Fillers

Fillers for facial wrinkles...

As we age, we lose fat in 21 distinct pockets below our facial muscles, which leads to sagging jowls, under eye shadows, flattened cheeks, and hollow temples. We also lose the skin-plumping layer of fat just below the surface of the skin, revealing wrinkles, folds, and expression lines. When facial filling first began in the 1980s, the only option was Collagen. Many patients had great results, but the effect only lasted two to three months, and allergies were common enough that spot testing was routinely required.  Since then, a number of fillers have been FDA approved for use. Although most are approved for a very specific use (lips, cheeks), most physicians use them in multiple areas of the face, so this can increase the number of options to a point of confusion.

Individual results from procedures cannot be guaranteed, and may vary between patients.

To help make sense of all the options, the first thing to understand is that there are basically two kinds of fillers. The first basic type is called a Hyaluronic Acid (HA) filler, and the other type is called a Collagen Stimulator. There are a larger number of HA fillers, and they have a lot of similarities, even between brands.

Hyalruonic Acids

Hyaluronic acid fillers are thin gels made of carbohydrates that are based on the same molecules that are normally found in the connective tissue around our skin cells. The original HA fillers are still used today and the full effect lasts an average of 4 to 6 months, with some product remaining in place up to 12 months. They are fairly thin and smooth, which makes them safe to inject anywhere in the skin. The effect is seen immediately, but since the HA molecules tend to attract water, for many patients the effect improves subtly over the first week after treatment.

In recent years, more cross-linking between the HA molecules has been used to make some of the HA gels thicker. This means more volume as well as effects that last more like 12-24 months, but it also means that they shouldn’t be used in superficial lines or near the eyes or lips. Any of the HA fillers can be partially or completely dissolved by injecting a solution containing the enzyme Hyalruonidase (brand name Vitrase) into the area where there is too much volume. This breaks down the filler within 1-3 days, but it can take up to 3 weeks for the body to completely clear the product and the swelling from the area.  Let’s look at some specific products.

Juvederm Voluma XC

Allergan’s newest filler is the only filler officially FDA approved for volumizing and lifting the cheeks. It has become extremely popular for its subtle but noticeable effects, especially for decreasing shadows under the eyes and cheeks in photographs. When full correction is performed (which was up to 6 syringes per patient in the study), the effect was still seen two years after treatment.  This filler can be used elsewhere in the face, but it cannot be used around the eyes or in the lips, and it cannot be injected superficially in the skin due to the thick nature of the gel. Voluma comes as a 1mL size, and many patients are happy with 1-2mL for a full treatment. The XC means that the filler contains lidocaine, a numbing agent, to make the injections more tolerable. All of the “XC” fillers are available in regular form upon request for patients with sensitivity to lidocaine.

Juvederm Ultra Plus XC

FDA approved for moderate to deep facial wrinkles and folds, this filler can be used almost anywhere. Ultra Plus is soft enough to blend in with the skin without lumps and firm enough to correct wrinkling, and it is most commonly placed in the nasal folds and around the chin and mouth. After injection, most patients return for correction in about 9 months. With complete correction, including a touch up treatment at 6 months, patients see results that last up to 18 months. We offer Ultra Plus in a 1mL size.

Juvederm Ultra XC

Juvederm’s softest filler, Juvederm Ultra is great for treating “smoker’s lines” above the lip or at the edge of the lip to prevent lipstick bleed, or it can be used to add volume for both the upper and lower lips. Ultra is also used for tear troughs or under-eye hollows and for improvement of superficial lines in a variety of places.  Due to its soft nature, it’s the fastest absorbing filler, with a duration of about 6 months, depending on the amount used and the amount of muscle motion in the area where it is injected. This is available in a 1mL and 0.5mL size.

Restylane Silk

The newest Galderma filler to the market, Restylane silk is the only filler actually FDA approved for injection into the lips as well as perioral lines around the mouth. Most patients think of the lip as only the colored part, but technically the lip includes the skin up to the nose as well, so it’s possible to correct lines and improve the lip shape without increasing the size of the colored portion of the lip at all (no duck lips!). Silk has a small molecule size, designed for the softest, smoothest feel possible and lasts about 6 months. It comes in a 1mL size with lidocaine to decrease discomfort.  

Restylane-L

The original Galderma lip filler, Restylane is indicated for moderate to deep facial folds and wrinkles, and can be used for everything from smoothing the under eyes and plumping the lips to filling in acne scars and wrinkles. Patients find that Restylane offers a very smooth correction for many areas of the face, and it lasts about 6 months before repeat injection is needed. Restylane comes in a 1mL or 0.5mL size for patients who are not interested in large volume correction. The L means it includes lidocaine, which is included to decrease discomfort.

Perlane L

Perlane is another filler from Galderma that has a larger particle size, which is indicated for deeper folds and increased volumizing compared with Restylane. It can also be used for acne scars and other types of volume loss in the skin. Because of the large particle size, it shouldn’t be used in the lips or near the eyes, but it does an excellent job in volumizing the cheeks. It comes in a 1mL size and has a lower cost than Juvederm Voluma, but it does not last as long (6-12 months vs 12-24 months).   The L means it includes lidocaine, which is included to decrease discomfort.

Collagen Stimulators

 

Collagen stimulators work differently than HA fillers. Instead of a gel that provides immediate volume exact where it is desired, collagen stimulators are absorbed and then stimulate the body’s tissues to produce its own collagen over the course of several weeks. Some patients find that the collagen growth is impressive with even one treatment, and others find that multiple treatments are needed for the desired effect. This has to do with a person’s metabolism as well as the amount of collagen they had in youth as well. Results can last up to two years. Collagen stimulators can be used in the temples, along the cheek and jawbones as well as in deeper folds and wrinkles in many places, but it is not meant to be used in the eyes or lips. There are two main types that are used at the practice, which will be discussed below.

Radiesse

Radiesse is actually a mixture of hyaluronic acid and a calcium based particle that stimulates collagen. The HA provides immediate volumizing and wrinkle correction, which is then maintained by the growth of new collagen as the HA portion dissolves over time. Because of this, the effect is immediate and can last 12-18 months for many patients, depending on the amount of product used and where it is injected (areas of the face with more movement will break down the product and the new collagen faster). Radiesse comes in a 1.5mL as well as a 0.8mL size and is one of the more economical fillers because of the larger syringe size available.

Sculptra

Scultpra is a pure collagen stimulator, made of a small molecules related to absorbable suture material. It is mixed with saline and injected in a series of sessions several weeks apart to stimulate collagen production. After the saline is absorbed (in about 24-48 hours), patients experience a gradual increase in the amount of volume in the areas injected over 6-8 weeks, at which time injections can be repeated if desired. The average patient has three sessions to achieve a full result. It can be used in conjunction with other fillers, although it is best to allow for the full effect before adding other fillers to the exact same areas. Sculptra is an excellent way to gradually replace a large amount of volume loss in many places over the face.
Now that the different types of fillers in our practice have been reviewed, it may be helpful to look at this flow chart to figure out which filler(s) will help achieve your individual goals. Keep in mind most patients end up using more than one type of filler.

Need help finding the right filler for you?

Some patients worry about the risks of fillers as well as the potential for complications or discomfort associated with their use. We do everything possible to minimize these risks, but they do sometimes still occur. The most common side effect with fillers is temporary discomfort. Many of the products contain lidocaine to help numb the skin as the product is injected, but we also use ice and a topical numbing cream to improve the experience. A dental block (numbing injections) can be used for the lips since they are the most sensitive, but this is saved as a last resort since it can distort the area slightly and affect the final result.

Another common risk is bleeding, bruising, and swelling. Usually this is minor and can be minimized by avoiding blood thinners for 7-10 days before injections. Significant bleeding is rare, but if it occurs it can take a few weeks to resolve in the worst cases. Luckily it will not affect the final result. This is critical for formal blood thinners like Plavix or Coumadin but is also important for over-the-counter medications like Ibuprofen and other NSAIDS as well as any supplements that can cause bleeding like fish oils and omega-3 fatty acids. Alcohol is also a blood thinner and should ideally be avoided for a few days before injections to minimize bruising and bleeding.

If bruising does occur, an herbal supplement called Arnica can be used both in pill form and topically to help resolve bruising and swelling. Some patients even begin taking Arnica before their injections to help prevent bruising and swelling.

Uneven correction or nodule formation can occur even if both the injector and patient do everything possible to avoid it. Most of the time, this can be corrected with the addition of more product or by dissolving product (if it is an HA). Unfortunately, some nodules are scar tissue based and may not resolve even after the product dissolves completely on its own. This is a rare occurrence that is more often felt than seen, and it can be surgically addressed under local anesthesia, but it is definitely something to be carefully considered before injections are performed.

Facial fillers for wrinkles

Individual results from procedures cannot be guaranteed, and may vary between patients.

Fillers ARE typically used to target

Smile Lines:

Smile lines, or nasolabial folds, are wrinkles run vertically from the bottom of the nose to the corners of your lips. This is a very popular injection site for injectable fillers like Juvederm.

Marionette Lines

Marionette lines are the vertical wrinkles that form below the corners of the mouth. These lines often annoy patients because can sometimes give the appearance of sad and/or a downturned expression. Juvederm is also a great solution for these types of age lines.

Vertical Lip Lines

Facial lines above and around the lips can begin to form over time due to ordinary lip muscle movement. However, environmental factors such as exposure to sunlight, smoking and stress can also contribute to how the area around our lips ages and the formation of vertical lip lines. Believe it or not, excessive use of straws can even lead to the formation of these lines.

Need help finding the right filler for you?

 

Juvederm Ultra

Price: $600 per syringe

Type of filler: Hyaluronic acid (sugar/protein molecule that is dissolvable)

Used for: Lips, tear troughs, superficial lines and wrinkles

Effect: Immediate effect, lasts 6 months

 

Juvederm Ultra Plus

Price: $650 per syringe

Type of filler: Hyaluronic acid (sugar/protein molecule that is dissolvable)

Used for: superficial or moderately deep wrinkles and folds except near the eyes

Effect: Immediate effect, lasts 6-9 months

 

Juvederm Voluma

Price: $850 per syringe

Type of filler: Hyaluronic acid (sugar/protein molecule that is dissolvable)

Used for: Deep volumization like cheeks, in front of the jowl, and the temples

Effect: Immediate effect, lasts 12-24 months

 

Restylane

Price: 550 per syringe

Type of filler: Hyaluronic acid (sugar/protein molecule that is dissolvable)

Used for: superficial or moderately deep wrinkles and folds in any location

Effect: Immediate effect, lasts 6 months

 

Restylane Silk

Price: $650

Type of filler: Hyaluronic acid (sugar/protein molecule that is dissolvable)

Used for: Lips, tear troughs, superficial lines and wrinkles

Effect: Immediate effect, lasts 6 months

 

Perlane

Price: $600 per syringe

Type of filler: Hyaluronic acid (sugar/protein molecule that is dissolvable)

Used for: Deep volumization like cheeks, in front of the jowl, and the temples

Effect: Immediate effect, lasts 6-9 months

 

Radiesse

Price: $750 per syringe

Type of filler: Part Hyaluronic acid, and part collagen stimulator (non-dissolvable)

Used for: Deep volumization like cheeks, in front of the jowl, and the temples

Effect: Immediate effect, lasts 12-18 months

 

Sculptra

Price: $750 per vial

Type of filler: collagen stimulator (non-dissolvable)

Used for: Deep volumization like cheeks, in front of the jowl, and the temples

Effect: Gradual effect over 6-8 weeks, lasts 24 months

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