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DERMAL FILLERS – The Whole Story

Preface and Disclaimer.

In this essay I compiled the very good and authoritive information on the websites of American Society of Plastic Surgeons (AAPS) and Better Health Channel that is produced with assistance from Australian Society of Plastic Surgeons (ASPS) and Australian Society of Plastic Surgeons’ procedures website : The Australian Foundation for Plastic Surgery

After reading this you are welcome to find more detailed information from the links here, but you must not decide on any action until after you have consulted a medical professional. The source sites all say this, and I repeat, that information here is not personal medical advice for you. That can only come from a medical professional after consultation with you. (Repeated here so you will see)

Facial wrinkles and Lines

Facial wrinkles and lines can be reduced with cosmetic injections into the skin. The two main types of injectable substances used are botulinum toxin type A and dermal fillers. To treat deep lines, the surgeon or cosmetic practitioner may decide to use both types of injectables to achieve the best result. You may read about botulinum toxin type A (more commonly called botox) on pages talking about dermal fillers. Sure, it is a “dermal” wrinkle treatment but it is not a filler. You can read about it on my separate page for botox.

What are dermal fillers?

They are just that – filling out, or bulking your skin, and in so doing they fill up and reduce wrinkles and creases in your skin.
There are many brands of dermal fillers. Australian Government regulations do not allow these brands to be promoted or talked about in general publications. You will see Brands of dermal fillers being advertised and promoted in US publications. The fillers are restricted drugs and must be prescribed by a medical doctor. The procedure must be performed by a medical doctor, or a registered nurse under the supervision of one. They are not available to beauty therapists or nurses working outside the supervision of a medical doctor.

There are two broad types of dermal filler – naturally derived and synthetically derived. The naturally derived fillers are collagen and fat. The synthetic ones are hyaluronic acid, hyaluron, polylactic acid, polyacrylamide and calcium apatite

What Can Dermal Fillers Do?

Dermal fillers help to diminish facial lines and restore volume and fullness in the face. As we age, our faces naturally lose subcutaneous fat. There is less stiffness in the skin and the facial muscles are closer to the skin surface. There is less resistance to creasing and so smile lines and crow’s feet become more apparent. The facial skin also stretches a bit, adding to this loss of facial volume. Other factors that affect the facial skin include sun exposure, heredity, and lifestyle.

Soft tissue augmentation using injectable fillers a highly individualised procedure and may not be suitable for everyone. Always talk to your Specialist Plastic Surgeon before making a decision. Your surgeon will assess your condition and general health, and plan the treatment that is best suited to you.

Dermal fillers can be used to:

  • Plump thin lips
  • Enhance shallow contours
  • Soften facial creases and wrinkles
  • Improve the appearance of recessed scars
  • Reduce early signs of aging, postponing need (or percieved need) for surgery
  • Improve the effect of facial rejuvenation surgery when done at the same time

What Dermal Fillers Cannot Do?

Non-surgical rejuvenation treatments, such as dermal fillers cannot achieve the result like what a surgical procedure such as a facelift would, but they may help delay the time when you would consider cosmetic surgery.
Also non-surgical rejuvenation treatments cannot achieve a long lasting effect like surgical treatments can. Their effect usually lasts only about six months.

How are Dermal Fillers Applied

They are not topical treatments that are absorbed through the skin. They are called injectables because they must be injected. The needles are very fine and for most treatments for most people anaesthetics are not used. This is a small sting like from a small ant, and is usually tolerated. The dermal fillers are injected along the creases, wrinkles and finer lines to plump the skin.

Dermal Injectables -Things to Consider

  • Choose treatment well – from appropriately qualified surgeons – and satisfy yourself about their training, expertise and experience.
  • Know the possible risks, side effects and complications.
  • Be realistic about your expectations.
  • Can you afford it ? In most cases it is not rebated by Medicare or private health insurance.
  • Don’t be impulsive. Cool off and ponder on it for a while.
  • Ask and ask – about any questions and concerns, and if not satified get a second opinion before going ahead.

Dermal Fillers – Precautions

The doctor must know if you

  • are taking any medications
  • have some medical conditions, such as an autoimmune disease
  • have a history of keloid scarring
  • have inflamed or infected skin
  • have severe allergies such as asthma, or have ever had an anaphylactic allergic reaction.
  • have anyfood allergies, especially to chicken
  • have an allergy to collagen
  • have ever had a life-threatening allergic reaction (anaphylaxis).

The decision to use fillers is extremely personal. You will have to decide if the benefits will achieve your goals and if the risks and potential complications of dermal fillers are acceptable. These risks and others will be fully discussed prior to your consent.
It is important that you address all your questions directly with your plastic surgeon. Although good results are expected from your procedure, there is no guarantee.
Your plastic surgeon and/or staff will explain, in detail, any risks. And you must satisfy yourself that all your questions are answered and that you have concerns because….
You will be asked to sign consent forms to ensure that you fully understand the procedure, as well as the risks and potential complications. The fine print will try to remove any risk to the surgeon of any “did not know” claims from the patient.

The Takeaway

  • Facial wrinkles and lines can be reduced with cosmetic injections into the skin.
  • The two main types of injectable substances used are botulinum toxin type A (not a filler but relaxes the facial muscles that cause the lines) and dermal fillers (which plump out the wrinkles).
  • The de-wrinkle effects of most cosmetic injectables are temporary and repeated regular treatments are needed to maintain the effect.

Dermal Filler Treatment – Complications

Complications from dermal fillers are uncommon. Potential risks vary depending on the specific filler used and the relative permanence of the filler substance and include:
bleeding, bruising, swelling and redness or rash and itching at the injection site, skin discolouration,
bacterial or viral infection, ulceration of the skin around the injection site, lumps (nodules) forming under the skin,
allergic reaction, acne-like skin eruptions, damage to the skin that results in a wound and possible scarring,
palpability of the filler under the surface of the skin, and under- or over – correction of wrinkles

About Some of the Dermal Treatments

There are several different types of dermal fillers. Dermal fillers differ in chemical make-up, longevity, and have varying degrees of softness. Softer fillers are used in the lips, for example, while sturdier fillers might be desired to enhance cheekbones.
Your surgeon will determine with you the best type and volume of filler needed for your particular areas of concern.
For many people, the use of “off-the-shelf” fillers can be a simple office-based procedure that can nicely enhance their appearance. These dermal fillers are very predictable, and have relatively minimal risks and side effects. These fillers are often injected in the surgeon’s office or medspa.

Hyaluronic Acid

Hyaluronic acid is a crystal-clear gel. This product can be used for cheek volume, naso-labial folds, lip enhancement, jaw and chin enhancement as well as for thin surface lines, such as those that occur around the mouth and across the forehead. How long a treatment lasts is individual, depending on age, skin type, life style and muscle activity, as well as injection technique. Expect 6-18months, depending on the type of gel used. You can see descriptive illustrated PDF about hyaluronic acid here on the downloads page.

Hyaluronan

Hyaluronan (a form of hyaluronic acid) – suitable for deep lines and acne scars. This product can be used as an alternative for people who are allergic to collagen. The effects last for about six months.

Polylactic Acid

Polylactic acid is injectable micro-particle. This product is suited to larger areas of finer wrinkles and parts of the face that have lost elasticity and appear sunken. The effect from polylactic acid is not immediate. The polylactic acid prompts the dermis (the skin foundation layer) of the treated skin to produce collagen. Visible results occur after 4-6 weeks after treatment as the skin thickens with new collagen formation. Generally, 2-4 treatment are required. Improvement can be expected to last for up to 24 months.

Calcium hydroxylapatite

This is the mineral that provides the structure for bones. The calcium hydroxylapatite for dermal fillers is biosynthetically produced, and is not an animal product. It is used for moderate-to-severe creases such as nasolabial folds, marionette lines and frown lines, enhance fullness of the cheeks and other facial contours.
It is applied as microspheres in a gel. As it does for bones, the calcium hydroxylapatite forms a scaffold on which collagen grows. This type of dermal filler is known to produce a very natural result, and side effects are rare. This dermal filler was first used in dentistry and reconstructive surgery and has a long safety record. It is long lasting but in time can be resorbed just as bone can be.
It has another special use for HIV-positive people who suffer from facial lipoatrophy, also known as facial wasting, which is a side effect of antiretroviral medications.

Polyalkylimide

This is a synthetic material often used by plastic surgeons for deeper wrinkles such as nasolabial folds or depressed scars. But it’s also helpful to enhance cheekbones and the jawline, and to replace facial volume lost due to age. This type of dermal filler also is a good choice to plump up your lips. Polyalkylimide is not typically used for fine wrinkles.
It is injected under your skin after your doctor delivers a local anesthetic, then it sets and can be molded into place, as if it is a small implant. After the injection, a thin layer of collagen slowly forms around it over the course of about a month. The gel is eventually completely surrounded. A single procedure can inject large volume. It is believed to be quite stable over time, and can even be removed if necessary.
As with calcium hydroxylapatite above it has a special use for HIV-positive people who suffer from facial wasting.
Benefits polyalkylimide as a dermal filler are that it’s biocompatible and it’s radio transparent. So there is very little reaction with human tissue and no allergy test is required, and it won’t interfere with x-rays.
This type of filler can also be used along with other fillers, such as hyaluronic acid used for a finishing touch for finer lines and wrinkles, for which polyalkylimide is not suitable.

PMMA

PMMA (polymethyl-methacrylate) This type of dermal filler, if properly delivered, offers long-lasting results. It is most often used to treat medium-to-deep wrinkles, folds and furrows, particularly nasolabial folds. It can also be used to fill out pitted scars and to augment thin lips.
When a more permanent solution to facial wrinkles is desired, PMMA is often used instead of collagen replacement therapy or hyaluronic therapy. PMMA has been used for many years in permanent surgical implants. Because of this, your surgeon will likely under-fill on the first treatment, adding more later if needed.
One of the downsides of PMMA is that a number of injections are needed to create volume and it can take up to three months to realize the full effects. It may also be visible under the skin. To avoid any unwanted results, it’s crucial that your plastic surgeon is familiar with the particular proper technique for this product.

Fat Injections (microlipoinjection)

In contast to all the “injectables” above, which are chemical, or natural products synthetically produced, fat tissue is taken from other areas of your own body using a thin needle. The fat is sterilised and injected into the facial lines or wrinkles, improve facial fullness or build up shallow contours. The effects can be long lasting. Touch-up injections may be needed in some cases.

Fat injection requires a more extensive procedure than “off-the-shelf” soft tissue fillers, but it is still a minor surgical procedure that can be performed in the surgeon’s treatment room or in an operating room.

A “donor area” must be determined (such as the abdomen or buttocks) and liposuction is used to extract the fat. The suctioned fat can then be transferred to the face, as a graft. The grafted fat then has to redevelop a blood supply in order to survive.
Most of the transferred fat usually survives, but the results can be a bit less predictable. The use of fat transfer involves additional discomfort in the donor area.

Collagen Injections

Collagen is a natural compound. You and the other animals have a lot of it. It makes the structural framework for many organs in your body, especially your largest organ, your skin. The dermis, the thickest layer in your skin is largely made of collagen. Collagen supports the skin’s blood vessels, nerve endings, hair follicles, also gives it its stretchiness. Wouldn’t it be good if we could easily give our skin a collagen top up to replace the collagen lost because of ageing, or weathering from harsh climate or sun exposure ? Well, to a certain extent we can.

Collagen fillers are produced by various means, and each has various brands. In brief, collagen is produced from several animals, from human skin, dead or alive, and possibly even from your own skin.

To use collagen derived from animal sources (usually bovine or porcine – cows or pigs) you need to first have an allergy test because some people are allergic.

Refined, purified and sterilized collagen from the skin of cadavers is unlikely to cause an allergy. Dermal filling with this collagen is recommended as 3 injections at one- to two-month intervals to achieve the best result.

If there are parts of you that need reduction while your face needs filling with collagen it is possible to do both. Collagen from your own skin can be harvested after a procedure such as a tummy tuck, and prepared for reinjection where it is needed. It can also be safely stored for five years and used as needed. This may come in handy, because the injected collagen is slowly resorbed and your face reverts to its previous look after about 6 months (more or less)

A recent development takes this process a further step. This takes a small piece of skin (several sq. cm) and clones it to grow to be much more in about a month, processes it for injection. Dermal filling with your own collagen is recommended as a several stage process. A minimum of three injections are recommended at two-week intervals. Because live cells are injected, improvement may continue for several months after the last injection.

Collagen Injections – Side Effects and Risks

Abscesses, infection, lumpiness, open sores and reactivation of cold sores (herpes), scarring, dead skin, skin peeling, and uneven skin texture.

An allergic reaction is possible, particularly from animal derived collagen and if an allergy test was not made beforehand.

There may be some swelling and bruising for the first 24 hours following collagen injections and the area may appear red for between a day and a week.

You can see a descriptive illustrated PDF about collagen injections on the downloads page.

Dermal Fillers – The Procedure

A dermal fillers procedure includes the the following steps:

Step 1 – Facial assessment and mapping
If you choose to utilize packaged soft tissue fillers, the plastic surgeon, or his specially-trained nurse, will evaluate your facial appearance and skin tone and examine the areas of your face to be augmented.
Strategic points on your face may be marked as the appropriate injection sites for the filler. Photographs may be taken of the areas to be treated.

Step 2 – Cleansing and anesthetizing
The injection sites will be cleansed with an antibacterial agent.
Pain at the injection site may be ameliorated by use of a very cold instrument to chill the skin, anesthetic ointment to numb the skin, or injection of local anesthesia.
While not painless, the injections are usually easily tolerated. Some liken it to the sting from some small ants (not the bull ant or fire ant!)

Step 3 – The injection
Injection usually takes only a few moments per site. The process of injecting, massaging, and evaluating the result is performed, and additional filler added as needed.
Depending on the number of areas to be treated, the whole process may be as short as 15 minutes, or as long as an hour.

Step 4 – Clean up and recovery
Once the results are deemed satisfactory, any markings will be cleansed off.
You may be offered an ice pack to reduce swelling and alleviate discomfort. Although the area may feel a bit tender for a day or two, it is usually not painful enough to require any medication.
Recovery from dermal filler treatment
There is no downtime with dermal fillers. These procedures can even be a “lunch time procedure” and you can even go straight back to work. (but you may want to hide your face for a short time, or cover it with an icepack, or a balaclava)
Your initial appearance after treatment with any dermal filler may include:

  • A somewhat “over-filled” or puffy appearance to treated areas
  • Mild swelling or bruising
  • Temporary numbness or redness

These conditions can be alleviated with topical icing and will improve within a matter of hours or just a few days.
When your own fat is the injected filler, the healing process is longer and may take a few weeks.

Facial Dermal Fillers – More Information

Descriptive Illustrated PDFs

To see good descriptive illustrated PDFs prepared for American Society of Plastic Surgery all about hyaluronic acid and collagen injections and the procedure (and copy them if you like) look here on the downloads page.

Facial treatments – before and after photos

AAPS Dermal fillers procedure

Videos

American Society of Plastic Surgeons Dermal Fillers Overview
American Society of Plastic Surgeons Dermal Fillers Results
Australian Foundation for Plastic SurgeryDermal Filler Procedures (authorised)
American Society of Plastic Surgeons Cleavage Rejuvenation Dermal Filler Procedure (unauthorised)
American Society of Plastic Surgeons Sculptra *
American Society of Plastic Surgeons Selphyl *
* not permitted to be promoted in Australia