Facial fillers are a fascinating and increasingly complex topic. Once upon a time it was simple – facial fillers were used to achieve small augmentations with a limited life span in the face (lips, cheeks), treat the ”other” type of wrinkle intrinsically resistant to Botox and there was only one type of filler around.
But let us start at the beginning. Until 2002 the only type of filler approved by the FDA for cosmetic purposes was a product manufactured from the connective tissue of cattle. The collagen contained therein is not identical to the human molecule. Despite careful processing a small risk of allergic reactions persisted. Skin testing prior to each application was mandatory. Sensitization could occur after repeat applications with even more severe allergic reactions as a consequence. Once injected the collagen based product was digested by the body’s own enzymes at a quite rapid rate with disappearance of all visible effects after six to eight weeks. It was really only useful for a Friday night date when injected at the beginning of the week.
Despite all its disadvantages the collagen based product set the stage for what was to come, although it never reached the popularity of current facial fillers. Lips could be enhanced safely and the so called static wrinkles became smoother. The latter are wrinkles which are resistant to treatment with Botox, which works for so called dynamic wrinkles. These arise when the face moves to express emotions (the technical term is ”facial animation”). With the face at rest dynamic wrinkles disappear. The probably best known dynamic wrinkles in the face are the crow’s feet around the eyes, glabellar furrows between the eyes and forehead wrinkles. Static wrinkles are present no matter if the face is ”animated” or at rest. Well known static wrinkles are the nasolabial folds appearing like parenthesis around the upper lip and their continuation, the labiomental fold, coursing from the angle of the mouth to the chin. Some dynamic wrinkles like the horizontal forehead furrows may eventually become static and thus do not even disappear when the forehead is at rest. So while facial fillers and Botox both come out of a syringe their respective areas of application and mechanisms are entirely different. Botox weakens the muscle which are responsible for dynamic wrinkles, facial fillers provide volume to decrease the depth of static wrinkles. They complement each other as both issues may be present at the same time as facial aging progresses. Under certain circumstances a filler and Botox may be combined. An example are the wrinkles between the eyebrows, where a filler is used to decrease their depth at rest in combination with Botox to keep them shallow during animation and at the same time increase the filler’s longevity in an area with now reduced muscle tone.
To date the FDA officially lists twentyone approved products for cosmetic applications in the United States, nineteen of which entered the market since 2002. The underlying substances provide a longer lasting clinical effect without the risk of allergic reactions. This relatively large number of different facial fillers results in quite a bit of confusion of patients and physicians alike. We may safely assume that further products will be approved in the future with a potential increase of said confusion. It thus of some importance that you a a consumer / patient acquire some basic understanding of the commonalities and differences between fillers to make rational choices among them.
Fortunately, it is quite easy once you blow away the smoke screen of media hype, throw away the high gloss marketing brochures and (again!) disregard your hairdresser’s advice. Despite the daunting number of products there is really only one difference between all these facial fillers: their physical characteristics. Based on the the physical characteristics all and any remotely sensible filler substance today belongs either to the group of hyaluronic acid gel based substances (in short HA type) or particle based substances (PB fillers).
Want an honest opinion, biased as it may be? We have been riding on the filler train for over twenty years and in our experience HA type fillers are the standard of care, world wide, for all ethnicities, for all ages and genders. Clear enough? We already hear you say ”… but wait a moment, Doc, I saw this Youtube video where Dr. Ozandso, a world renowned hemorrhoid specialist, says the new SparkleMaX filler is the future!”.
Understanding and correctly applying HA type facial fillers is a matter of familiarizing oneself with the science behind them. The building block of all HA type facial fillers is hyaluronan, biochemically a sugar, which is identical across all mammals including humans and across species of bacteria. When threaded on a chain like pearls on a necklace hyaluronans form the so called extracellular matrix of the body, where its cells are embedded like raisins in a pudding. The cells themselves produce hyaluronic acid and also the enzymes to digest it. It is thus a natural substance, not known to date to cause any allergic reactions. Due to the absence of interspecies differences hyaluronic acid is manufactured on a large scale by fermentation of sugars in cultures of certain species of streptococci. The process is similar to the production of alcohol, another commercially very successful sugar. As the largest organ of the body skin contains large quantities of hyaluronic acid. Hyaluronic acid is the lubricant in joint fluid and the main constituent of the vitreous body of the eye. Hyaluronic acid owes its functional importance to its viscoeleastic properties and the capability to bind water. The latter property is the basis of countless moisturizers and hydration cremes claiming to keep skin well hydrated and young. In the course of aging the hyaluronic acid content of the skin decreases. Augmenting the amount of hyalronic acid in the skin is thus a natural, biological, minimally invasive, homeopathic, feel good and so forth anti-aging therapy – but due to chemical and physical obstacles not very successful with cremes.
The body’s own enzymes break HA type fillers into its individual sugar molecules, which then are further metabolized in the liver, eventually yielding water and carbon dioxide, the fundamental end products of all metabolism. Modern chemical processing technologies produced more stable form of hyaluronic acid, which persist longer at the location where injected. Their gradual digestion increases the water binding capacity by exposing more binding sites on the molecules. The increased binding of water prolongs the volume enhancing effect – isovolemic degradation, the secret to the longer lasting clinical effects of HA type fillers compared with collagen based products. The eventual complete degradation of HA type fillers also terminates the clinical effect. This can be a blessing as it also terminates any of the extremely rare potential complications such as lumps and irregularities. Should any of those occur and be significant enough the commercially available antidot hyaluronidase, identical to the body’s own enzyme digesting hyaluronic acid, can be injected locally to hasten the resolution.
PB fillers on the other hand contain particles of artificial substances, either like plastic (methylmetacrylate, such as in Artefill, polyacrylamide such as in AquaFill, only outside the US) or ceramic (hydroxyapatite, such as in Radiesse). The body has no means of digesting or removing them. The particles have to be suspended in a carrier substance to ensure the entire mixture flows smoothly through a small bore syringe when injected. The carrier substances are most often derivatives of polyglycolic acid, a sugar chain built along the principles of hyaluronic acid, or collagen derived from cattle, with all the problems associated with collagen only facial fillers. The carrier substance is digested by the body, the particles are not. Instead, the particles are regarded as foreign bodies provoking ingrowth of fibrous tissue at the injection site in an attempt to wall off the intruder. Some of the effect of PB type fillers thus disappears relatively fast, part of it remains, resulting in permanent volume augmentation. Contrary to the myths spread on internet forums and Dr. Ozandso’s TV show, PB fillers cannot be suctioned out, squeezed out or removed (only partially!) in any other meaningful way but surgery. The latter often requires an external incision on the face, which may be sufficiently well covered with make-up eventually in a person with light skin, but more likely than not represents a permanent disfigurement in any individual with dark skin in the Caribbean. Complications are permanent and largely irreversible. Like a time bomb they may occur years after injection. Over time we have seen more facial soft tissue infections and abscesses from PB fillers and the attempts to squeeze them out or suction them than any other implant or injectable substance. We have seen faces ”aqualifted” to resemble untreated frontonasal dysplasia, partial blindness after PB fillers found their way into the eye sockets, noses scarred enough after repeat exposure and infection of PB fillers to warrant a total reconstruction and lips of the consistency, mobility and shape of a duck’s beak – all by and large incorrectible disfigurements for the rest of the life of their bearer. So if you take only one message away from this section before you direct your attention again to Youtube videos – do not have PB fillers injected into soft tissues. Anywhere. Ever. One may consider these products for use immediately on top of the facial skeleton (except the nose and around the eyes), but then there are better, more cost effective and less complication prone technologies around to augment the facial skeleton. If you really desire more permanent soft tissue volume restoration in the face than HA type facial fillers can provide then fat grafting is the way to go.
”Ok, ok, Doc, you got me hooked, HA type fillers are the best thing since sliced bread, a miracle of modern aesthetic medicine, but on Dr. Ozandso’s website it says whenever there is more than one solution for the same problem none of them ain’t really good and there are almost twenty of these little miracles around, what ya say ?”. Well, we say go back to the basic science of HA type fillers again, this time looking at both the chemistry and physics of what makes HA type products different.
HA type facial fillers are a clear gel of chemically cross linked concentrated hyaluronic acid polymers. They have the consistency of liquid soap. The concentration of hyaluronic acid polymers and the engineering process used to cross link them into polymers determines the differences between various products. The hyaluronic acid concentration is fairly uniform across various HA type facial fillers, about 20mg per milliliter. The length and concentration of polymers differs significantly. Restylane for instance contains about 100,000 polymers per milliliter and can be injected through a relatively small bore needle. It is injected at the depth of the mid dermis. It is FDA approved since 2011 for lip augmentation and also used for the treatment of deep wrinkles like the nasolabial and labiomental folds or the so called nasojugal fold at the transition between eyelid and cheek. Another variant of Restylane contains about 200,000 polymers per milliliter but of shorter length rendering the gel more liquid and permitting injections with an ultra fine needle into very superficial fine wrinkles. Almost at the opposite end of the spectrum of HA type facial fillers are products like Perlane with about 8000 polymers per milliliter. It is used for very deep folds or on top of the facial skeleton, but not close to the skin surface. So different HA type fillers often target different types of wrinkles, skeletal augmentation or lip enhancement. The duration of their effect on the other hand is fairly uniform and in our experience limited to six to eight months. Any differences here exist mainly in the imagination of the manufacturers’ marketing departments and their paid consultants, but not in real life. Cost however does differ, depending on the sophistication of the engineering process and the quality of the product. This is not so much an issue for products used in the United States as none of them would have made it through the FDA and the US tort law system unless both engineering and quality were fairly flawless. Brand determines the main differences in cost of HA type fillers in the US. But differences in engineering and quality play a big role in other parts of the world. And just to shatter all illusions: cheap thing no good, good thing no cheap – allegedly a traditional Caribbean proverb enjoying considerable popularity among the East Asian population (mainly when they sell, less so when they have to buy).
Thus also the final advice from this section – you do not want cheap things for your face.
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Trinidad Institute of Plastic Surgery – the superior choice for facial fillers in the Caribbean, Antigua and Barbuda, The Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Lucia, St. Kitts and Nevis, St. Vincent and the Grenadines, Suriname, Trinidad and Tobago, Bermuda, British Virgin Islands, Cayman Islands, Turks and Caicos Islands, Miami, New York, Toronto, London