The Increased Popularity of Dermal Fillers


Lois W. Stern

With grateful appreciation to Dr. Lawrence Bass for his helpful input for this article

Soft tissue fillers can help achieve a younger, more rested appearance by restoring facial volume which is lost during aging. In a fifteen minute office treatment with minimal recovery time, features such as deepened nasolabial folds, jowls, marionette lines, cheek flattening or hollowing, tear troughs, vertical lines between the eyebrows and chin contouring can be corrected.

Filler treatments are performed during a brief office visit. The area to be treated is first numbed with an injected anesthetic block, a topical anesthetic gel, cold air or a combination of these numbing agents. Afterward, mild swelling and redness is usually seen for a day or two. Bruising is possible but may not occur at all. Larger volume injections or injections in the eyelid area are more likely to have visible recovery for a longer period of time.

There are a growing number of FDA approved fillers for these types of treatments. Several of the leading fillers will be discussed below but certain general principles apply. For each class of material several fillers usually are available, but might vary in stiffness, thickness or durability. Fillers have each found particular applications where they work best – their niche - although this will vary somewhat from provider to provider.

The key to success with fillers is carefully analyzing exactly where correction is needed. There are then usually only a few choices about which filler will work best. The skill of the injector is another critical factor. The injector must have the aesthetic sensibilities to know which features should be corrected and by how much as well as the manual skills to be very precise and exacting. Otherwise the desired result will not be produced. So you, the patient, must exercise caution in selecting a skilled, experienced individual for your treatments.

Fillers, like all aesthetic treatments, improve or minimize the unwanted feature or aging change, but the undesired feature will not be completely eliminated. Pushing too hard for maximal correction is a recipe for disaster. An unnatural look is almost sure to result. For example, the nasolabial fold deepens during aging. But even a fifteen year old has some depth in their nasolabial fold. It is a natural part of youthful human features. Trying to eliminate the fold completely in the name of complete correction ends up producing an alien appearance which is not particularly desirable.

Several of the more popular fillers today are known as hyaluronate fillers. Hyaluronate is a gel matrix material found in skin and connective tissue which glues proteins and other tissue materials together. These filler materials s are produced in laboratories through recombinant technology. Restylane® and Perlane® are two of the most popular hyaluronate fillers offering typical durabilities of six and nine months respectively. These products are widely used for lip augmentation, treatment of nasolabial folds and marionette lines, rhytids (wrinkles) and nasojugal folds (tear troughs), among others. Some hyaluronate products now contain lidocaine, to minimize discomfort while being injected.

  • Juvederm™ Ultra and Juvederm™ UltraPlus are two competing hyaluronate fillers with similar properties. The Juvederm™ family of products is cross linked differently than the process used to produce Restylane® and Perlane® and has received FDA labeling for longer durability, up to one year.

  • Another material, Radiesse®, is composed of hydroxylapatite, a mineral matrix naturally present in the human body and suspended in a carrier gel for injection. Made synthetically, it is a sterile product that has no components derived from human or animal sources. Hydroxylapatite has been used in humans in the United States since the early 1980’s, amassing an extensive record of safety and biocompatibility. More than three hundred thousand treatments with Radiesse® have been performed worldwide, supporting its safety record in this current injectable form. The material is slowly absorbed over a period of several years. Improvement results vary from individual to individual and with the facial area being treated, but averages twelve to eighteen months. Because Radiesse® is not a protein, tissue reaction is minimal. Other hydroxylapatite products are under development or testing in the US but are not yet approved.Some hyaluronate products now contain lidocaine, to minimize discomfort while being injected.

  • Sculptra™ is injectable filler which is composed of poly-lactic acid, a material used in certain types of absorbable sutures. This material provides a good foundation treatment for tissue firming or facial volume enhancement. It is not ideally suited for very fine shape control of surface details. Thus, its major applications are for cheek enhancement and treatment of cheek hollowing, among other areas. After a series of three monthly injections, results seem to last two years or more on average. The material is FDA approved for treating facial wasting from HIV. The manufacturer has applied for FDA cosmetic approval, which is still pending at the time of this writing.Some hyaluronate products now contain lidocaine, to minimize discomfort while being injected.
    Watch this video to see patients receiving filler treatments.

  • There are additional fillers that are composed of materials that are not naturally found in the human body. These fall into two groups: absorbable and non-absorbable. Absorbable fillers are safer in that the material, even if it causes an unfavorable reaction, will ultimately be completely removed from the body. Non-absorbable fillers will always remain and can never be completely removed. This provides a long-lasting or even permanent correction, but if trouble develops, it is more likely to be significant in magnitude and will be more difficult to treat. Some hyaluronate products now contain lidocaine, to minimize discomfort while being injected.

  • Artefill® is the only non-biological, non-absorbable filler in the United States that has a specific FDA approval for an aesthetic indication, correction of nasolabial folds. The material is composed of a mixture of porcine collagen and methacrylate microspheres (tiny beads of the material found in superglues). As the collagen absorbs, the response to the miscrophere stimulates new collagen production. The correction is thought to be permanent. As you continue to age, of course, the treated feature will slowly worsen so eventually retreatment will be required.

    Concerns about Artefill® stem from experience with its predecessor in Europe, Artecoll®, where granulomas (inflammatory nodules) and other inflammatory reactions similar to those seen with injected liquid silicone occurred. Modifications in the US product, Artefill®, are believed to have overcome these problems, although due to the permanent nature of the material, it will be years before the late behavior of the material can truly be known. Common application areas are in the nasolabial folds. The material should not be used for lip augmentation.

  • Liquid silicone is not FDA approved for aesthetic injectable fill, but some physicians use this material off label for aesthetic applications. These practitioners feel that the material is safe when multiple sessions of micro droplet injections are used, whereby only tiny drops of silicone are injected in any one spot at each session. However, many physicians feel strongly against using even a medical grade silicone, due to potential problems such as the development of inflammatory nodules, changing shapes, pain or skin erosion.
    Note: See Lois W. Stern's article: Avoid Dr. Jiffy Lube - Write Your Own Cosmetic Surgery Success Story

This is not to say that all individuals get into trouble with silicone, but rather that the percentage of individuals who will develop an inflammatory reaction is much too high to be acceptable for an aesthetic procedure. Once a problem develops, it can be treated but rarely brought under control for good, due to the permanent nature of the material. I mention the above to emphasize the importance of using only FDA approved fillers administered by an individual who is legally qualified to purchase the genuine material and experienced in its use. You have only one face; it’s a terrible place to economize or gamble.

While fillers are not a substitute for a facelift, they can help maintain the appearance of the patient who does not choose surgery as a personal option or one who is not yet ready for a facelift. Fillers are also of benefit to some patients who have had a facelift by helping to achieve a more complete correction through volume enhancement, as skin tightening alone does not correct everything that occurs during the aging process.

Addendum: The medical community and science are continually searching for innovations to improve the comfort and effectiveness of aesthetic technologies and techniques. One I recently read about is DermaSculpt, where fillers are inserted through a blunt end cannula rather than a series of injections, a possible refinement to the way fillers are commonly administered today. Learn more.

© 2011, updated 2013 by Lois W. Stern

Lois W. Stern is the author of Sex, Lies and Cosmetic Surgery and Tick Tock, Stop the Clock ~ Getting Pretty on Your Lunch Hour as well as numerous magazine articles. Her Professional Edition DVD is a popular aid to office staff while interacting with their patients.

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