A patient comes to you unhappy with the appearance of lines on the lower face. You hand the patient a mirror and, as pointed out by the patient, the areas of concern are the nasolabial folds, marionette lines, oral commissures, and lips. You explain that the best treatment would be a dermal filler to add more volume to the affected areas and decrease the appearance of the wrinkles. Now the question comes…which dermal filler should you recommend and use?
There are plenty of dermal fillers out there from different manufacturers. They all work toward the same goal of replacing volume and decreasing the signs of aging. The main differences are the material each is made from, the duration of action, and the mechanism of action. In this article, I will mention only the more commonly used and FDA approved products manufactured in the US.
Human Collagen:
Cosmoplast and Cosmoderm. These products are manufactured by Allergan. This is a very soft product to inject and since it is human based, it is very compatible and rarely causes any sensitivity reactions. The main advantage is that the product contains lidocaine so the injection is more comfortable for the patients. I recommend this product for patients who are concerned with pain. The product lasts approximately 4-6 months on average. It must be refrigerated. Cosmoderm is used for fine wrinkles, Cosmoplast is used for deeper wrinkles and Cosmoderm 2 is made for glabellar lines.
Hyaluronic Acids:
Non-animal based: These include Restylane, Perlane (a more robust product), manufactured by Medicis, Captique, and the new and longer lasting Juvederm, both manufactured by Allergan. Restylane lasts on average 6 months, Perlane supposedly longer since it is more robust, and Captique about 4 months. Juvederm is an exciting new product and is approved to last much longer: 6-12 months. It is a very soft product and injects very nicely. It comes as Juvederm Ultra and Juvederm Ultra Plus, used for deeper wrinkles.
Avian based: Hylaform. These products inject very much like Restylane, but only last approximately 4 months. They come in a variety of concentrations (Hylaform Plus, Fine Lines, etc.) so use can be tailored for fine wrinkles to deep wrinkles.
Semi-Permanent Fillers:
Calcium Hydroxyapatite: Radiesse. This product is manufactured by BioForm and is very biocompatible with the human body since calcium hydroxyapatite is a natural substance found in bone and soft tissues. Once optimal correction is achieved, the product lasts as long as 1-2 years. It may take a series of injections to reach the final desired endpoint. The calcium hydroxyapatite stimulates the production of new collagen. This product when injected splits tissue planes so induces a bit more pain and causes more bruising than the other fillers listed. An advantage to this product is that it can be used as an injectable implant to enhance the cheek bones, decrease the appearance of humps on the nose and fill in jowl sulci.
Poly-L-Lactic Acid: Sculptra. This product is manufactured by Sanofi-Aventis and is also very biocompatible. Sculptra is packaged in a vial and must be reconstituted at least 3 hours (ideally the day before use) with sterile water and lidocaine. Results are not immediate, as the water used to reconstitute the product gets absorbed within the first 2 days after injection. The remaining poly-L-lactic acid stimulates new collagen production. The injections are less painful since the product is reconstituted with lidocaine. This product requires a series of injections spaced at least 1 month apart. Once optimal correction is achieved, results can last up to 1-2 years.
Permanent Fillers:
Polymethylmethacrylate: Artefill. This product is made from acrylic microspheres suspended in bovine collagen with lidocaine. Given the presence of bovine collagen, it requires a skin test prior to injection. This product stimulates the production of new collagen.
Expanded polytretrafluoroethylene (ePTFE): SoftForm/Ultrasoft. This is a permanent implantable device that comes in various sizes. It is useful for the lip border and nasolabial folds.
Autologous:
Fat: Using the patient’s own fat eliminates the risk of allergy. It has variable persistence and must be harvested from another site. Risks include hematoma formation, fat necrosis and infection.
This article only discusses a few of the many available dermal fillers. The permanent fillers seem to be rarely used in the US, possibly because if left with an undesirable outcome, the results are permanent. My favorite filler to inject currently is Juvederm. The product injects so smoothly and the results are beautiful. As well, Juvederm is approved to last longer than other products which is very appealing to the patient. If a patient really needs facial shaping, I will choose to use Sculptra, as long as the patient understands that results are not immediate, as with the other fillers. When a patient would benefit from cheek implants or jowl sulcus correction, but does not want to undergo surgery, I will offer them Radiesse because this product can be injected along the bone and serve as an injectable implant. Again, if the patient has a low pain tolerance, I may offer Cosmoderm or Cosmoplast. If a patient has had several previous injections, has been happy with the results and has had no allergic reactions, I will often time stick to the same product.
Each patient requires an individual assessment because when choosing the right filler, several factors must be taken into account, such as previous use of a filler, allergies, patient tolerance, depth of folds, duration of filler and cost. One can also layer the fillers for optimal results.
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