Use of Fillers in Cosmetic Dermatology

Contrary to popular belief, the injection of material under the skin to plump out wrinkles is not a new idea. From the early 1900s to the 1960s liquid paraffin wax injections were used in China as a treatment for wrinkles. Please do not try this at home!

Nowadays we use either Collagen or Hyaluronic acid products.

Collagen based fillers were the first of the modern day fillers. They have been used very successfully since the mid 1980s to the present day. The collagen has the advantage of being easy to work with and local tissue reactions such as redness and swelling after treatment are fairly minimal. However, one in 30 people are allergic to it necessitating a test dose (normally on the forearm) to be given. Any reaction to the collagen is then checked twice; after two to three days and again after one month.

Hyaluronic acid based products such as Juvederm Ultra® and Restylane® are modern products which are commonly used. Hyaluronic acid is a naturally occurring substance in all of our deeper skin layers. It consists of chains of sugar molecules which attract water by osmosis, hence plumping up tissues. Babies have a lot of Hyaluronic acid in their skin which is part of the reason it is so soft. Hyaluronic acid has the advantage of causing less frequent allergic reactions (about one in 4000 people) so allergy testing beforehand is not generally needed. It also tends to last longer than Collagen, although redness and swelling after the treatment is more common, generally settling in two to three days. Injections of Hyaluronic acid tend to be rather uncomfortable so some form of local anaesthesia is normally used. Hyaluronic acid in Juvederm Ultra® and Restylane® are manufactured by fermentation from genetically engineered bacteria; it contains no animal material at all.

Juvederm Ultra® is now my preferred filler as it contains local anaesthetic which greatly improves the comfort of filler injections.

Which areas can be treated?

Fillers can make a dramatic difference to wrinkles, particularly to those in the lower part of the face, where gravity and aging are the main wrinkle culprits. They are especially suitable for Nasolabial lines (between the nostril and corner of the lips) and Marionette lines, which run down from the corners of the lips. Usually one syringe of Juvederm Ultra 4® (0.8ml) per Nasolabial line (i.e. two syringes to treat the face as there are two of these lines on most people's faces!) is required although more may be required where the lines are very deep. Marionette lines normally require about 0.5ml per side.

Fine vertical lines on the upper lip and crows feet around the eyes can also be treated. I often recommend a combination approach here with some Botulinum extract first as these wrinkles are caused by muscle action.

Fillers are a popular treatment for tissue augmentation, especially the lips and cheeks. For reasons discussed below, lip treatment tends to be the shortest lived treatment. Lips are the most sensitive part of the body so some swelling and tenderness will be expected afterwards. Usually 1 syringe (0.8ml) of Juvederm Ultra 4® is sufficient to augment most lips.

Which areas are suitable for treatment?

  • Frown lines on the forehead (often in combination with botulinum injections)

  • Crows feet around the eyes

  • Vertical lip lines

  • Lip-line deficiency - to augment the lips

  • Nasolabial lines (or smile lines below the cheeks)

  • Marionette lines (lines below the corners of the mouth)

  • Pitted Acne scars

What are the side-effects?

Hyaluronic acid products do cause swelling and redness and tenderness immediately after the treatment. This may take two to three days to settle down. Occasionally an eczema-like reaction can occur after treatment. This usually responds to hydrocortisone cream which can be bought from any pharmacy. With any injectable treatment infection is always a risk, so areas with eczema and active acne are best not treated as the infection risk is higher. Despite the impression given by the media, Hyaluronic acid injections are definitely not a "lunchtime" treatment, whereas Botulinum extract injections can be. This is because swelling and redness will be obvious to work colleagues on return in the afternoon.

How long do fillers last?

Collagen tends to last three to four months, depending on how much and which area is injected.

Hyaluronic acid products tend to last six to nine months on average; again depending on where and how much is used.

In areas where there is a rich blood supply, such as the lips, any filler material will last less time as the high blood flow will absorb the material. Similarly, material injected into areas with strong muscle action, such as around the mouth and lips, will tend to be squeezed out of the tissues and hence tend to last a shorter time. For this last reason, I am particularly keen on combination treatments with Botulinum extract. This helps to reduce the strength of muscle action so the fillers last longer.

Am I suitable for treatment with fillers?

Only a face to face consultation with Dr Campbell will establish this, but there are certain medical conditions where fillers may not be suitable. These include:

Pregnancy or breastfeeding.

Poorly controlled Diabetes, severe Angina or severe Allergies or Anaphyllaxis.

Any Autoimmune disease such as SLE, Rheumatoid Arthritis or any Vasculitis.

A history of Keloid or Hypertrophic scarring.

Previous Roaccutane treatment in the last 12 months, or current anticoagulant or steroid treatment.

A chemical or laser peel or bad sunburn in the area to be treated within the past six weeks.

What if I am not happy with the results?

Dr Campbell reviews all his cosmetic dermatology patients two to four weeks after the initial treatment. Occasionally, lumpiness can occur in the areas treated. This responds to firm massage to disperse any such areas, and can safely be performed by the client themselves. Rarely prolonged allergic reactions to the filler materials can occur, but these nearly all settle with the application of hydrocortisone cream and with the passage of time. Should you not be happy with the ultimate from the filler treatment, it will eventually wear off, but rest assured that most people are delighted with the effect.

® Juvederm Ultra is a registered trademark of Allergan
® Restylane is a registered trademark of Q Med Aesthetics