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Dermal fillers are gel-like substances injected into the skin to smooth out wrinkles and lines. Fillers can also be referred to as cosmetic injectables, soft tissue fillers, and cosmetic fillers. Besides erasing wrinkles and lines, facial fillers can also be used for a number of skin issues, including:

• adding volume to sunken facial areas, like the cheeks;
• augmenting face contours for better definition and symmetry;
• augmenting lip shape and volume for a plump and well-defined lips;
• restoring the youthful appearance of the hands;
• improving skin hydration;
• improving the appearance of acne scars.

The success rate of the aesthetic treatment depends on the age and lifestyle of patients, the type and amount of filler administered, and the condition of the skin. Although regulatory agents have not approved certain uses, some face fillers are still used:

• to augment foot shape by increasing the fullness;
• to inject into a tendon, ligament, muscle and bone;
• for breast augmentation;
• for buttocks augmentation.

Injecting into these areas may cause scarring, pain, infection, disfigurement, or death.

Types of Dermal Fillers

Due to immense advancement in health-care and biotechnology, dermal fillers exist in various forms to suit individual needs. The materials also determine fillers’ durability once injected into the skin. So far, there are 5 different types of face fillers that have been approved by regulatory agencies:

Collagen (Absorbable/Temporary Filler)

Collagen is a type of versatile protein that provides structure of varying mechanical strength to countless tissues. It is derived and purified from bovine sources or even human cells. When injected, this type of filler restores the lost collagen, making the skin appear smoother. Collagen is bioresorbable, so the effects only last for about 3 to 4 months, making them the shortest acting filler material.

Hyaluronic Acid (Absorbable/Temporary Filler)

Hyaluronic acid is actually a complex polysaccharide (sugar) molecule found naturally in large quantities in the human body. These molecules are strong humectants, which retain water to provide hydration to other cells for optimal performance. When injected, the gel works to volumise and hydrate skin structures. In addition, new cell growth (e.g. collagen) is also promoted, and the network of collagen and elastin fibres get strengthened. This is a widely used ingredient in skincare and aesthetic treatments due to its effectiveness and minimal risks of foreign body reactions. Hyaluronic acid gel can be manufactured using gram positive bacteria like streptococcus and staphylococcus. The cell structures of these bacteria are rich in hyaluronic acid, which can be easily extracted and purified without altering the efficacy. It can also be derived from animal sources. Due to its high biodegradability, the gel is slowly disintegrated into the surrounding tissues making the results non-permanent. Usually, the desirable effects of hyaluronic acid gel can last 6 to 12 months or more.

• Examples of hyaluronic acid-based fillers include, Juvederm XC, Juvederm Voluma, Belotero Balance and Restylane Silk.

Calcium Hydroxylapatite (Absorbable/Temporary Filler)

Calcium hydroxylapatite is a mineral deposited abundantly in the skeleton system. Cosmetic fillers made with this material consist of uniform microparticles of calcium hydroxylapatite suspended in a smooth gel carrier. Besides providing a filling effect on deep lines and folds, this aesthetic filler promotes the formation of new collagen cells in a process known as neocollagenesis. This material is also biodegradable and biocompatible, with very little risk of osteogenesis (new bone formation) in soft tissues. The consistency of the gel is usually thicker compared to hyaluronic acid gel. Hence, it is a semi-permanent filler with effects typically lasting around a year or more in most patients.

• Radiesse is a popular calcium hydroxylapatite-based filler.

Poly-L-Lactic Acid (PLLA) (Absorbable/Temporary Filler)

Poly-L-Lactic Acid is a non-toxic biodegradable synthetic polymer. This polymer has been used extensively for medical applications such as sutures, intra-bone plates, and screws, as it is very durable and compatible with human tissue. When injected, these fillers do not produce instant results. Rather, PLLA works to help stimulate body’s own collagen production. Over time, deep lines and sunken areas get filled in subtly, yet effectively. Patients suffering from lipoatrophy (significant facial fat loss), as a result of human immunodeficiency virus (HIV) or other medical conditions, respond well to PLLA injections. This semi-permanent absorbable filler can last up to 2 years after administration, after which it will be metabolized by the body.

• Sculptra is a popular brand made from PLLA.

Polymethylmethacrylate (PMMA) (Non-Absorbable/Permanent Filler)

This synthetic material is actually an acrylic polymer. For aesthetic treatment purposes, PMMA is manufactured into microspheres or small beads suspended in a gel-like solution. This solution usually contains bovine collagen. When injected, the microspheres remain underneath the skin to provide a lifting effect.

• PMMA fillers include Artefill.

What are Dermal Fillers Used For?

Under Eyes

The tear trough refers to the fold from the corner of the inner eye that extends outwards and downwards. Commonly referred to as “eye bags,” the tear trough can appear puffy, making a patient appear tired, or they can appear sunken in due to aging or weight loss. The result of is the an exhausted appearance. Facial fillers are injected into this area to make it appear more even.

For Dark Circles

Also known as raccoon eyes, panda eyes or eye rings, dark circles occur when the already thin skin of the eye areas become even thinner due to aging or loss of orbital fat tissues. Since the skin is thinner, the underlying vast network of blood vessels and muscles become more noticeable and give a dark discolouration to the skin. In addition, other factors like genetics, dehydration, lack of sleep, and stress can also cause dark eye circles. Cosmetic fillers aim to diminish the appearance of dark circles and give the patient a youthful, bright glow.

For Acne Scars

Acne is a type of skin inflammation that occurs when the dead and keratinized skin cells clump together resulting in blocked pores. This process feeds common skin bacteria, P.Acnes, which multiplies and causes inflammation, redness, and sometimes pain. As well, this can lead to unwanted scarring. Due to the bacteria, the skin doesn’t have the materials necessary to repair itself, and scar tissue is formed. The appearance of atrophic scars such as ice pick, boxcar, and rolling scars can be reduced using dermal fillers as they help fill in depressions in the skin. When the cosmetic fillers are injected, collagen production is increased and the uneven scars can be improved.

For Cheeks

Besides formation of wrinkles and lines, another major sign of aging is loss of facial volume. This happens because the collagen and fat reserves get depleted gradually. Some patients with HIV and other medical conditions experience lipoatrophy due to weight loss. Some medications, such as antiretroviral drugs, bring about localized loss of fat tissues, especially in the cheeks. So, soft tissue fillers are administered to bring back fullness to the cheeks by stimulating collagen production.

For Lips

A lot of patients opting for lip augmentation treatments are unhappy with their undefined lip shape and/or thin lips. However, the shape and size of the lips is determined by genetics, which alters with age. Moreover, some lifestyle habits like smoking may actually cause the formation of smoker’s lines (fine wrinkles around the lips which are sometimes known as lipstick lines because they cause lipstick to bleed when applied). Furthermore, some patients may suffer from persistent dehydrated lips. So, when face fillers are injected, the vermilion borders of the lips can be augmented for a shapely pair of lips. The volume and hydration can also be increased for a voluptuous pout.

For Wrinkles and Fine Lines

The skin is made of 3 layers: epidermis, dermis and subcutaneous fat layers. There are a lot of cells and tissues that work together to ensure the optimal performance of skin. However, the three most important cells are collagen, elastin and hyaluronic acid. The first two cells are actually protein fibres that makes the skin pliable. Hyaluronic acid, on the other hand, provides hydration and nourishment to the collagen and elastin fibres, so that they can function without breaking apart. Some factors like aging, excessive sun exposure, unhealthy diet, stress, undiagnosed and uncontrolled medical conditions, and smoking can cause these cells to work more slowly. As a result, skin elasticity and hydration deteriorates. Combine this with repeated facial movements, and you get fine lines and wrinkles. These skin depressions might make your patients appear tired or upset, even when they are not. So, soft tissue fillers help to reduce the unsightly appearance of these wrinkles by providing a filling and lifting effect. So, skin appears smoother and more radiant.

For Face Lift

Besides wrinkles, lines and scars, sagging skin can be distressing for patients, too. Once volume is lost, the skin can start to sag, especially around the neckline. The aging process coupled with other influences like weight loss, sun damage, stress and gravity affect the skin’s integrity, resulting in loose skin. Dermal fillers can be injected in these areas to give more definition and support. Hence, skin appears tauter and more contoured.

Face Fillers Side Effects

Dermal filler injections may cause some side effects. Doctors should discuss the expected results, and any side effects, contraindications, and precautions prior to the treatment. Only certified physicians with extensive training, skills and experience in dermal filler injections should administer cosmetic injectables.

Common Side Effects

• Most of the common side effects experienced by patients are due to inflammatory reactions. These injection site reactions are actually the body’s physiological process in combating trauma (i.e. injections). These reactions should subside on its own within 2 weeks.
• Inflammatory reactions such as pain, swelling, redness, itching, bruising.
• Undesirable reactions like poor/weak filling effect, Tyndall effect (bluish discolouration of the injected areas) and lumps may be caused by inaccurate injection techniques.

Severe Side Effects

• Severe or adverse reactions occur when proper precautionary methods are not followed. Patients’ medical records (e.g. health condition, allergies, medications and/or supplements taken, previous aesthetic treatments) must be obtained before starting treatment.
• Symptoms of an allergic reaction (e.g. swelling of the mouth, tongue, throat or other parts of the body, nasal congestion, difficulty breathing, rashes, dizziness) may occur if your patients are not properly tested prior to treatment.
• Other adverse reactions like vision abnormalities, stroke, and occluded blood supply may happen when the filler gel is injected with the wrong technique at the wrong location.
• Formation of hard nodules, granulomas (inflamed mass of tissues), abscesses (pus) and necrosis (tissue death) can also happen at the injected site.
• Some rare cases such as leakage of dermal filler material at the treated area or migration/displacement of filler material from the original site have also been reported to FDA.