Injectable Fillers are used to plump up (i.e., fill) folds and furrows on various locations of the face. They work by "puffing up" the area in question to bring it more into line with the surrounding contours. The most common sites enhanced in this manner are the nasolabial lines (which go from the nose to the corners of the mouth) and the marionette lines (which go from the corners of the mouth to the chin) but many other parts of the face and body can be treated. Fillers can be used to create fuller lips, including the lower and/or the upper lip, to enhance the cheekbones, to improve the appearance of other portions of the face (such as the pre-jowl sulcus), and to minimize the appearance of lines on the hands. While facelifts and other surgical procedures may be necessary to achieve ideal correction, injectable fillers instead of or, more commonly, in addition to these procedures, can enhance the results further. For example, nasolabial lines are not generally treated with maximum efficiency by a facelift. They may be improved but due to their distance from the points of tension with a facelift (above and behind the ears) and their genesis (which is partly a consequence of smiling and other facial movements), these lines may not receive adequate improvement from a facelift alone. The addition of a filler extends and enhances the process. Fillers are similarly useful in younger patients who have not yet developed enough excess facial tissue and jowling to warrant a facelift and in patients who do not want a facelift or who, for medical reasons, cannot have one but who nevertheless desire cosmetic improvement in those regions.

Once the decision has been made to have a filler, there are many choices.  One issue is how long the filler will last.  One might think that a permanent filler is the best choice, but there are many potential problems with this.  First, since your face changes as you age, what looks best right now might not in a few years.  The amount – and location – of whatever fillers you get is something that you may want to be able to adjust as you age.  Secondly, some of the permanent fillers can be associated with some – permanent – problems, or complications, particularly if your body has a reaction to them.

The most commonly used fillers right now are the hyaluronic acid products, which include Restylane, Perlane, and Juvederm (of which there are two forms, Juvederm Ultra and Juvederm Ultra Plus).  Restylane and Juvederm Ultra are the shortest-lasting fillers, lasting about 4-8 months (depending on the amount you have injected).  Perlane and Juvederm Ultra Plus last longer (about 6-12 months).  I prefer to use them for first-time filler patients until we see what each person likes, and many people stay with these indefinitely.  They are proven, safe, and effective.  In order to make the procedures more comfortable to tolerate, the companies have added an anesthetic (lidocaine) to each of the fillers so that they are now called Restylane-L, Perlane-L, Juvederm Ultra XC, and Juvederm Ultra Plus XC.

In addition, in the event that too much is injected into one spot the hyaluronic acid fillers can be by injecting a chemical that essentially dissolves the filler reversed (there are a few, very rare complications that can not be reversed).  It’s called hyaluronidase and if you’re having this procedure done, it is reasonable to ask you doctor if hyaluronidase is available just in case there’s a problem.

Each is available in individually packaged syringes that contain about 1 cc.  Most people are treated with 1-2 syringes for maximum benefit.  Some people have two syringes injected at once; others have one syringe injected at the first visit, and then come back about a month later to have more done, depending on where it is needed most.

The other prepackaged filler is Radiesse, which is a little different.  Radiesse consists of calcium hydroxylapatite (CaHA) particles, which are suspended in a hyaluronic acid gel.  Those particles stimulate the growth of collagen, which is one of the building blocks of your own tissues.  As a result, Radiesse lasts longer than the straight hyaluronic acid gels. Depending on how much is injected, the correction can last up to 18 months and, in some cases, even longer.  Radiesse is available in two sizes:  0.8 cc (just a little less than the hyaluronic acid gels) and 1.5 cc syringes.  Maximum correction, as with the hyaluronic acid gels, often requires more than one syringe.

The good thing about Radiesse is that it lasts longer.  But one issue to consider is that, unlike the hyaluronic acid gels, you cannot completely reverse the effects if there’s any sort of a problem with them.  Hyaluronidase may work on the gel portion of Radiesse but it will not do so on the CaHA.  Problems are rare but, if they do occur, there is a certain peace of mind knowing that hyaluronidase is an option.

Treatment takes about 20-30 minutes depending on how much is being done, and whether or not a topical anesthetic is used (in which case, an additional 30-60 minutes is required for maximum effectiveness). Several sessions may be required for the best results. These substances are packaged in pre-filled syringes with specific amounts of the material in each syringe. The cost of the treatment depends, among other factors, on the number (and size) of syringes used.

These are truly lunch-time procedures, as the patient can resume his or her normal activity right after treatment. Because no preparation of the material is required (i.e., they are prepackaged and always available) last minute appointments and scheduling changes are easily accommodated.  Makeup can be applied directly on the treated areas. As with any injection, they are associated with the risk of bruising and other potential problems but they are generally safe and effective, and have very few side effects.

There are many other substances available, each with its own set of advantages and disadvantages, and new ones become available on a regular basis. There are, for example, permanent injectable substances and permanent implantable materials (the difference being, among others, the size and thickness of the product). Even within the category of non-permanent injectable fillers, there is a wide range of duration of correction available, depending on exactly which product is selected. Notable among the longer-lasting injectables is Sculptra, which is often used as a larger volume replacement for patients who have hollowing of the cheeks as a result of aging.  It is also used for patients who have lipodystrophy (fat loss) as a side effect of anti-retroviral medications used to treat HIV.  Unlike the other fillers, Sculptra causes significant new tissue growth (neo-collagenesis).  This means that it stimulates growth of your own tissues via a process that can last for up to two years, or even longer.

The field of injectable fillers is rapidly changing and growing, and new developments can be anticipated on a continuing and on-going basis.  As always, the first step is a consultation.  You’ll have a discussion to find out what you’d like to accomplish, you’ll be examined, and then you will typically be presented with a range of options. 


Alan M. Engler, MD, FACS - Board Certified Plastic Surgeon
122 East 64th Street New York, NY 10065 USA
(212) 308-7000

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