As our skin ages, the dermis gradually loses its major constituents: collagen, elastin and hyaluronic acid. Collagen acts as the major support protein for our skin; elastin allows our skin to stay firm and resist wrinkles; hyaluronic acid helps to trap water and add volume and shape to our skin.

Dermal fillers are being used more and more to help reverse the changes associated with aging. Because the goal is to return the dermis to its original youthful state, dermal fillers can give a more natural appearance than surgical face lifts. Dermal fillers are being used to reduce or eliminate wrinkles, raise scar depressions, enhance lips, and replace soft-tissue volume loss.

The ideal dermal filler should be easy to administer, provide reproducible cosmetic results, remain in the dermis for a significant period of time, and have a superior safety profile. Injection of fillers usually requires the use of either a topical numbing cream or a local injection of numbing medication. Then, using a small needle, the dermal filler is injected into each wrinkle or scar that requires treatment. Some mild burning and stinging is normal and quickly resolves.

What are facial dermal fillers?
Dermal fillers are substances that are injected just below the surface of the skin to fill in lines, wrinkles, and scars. Unlike face lifts that stretch the skin, fillers add volume for a more natural youthful appearance. Fillers can also increase the fullness of the lips (see section on lip enhancement) and lessen the downward slant of the corner of lips. The most common areas treated are the smile lines around the nose and mouth, fine lines above the mouth, frown lines between the eyes, and acne scars.

There are two classes of dermal fillers:
Permanent and temporary. The main permanent dermal filler in use today is silicone. There are a variety of temporary dermal fillers currently in use and several will be discussed below: Hydroxyappetite (Radiesse), hyaluronic acid (Restylane and Hylaform), sculptra, fat, and collagen. Temporary fillers are absorbed by the body over time, usually in 2-6 months and require repeated treatments to maintain the effect.

The results can last from three months to five years, depending on the filler being used. Collagen provides the shortest duration with effects lasting anywhere from three to six months. Restylane tends to last a bit longer with effects lasting from six months to one year. Radiesse can provide results that last greater than 3 years.

Types of Dermal Fillers:
Several classes of dermal fillers are marketed in the United States today. They include: collagen based fillers (i.e. Zyplast and Cosmoderm), hyaluronic acid based fillers (i.e. Restylane and Hylaform), and calcium hydroxyl apatite fillers such as Radiesse. Moreover, promising dermal fillers are in development that will offer superior capabilities in the future.

Silicone Dermal Fillers
The use of silicone fillers has been controversial in the past because of the risk of bumpy scars called granulomas that 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 you do not repeat treatments once the desired look has been achieved.

Collagen Fillers
Collagen is an abundant natural protein found in the body that provides structural support to skin, muscle, tendons and bone. In the skin, fibers of collagen are woven together to provide texture, resiliency and shape. Collagen is one of the substances lost during the normal aging process. Collagen injections are performed in an office setting and require no recovery time. They usually take less than an hour to perform. The main risk of collagen injection is an allergic reaction. Some of the collagen products are made from animals and require allergy testing prior to use (see below). The effect lasts between 3-6 months. Combinations of fillers are used to achieve a natural, full look.

Bovine (cow) collagen
Zyplast — Requires skin testing (for deeper wrinkles)
Zyderm — Requires skin testing (for fine lines)

Human (foreskin) collagen
Cosmoderm — No skin testing (for fine lines)
Cosmoplast — No skin testing (for deeper wrinkles)

Radiesse (Formerly called "Radiance")
Radiesse is made of a synthetic substance containing microspheres of calcium hydroxylapetite. There are no allergic reactions associated with this filler. With proper technique and local anesthesia, the injections are not very painful. There may be some bruising after the procedure but most patients return to normal activities the next day. One of the advantages of Radiesse is that it can last up to 3 years. Radiesse has been used for lip augmentation.

Restylane
Restylane is natural cosmetic dermal filler that is made of non-animal-based hyaluronic acid. The fact that it is non animal based decreases the risk of animal based disease transmission or allergic reaction. No pre-testing required. Restylane has been approved by the FDA for use in moderate to severe facial wrinkles and folds, such as nasolabial folds. There is usually no recovery after Restylane injection. The effect lasts approximately six months.

Hylaform
Hylaform is another hyaluronic acid based dermal filler that has recently been approved by the FDA for treatment of facial wrinkles. Hylaform is made from avian (bird) origin, and individuals who have allergies to avian products should not use this filler. It is believed that it last up to six months. It can be combined with bovine and non bovine type injections to address many parts of an aging skin.

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 3 months to 3 years.

What are the risks of fillers?
Each filler is unique and has its own risk profile. Side effects are uncommon but in general can include limited allergic reactions (hypersensitivity), ulceration, reactivation of herpes infection, bacterial infection, localized bruising, and granuloma formation.

Hypersensitivity reactions to the older collagen-based dermal fillers were frequent and required skin testing ahead of the treatment, but are becoming less common with the use of human collagen (Cosmoderm, Cosmpolast) instead of cow derived collagen (Zyderm, Zyplast).

Ulceration is rare and occurs when the filler is injected into a blood vessel; cutting off the blood supply to the overlying skin. Bacterial infections are rare and may be treated with antibiotics. Localized bruising is temporary and may be reduced by applying ice before and after injection. Granuloma formation is a rare complication that may require steroid injections, or surgical extraction of the granuloma.

How will I look after my treatment?
Following your injections, normal activities can be resumed immediately. Discomfort is minimal. The treatment site may have a little swelling, which may last a few hours. There may be some slight bruising which can be covered with make-up. Depending on the area treated, correction can last up to six months or longer. If the lips are treated, initial swelling and tenderness may occur within the first several days, but subsides after two or three days.