Botulinum toxin injections and wrinkle fillers are two of the most popular cosmetic treatments people get today to help maintain or reclaim their youthful appearance.

People generally turn to these procedures because they can be performed in the office with limited recovery. These are truly the “lunch time lifts,” unlike the mini-facelifts of several years ago that surgeons were touting as lunch time procedures.

Thanks to science and advances in manufacturing, a host of fillers are available—so many that it is impossible for any one doctor to use all of them. Quite frankly it does not make sense for all doctors to use all the available fillers.

Instead they will become familiar with a short term, a medium and a long- lasting filler to meet their patients' needs. With all available FDA approved wrinkle fillers there is an up side and a down side.

Hyaluronic Acid or Non?

All wrinkle fillers can be divided into two groups: the hyaluronic acid (HA) fillers, and the non-hyaluronic acid (non-HA) fillers.

It's true that HAs have taken the filler market by storm over the past several years and everything is now compared to them. Interestingly, cow collagen fillers were the king of fillers not too long ago; now they are rarely used by most physicians. As mad cow disease ran through parts of Europe, people sought out alternative fillers (despite the fact that collagen fillers were prepared from a protected herd in the United States). The hyaluronic acids were about to take off.

The HA fillers are divided into two categories: HA's derived from birds and those genetically engineered with bacteria.

The first group was the “early bird,” if you will. The Hyalaform products were created from rooster combs. The problem early on was that some roosters had more hyaluronic acid than others, so the concentration could vary from syringe to syringe. Changes in manufacturing have apparently corrected this now.

Cultured HA's
The bacterial cultured hyaluronic acids (Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus) are more popular. The products are very similar in that they are made by gram positive bacteria.

Therefore anyone with multiple severe allergic reactions (including anaphylactic reactions) basically should not be given any filler to avoid a serious reaction.

About one out of five thousand patients may have antibodies to the bacteria that make the hyaluronic acid. This can result in an allergic reaction.

I have never seen it in a patient of mine, but a dermatologist referred a gentleman who had Restylane injected into the corners of his mouth. He developed redness and a slight rash at the injection site.

I put him on a course of steroids by mouth and that took care of it. The Allergan products, Juvederm Ultra and Ultra Plus, are cross-linked and therefore tend to last slightly longer than un-cross-linked hyaluronic acids. The potential for lumpiness, swelling and bruising are the same for any filler in this category. The benefit of using a hyaluronic acid filler is that it is reversible. In the old days if someone had a lump from collagen you were stuck with it until it broke down. A hyaluronidase can be injected to smooth out irregularities of the hyaluronic acid if necessary.

Non-Hyaluronics
All other fillers are lumped into the non-Hyaluronic acid group. The old guard fillers of bovine collagen, Zyderm and Zyplast are in this category. As mentioned earlier their popularity has faded. A skin test and a thirty day waiting period following it contributed to its decline. Most patients want correction now!

Some long term fillers are in this group. Radiesse, calcium hydroxyl apatite, has received several different FDA approvals over a fifteen year period. It is the framework of teeth and bone; however it is synthetic. It is a whitish implant with microspheres of the calcium hydroxyl apatite.

For many, when the implant is injected underneath the skin (the particles are too large for fine facial lines) their body will lay down collagen around the microspheres resulting in a several year effect. However, I have seen some patients break the particle down within a few months.

Another filler in this group is Sculptra (poly-L-lactic acid). It is FDA approved for HIV positive patients with lipoatrophy. Since they cannot mount a normal immune challenge to the implant, many have enjoyed long term correction. I have seen granulomas and distortion of the cheek from healthy patients who have had this filler injected.

Do Your Homework!
ArteFill is polymethyl metacrylate, or you can just say hard contact lens beads coated with cow collagen. Its predecessors Artecoll and Arteplast were associated with the occasional development of tender bumps under the skin called granulomas. These could work their way up to the surface as the body tried to eject the material. It is theorized that this was caused in earlier versions by rough, irregular microspheres. The newer preparation of ArteFill has smaller smoother microspheres and a lower rate of granulomas. However a skin test is necessary before treatment begins.

Cymetra, human dermis in which all the cells have been removed and then broken into microscopic pieces, was enjoying its heyday 7-8 plus years ago.

The sheet form of the product called Alloderm works great for about 90% of patients. However, as the sheets were broken into tiny little pieces it damaged the framework too much. This resulted in the body just clearing it away for most patients. An occasional patient does very well with it.

Micro droplet silicone is back on the market, since the FDA has approved a preparation of silicone, Silikon 1000, for use in the eye as a volume filler. It is being used off label as a wrinkle filler and lip filler.

One of my concerns in listening to colleagues of mine from Europe where they have used both liquid silicone and the Artecoll products is that they say the cells that surround the implant are giant cells.

These cells can be unpredictable sitting there for years and then become stimulated by a trigger such as a virus. This can result in the body developing redness and swelling around the area or the material can work its way up to the surface and spit out.

My take on the whole thing is this: permanent is permanent, but can carry a price of possible rejection, painful lumps, and hardness. The Hyaluronic acid fillers have resulted in a very well tolerated, moderately lasting filler for most.

And the good news, if you do get some unwanted swelling or a lump, it is not permanent. Individual results will vary, so do your homework before deciding which filler you are going to try.

For more information please call Dr Maloney at 770-804-0007.

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