All wrinkle fillers can be divided into two groups: the hyaluronic acid (HA) fillers and the non-hyaluronic acid (non-HA) fillers. Yes, the HAs have taken the filler market by storm over the past several years and everything is now compared to them.

The non hyaluronic acid fillers were led by bovine collagen. Collagen, known as Zyderm® and Zyplast®, used to be the number one wrinkle filler around the world. Since it was made from cow hide, an allergy test was needed before the actual treatment. Even if the initial test was negative, patients could develop an allergic reaction at any point in the treatment. Use of collagen began to decline in Europe with the advent of mad cow disease. People began avoiding all cow products even gummy bears. This concern spread over to the United States, though cow herds in the United States were protected and very safe.

New fillers began to appear on the market to meet the void left by collagen. Leading the first list was hyaluronic acid (HA). HA is a naturally occurring sugar that is found in all living cells. It is one of the main components in the supporting layer of our skin. HA holds on to water like a sponge, being able to absorb more than 1000 times its weight. This helps to attract and hold water, hydrating your skin and increasing its volume and density.

One of the first hyaluronic acid fillers was isolated from rooster combs. However, some roosters had more hyaluronic acid and some had less, so the concentration could vary from syringe to syringe.  Hylaform was an early HA from a bird source. I don’t favor this product as the HA molecule chain is shorter than other HA products on the market, so it tends not to last as long as the longer chain products.

Restylane® is the first cosmetic dermal filler free of any animal source. It is genetically engineered, meaning it is made by bacteria, similar to many antibiotics we use. Restylane® may contain trace amounts of gram- positive bacterial proteins and should not be used in patients with a history of allergies to such material. Approximately 1 in 5,000 people may be allergic to these proteins. Such a reaction is unusual; therefore no skin testing is necessary.  If an allergic reaction develops, it can generally be treated with a steroid cream.  Restylane® is a longer chain HA and for most people lasts between four and six months. One should understand that the first time one receives a filler of any type, it is an experiment to see how one’s body responds to it. The effects could be short lived or longer.

Juvederm Ultra® and Juvederm Ultra Plus® are HAs manufactured by Allergan. They were FDA approved in June 2006. They have been used in Europe for over 15 years. Allergan acquired the product and brought it over to the United States. These products have the same length HA chain as Restylane® but they are crossed linked. The HYLACROSS technology creates a product that has been reported to last longer than uncrossed linked HAs. Generally patients may maintain correction of wrinkles for 6-9 months with these products. The Juvederm Ultra® is best for fine lines as around the eyes and lips, whereas the Ultra-plus form is thicker and better used for the corner of the mouth and folds between the cheeks and mouth. The Juvederm® products are the number one filler in the United States.

All other fillers are lumped into the non-hyaluronic acid group. 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 contributed to its decline. Most patients want correction…now!

There are some long term fillers in the non-hyaluronic group. Radiesse™ - calcium hydroxyapatite (the framework of teeth and bone) - has received several different FDA approvals over a fifteen year period. Radiesse™ is a synthetic. It is a whitish implant with microspheres of the calcium hydroxyapatite. 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 long lasting effect. However, I have seen some patients break-down the particle within a few months.

Sculptra® (poly-L-lactic acid) filler is in this category. It is FDA approved for HIV positive patients with lipoatrophy. Since HIV patients cannot mount a normal immune reaction to the product, many have enjoyed long term correction. This product is FDA approved for non HIV patients now.

ArteFill® - polymethyl methacrylate - is basically 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 the cause of this was due to the fact that the earlier preparations had rough irregular microspheres. The newer preparation of Artefill® has smaller smoother microspheres and the rate of granulomas is much lower.

Cymetra™ is human dermis in which all the cells have been removed and then broken into microscopic pieces. Cymetra™ enjoyed its hay-day seven to eight plus years ago. The sheet form of the product, called Alloderm®, works great for about 90% of patients. However, it seems 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 person would do very well with it.

Micro droplet silicon, Silikon 1000, is back on the market as an FDA approved preparation to add volume to the eye area. It is being used “off label” as wrinkle filler and lip filler. The concerns after listening to colleagues from Europe (where both liquid silicone and Artecoll® products were being used) are giant cells that surround the implant. These cells can be unpredictable. They can exist there for years, and then possibly become stimulated by a trigger – such as a virus – and result in redness and swelling around the area, or the material may work its way up to the surface and “spit out.”  

My take on the whole thing is:  permanent is permanent. Permanent can carry the price of possible rejection, painful lumps, and hardness. For most patients, non-permanent hyaluronic acid filler is moderate lasting and very well tolerated. With these fillers you may get some unwanted swelling or a lump, but it is generally not permanent. Any lumpiness can be smoothed out with an injection of hyaluronidase. Individual results will vary.

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