Dermal Fillers


By Eduardo Weis MD

10668415_lAs the skin ages and is subjected to wear, tear and sun, it falls into disrepair. Production of the three major components of healthy skin—collagen, elastin and hyaluronic acid—slows.

Collagen is the support system for the skin. Hyaluronic acid helps the skin hold on to moisture. Elastin helps the skin remain elastic and firm. The skin wrinkles and folds. The lips, which are plumped by collagen, thin as well.

Dermal fillers are one of the most widely used treatments for wrinkles, depressed scars and volume loss in the face and body. They are injected just below the top level of the skin, the epidermis.

There are several different types of dermal fillers, distinguished by the material they are made from, the duration in the skin, and the way they work. Some dermal fillers are made from components that occur naturally in the skin, like collagen and hyaluronic acid. Others are made with artificial substances like poly-l-lactic acid, silicon and PMMA. Another type of filler is autologic—taken from our own bodies. Most autologic fillers are made from our fat.

The duration varies from short-lasting (a few months), through long-lasting (a few years), to permanent. Some fillers will just increase the volume, others will stimulate the production of new collagen and elastin, and some will do both.

4 Dimensional approach

The number of non-surgical procedures nowadays is increasing exponentially, because people are very concerned about down-time and cost. Combining multiple non-invasive procedures, we can achieve excellent results without the down time, and with a more reasonable price.

We call this the 4-dimensional treatment approach, which includes lasers, chemical peels, Botox, and cosmeceuticals for the more superficial spots and wrinkles; and more aggressive lasers, fillers, and radio frequency for the more advanced wrinkles and skin laxity. However, the key for success would be to combine all these treatments according to each patient’s case and maintain the results as needed with continued evaluations and treatments.

In this article, we will present a very comprehensive review on dermal fillers so when you go for a cosmetic consultation as a patient, you have a more informed and objective understanding so you can make a good decision.

Hyaluronic Acid (HA)

HA is a naturally occurring polysaccharide found in the extracellular matrix in many human tissues; approximately 50% of the total HA in the human body is found in the skin. It is present in all animal species, and its chemical structure is uniform throughout nature. In its pure form, HA has no potential for immunogenicity.

Early work with pure HA revealed many characteristics that seemed ideal for soft-tissue augmentation; however, its rapid tissue clearance made it a poor candidate for aesthetic applications. Continued study led to successful cross-linking of HA, which maintains its natural positive characteristics but increases tissue residence time and product durability, and enables the production of effective dermal fillers.

The FDA approval of the first HA dermal filler (Restylane®) in 2003 revolutionized the aesthetic market. HA products require no skin testing, have minimal adverse events, and provide soft, natural results. HA filler injections were the second most common aesthetic procedure (after botulinum toxin injection) in 2009.

Despite differences in chemical and physical characteristics, commercially available HA fillers carry the same indication for injection into the mid to deep dermis for the correction of moderate to severe facial wrinkles and folds (such as nasolabial folds).

In general, adverse events associated with HA fillers are localized, mild to moderate, and temporary. The most common are redness and bruising. One safety advantage of HA fillers is that adverse reactions or poor product placement can be reversed with the injection of hyaluronidase, a soluble protein enzyme that breaks down and hydrolyzes HA.

Calcium Hydroxylapatite

This novel filler, Radiesse, was FDA approved in December 2006 for the correction of facial wrinkles and folds, and for the correction of HIV-associated facial atrophy. In 2009, it received FDA approval for cosmetic use in non-HIV patients as well. The dermal filler is composed of 30% calcium hydroxylapatite and 70% carrier gel. The clinical results may last as long as 12 months or longer, although the carrier gel lasts no longer than six months, thus often resulting in a slight decrease in correction at that time.

Radiesse is nearly always injected subdermally at the dermal-subcutaneous junction; therefore, this product is not a true dermal filler. Studies from 2008 suggest that calcium hydroxylapatite may induce neocollagenesis, although further research is needed. Most commonly, Radiesse is used for the correction of nasolabial folds, atrophic cheeks, and temporal wasting. Following injection (similar to other dermal fillers) some swelling and bruising will occur and will typically resolve within one week. Serious adverse events are rare; however, a granulomatous-like response to an older HA formulation has been reported in the literature.

It is very important to select a well trained doctor, and avoid non-certified injectors just to save some money or because of peer pressure.

Poly-L-Lactic Acid

This novel product (Sculptra) differs from all other agents in several aspects. Poly-L-lactic acid is a synthetic, biodegradable, biocompatible, immunologically inert peptide polymer (similar to reabsorbable sutures) that is believed to stimulate fibroblasts to produce more collagen, thus increasing facial volume.

Although poly-L-lactic acid is nearly always injected subdermally, dermal neocollagenesis occurs (formation of new collagen), thus it is a dermal stimulating agent, not a true dermal filling agent. Several limitations have prevented poly-L-lactic acid from becoming as popular as other products. Poly-L-lactic acid must be premixed prior to use, making immediate treatment impossible. Unlike dermal fillers, results are not appreciated for four or more weeks. Lastly, most patients require 2-3 treatment sessions that are at least 4-6 weeks apart.

Because poly-L-lactic acid is not a true filler, but relies on neocollagenesis to achieve clinical improvement, the clinical results from this agent are less predictable than those of the true dermal fillers. Dermal nodules have been reported after treatment and often take seven months or much longer to develop. When treating the face, these nodules can often be felt, but not seen. Reconstitution of the product with six or more milliliters of sterile water, in addition to vigorous post-treatment massage, is believed to reduce the incidence of nodule formation.

It is very important, once again, to select a well trained doctor and avoid non certified injectors just to save some money or because of peer pressure.

Silicone Dermal Fillers

The use of silicone fillers has been controversial in the past because of the risk of bumpy scars, called granulomas, which can form even decades after treatment. New formulations of silicone and new injection techniques have reportedly eliminated granuloma formation, but long-term studies are still in progress. The FDA has not approved silicone for this particular use. One advantage of silicone is that you do not repeat treatments once the desired look has been achieved.

Lipotransfer (fat)

This procedure is unique because it removes fat from one area of your body and transfers it to the area of concern. The main advantage of lipotransfer is that it eliminates the risk of an allergic reaction. Lipotransfer is a two step procedure. First, liposuction is performed using local anesthesia to collect the “donor” fat. Fat is then injected into the face, just below the second layer of the skin (dermis) or into the muscle. Bruising, swelling, and redness are common afterward and usually last a few days. No good studies have been performed to evaluate how long fat fillers last. Patients report variable results from three months to three years.

All these products are very effective, but as you can see, there are many differences in how and where they work, and only a well trained doctor can determine which one is good for you, and more importantly, inject them in a safe and artistic way, and in the event of a complication, can manage it in a professional and experienced way.