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and bone. In recent years, porcine collagen has been and glutaraldehyde makes Cosmoplast® less prone to
marketed as an intradermal filler under the brand name of degradation. Cosmoplast® is used for the treatment of
Evolence™ (ColBar LifeScience Ltd., Herzliya, Israel). Studies deeper wrinkles and deep scars whereas Cosmoderm® is
involving human medical devices have shown that porcine used for the treatment of superficial wrinkles, both with
[20]
collagen is less immunogenic than bovine collagen, although effects lasting for 3-7 months. The Inamed clinical study of
the amount of published data regarding its potential as human collagen immunogenicity concluded with a 95% upper
[10]
intradermal filler is still relatively insignificant. In a phase confidence interval that the probability of a hypersensitivity
I clinical trial with 12 patients receiving treatment for reaction from either Cosmoplast® or Cosmoderm® is less
nasolabial folds, both Evolence™ and Zyplast® were found than 1.3%.
[21]
to be safe and effective. The degree of improvement in
[10]
wrinkles, graded by blinded examiners, was observed to AlloDerm is a sheet derived from human dermis that requires
be much greater for Evolence™ at both the 6-month and a multi-step treatment to ensure optimal efficacy. Cymetra®
18-month visiting periods. A larger randomized, double- (LifeCell Corp., Branchburg, NJ, U.S.A.) is an injectable
[11]
blinded trial found no significant difference in effectiveness form of AlloDerm. Very few trials have been conducted
[22]
between Evolence™ and NASHA (Restylane®) in the comparing human-derived collagen with other types of
treatment of nasolabial folds at the 6-month assessment. fillers. A randomized trial comparing Zyplast® (bovine
Although there were no positive skin tests against porcine collagen) and Cymetra® (human collagen) injections to the
collagen, 6.1% of patients developed IgG antibodies to upper lip showed that Cymetra® had a much higher post-
porcine collagen. Although there were immunogenic treatment value than Zyplast® by the 12-month visit, with
reactions, it is important to note that none of them were bruising being the most commonly observed adverse effect
[23]
considered to be adverse in nature. [12] for both fillers. Because Cymetra® is of human origin,
skin testing is not required prior to use.
Another study was conducted comparing the safety and
efficacy of TheraFill®, a porcine collagen filler, to a bovine Although collagen treatment is beneficial for most
collagen filler for the treatment of nasolabial folds. In total 61 individuals, it has its limitations. Patients who are sensitive
patients were evaluated in this randomized, double-blinded to bovine collagen must instead use human collagen, which
and split-face study over a 12-month period. The Wrinkle is typically more expensive. Individuals with autoimmune
Severity Rating Scale (WSRS) rating of TheraFill® was shown diseases should completely avoid the use of foreign collagen.
to be higher than that of bovine collagen filler by a small Finally, the results typically last for a short period of time as
margin, although not enough to be considered statistically the body absorbs external collagen naturally.
significant. Both fillers were similarly effective and safe
without eliciting severe adverse reactions, suggesting that Hyaluronic acid
TheraFill® could suitably replace bovine collagen filler. [13] HA is a very commonly found substance which is usually
derived from either bacteria or rooster combs for use as an
Many studies have been performed which assess the efficacy intradermal filler. Although several products containing
[24]
of bovine and porcine dermal fillers. The aforementioned HA-related proteins have shown a theoretical risk of
studies discuss the adverse/allergic responses and the hypersensitivity, there is no requirement for skin testing
efficacy of treatment provided by these fillers. [14,15] More prior to use. [24]
comparative studies have been done between bovine or
porcine and other fillers to choose the safest and most Restylane®, a type of non-animal stabilized hyaluronic
preferred treatment. With the advent of new technology, acid (NASHA), is a stable, partially cross-linked form of HA.
[16]
the cosmetic industry has moved on to various other types It is fermented by bacteria and has a long track record of
of intradermal fillers including human collagen, smooth safety (over 10 years) as an intradermal filler. Due to rapid
gel hyaluronic acid, poly-L-lactic acid (PLA), poly(methyl degradation of hyaluronic acid in the skin, cross-linking
methacrylate) (PMMA) microspheres, etc., which have proven is required in order to produce a hydrophilic HA polymer.
to be better alternatives to bovine and porcine fillers. These Because no anesthetic is associated with Restylane®,
are discussed in detail below. topical anesthesia or a nerve block may be administered
prior to its use. Narins et al. conducted a double-blinded,
[25]
Human collagen randomized, and longitudinal comparison study between
Collagen has traditionally been extracted from animal sources Restylane® and Zyplast® for treatment of the nasolabial
or cadavers. Recently researchers have proposed obtaining fold. In the study involving 138 patients, the Wrinkle
human collagen from other sources including adipose tissue Severity Rating Scale (WSRS) (with 1 being the lowest and
obtained after liposuction and from yeast or bacteria 5 being the most severe) and Global Aesthetic Improvement
[17]
used for the production of recombinant human collagen. Scale (GAIS) (on a scale of 5 ranging from “worse” to “very
[18]
Moreover, human collagen can now also be synthesized much improved”) were used at 2, 4, and 6 months after
in the lab as discovered by Raines. Cosmoderm® and baseline. Both groups showed similar improvements with
[19]
Cosmoplast® (Inamed Aesthetics) are some of the currently 90% of patients exhibiting improvement by 1 or 2 scores
available products made of human collagen; both contain according to the WSRS rating. At 6 months, more patients
lidocaine and have received FDA approval. The collagen showed improvement with Restylane® (56.9% for WSRS; 62%
content is produced from a single human dermal fibroblast for GAIS) than with Zyplast® (9.5% for WSRS; 8% for GAIS).
cell line. Cross-linking between lysine residues on collagen Reactions (e.g. swelling, tenderness, bruising, redness and
Plast Aesthet Res || Vol 3 || Mar 23, 2016 75