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What are the differences among the various fillers?

Volume fillers were originally developed and introduced to fill in fine lines and wrinkles.  As the technology improved, it became possible to also fill in furrows and some folds.  The original dermal fillers were collagen (bovine, porcine, human), but there were various problems with these, including some people’s allergies to cow products. They tended to not last for a very long time and did not provide much bulk volume.

More modern fillers have become very popular and worldwide there are many more brands and forms available than there are in the USA.  The dominant filler is now HA (hyaluronic acid) which is a synthetically produced purified sterile product which comes in prefilled syringes for immediate injection.

We all have HA in our skin.  It plays a vital role in retaining moisture.  We also have HA in other critical areas such as joints. Our bodies also produce an enzyme called hyaluronidase which helps to degrade damaged or old HA and ‘recycle’ it within our bodies.   This is a continual, ongoing process in our skin and increases with some types of injuries to the skin.  The various brands and types of HA fillers have different lengths and cross linking (HA are long chain-like molecules).  The cross-linking and length profoundly impact key physical properties.  These physical properties, along with the amount of material injected, the location of the injection, and the technique of the injector determine what you will look like after your injections.

For those of you who are more technically inclined, the two key properties are called G’ (G Prime…and think of G’ as analogous to viscosity although that is an oversimplification) and the cohesiveness.  These determine how the material flows: is it still or silky? Does it lift or just flow? etc.  Popular brand names in the USA are Juvéderm Ultra®, Juvéderm Ultra Plus® and the soon to be FDA cleared Juvéderm Voluma® (out of the country there are more forms of Juvéderm) and other popular brands are Belotero Balance®, and Restylane®.  Likewise out of the country there are other forms of these as well.

Very generally speaking, Belotero works very well for fine lines like those on the upper lip from smoking. Restylane and Juvéderm Ultra perform well for all-purpose treatments from finer lines to deeper folds and furrows.  Perlane has a very high G’ and is often used where more lifting or filling is needed and has been thought to be perhaps preferable for this, although some recent studies indicate that Juvéderm Ultra Plus may actually be a bit superior or longer lasting. I believe this may be related to the higher cohesiveness of the Juvéderm Ultra Plus even though the Perlane has a significantly higher G’.  In any event, both perform very well when properly injected.

Juvéderm Voluma has proven to be a remarkable advance in both duration of activity (it may last as much as twice as long as the HA fillers above-up to 18 to 24 months) but also in its ability to ‘lift’ and to restore lost mid-face volume from fat loss. FYI, grafting your own fat remains also an option for volume filling but requires general anesthesia, more recovery time, and greater cost. Properly performed fat grafting can produce very long-lasting results for many years. Improperly done fat grafting is very difficult to reverse or correct.  One great thing about the HA fillers is that synthetic hyaluronidase comes in sterile vials that can be injected to hit the ‘undo button’ and ‘erase mistakes’ so that typically in a few hours or a few days the HA can be removed if need be.  That is not the case with non-HA fillers.

Another significant asset with Juvéderm Voluma is that it can be injected with blunt cannulas. These look like long needles but have no point and are slightly flexible with opening(s) on the side of the tip.  A ‘pilot hole’ has to be created with a tiny traditional needle which is then removed and the cannula is inserted and entire central cheek areas may be injected with only this one small needle entry.  There also appears to be less discomfort and bruising, and perhaps fewer complications than with traditional needles.  The cannula method is used very widely in Europe, Canada and other countries (Voluma has been available in Europe since 2005 and in over 60 countries) and it allows the injecting physician to maximize his or her artistic skills and truly ‘sculpt’ a very soft, natural youthful look.  Restoring mid-face volume loss is a major topic in itself we can cover another time.  Note: The mid-face volume loss is one of THE keys to rejuvenation of aging faces in a natural manner and may also be a critical component of traditional face lifts.

All the current fillers may also be injected using cannulas.  Several of these fillers come with lidocaine added (lidocaine is an older very safe anesthetic agent, although reactions may rarely occur).  The others may have lidocaine added just prior to injection using a sterile mixing apparatus.  Topical numbing may be used, and some people prefer to use nerve blocks similar to what a dentist uses. I prefer not to use nerve blocks as these add to the discomfort and, more importantly, may distort the skin contours.

Fillers can be (and often should be) used in conjunction with other procedures.  Your physician can advise which ones can be combined during the same visit and those which should be separated, but generally speaking the neuromodulators (e.g. Botox® Cosmetic, Xeomin® & Dysport® in the USA) make a great combination for same-time injection.  While we are on this subject, bruising is the primary temporary side effect for most patients and there are ways to minimize this, including injection techniques, needle size, ice packs, attention to fish oil and baby aspirin, and also by using certain lasers or IPL light treatments within the first day or two after treatment.  Discuss these with your physician for your specific situation.

Other popular NON-HA fillers in the USA include Radiesse® and Sculptra®.  These are both long lasting materials and when injected by a skilled injector can produce very nice results.  Radiesse has some limitations: for example, I typically use Radiesse for deeper folds and furrows in combination with HA fillers for finer lines, but there are a number of off-label uses which produce very nice results.  Sculptra is a collagen stimulator and also can produce very fine results particularly on the mid face. Sculptra often requires multiple injection sessions (often three) and results take time to appear as the body produces more collagen.  Full facial rejuvenation using Sculptra (often in combination with HA fillers) when seen several months after completion of injections and when performed by a very skilled injector can be quite impressive.   With Radiesse and Sculptra, however, patients should be aware that unlike the HA fillers and hyaluronidase discussed above, there is no ‘undo button’.  Once injected, they are there for a long time.

A few last thoughts.   All HA fillers (except possibly Belotero) may produce a faint blue-gray coloration in the skin.  This typically is seen in patients with very fair light skin tone and is caused by an effect called the Tyndall effect (similar to why the sky and ocean are blue; this has to do with the way light is scattered by the HA particles).  This can be annoying to some patients, especially if the HA is injected very superficially.  Radiesse is white in color and may show through the skin as well.  Sculptra does not have these properties.   All of these materials appear to stimulate production of your body’s own natural collagen to varying degrees.  Thus, when they wear off and are gone, some partial correction or improvement may persist long-term.  This is highly variable but can be a very nice effect as well.

The technique, technical skill, artistic eye, and experience of the injectors make a HUGE difference in the result.  It also may impact how many syringes of filler are needed. I often find I use half the number of syringes or less than a patient who is unhappy with prior treatment elsewhere has received, so truly the volume/number of syringes can matter greatly.  What I have found in traveling around the world is that all the great master luminary injectors have subtle differences in their techniques and also vary sometimes widely in their choice of fillers, but the final result on a patient will be very similar to what I would have envisioned using my techniques.  When we all get together at meetings and share our tips and ideas I think most of us agree that it is the end result and the safety that is critical and that each of us have slightly different ‘recipes’ for achieving a very similar outcome.  These are not skill sets that come overnight from a course or a DVD, although the quality and availability of excellent training materials produced by expert injectors has really increased in the last few years.  Not everyone is going to produce the same result, and price (high or low) is not necessarily a predictor of what you will look like after you are injected. There are some remarkably talented injectors of all ages and specialties, but there are many people poorly trained or who simply don’t have the technical skills or the artistic eye for fillers. Fillers are more difficult than neuromodulators such as Botox, Xeomin or Dysport, so if you are reading this, please choose your injector with care.  You might take in a photo of what you would like your lips to look like, or a photo of you when you were younger…and if you see a lobby full of ‘duck lips’ I would consider another injector!

Posted in Laser and Cosmetic