Dermal Fillers & Injectables
Aging is a sensitive subject, and it’s not surprising when one considers how important a person’s appearance is to their self-esteem. As the concern around aging grows so does the popularity of cosmetic procedures that help patients to reverse the signs of aging. In recent years dermal filler injections have emerged as one of the most popular methods to fill out and obscure wrinkles. In 2010, 1.8 million of the procedures were performed in the United States while 2016 saw 2.6 million performed.
- How do Fillers Work?
- Not a Candidate
- How to Prepare
- How Many Treatments?
- Side Effects
- Pros & Cons
As difficult as it can sometimes be to accept, it is a fact of life that as we age our skin transforms and changes. Age spots, dryness, and wrinkles are just some of the ailments that will affect our skin as it becomes increasingly thinner, coarser, and we suffer from volume loss.
In the United States, the skincare market generates an estimated 17 billion USD per year, and this number is on the rise. This growth is largely driven by the fact that we live in a “selfie” culture that centers around the prominence of the face and as a consequence Americans are becoming more conscious of their appearance.
A study recently conducted by Dermstore found that young women in today’s society have started to try and mitigate the effects of aging much, much earlier than the generation before them, finding that the average millennial starts using anti-aging products at the age of 26.
You may have heard of this medical procedure, and you may be wondering – perhaps because you or someone in your family is considering the procedure – how it works, what they are for, and whether they are safe. In this piece, we are going to take a look at all of these elements so that you can find everything you need to be informed.
Dermal fillers are essentially soft tissue fillers that are injected into areas of the face to fill out wrinkles and thereby restore a smoother and more youthful appearance.
The material that is injected into the skin, however, will eventually be absorbed by the body which means that the results are only temporary. The results themselves will vary according to the patient, their goals, and the type of dermal filler that is used. There is a range of FDA-approved dermal fillers and injectables on the market. The most common include:
Collagen Hydroxylapatite Poly-L-Lactic Acid – PLAA (the most common version being Sculptra® Aesthetic) Neurotoxins (the most common being [Botox®, Xeomin®, and Dysport®] Sodium Hyaluronate (the most common being Restylane®, Refyne®, and Restylane® Defyne) Hyaluronic Acid (with or without the anesthetic lidocaine, which is used for comfort) Polymethylmethacrylate Beads, Collagen, and Lidocaine (the most common being Bellafill®)
It should be noted that Bellafill® is more uncommon and even banned outright in some states. The most appropriate option will vary from patient to patient according to their specific needs and the area in which they need to be treated.
What Are the Benefits of Dermal Fillers?
Essentially, dermal fillers will help the patient to achieve a more youthful look by filling out wrinkles and facial lines in certain areas. One of the most important benefits of dermal fillers is the fact that there is no waiting time for a result. From the moment that a person has the procedure performed they will witness immediate benefits, and there is no prolonged process that requires swelling or bruising to subside.
Many patients also appreciate the relatively long-lasting results that can be achieved. While the length of the results will vary according to the type of filler used, they can last for an impressive amount of time, sometimes several years.
Finally, patients also opt for dermal fillers over alternative injectable procedures like Botox® due to the more natural results that the procedure can achieve. There is a subtlety to the results achieved by dermal fillers, and it can help a patient to feel comfortable and natural afterward.
How Do Dermal Fillers and Injectables Work?
The way dermal fillers and injectables work varies according to the material injected. Here is a short overview of the way that the main dermal filler methods work:
Collagen Collagen is a protein that inspires the production of new skin cells. When collagen (bovine or human) is used as a dermal filler, it is injected into the deepest skin layers (known as the dermis), to replenish the natural collagen fibers that are lost during the aging process. The new collagen is absorbed into the deepest layer of skin. The result is a more youthful appearance, added volume in sunken areas, and added support for the uppermost layer of skin (called the epidermis). Some collagen-based dermal fillers are bovine based and others are derived from human collagen. The injected substance is composed primarily of naturally occurring collagen fibers and is absorbed directly into the lower layer of skin.
Hyaluronic Acid (with and without lidocaine) Hyaluronic acid (HA) is a naturally occurring substance that is already found in a person’s skin. It helps keep skin plump and hydrated. HA fillers are typically soft and gel-like. The results are temporary, lasting 6 to 12 months or longer before the body gradually and naturally absorbs the particles. Most HA fillers are infused with lidocaine to help minimize discomfort during and after treatment.
Hydroxylapatite Calcium Hydroxylapatite fillers, known more commonly by their brand names such as Radiesse®, are a compound of minerals that are originally found in human bones. The substance used in fillers is biosynthetically created, however, and contains no animal or human products. The gel-like substance is dissipated into the target area, where it eventually is replaced with soft tissue growth. After 2–3 months, the product is resorbed and replaced by collagen.
Poly-L-Lactic Acid (PLLA) Polylactic acid, marketed as Sculptra® Aesthetic, is a dermal filler made with a biodegradable synthetic material called poly-L-lactic acid. Poly-L-lactic acid, interestingly, was originally a suture material used for patients after surgery. After injection, the filler is absorbed into the body and causes a reaction that effectively works to rebuild collagen in the target area over a few months.
Polymethylmethacrylate Beads, Collagen, and Lidocaine Bellafill® is an FDA-approved cosmetic treatment that’s been proven to be highly effective for use as a dermal filler. Bellafill® serves as a permanent implantation procedure to correct nasolabial folds or deep smile lines in both women and men. Unlike many other types of dermal fillers, Bellafill® is non-resorbable and permanent, which means that patients will not need multiple treatments to maintain the effects of the procedure. Bellafill® is also used to treat moderate to severe facial acne scars on adults, primarily in the cheeks.
Bellafill® injections are created with a blend of microsphere-enhanced bovine collagen and lidocaine, a local anesthetic. The microspheres that are added to the collagen are created from polymethylmethacrylate (PMMA), a synthetic, FDA and USDA-approved material used to create the implants. The microspheres measure to about 30 to 50 microns in size and are barely visible to the naked eye. Some patients are allergic to this product and will need to pass a skin test before the treatment can be applied.
Sodium Hyaluronate Restylane® Refyne, and Restylane® Defyne are sodium hyaluronate-based gels. Sodium hyaluronate is a more soluble form of hyaluronic acid with smaller molecules and greater penetration than HA. Sodium hyaluronate-based products offer patients more natural and more pliable results.
Neurotoxins Botulinum toxin, most commonly known by the brand name Botox®, is a neurotoxin derived from Clostridium botulinum, a gram-positive bacterium. The neurotoxin is injected into a muscle to erase wrinkles caused by frowning, smiling, and other muscle contractions. The neurotoxin relaxes the muscle and softens wrinkles caused by the contractions. Botox® will not work on wrinkles that have not been caused by muscle contractions, like sun damage or smoking habits.
Botulinum toxin treatments are effective and efficient and can take under fifteen minutes to apply. According to its manufacturer, the effects of Botox® can be evident within 48 hours, but in some cases, it can take up to a week.
Other brands of neurotoxin injectables that have similar effects of Botox® include Dysport® and Xeomin®. The manufacturer of Dysport® reports a median onset of effects in roughly two to three days. The manufacturer of Xeomin® reports that it takes an average of three to four days for the initial effects to become evident, and up to a month to appreciate the product’s full effects.
Who is a Good Candidate for Dermal Fillers?
Given that there is such a wide range of treatment options available, suitability varies from patient to patient according to their specific needs. This means that there should be an appropriate treatment method out there for most patients and they will be considered good candidates in the following circumstances:
Collagen The ideal candidate for a collagen injection is a healthy individual between the ages of 35 and 60. Candidates for collagen injections will have early signs of aging in the facial areas like smile lines, frown lines, and crow’s feet around the eyes, mouth, nose, between the eyebrows, and on the forehead.
Hyaluronic Acid (with and without lidocaine) The ideal candidate for hyaluronic acid with lidocaine fillers, like Juvederm® XC or Captique®, is in good physical and psychological health. The candidate will have realistic expectations and want to treat early signs of aging in the face, like crow’s feet, smoker’s wrinkles around the mouth area, frown lines, worry lines, deep smile lines, and some types of scarring.
Hydroxylapatite Ideal candidates are generally between the ages of 35 and 60, and understand that results and how long these results will last vary between individual patients. They also understand that the longevity of results is influenced by lifestyle, skin type, age, muscle activity in the treatment area and their body’s rate of collagen production.
Poly-L-Lactic Acid (PLLA) The ideal candidate for the PLLA filler Sculptra® Aesthetic is in good physical and psychological health.
Polymethylmethacrylate Beads, Collagen and Lidocaine The ideal candidate for Bellafill® has moderate to severe facial wrinkles and folds and desires a permanent solution that doesn't require surgery.
Sodium Hyaluronate The ideal candidate for Restylane®, Refyne®, and Restylane® Defyne has moderate to severe facial wrinkles and folds.
Neurotoxins The ideal candidate for neurotoxin treatment has frown lines caused by repetitive movement of the forehead muscles.
Who Should Not Have This Treatment?
There are instances where circumstances dictate that a patient needs to be excluded from a particular treatment method. The best way to determine suitability is through consultation with a skin care professional, but these are the general instances where a person will find themselves to be unsuitable:
Collagen Collagen injections may not be suitable for those that are pregnant or nursing. It is also not recommended for people with certain autoimmune disorders. In collagen injections that contain bovine collagen, patients with allergies to cows or cow products should not have this procedure.
Hyaluronic Acid(with and without lidocaine) Hyaluronic acid fillers with lidocaine are not recommended for individuals with active skin lesions or infections in the area to be treated or who have a known sensitivity to lidocaine.
Hydroxylapatite Hydroxylapatite based fillers are not recommended for individuals who have a history of severe allergies or anaphylaxis, are pregnant or breastfeeding, have an allergy to any part of the product, have a bleeding disorder, or have an allergy to lidocaine or medicines like it.
Poly-L-Lactic Acid (PLLA) Sculptra® Aesthetic is not recommended for individuals with active skin lesions or infections in the area to be treated or who are susceptible to hypertrophic/keloid scarring.
Polymethylmethacrylate Beads, Collagen, and Lidocaine Bellafill® is not recommended for individuals with active skin lesions or infections in the area to be treated, have a known bovine or lidocaine allergy, or who are susceptible to hypertrophic/keloid scarring.
Sodium Hyaluronate Restylane®, Refyne®, and Restylane® Defyne are not recommended for individuals with severe allergies or known allergies to lidocaine.
Neurotoxins Neurotoxin treatment is not recommended for patients with an infection or irritation in the area to be treated. It is also not suitable for patients that are hoping to correct wrinkles caused by sun damage, smoking, or other non-muscle-related factors, or to enhance the quality of the skin texture.
How Should I Prepare for Treatment?
One of the advantages of dermal fillers is the fact that preparation is entirely uniform regardless of the treatment type that the patient elects to choose.
Generally, patients will have to ensure that they do not consume alcoholic beverages for at least 24 hours before treatment. They should also avoid anti-inflammatory/blood thinning medications if possible for 2 weeks before treatment, and refrain from smoking during that time as well.
Certain medications need to be avoided, such as aspirin, Ibuprofen, Motrin®, Advil®, Aleve®, and other NSAIDs, as these have a blood thinning effect and can increase the risk of bruising and swelling after injections. Supplements like ginkgo biloba, ginseng, St. John’s Wort, Omega 3/Fish Oil supplements, and Vitamin E should also not be taken before treatment.
The patient should reschedule their appointment at least 24 hours in advance if a rash, cold sore or blemish develops on the area. If there is a history of cold sores, then the patient will need to notify the provider as an antiviral medication before treatment may be prescribed.
Finally, patients need to be sure to have a good breakfast, including food and drink before the procedure to avoid nausea or lightheadedness.
Is Anesthesia Used During Treatment?
The type and intensity of the anesthesia used during the procedure will vary according to the treatment type. Neurotoxin injections are the only procedures that are normally applied without a local or topical anesthetic.
Collagen: Topical; local Hyaluronic Acid (with lidocaine): Topical; local Hyaluronic Acid (without lidocaine): Topical Hydroxylapatite: Topical; local Poly-L-Lactic Acid (PLLA): Topical; local Bellafill: Topical; local Sodium Hyaluronate: Topical; local Neurotoxins: None
How Many Treatments Are Needed to See Results?
For most procedures, the results will be noticeable at once after only one procedure. In others, the results may take a while but will improve over time. In general, the number of treatments that are required to see results will vary from one treatment type to the next:
Collagen: Once Hyaluronic Acid (with lidocaine): Once Hyaluronic Acid (without lidocaine): Once Hydroxylapatite: Once Poly-L-Lactic Acid (PLLA): Three sessions spaced one month apart Bellafill: Once Sodium Hyaluronate: Once Neurotoxins: Two to four treatments
Are Results Permanent or Temporary?
This varies according to the treatment type that the patient elects to undergo:
Collagen The body will eventually absorb the collagen and upkeep treatments will be necessary to maintain results. This is one of the key reasons that collagen treatments have waned in popularity as hyaluronic acid fillers tend to last longer and patients are less likely to have an allergic reaction.
Hyaluronic Acid (with and without lidocaine) This option can last for up to two years. The body will absorb the hyaluronic acid over time, and upkeep treatments will be necessary to maintain results.
Hydroxylapatite This option can last for up to one year. This option provides temporary improvement in facial contouring and reduction in the appearance of skin folds, lines and wrinkles, which means maintenance injections will be required to maintain optimal results.
Poly-L-Lactic Acid (PLLA) This option can last for up to three years. Some results can typically be seen after a course of 3 treatment sessions however significant results can usually be seen after 6 months and results continue to improve for an additional 1-4 months.
Polymethylmethacrylate Beads, Collagen, and Lidocaine While permanent, overcorrection or over injection is not recommended with polymethylmethacrylate microsphere-based fillers and therefore successive treatments every 2-3 months may be required to reach the desired fullness.
Sodium Hyaluronate This option can last for up to 18 months. Once the filler has been absorbed, however, upkeep treatments will be necessary to maintain results.
Neurotoxins This option can last for up to 6 months. Results are temporary and will require multiple treatments to see an effect. Results can take several days to appear, and it may take a few weeks to see further improvement. Maintenance treatments will be necessary every 3-6 months.
Are There Side Effects From Dermal Filler Treatments?
As with any other cosmetic procedure, there is a range of potential side effects that patients face when they elect to undergo one of these dermal filler procedures. Patients should note that the following lists are not exhaustive of all potential outcomes. For a comprehensive guide to side effects and complications that can occur with these procedures, visit your board-certified cosmetic surgeon or dermatologist for more information.
Collagen Side effects from collagen injections may include rejection and an allergic reaction if the collagen is derived from a bovine/porcine cell. Patients could also experience redness, swelling, bruising, and lumps from the injections.
Hyaluronic Acid (with and without lidocaine) Possible side effects from hyaluronic acid with lidocaine injections include redness, swelling, bruising, asymmetry, and small bumps at the injection site.
Hydroxylapatite In this treatment, the most adverse side effects and complications that have been reported include a loss of sensation, a bumpy rash, nodules, and difficulty in performing daily activities. Bruising, swelling, reddening of the skin, and itching is among the most common side effects experienced by patients after treatment. A very small risk of accidental injection into a blood vessel is also possible, though rare—and can cause serious complications.
Poly-L-Lactic Acid (PLLA) Side effects from Sculptra® Aesthetic may include redness, swelling, tenderness, injection site pain, bleeding, bruising, itching, and bumps.
Polymethylmethacrylate Beads, Collagen, and Lidocaine Side effects from Bellafill® may include bruising, itching, rash, persistent swelling or redness, or increased sensitivity at the injection site. Bellafill® contains microspheres that help provide the support for wrinkle correction, but the microspheres are not absorbed and can only be removed surgically.
Sodium Hyaluronate After their treatment the patient may experience side effects such as swelling, redness, pain, bruising, headaches, tenderness, lump formation, itching at the injection site and impaired hand function.
Neurotoxins Side effects from neurotoxin injections may include itching, pain, redness, or swelling at the injection site, pain in the face, or swelling of the eyelids that usually resolves within a few hours. Patients also commonly report difficulty swallowing after treatment, stomach pain, nausea, diarrhea, shortness of breath, muscle stiffness, neck or back pain, fever and flu symptoms, anxiety, and other symptoms.
What’s the Recovery Process Like?
This process is largely the same for the majority of the treatment options, but there are a slightly different process and list of precautions that neurotoxin injection patients will have to account for.
In general, patients need to avoid significant movement or massage of the treated area unless instructed by the provider.
What’s more, the patient should avoid strenuous exercise for 24 hours as well as extensive sun or heat for 72 hours. To avoid excess swelling, the patient should avoid consuming excess amounts of alcohol or salts. If there is swelling, then the patient should apply a cool compress for 15 minutes each hour. Tylenol should be used for discomfort, and the patient should sleep face up and slightly elevated if swelling is present.
If the patient undergoes a neurotoxin treatment, then they should not manipulate the treated area for 3 hours following treatment. It is also essential that they do not receive facial/laser treatments or microdermabrasion after injections for at least 10 days.
The patient should not lie down for four hours after a neurotoxin injection to help prevent migration. It can take approximately four days to a week for results can be seen. The patient should not perform activities involving straining, heavy lifting, or vigorous exercise for six hours after treatment. This will help keep the neurotoxin in the injected area and not elsewhere.
What Do Dermal Fillers and Injectables Cost?
Collagen: $250 - $1500 per session Hyaluronic Acid (with lidocaine): $450 - $750 per syringe Hyaluronic Acid (without lidocaine): $450 - $750 per syringe Hydroxylapatite: $600 - $800 per syringe Poly-L-Lactic Acid (PLLA): $600 - $900 per vial Polymethylmethacrylate Beads, Collagen, and Lidocaine: $650 - $1000 per syringe Sodium Hyaluronate: $350 - $800 per syringe Neurotoxins: $225 - $400 per treatment
Conclusion: The Pros and Cons of Dermal Fillers and Injectables
Collagen One of the key benefits of this option is that the collagen can potentially be made from the patient’s skin so that it will not be rejected by the body. This benefit is offset by the fact that it provides just a temporary solution and does not last as long as other fillers.
Hyaluronic Acid (with and without lidocaine) While this option is reversible, long-lasting, and is less likely to be rejected by the patient it still requires regular upkeep treatments.
Hydroxylapatite This option gives patients immediate results that improve over time. It’s also less likely than other options to produce a poor reaction. The patient will require regular maintenance treatments, however, and it is only recommended for those patients aged over 35.
Poly-L-Lactic Acid (PLLA) This option can achieve very long-lasting results and inspires the production of additional collagen. Unfortunately, these results can take a long time to manifest themselves.
Polymethylmethacrylate Beads, Collagen, and Lidocaine The big benefit of this option is that the results are permanent, but they are also difficult to reverse or remove. There is also the risk of nodule formation and asymmetry, and it can require multiple treatments.
Sodium Hyaluronate This option gives natural and free facial movement, but it does require regular maintenance treatments.
Neurotoxins This is a quick treatment option that has little to no recovery time. This is offset by a relatively short time the results last and the need for multiple treatments.
Patients should always consult with a board-certified physician or cosmetic surgeon before having a dermal filler treatment. Fillers and injectables come in a wide variety of applications and are not always suitable for everyone. If you’re considering a dermal filler treatment to address your particular skin issues, make sure to speak in-person with a trained and qualified medical professional who can evaluate your case and recommend the best treatment to suit your needs