Laura Andrews et al. takes us back to the 1800s during which time fillers were first conceptualized and the hollow needle and syringe were invented. I found it incredible how far back people were interested in finding a way to correct volume loss, not initially for cosmetic purposes. The journey has not been without hills and valleys as physicians dealt with complications and issues with the early products. Managing untoward events has become of paramount importance as the holy grail of safe injections for all is pursued. Restylane was the first hyaluronic acid (HA) filler to gain Food and Drug Administration (FDA) approval in 2003. Almeera Lateef et al. show us how this early product came into use and led the way to the widespread use of HA products over the past two decades. This filler taught us a lot about managing adverse effects and the advent of hyaluronidase for use as a filler dissolver changed the landscape of the management of untoward effects such as filler embolism and undesirable placement. Whole societies have formed around the dissemination of information on complication management, providing essential resources for those who use fillers. Our mission to protect patient safety must remain at the forefront of all we do as we perform elective procedures which bring joy to many. Market growth breeds competition and when a pharmacist named Gavin Herbert formed a company to develop novel formulations such as steroid eye drops and decongestants, the stage was set for scientists and physicians to figure out another way to do things. Inventors were looking for novel ways to crosslink HA so fillers would last longer. In parallel to development in the Restylane filler line, the Juvederm family of fillers based their product line on new crosslinking techniques as described by Chelsea Shope et al. This chapter takes us along as several products are developed, many with approvals for different applications. The upward trajectory of research and development was incredible at the time as we learned so much about the physical characteristics of the products being used and how to exploit those for the benefit of patients. Continued clinical experience led to the desire among many to not just inject fillers below the skin and into the deep tissue or periosteal plane as was being done routinely, but to inject more superficially into the dermis. However, early fillers were plagued by the Tyndall effect, referring to the light scattering that could make certain fillers have a bluish appearance through the skin surface. As Chelsea Shope et al. explains in the chapter covering Belotero Balance, how this new filler technology became popular as research showed it could achieve an even distribution in the reticular dermis with a favorable safety profile. Fortunately, its physical characteristics resulted in a lack of Tyndall effect when injected superficially, allowing a wide range of uses in the hands of experienced injectors. While the first incarnation did not have lidocaine, subsequent versions did, making injections more comfortable. Finally, we learn about another technology that has not yet gained FDA approval, however, is available in many other countries. Algeness, as described by Dr. Andraia Lee et al. is an agarose gel filler marketed as an alternative to HA products. Unique in its use of agarose, Algeness may serve as a structural scaffolding and does not attract water as HA fillers are known for. Several products in the line have been developed and trials are underway, with promising prior clinical results, to demonstrate the effectiveness and safety needed for approval. I cannot thank these authors enough for their excellent contributions to the field. They are sharp minds who will do well in their respective fields as they are doing right now. Very specially, I wanted to thank Dr. Alan Snyder, a good friend and colleague who instrumentally organized the authors, reviewed, wrote, and made my job so much easier as we brought this book to fruition. Dr. Michael Gold, who invited me to be Editor for this project has a heart of gold and has been a mentor, colleague, and friend of mine for many years. Thank you for making this happen, for your kind invitation, for all you do for dermatology, and for making the world a better place. Kudos!