Injectable Fillers – Smart or Not?


Injectable dermal fillers aka “facelift in a bottle”

The liquid face lift has been popular for years and for understandable reasons – a more youthful appearance with no downtime, no anesthesia, and no going under the knife. There are even house parties devoted to facial treatments that utilize injectables for facial rejuvenation (for obvious reasons BFT does not recommend doing this.)

 

 

Dermal filler injectables are not to be confused with Botox which is not a filler but rather a low concentration of a bacterial toxin that paralyzes facial muscles by preventing the release of neurotransmitters from the nerve endings that in turn cause muscles to contract. Botox eliminates the distortion (i.e. wrinkles) caused by normal facial muscle activity; dermal fillers do their work by filling in the “voids” or loss of volume within the dermis that causes most wrinkles. Fillers are also used to “plump” underlying tissues including subdermal fat that is lost through the aging process. Dermal (and subdermal) fillers can effectively plump, fill, and re-contour the face.

 

In general, dermal fillers are indicated for injection into mid to deep dermis for the correction of moderate to severe wrinkles and folds. Some products have limited indications for use such as correction of nasolabial folds but are contraindicated for injection in areas other than nasolabial folds. Some dermal fillers are also indicated for use to fill areas of acne scars. All dermal fillers are contraindicated for patients with known sensitivities to the filler material, a history of severe allergy or anaphylaxis, and bleeding disorders.

Precautions

The following precautions apply to all dermal fillers. There are additional warnings that may be product specific, such as those related to a particular material composition.

  • Avoid injection into blood vessels or near major vessels as vascular occlusion may occur and can result in tissue necrosis (death).
  • Avoid injection into areas of infections. Injection should be deferred until infection or inflammation has been controlled or resolved.
  • Injection into patients with a history of previous herpetic eruption may be associated with reactivation of the herpes.
  • The safety in patients susceptible to keloid formation, hyperpigmentation and hypertrophic scarring has not been established.
  • Long term safety and effectiveness of the products beyond the duration of clinical studies have not been investigated.

Common side effects include:

Bruising

Redness

Swelling

Pain

Tenderness

Itching

Rash.

 

Less common side effects include:

Raised bumps in or under the skin (nodules or granulomas) that may need to be surgically removed.

Infection

Open or draining wounds

A sore at the injection site

Allergic reaction

Necrosis (tissue death)

 

lumps after filler

 

 

herpes simplex after filler

 

 

 

 

 

 

bluish hue after filler

 

 

forehead necrosis after filler

 

 

 

 

 

 

 

 

 

 

 

 

 

Allergy testing is required for particular types of filler materials, such as those taken from cows (bovine). In rare cases, severe allergic reaction (anaphylactic shock) that requires immediate emergency medical assistance can occur.

The following rare side effects have also been reported to FDA:

  • Migration/ movement of filler material from the site of injection
  • Leakage or rupture of the filler material at the injection site or through the skin (which may result from tissue reaction or infection)
  • Blurred vision and flu-like symptoms

Materials

It is important to know that not all injectable dermal fillers are created equal, and each has specific purposes for which it is best suited. Most injectable wrinkle fillers have a temporary effect, because over time they are absorbed by the body. The FDA has approved only one product made from a material that remains in the body and is not absorbed. Some wrinkle fillers contain lidocaine, which is intended to decrease pain or discomfort related to the injection.

Absorbable materials (temporary)


  • Collagen: Collagen is a type of protein that is a major part of skin and other tissues in the body. Sources of purified collagen used in wrinkle fillers can be from cow (bovine) or human cells. The effects of collagen fillers generally last for 3-4 months. They are the shortest lasting of injectable filler materials.
  • Hyaluronic acid: Hyaluronic acid is a type of sugar (polysaccharide) that is present in body tissues, such as in skin and cartilage. It is able to combine with water and swell when in gel form, causing a wrinkle smoothing effect. Sources of hyaluronic acid used in wrinkle fillers can be from bacteria or rooster combs (avian). In some cases, hyaluronic acid used in wrinkle fillers is chemically modified (crosslinked) to make it last longer in the body. The effects of this material last approximately 6 – 12 months.
  • Calcium hydroxylapatite: Calcium hydroxylapatite is a type of mineral that is commonly found in human teeth and bones. For wrinkle filling, calcium hydroxylapatite particles are suspended in a gel-like solution and then injected into the wrinkle. The effects of this material last approximately 18 months.
  • Poly-L-lactic acid (PLLA): PLLA is a biodegradable, biocompatible man-made polymer. This material has wide uses in absorbable stitches and bone screws. PLLA is a long lasting filler material that is given in a series of injections over a period of several months. The effects of PLLA generally become increasingly apparent over time (over a period of several weeks) and its effects may last up to 2 years.

Non-absorbable materials (permanent)

  • Polymethylmethacrylate beads (PMMA microspheres): PMMA is a non-biodegradable, biocompatible, man-made polymer. This material is used in other medical devices, such as bone cement and intraocular lenses. PMMA beads are tiny, round, smooth particles that are not absorbed by the body. For wrinkle filling, PMMA beads are suspended in a gel-like solution that contains cow (bovine) collagen and injected into the wrinkle. These products are for use only in treatment of nasolabial folds ( also called “marionette lines”)

Autologous Fat
Autologous fat is fat harvested from one’s own body. Its use eliminates the risks of allergic reaction or rejection by the body, since it is one’s own tissue. However, not all of the live fat cells survive when transplanted into the new site, so a fairly high rate of re-absorption is to be expected. Because of this, the physician will usually overfill the area being treated, which can leave the patient with a result that may look — at least temporarily — abnormal.

The Commercial Fillers (not an inclusive list)

Juvederm is a dermal filler used to fill and smooth moderate to severe facial wrinkles and folds. It is available in modified versions which are useful for adding volume to lift and contour the face. Juvederm is made of hyaluronic acid, a natural substance in the body that helps maintain skin volume and hydration as well as joint lubrication and cushioning. Hyaluronic acid retains moisture, absorbing more than 1,000 times its weight in water. It also binds with collagen and elastin, transporting essential nutrients to these fibers which make up much of the support structure of the skin. The hyaluronic acid in Juvederm and the other dermal fillers listed here is not derived from animal sources.

Restylane is also made from hyaluronic acid, but is used mostly for moderate facial lines and wrinkles as opposed to lifting and contouring purposes. Restylane is often used in conjunction with Botox to enhance and extend the life of results.

Perlane is made by the same company (and from the same hyaluronic acid) as Restylane. The difference is that the gel particles are larger and, therefore, Perlane is more effective at filling in deeper folds and achieving increases in facial fullness. Perlane is also often used to augment lips and other areas of the face that could benefit from a restoration of youthful volume.

Radiesse is made from calcium-based microspheres (hydroxyapatite) suspended in a water-based gel. Radiesse provides both immediate and extended results because it stimulates production of collagen and encourages tissue regeneration. It is most commonly used for the smoothing of nasolabial folds and marionette lines, for cheek augmentation, and to plump up sunken areas below the eyes.

Artefill is the first and only non-reabsorbable dermal filler to be approved by the FDA. Its claim to fame is that it provides a permanent support structure for lasting wrinkle correction, which means that its effects are both immediate and long-term. Artefill is made of polymethylmethacrylate (PMMA) microspheres, a material that has been used for years in surgical implants. However, since it is not a natural substance, there is a risk of allergic reaction. Because the results are considered to be permanent, physicians using Artefill generally prefer to under-fill on the first treatment, adding more at a subsequent appointment, if needed. Generally, full results are seen within six months of the procedure.

Sculptra is generally used as a treatment for facial lipoatrophy, the loss of fat beneath the skin that sometimes causes sunken cheeks, indentations, and hollow eyes. The main component of Sculptra is poly-L-lactic acid, a bio-compatible substance that does not cause damage to surrounding tissues. Unlike other dermal fillers, Sculptra does not produce immediate results. It works by stimulating collagen production, so results appear gradually over a period of a few months. Three to five treatments are usually required, and results can last up to two years or more

So,  are injectable fillers a smart thing to do?  Or not?

We cannot answer that for you, but we can (and have) pointed out the risks & benefits. We report – you decide.

There is a corollary question – do any smart people use fillers?  We cannot answer that either (we could find no clinical trials measuring both intelligence and outcomes for any aesthetic procedure). However, with the magic of Photoshop, we can at least imagine the possibility!

 

BFT thinks this smartie looks better with wrinkles, but that may be because he seems to be suffering post-procedure dyspigmentation.

 

 

References

Gladstone, H. & Cohen, J. Adverse Effects When Injecting Facial Fillers. Seminars in Cutaneous Medicine and Surgery, Volume 26, Issue 1, March 2007, Pages 34–39

4 Comments

  1. Kath says:

    Thanks for the quick reference guide. Someone interested in “doing” fillers would have to do a bit of online searching, I think, to find side effect pics as shown here. I think, maybe, curious people hear or may be told about side effects but seeing the pics of them may really make a brain stand at attention. But I’m sure those who’ve taken the filler route really believe the risks are really minimal anyway i.e. everything you do has side effects anyway.

  2. Dennis says:

    How do you guys feel about permanent silicone implants, such as submalar cheek implants?

    • drgeorge says:

      Permanent implantable silicone devices have a long history of safe and successful use in esthetic medicine, particularly in restoring shape following traumatic loss of tissue, or where a defect is congenital. These are typically molded into a relatively firm shape and are in no way similar to the soft jelly-like silicone encased in a plastic envelope used in breast implants. The complications from such devices are post-operative bleeding with hematoma (blood clot) formations, infection, local tissue erosion including of the skin, or migration out of position. Experienced surgeons with very low complication rates operating in accredited operating facilities should be sought out. Each case is different. Hope this helps.

  3. SavvyGo says:

    Smart people do facial exercises! They are extremely effective in shortening muscles that are slack from gravity and un-use. There is a woman in her 80′s and two in their 60′s that look 20 years younger that have great facial exercise programs: Eva Fraser, Carole Maggio, & Carolyn’s Facial Fitness. I don’t understand why everyone isn’t doing these exercises, it’s only 15 minutes a day!!!! I just found out about them and cannot believe I did not know about them. Why isn’t everyone doing them? I guess it’s the same reason people don’t exercise their bodies.

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