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Wednesday, February 13th, 2019
A filler, by present aesthetic definition, is an injectable substance used to correct wrinkles, folds, or volume loss in the body, particularly the face. As fillers have evolved, they have replaced early facelifts, redo facelifts, facial implants, and many other surgical procedures such as lower blepharoplasty, peels, and laser resurfacing in many cases. Their popularity continues to increase. But, what are these and how do we use them? Read on to find out.
There are many different types available, including fat, collagen, collagen precursors, “collagen generators,” and semipermanent to permanent substances. Fat is an excellent option and also semipermanent but requires harvesting the fat before it can be injected. All of the others are products that can be taken off the shelf ready for injection. Collagen, the first filler developed, is rarely used anymore because its results last at most 6 months and frequently much less. Collagen generators, such as Sculptra are less often used, since they take a significant time to achieve results that can be achieved by other fillers almost immediately and since many of the other fillers now have a longevity as long these. Additionally, the collagen precursors have recently been shown to also stimulate collagen, the building block of the support layer of the skin and deeper tissues. The permanent and semipermanent fillers, (Bellafill®, silicone) though still used, are less so because of difficulty in using without a high problem rate. The most common fillers used today are collagen precursors, either calcium hydroxyapatite or hyaluronic acid. The hyaluronic acid fillers, because of their safety record and reversibility if problems arise, are, by far, the most common. They come in multiple consistencies, each better at correcting specific parts of the face or elsewhere. There are also many brands of these. I use the Juvéderm® family of fillers which have the greatest longevity and widest spectrum of product characteristics.
Lips generally present 3 different aesthetic problems. They can be too small congenitally, asymmetric, or lose volume with age. As they lose volume, the upper lip flattens and loses its normal pout and appears smaller, the skin of the lower lip becomes the most prominent portion rather than the vermillion and wrinkles develop. Over the years, different surgeries to correct these problems, including implants have been used. Presently, however, use of a filler generally gives a better, more natural result. I generally use either Juvéderm® Ultra or Juvéderm® Vollure, depending on the specific need. Both provide volume filling, though Ultra® provides slightly more fill for the same volume injected. It lasts approximately 10-12 months in the lip where Vollure® lasts about 18 months or longer. I use Juvéderm® Volbella for finesse of the shape and for any fine lines remaining after restoring volume. It also works excellently if only a small amount of correction is needed since it comes in a smaller quantity than the other products.
Loss of volume is one of the main problems that occur to the face and body with age. It is responsible for many of the other problems generally considered signs of aging. In the face, as volume is lost, the tissues descend forming superior flatness and, inferiorly, folds or creases at the places where the underlying ligaments prevent further descent. When we first started using fillers, one of the most common areas of injection was along the nasolabial folds, the junctions between the cheek and the lips. This, however, did nothing for the superior areas that had lost volume and had caused the increased prominence of the nasolabial folds. Presently, we most commonly treat the nasolabial fold areas by refilling the upper cheeks. This usually effaces and reduces the folds. If not, we will revert to filling the fold, but this is now much less common than previously. We also treated tear troughs, those depressions that appear to be bags in the lower eyelid area by trying to fill the lines. I discovered many years ago that the most efficient method of doing this is to fill the cheek under the tear trough, thus pushing the tissues back up to their normal position. This method is now being taught throughout the industry. Although I previously used Radiesse®, a calcium hydroxyapatite filler for this, I now use Juvéderm® Voluma. It is placed deep, just on top of the bone, and pushes the tissues up, replacing fat that was lost. It generally lasts at least 2 years but, in a few cases, has lasted over 4 years. For the areas where there is no bone to push against, such as in the lateral cheek, both Voluma® and Vollure® can be used more superficially. Treatment here frequently effaces marionette lines reducing the need to treat them individually. Other areas like the Back of the hand can also be filled to hide the signs of age.
If fine lines and wrinkles are not eliminated by use of Botox® or replacing volume, fillers have also become our best option. Previously the only thing available was either a leveling peel or laser procedure. The problem with both of these is that recovery takes at least 10 days to 2 weeks with significant discomfort for that entire time. Fillers have allowed us to correct the problem almost immediately with minimal down time and no continued discomfort. Although fillers were originally designed for intradermal use and are still called “dermal fillers,” this is the only time we actually presently place the filler in the dermis, the support layer of the skin. Volbella®, a relatively thin though strong filler, works excellently when placed in lines and wrinkles. Unlike many other fillers placed in this location, it rarely causes a blue line (the Tyndall effect). This elevates and frequently eliminates the wrinkles. Since the wrinkle is generally caused by loss of thickness of the dermis, I generally, also, crisscross either Volbella® or Vollure® under the area of wrinkles to thicken and stiffen the skin, making it less reactive to the underlying muscle pull. We then make certain that you are on a good retinol or tretinoin (Retin-A) so the body can use some of the filler to create its own collagen returning the skin to its younger thickness. By doing this, the most I have had to inject the wrinkles to get them to remain minimal, is twice.
An excellent option for folds and volume replacement is fat. It can be used anywhere a filler can except intradermally. However, when placed just below the dermis it can stimulate dermal growth and improvement in the skin because of the inherent stem cells within the fat.
To discuss further the difference between these, the advantages and disadvantages of each, and how they might help you, please call our office in Highlands at 828-526-3783 to schedule an appointment.