Facial fillers replace skin substances that, when lost, cause wrinkles. The skin thins by loss of collagen and fluid. In youth, the skin remains plump from a natural sugar called hyaluronic acid that attracts and binds water. Fillers are substances that are injected to fill in wrinkles and facial depressions that may come with age. With the advent of choices for facial fillers, we can choose the best for the specific problem and longevity.

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There are now so many fillers available, we prefer to categorize them by their ideal usage. Fillers can be used to treat three conditions:

1. Superficial fine lines
2. Facial folds and crevices
3. Facial volume loss

We all want fillers to last as long as possible, but don’t want bumps. The most superficial lines—those that appear “etched” into the skin—require the thinnest fillers. As the need for more volume replacement increases, fillers are placed deeper and can be thicker. Medium thickness fillers are used for actual folds in the skin and deeper crevices, such as the naso-labial folds. Naso-labial folds run from the corner of the nose to the corner of the mouth. Medium depth fillers also may be very effective for melo-labial folds (also known as “marionette” lines) that run down from the corners of the mouth to the jaw. These thicker fillers are also longer lasting than the thin, superficial fillers.

Since there a number of available fillers for fine and deep wrinkles, both may be used in the same patient. We often layer them in the same areas in order to plump folds and fill the lines that often lie in the depths of those folds.

The thickest fillers are better for volume enhancement, and are used to treat the areas of the face that need to be “plumped up.” Currently, the two available options for large volume replacement for the face are using one’s own fat. The fat is re-injected immediately after removing from elsewhere in the body. For patients who don’t wish to have this procedure, Sculptra is an excellent alternative.

There are many fillers, too numerous to discuss. The most recently approved fillers are made from Hyaluronic Acid (Restylane, Hylaform and Captique). Hyaluronic Acid is a clear gel that already exists in the human body. It attracts water, hydrating your skin. Hyaluronic Acid fillers have been safely used in Canada and Europe since 1996. Unlike many other fillers, Restylane is non-animal based and poses no risk of animal disease transmission or allergic reaction. Hylaform is animal derived but of very low allergy potential. Another promising hyaluronic acid filler, currently being investigated for approval for use in the USA, is Juvederm.

The hottest new application for Restylane is to fill dark circles under the eyes. Often, dark circles are the result of fat bulging in the lower eyelid that is exaggerated by a hollow area called the “tear trough.” By placing Restylane into this tear-trough, there is less shadow and therefore improvement in dark circles, making you look more rested.

Radiesse is one of the newest non-surgical facial contouring fillers, which delivers an immediate, long lasting result. Radiesse may be thought of as a longer lasting filler for deep facial folds and may even be used for volume enhancement. Radiesse has been shown to last even longer than hyaluronic acid fillers for treatment of naso-labial folds and marionette lines. Currently, it is approved for use elsewhere in the body and cosmetic use for the face is still considered “off label”. Discussion with the treating doctor can help determine if this is an appropriate filler for you. Radiesse provides the immediate visual improvement common with other fillers, along with the benefit of long-lasting results. This is because Radiesse is made of very tiny, smooth calcium hydroxylapatite (CaHA) microspheres. These particles stimulate your own collagen to grow.

Below are the most commonly used fillers:

Superficial Fillers (Fine lines and wrinkles):

	Collagen: Zyderm 1, Bovine derived and requires an allergy test
	Cosmoderm 1, Human derived, no allergy testing required
	Restylane fine lines and Hylaform fine lines, Hyaluronic acid (not yet FDA approved)

Medium Depth Fillers (Medium Wrinkles):

	Collagen: Zyderm 2, Zyplast
	Cosmoplast
	Restylane, Hylaform, Captique, Juvederm Radiesse

Deep Fillers:

	Perlane; thicker form of Restylane, not yet FDA approved
	Hylaform Plus; thicker form of Hylaform
	Radiesse; calcium hydroxyapetite granules (currently FDA approved for other uses but also used as a facial filler). Expected to last longer than hyaluronic acid though effects of long term use have not yet been established.
	Artefill; PMMA (Teflon) beads in Collagen, (also pending FDA approval). Long term filler also still pending extended long term testing.

Large Volume Fillers - when patients require more than a few cc of facial volume enhancement

Fat lipotransfer; spinning own fat is certainly the most natural filler. By spinning the fat in a centrifuge then placing by multiple passes depositing very small amounts with each pass, the fat has a much better longevity. There is more swelling than with other fillers, but the results are smooth, natural and often long lasting.

Sculptra; Poly-L-Lactic acid. In Europe this substance is called NewFill. Patients retain long lasting facial volume enhancement after 2 to 4 repeated injections spaced a month apart. This product was just approved by the FDA for facial hollowness. Sculptra is a true volume filler for the face. It can restore youthful fullness to the cheeks, temples and anywhere in the face there has been considerable loss of youthful fat. Collagen and Hyaluronic acid products are best used for lines, folds and wrinkles. When you desire true restoration of fullness, Sculptra may be the ideal substance.

Inserted Substances - requires a minor surgical procedure

Alloderm; derived from Human tissue, remains soft after insertion. Alloderm is rolled into sheets and placed into facial folds and into the lips. During processing, cells are removed from tissue and it is specially treated to assure that no diseases are transmitted with it. The area treated is very swollen for a few days. Alloderm may last from 1 to 2 years or more. We find that the amount present at 6 months is the amount that will last the next few years

ePTFE; the most well known forms are Gortex and Softform. Currently, our favorite is Advanta. These are inert tubes that are inserted into the lips under local anesthesia. Advanta implants are available in different sizes. Advanta implants are not visible but may be felt when pressing deeply. This substance is permanent, but there is a small incidence of infection or extrusion for during the first few

Questions? Contact Dr. Pearlman or our Aesthetician about Skin Rejuvenation and Facial Fillers.