Wrinkle Fillers

Soft Tissue fillers are substances designed to help rejuvenate the aging face with a goal of restoring a more youthful appearance. They are used to fill lines and wrinkles, such as those found near the nose and mouth (nasolabial and marionette lines). Fillers can help enhance shape and definition to areas such as the lips and jaw line and are also used to restore fullness (volume) to cheeks, temporal areas and under the eyes. They are injected at varying depths into the skin and soft tissues and while the majority of fillers are used in the face, they can also help restore/rejuvenate other areas such as the hands and decollate.

There are a number of different types of soft tissue fillers available today and the most widely used are known as hyaluronic acid or HA fillers.  Hyaluronic acid is a naturally occurring substance fund in many parts of the body with the greatest percentage found in the skin.  Hyaluronic acid binds with water to give the skin a full, plumped appearance.  It also protects and lubricates the skin.  As one ages, the amount of hyaluronic acid decreases which can make the skin drier and less supple. There are a dozen different HA soft tissue fillers available in the US today.  Some contain lidocaine which acts as an anesthetic making the injections more comfortable.  Manufacturing processes differ among the HA products thus they have different FDA-approved indications.  Manufacturing differences also impact the longevity of the HA fillers; some last as little as 6 months while others can last up to 24 months.  One reason HA fillers have become so popular is that they are quickly reversible; if the results are not acceptable, the product can be removed by a tiny injection of a substance (hyaluronidase) that will almost immediately dissolve the filler.

There is another group of products available which are often referred to as collagen-stimulating fillers.  These contain synthetic, biodegradable materials which stimulate the production of the body’s own collagen.  These products can last from 12-24 months. Finally, there is one FDA-approved product classified as a permanent filler. The product contains tiny microspheres of a synthetic resin suspended in a bovine collagen, lidocaine mixture. This product lasts 5 years or more.

Treatment Benefits

In the right hands, soft tissue fillers can help restore a more youthful appearance to your face. These products can fill lines, wrinkles and deeper facial folds or other depressions such as acne scars.

HA fillers can add volume and improve the shape of facial features such as the midface and chin. They can also enhance the fullness of the lips and define the lip border, or create a “Cupid’s bow.” They are often used to fill the hollow under the eyes and can be used to shape the brow and provide volume to the cheeks.

Treatment with collagen-stimulating products can add volume and improve the appearance of deeper facial folds or other depressions such as concave scars. They can also be used to add volume and improve the shape of facial features such as the cheeks, midface and chin.

Permanent fillers are more often used for deeper facial folds or lines.

 

U.S. FDA-Approved Soft Tissue Fillers

While there continues to be new soft tissue fillers approved by the FDA, some of those that have been around for many years are being discontinued. The reason for a filler to be discontinued is typically not due to problems with a specific product, but is more likely due to such things as an improved formulation which has received FDA approval. Following is a listing of those products that are FDA-approved (as of 6/24/14). Also included are those products that have recently been or are soon-to-be discontinued.

 

Collagen
Product Name Year Approved Notes
Zyderm 1981 Animal-based collagen – No longer available
Zyplast 1985 Animal-based collagen – No longer available
CosmoDerm/CosmoPlast 2003 Human-based collagen – No longer available
Evolence 2003 Animal-based collagen – No longer available
Hyaluronic Acid (HA) Fillers
Restylane 2003
Juvéderm Ultra and Ultra Plus 2006
Perlane 2007
PREVELLE Silk 2008 Contains lidocaine (anesthetic)
Hydrelle 2009 Contains lidocaine. Formerly known as Elevess, which was approved in 2007
Juvéderm Ultra XC/Ultra Plus XC 2010 Contain lidocaine (anesthetic)
Restylane-L and Perlane-L 2010 Contain lidocaine (anesthetic)
Belotero Balance 2011
Juvéderm Voluma 2013 Contains lidocaine
Restylane Silk 2014 Contains lidocaine
Collagen Stimulating Fillers
Sculptra Aesthetic
(Poly-L-lactic acid – PLLA)
2004 Launched in 2004 with an indication for patients with lipoatrophy. Received aesthetic indication in 2009
Radiesse (Calcium hydroxylapatite – CaHA) 2006 Available and used prior to 2006; however this was the year Radiesse received a cosmetic indication from the FDA
Permanent Fillers
ArteFill (Polymethylmethacrylate – PMMA) 2006 First and only permanent soft tissue filler available in the US

 

Treatment Process

Your Injections

The area to be injected must be clean. Make-up must be removed and alcohol pads are used to thoroughly clean the area before treatment. Pain management is handled in a number of ways including applying ice to the area, utilizing a topical anesthetic cream, or a local anesthetic via injection (such as a dental block) may be used for your comfort. Some products are already mixed with lidocaine and after the initial stick; the lidocaine will numb the area that is being injected. Some physicians will also mix lidocaine with products that do not already contain it. Once your treatment area is numbed, your doctor will make injections in several locations, placing the filler where correction or volume enhancement is desired.
  • Your doctor may massage or manipulate the area where the filler has been placed
  • The treated area may be cleansed again
  • You may be given ice or cold packs to place on the treated area to minimize swelling and bruising
  • The entire treatment process may take 20 to 30 minutes or more

After Your Injections

  • You may experience mild swelling or bruising from any type of injection. Ice or cold packs can help to minimize swelling or discomfort
  • You can generally apply make-up over the treated area immediately
  • Hyaluronic acid fillers may result in 3 to 7 days of swelling, redness and post-injection bruising
  • Collagen stimulating or permanent soft tissue fillers may result in 5 to 7 days of swelling, redness and post-injection bruising
  • If you have received Sculptra treatment, your results will develop over the coming weeks. You may require 2 to 3 treatments spaced apart to gain the improvement you desire

Your Results

Your results are visible immediately. However, due to swelling, you may look a little fuller than you might expect. This will improve rapidly over the next few days.

  • The improvement from HA fillers can be variable since the concentration of hyaluronic acid in each product differs. Results with Restylane, Juvéderm Ultra and Ultra Plus, and Perlane typically last between 6-12 months while the results with Prevelle Silk may be slightly less. Juvéderm Voluma has been shown, in some cases, to last up to 24 months.
  • Studies have shown that the improvement with some HA fillers can be enhanced if you get treated again between 6-9 months after your first treatment. Restylane has shown longevity to 18 months with re-treatment
  • The improvement from Radiesse and Sculptra begins to disappear within 12-18 months after treatment
  • Artefill is considered a permanent treatment thus results are still noticeable 5 years post-treatment

If you do not repeat treatment once your results have begun to diminish, or as directed by your doctor, your appearance will return to its pre-treatment state.

 

Commonly injected sites

The approved indications for the HA fillers vary.
Belotero, Restylane, Perlane, Juvéderm Ultra and Ultra Plus and Prevelle Silk are indicated for injection into the mid to deep dermis for the correction of moderate to severe facial wrinkles and folds (such as the nasolabial folds).
Nasolabial folds are creases that develop from the nose to the outside corners of the mouth.
Restylane Silk and Restylane are indicated for lip augmentation while Restylane Silk carries an additional indication for the correction of fine lines above and around the lips.
Juvéderm Voluma is indicated for cheek augmentation.
The approved indications for Radiesse are for subdermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds; also intended for restoration and/or correction of the signs of facial fat loss (lipoatrophy) in people with human immunodeficiency virus (HIV).
The approved indications for Sculptra are for restoration and/or correction of the signs of facial fat loss (lipoatrophy) in people with immunodeficiency virus HIV); also for use in immune-competent people for correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles in which deep dermal grid pattern (cross-hatch) injection technique is appropriate.
Artefill is approved for the correction of nasolabial folds.
FDA approved indications tell a physician what the product has been approved for, based on the submitted clinical trials. Physicians have discretion to use a product for uses other than approved indications when he/she feels it is warranted. These decisions are based on experiences of the injector as well as the knowledge learned from leading physicians in the field. HA fillers are often used to enhance the lips and to add volume and shape to the midface, the jawline and chin. These fillers can also be used to improve hollows and depressions below the lower eyelid, often called the tear trough. Although less common,  fillers can provide temporary correction to a pinched or asymmetric nasal tip, or fill depressions at the nasal bridge.
Radiesse and Sculptra have been used to improve the volume in the midface and cheeks and to enhance the chin and jawline. In addition, collagen stimulating fillers may be used to fill concave scars, and to enhance a nasal tip.
Communication between you and your physician is vital for a successful outcome! Be specific in what you want and listen to the advice of your physician. Together, you can develop a treatment plan that meets your needs and expectations.

 

Questions to Ask Your Doctor

 

Doctor

  • What is your board certification?
  • How were you trained to do injectable treatments?
  • Do you regularly provide soft tissue filler treatments?
  • How many people have you treated with a condition similar to mine?
  • Will you personally inject me? If not, what are the qualifications of the person who will?

Brand

  • Exactly what name brand of injectable do you recommend for me?
  • Is it U.S. FDA approved specifically for cosmetic purposes?
  • May I see the packaging to verify the brand name?
  • Did the product come from the manufacturer or did you get it elsewhere?

Safety

  • Are there any precautions I should take before my injectable treatment?
  • What type of anesthetic is available, and what is your preferred means of anesthesia?
  • What can I expect to experience after my treatment?
  • How do you treat any problems that may arise?
  • What are the potential risks of treatment?
  • How long will my results last?
  • What if I am not satisfied with my results – what options do I have?