Fillers are natural or synthetic substances which are used to “fill” areas which have become deficient from aging, trauma, congenital defects, or for cosmetic enhancement. The choice of filler for the location and the application is constantly evolving from the influx of new materials.
The most common use of fillers, is to soften or erase the lines and grooves of the face associated with aging. Below are the most common:
- Nasolabial line (from the corner of the nose to the angle of the mouth)
- Marionette line (from the corner of the mouth toward the chin)
- Oral commissure (the depression at the corner of the mouth)
- Tear trough (from the nasal corner of the eye extending at an angle down the cheek)
Other uses include the ability to change the shape of deeper underlying facial structures such as the cheek area, nose or chin. Longer lasting or permanent fillers can sometimes take the place of implants in these areas and avoid surgery. Fillers can also be used to fill out hollow areas and rejuvenate them such as the temple and the back of the hands.
In early cases of aging, it is frequently possible to rejuvenate the face with restoration of volume alone and without a surgical incision. The addition of fillers in an area of moderate sagging will often “lift” the area without surgery. These techniques are now being referred to as the “Liquid Facelift.”
Collagen: Natural substance refined from cows or human skin which unfortunately tends to go away rapidly. First approved by the FDA over twenty years ago, there are disadvantages to note. They require two skin tests to insure there are no problems with allergies. If done properly that means a wait of 4-6 weeks. Second, they have poor duration, in some areas only lasting for a few months. Third, they have a tendency to “clump” and become irregular. Human derived collagen was approved by the FDA but continues to have many of the same problems. These products are still on the market but rarely used, except in special circumstances.
Hyaluronic Acid: Like collagen, Hyaluronic Acid fillers are very similar to a natural substance found in the skin. When Collagen proved to be such a disappointment in terms of duration, other substances were explored. One of these is hyaluronic acid. First made from animal products and subsequently having allergy issues like all animal products, there are now synthetic products that are used and referred to as “Nonanimal Stabilized Hyaluronic Acid (NASHA).”
- No skin test is required for the synthetic versions
- They have reasonable durability generally considered to be 6-9 months
- They are mostly free from clumping when injected properly
- Reasonable cost
- Immediate improvement with minimal stimulation of the body’s own fibrous reactions
- Can be used in most areas of the body
- Reversible (Non-Permanent)
Common Types of Hyaluronic Acid Fillers
Restylane: One of the first synthetic fillers and still very dependable. Can be used in all areas of the face for minor irregularities. Cross-Linked Hyaluronic acid, a natural filler substance which predictable lasts from 9 months to one year.
Perlane: Similar to Restylane, but with a slightly larger particle size for longer duration. Should be used in a deeper plane than Restylane. Similar duration as Restylane.
Juvaderm: Slightly more concentrated, but with a good flow during injection. Many favor in the areas around the eyes. Lasts about 4-8 months.
Prevail Silk: This is another non-animal filler with the addition of local anesthetic to the formula and an extra step in cross-linking of the molecule which is supposed to improve the durability. The anesthetic makes the injection more comfortable, yet duration has been seen to be the same as other common fillers above, despite claims.
Radiance: Generally injected over several sessions. Originally approved by the FDA as a deep volume replacement, it is now used to correct wrinkles and folds of the face. The effects are both immediate and delayed. There is an immediate effect of volume change and the body reacts to the microspheres and contributes fibrous tissue and collagen to increase the fill and add to the durability. This contributes to the extended duration of 12-18 months.
This filler should not be used in the lips or eyelids since there is more risk of clumping and irregularity. There is no method to reverse the treatments except for actual surgical excision or time.
Sculptra: Also first approved by the FDA as a deep volume replacement which has now found more general applications. Generally this is used in two to three sessions 1 to 2 months apart. Injection technique and aggressive massage over 5 days are necessary to prevent clumping and reduce the risk of nodule formation. Duration is considered to be 18-24 months, although some patients report even longer residual effects. There are several areas which seem particularly suited to this filler – the temples and the backs of the hands.
Silikon 1000: Highly purified silicone oil used “off label” for permanent fill of many different areas. Must be used in multiple tiny injections and built up to final objective.
This is an ultra pure clear silicone fluid approved by the FDA for use in eyes with detached retinas. Under FDA regulations, it is within the authority of a practicing physician to use an approved substance for an alternative purpose as long as this is thoroughly explained to the patient. This practice is called “off label use”. Because of it’s lack of any color it seems to have attracted a particular application to treating of the fine vertical lines around the mouth, smoker’s lines, for example.
Artefill: This is the first permanent filler approved by the FDA. Since it is suspended in bovine collagen, it requires a collagen skin test 4 weeks prior to injection. After injection, the collagen is gradually absorbed and the spheres remain permanently stimulating a fibrous response augmenting the fill. Some redness and irritation is normal immediately after injection and resolves on its own. This filler has both an immediate and a long term (permanent) effect.
Done over multiple sessions because of the permanence and rarely done for first time filler users. Should not be used in the lips or in areas of especially thin skin such as the eyelids.
Fat or Lipostructure: Removing fat from one area and concentrating it to place in another area has been a very successful procedure for over 15 years. Over time, this process has been refined and the techniques for removal of the fat and replacement, with maximal survival of the fat cells have dramatically improved.
Duration is generally considered to be about 10 years. The advantages of lipostructure include, that it: is totally natural, reduces the area of harvest, remains soft and natural, and is readily available in most individuals.
Disadvantages include: the color of the fat which can show through thinner tissues, the natural absorptions of 20% or more of the injected fat, the need for a donor surgical area, and the limited amount of fat that can be injected at one time.
Fillers Comparison Chart
|Cost||Material||Duration||Immediate / Delayed||Reversibility||Special Applications|
|Restylane||$||Hyaluronic Acid||6-8 months||Immediate||Completely||All Areas|
|Juvaderm||$||Hyaluronic Acid||4-8 months||Immediate||Completely||All Areas|
|Perlane||$$||Large Particle Hyaluronic Acid||6 months (plus)||Immediate||Completely||All Areas|
|Radiesse||$$$||Calcium Hydroxylapatite||12-18 months||Immediate and Delayed with fibrin and collagen||None Surgical Only||Avoid Lips, can show color if superficial|
|Sculptra||$$$||Poly-L-Lactic Acid||18-24 months||Mostly Delayed with body’s response||None Surgical Only||Use Deeper with multiple treatments over time|
|Artefill||$$$||Bovine Collagen PMMA Beads||Permanent||Immediate and delayed||None Surgical Only||Multiple sessions to build on|
|Silikon 1000||$$$||Medical Silicon Oil||Permanent||Immediate with minor delay||None Surgical Only||Off Label|
|Lipostructure||$$$$$||Autologous Fat||10+ Years||Immediate||Partial with micro-aspiration||Vascularized bed necessary not near eyes|
Recoveries vary with the type of filler and location, but a quick recovery time is one of the many benefits most people choosing injectable filler treatments can enjoy.
Though the ideal substance doesn’t exist yet, many cosmetic problems can be solved with current filler technology. Results of the treatments are highly individualized, so you should talk with Dr. Kress for more details.
Filler Substance FAQ’s
- I’d like to have my lips enlarged. How do I communicate this to a surgeon?
Computer imaging programs are of some assistance, although in truth, they are not as subtle as we would like for doing minor changes in the lips. We always find it useful if patients will bring pictures from magazines of what they consider to be ideal. By studying these pictures We can see which areas of the lips should be emphasized. We also can see what the patients consider to be the ideal proportion between the upper and lower lips. A picture is a great communication tool.
- What’s the most common problem with fillers?
There are really two problems that go hand-in-hand—there is some swelling, so the patients get a false sense of what their results will be, and some of the filler substance gradually does absorb. Consequently, probably the most common problem is disappointment. At some point shortly after the swelling has subsided, the patient will be extremely pleased only to see the results disappear. Lipostructure is the one possible exception.
- Are there surgical approaches to lip augmentation?
Dr. Kress does perform lip augmentation surgery. For years there have been flaps that are designed to roll skin from inside of the mouth into the lips, increasing the volume of the lips. There are two potential complications: (1) they will create a scar that may be visible or (2) they will create a scar that can be felt by the patient.