Dermal fillers, or skin fillers, are materials injected into the skin to reduce the appearance of wrinkles. There are a number of approved dermal fillers on the market, including: Restylane, Juvederm, Radiesse, and Sculptra. The most popular dermal fillers are derived from hyaluronic acid. The discussion below is general and not necessarily relevant to each individual product.

About Dermal Fillers

Dermal fillers are substance injected into or below skin to augment or replace volume. The result are seen immediately, but it may take several visits to achieve the correct correction; some older fillers lose some volume quickly, so “over-correction” is common practice. There is usually no down-time due to the procedure. Most fillers are not permanent, with results lasting about six months. There are many choices, as listed above.

What is hyaluronic acid?

Hyaluronic acid is a naturally occurring glycosaminoglycan found in the dermal matrix of all species without interspecies variability.

What is the ideal skin filler?

No one filler is “ideal” for every application. The general attributes of the ideal filler are:

-Good correction
-Long lasting
-Natural look and feel
-Does Not migrate
-Easy to implant
-Cost effective
-Readily available
-Inert
-Non-carcinogenic
-Non-immunogenic
-Sterile
-Removable

What are the categories of dermal fillers?

-Protein products such as human collagen, bovine collagen, and fascia lata
-polysaccharides such as hyaluronic acid
-fat
-synthetics

How are dermal fillers injected?

There are several possible methods. In the multiple puncture technique, the needle, bevel up, is injected at an angle to the skin of approximately 30 degrees. Multiple injections are made to fill the desired area. In the microdroplet technique, tiny quantities are injected in different planes in the defect. In linear threading, the needle is placed almost parallel to skin and injections made while withdrawing the needle; this may provide too shallow placement for some materials.

For each filler the physician must consider the use, means of injection, proper plane of injection, and desired overcorrection (if any).

Injections can be painful, especially in the central face and perioral areas. Topical anesthesia or ice for 15 minutes prior may be sufficient. Nerve block or regional anesthesia may sometimes be required. Newer fillers include an anesthetic, obviating the need for ice or pre-treatment with a topical agent.

How should the patient be counseled before the dermal filler procedure?

For each dermal filler, the patient should be advised of the risk/benefit ratio (see each specific product for details), and informed of the expected duration of effect. The patient should be instructed to avoid aspirin for 7-10 days prior to the procedure and other NSAIDs for 3 days. The patient should be asked to complete a questionnaire with relevant information, including: medications, history of hypersensitivity reactions, history of herpes facialis, medical history, whether she is pregnant or lactating, any history of autoimmune disease, and importantly what are the patient’s expectations from the procedure and what morbidity is tolerable (e.g. erythema, swelling etc…).

How should the patient be evaluated before the dermal procedure?

The cause of wrinkles and facial damage must be assessed. Are the lines dynamic or static? Is there photodamage, gravitational pull, or aging. Aging results in loss of subcutaneous fat and the prolonged results of the pull of gravity. Photodamage results in breakdown of supporting skin structures, such as collagen and elastin, and can also lead to skin cancer. Evidence of trauma, disease, inflammation, or prior surgery should be sought.

Assessment includes the size, depth, location, and integrity of adjacent structures for each line. Non-facial sites, such as dorsum of the hands, should be inspected as well. All amenable defects should be noted: rhytides, distensible scars (e.g. acne or trraumatic), and the vermillion border of the lip and the oral commisure.

How should the patient be counseled after the dermal filler procedure?

Ice and/or compression can be applied to minimize bruising. It may be helpful to sleep with the head elevated for the first several nights after the procedure in order to minimize edema and ecchymoses. Antiviral medications should be considered for perioral injections in patients with a history herpes labialis.

Generally, who should not receive dermal fillers?

The dermal filler products have not been tested in pregnancy and breast feeding. Dermal fillers should not be injected into an infected or inflamed site. It should not be used in patients with abnormal hemostasis or allergy to any component. Dermal fillers should generally not be used in the glabellar area (see below). Caution should be exercised when using dermal fillers in thin or atrophic skin; the material may be detectable. Each product must be be injected at the specified depth.

Generally, what are the adverse effects of dermal fillers?

The list of possible adverse effects is long. Some are technique-dependent and some due to reactions to the product. Possible adverse effects include: asymmetry; purpura/hematoma; erythema; edema; induration; pruritus; tenderness; dysesthesia; lumps, cysts, abscess; discoloration; intermittent swelling; necrosis; scars; allergy; infection; and extrusion.

Severe adverse effects include: blindness, cerebral infarcts, and fat embolus. These devastating complications can occur with injection into the glabellar and periorbital area, which are supplied by the internal carotid artery. Dermal fillers should be avoided in these areas. Arteriole occlusion manifests as immediate burning and a dusky appearance. If this occurs, the injection must be stopped immediately. Topical nitroglycerine or dimethylsulfoxide (DMSO) may help increase blood flow to area.  Hyaluronidase can be used to dissolve hyaluronic acid fillers. Rarely, connective tissue diseases have been reported to occur with the use of bovine collagen. However, investigatory FDA panels found no evidence of a link.

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