Picture by Cathy VanHeest at Unsplash
The fillers
Fillers are liquid (viscous) implants that are injected into or under the skin. With fillers you can aesthetically treat various annoying indications. On the one hand, fillers are used to add volume to the face. Simply put, there is a lack of volume in the cheek region, for example, and we inject an implant deep down to the bone to fill in the missing volume. Over the past few decades, methods and materials have evolved significantly. The topic of filling volume with fillers will be the subject of an extra article. Today we are talking about superficially injected fillers, which are intended to level wrinkles that are not caused by your facial expressions.
Since we always try to inform you as comprehensively as possible, we would like to take this opportunity to discuss the various materials that have been used as fillers and are used today.
Fillers are materials that are among the most commonly used in aesthetics. There are over eighty companies offering fillers in Europe. Fillers are also CE certified as liquid and therefore injectable implants, which means that you are not allowed to deliver any active ingredients except for a small amount of local anesthetics such as lidocaine, which only serve to make the injections even more bearable.
With breast implants, we are only dealing with one material – silicone. With fillers, the situation is different. New fillers are continuously coming onto the market, some of which contain new materials. This does not make the choice any easier for doctors. For one thing, the past has taught them painfully that not everything new is necessarily better. There have also been situations where companies have had to withdraw new fillers because complications were too severe. On the other hand, doctors naturally want to offer their patients the optimum materials for the indication in question.
In the past, there have been repeated attempts to produce so-called permanent fillers, especially with the substance acrylate. These are fillers that remain permanently in the tissue, similar to breast implants. This path has so far proved to be an errant one. At the time, there were a number of complications, some of them severe. But there are still patients who carry permanent fillers and are comfortable with them without complications. This is a good thing and every patient should be happy with it. However, these patients should be aware that they are carrying ticking time bombs and they should not under any circumstances have subsequent work done with materials used today. This can lead to serious disfigurement.
That is why permanent fillers are no longer used today. All fillers dissolve after some time and are removed. When filling with volume, we are always dealing with deeper deposits. Other fillers treat more superficial wrinkles, which we will deal with in a moment. The consequence of the negative experiences with permanent fillers means that volume filling must be repeated after some time. This is important for you as a patient. It has the advantage that the filling can always be adapted to your specific age status, and it has the disadvantage that the filling costs something and you have to put up with the filling. Fillers for deeper regions should be renewed today after 18 to 24 months.
The gold standard of filler materials to date has been the use of hyaluronic acid. Hyaluronic acid is naturally present in the skin, but it must be chemically altered so that it remains there longer. This process is called cross-linking. The stronger this cross-linking is carried out, the longer the material remains in the body. Recently, cosmetic companies have been advertising that they offer cosmetics with hyaluronic acid. This has nothing to do with fillers, although one company even uses the term filler. Cosmetics are always only short-term results of one or more days at the most. In no case can longer lasting results be achieved with them.
It would be going too far at this point if we now described the chemical processes that lead to crosslinking, and these are not all known even to doctors because each company has developed its own crosslinking technology. The products of all major manufacturers are considered safe and usually do not cause complications. Every doctor who treats esthetics has chosen one or two products, perhaps he uses another product for very special indications.
Another advantage of hyaluronic acid is that in the event of unforeseen complications, such as swelling in the treated area, it can be immediately dissolved by another substance, hyaluronidase.
In recent years, some medical colleagues have also looked at how to create the best possible volume buildup with the least amount of material – a good filler is relatively expensive. Marketing-wise, these techniques are sold as specialties and filler companies have secured rights to them, thus trying to closely associate the technique with the product. Such strategies will not be successful because both – injection points and material used – have very little to do with each other. Under terms such as 8-point technique, Nefertiti Lift or di Maio technique (MD codes), nothing else is offered than standards developed by very experienced colleagues, which sometimes simplify a volume build-up in a material-saving way. However, those who exclusively use fillers to contour a face instead of working with combination therapies can also easily call up very large sums for a treatment.
As another material for fillers, we would like to mention polylactic acid (brand name Sculptra). Although hyaluronic acid as a material dominates aesthetics, there are also other materials that have been certified. In the past, there have been complications with this material, sometimes of a serious nature. A few years ago, the manufacturer revised the instructions for the approach and treatment and was thus able to drastically reduce the number of complications. Nevertheless, we would like to describe this filler as a special filler that produces very good results in some clearly defined indications, for example in the treatment of the décolleté, although the focus is less on filling than on smoothing wrinkles. This also applies to smoothing effects on the face. However, we would like to point out that for the region of the décolleté, for example, other procedures are also available, e.g. treatment with threads or needling.
Another material is the calcium hydroxylapatite used under the product name Radiesse. It is a substance found in the body in the teeth and bones. Initially, this filler was used for all regions, but it turned out that the treatment of lips was associated with a greater number of complications, which led to the exclusion of this region. With the new valid treatment instructions, numerically greater complication rates were no longer reported. Some physicians readily use this material and in a large number of patients.
We do not quite understand why a substance is used that cannot be dissolved again like hyaluronic acid if something should happen.
There have been other materials such as collagen, agarose, brown algae or silicone oil. So far, these have not been able to establish themselves on the market. The approval for the collagen-containing product Evolence was withdrawn in America in 2009 by the regulatory authority there (FDA = Federal Drug Administration) because many complications were associated with it.
The non mimic wrinkles
The superficial use of fillers involves fillers on the surface of the skin that even out the small peaks and valleys we call wrinkles and thus level them out. These are almost always hyaluronic acids specifically designed to treat the superficial wrinkles. However, the treatment only works if there is no mimic activity causing the wrinkles. You can easily distinguish these wrinkles from the mimic-generated ones: No matter what face you make, they are always seen to the same extent. A good example is our nasolabial folds, which become more pronounced as we age. These are the two wrinkles that develop to the right and left of the nose, and they usually consist of a valley (crease) and a hill (a bulge of sunken fat). On the one hand, we can melt away the bulge or the “nasolabial mound” by injection lipolysis, but on the other hand, we can also fill the developed valleys of the wrinkle with a filler. Both together actually produce an optimal result. The same applies to the famous Merkel wrinkle (so named after the German chancellor), only here we do not use injection lipolysis as a combination partner for our filler, but rather botulinum.
The small criss-cross wrinkles can also be treated very well with a surface filler. However – and this applies to all surface fillers – these hyaluronic acid-based fillers are less cross-linked than the fillers used to build up volume. Less cross-linking inevitably means that the fillers are also broken down more quickly – they remain in the tissue for around 6-9 months.
Risks and side effects
More serious complications in the surface area are virtually unknown when used properly. This does not apply without restriction to volume fillers. Serious complications have been described here in recent years, but these are extremely rare. More on this in the article on volume filling with fillers.