— Originally published in FLL#36 • Written by William A. Carter M.D.
In our country, next to treatments with botulinum toxin (BTA), the most commonly performed professional service in the office aesthetic arena is placement of various fillers. Since 2014, over one million facial filler injection treatments have been done annually in the United States. Whereas BTA inhibits the contraction of facial expression muscles and thereby lessens active skin wrinkling, fillers work in an entirely different manner.
Facial fillers are placed in the skin’s dermis, subcutaneous space, or above the periosteum. They all act by taking up space. By taking up space, they lift up fixed lines and wrinkles, or provide needed volume in regions of the face where volume has been lost over time.
In my early days of doing this type of work (around 1999 to 2000), all that we had in the filler toolbox which had been cleared by the FDA was bovine collagen and autologous fat. The cow collagenderived fillers lasted a maximum of three to four months, and the fat duration was unpredictable. A few short years later, we had the first FDA cleared hyaluronic acid filler available, Restylane. Gradually, other fillers followed. We now have seven different hyaluronic acid fillers, one made of calcium hydroxylapatite (Radiesse), one from small spheres of methylmethacrylate mixed with bovine collagen (Artefil), and one from poly-L-lactic acid (Sculptra). These all have their own place in our aesthetic armamentarium. Interestingly, the pure collagen fillers have disappeared from the United States market altogether.
Each particular filler selected for a given patient is chosen due to factors such as: area of the face where the filler will be used, desired duration of corrective or enhancing effect, amount of filler needed, client experience with previously used filler(s), available “down-time” following injection, and financial resources.
The thinner, less viscous, and stiff fillers are used for softening fine lines and wrinkles, whereas the thicker, more robust fillers are used for larger areas of depressions in the skin or enhancement and correction. The thicker fillers are used for small lips, deep nasolabial folds, or pronounced marionette lines. Sometimes the need is to enhance mid-face volume which has been lost, or to generally plump up a thinning, cachectic face during aging.
For mid-face volume, we use fillers such as Juvederm Voluma, RestylaneLyft (same as Perlane), Radiesse, or Sculptra. For a thin face which has a wasting-away appearance, Sculptra has been my favorite. A few treatments with Sculptra can give much more than two years of benefit. In fact, some experts in the field feel that the beneficial effect can last many years.
My favorite way to use fillers is to tastefully enhance the lips. Interestingly, only Restylane and Restylane Silk are officially FDA cleared for lip use. However, we use almost all of these “off label” products in the lips depending upon the patient’s particular circumstances. The only strict taboos for lip use would be Radiesse and Sculptra. For lips, I have successfully used thinner fillers like Restylane Silk, and Belotero in some instances. In other situations I have even utilized the thicker fillers, like Juvederm Ultra Plus, Perlane, or Juvederm Voluma if the circumstance calls for it.
In my practice, the expanding use of fillers has been incredibly gratifying. Having now a wider choice of available products makes it much easier to elegantly meet the consumer’s unique needs and circumstances.