By now, most cosmetically minded people have heard about aesthetic fillers—those magical injectable gels which plump up the lips or smooth out wrinkles and folds. For years, “collagen injection” was the catch-phrase, as this naturally existing component of the skin’s dermis was the main option for filling. But so much has changed in the world of injectable fillers. And as more options have become available, there is more confusion about what is safe, what is effective, and what should be avoided. To help shed some light on this topic, here’s a brief outline of the past, present, and future of cosmetic fillers:
- It’s no longer all about collagen. Although collagen is appealing as a filler because it occurs naturally in the skin, the main problem is that it doesn’t stick around for very long. Even with the newer human recombinant form of collagen which does not require allergy testing (the earlier versions came from cows and some people were allergic to the cow protein in the filler), the body reabsorbs the material in a few months. The current most popular options for fillers which have largely replaced collagen are hyaluronic acids (HA) or hydroxyapetite fillers. HAs such as Restylane or Juvederm or hydroxyapetite fillers such as Radiesse do not require allergy testing and they last longer in the body.  In addition there are different preparations appropriate for different depths for the HA fillers.
- A shift from focused to global treatment—the liquid facelift. Fillers were initially used as a treatment of specific localized problems such as thin lips or deep folds around the mouth. Increasingly there has been a shift in thinking about how fillers can be used. Specifically, fillers have been used more and more to address the overall changes that happen with the aging process with loss of volume, deflation of the soft tissue, and overall sagging of areas of the face. Larger volumes of fillers are now placed into areas of hollowing such as the under-eyes, cheek bone areas, and jawline to volumize, lift, and rejuvenate the face. Particularly for the patient who wishes to look younger but does not want to go through with the recovery or expense of surgery, the “liquid facelift” with injectable fillers can provide a dramatic improvement through an in-office procedure.
- Fillers are still non-permanent and that’s a good thing! One of the few criticisms about injectable fillers is the fact that the effect goes away after several months. Because most of the commercially available fillers absorbable, the volume that is introduced will recede after several months to a year. And while this is viewed as an inconvenience for some, in my opinion, this is a good thing. The reason is two-fold. First and foremost, permanent fillers have the risk of creating permanent problems. There is a greater risk of problems such as infection or adverse tissue reaction with permanent fillers because these materials are, by definition, non-biodegradable. Second, the face and soft tissue is ever changing. The aging process affects us all creating changes in the shape and anatomy of our facial features. Thus a permanent filler may cease to provide an appropriate, cosmetically favorable effect over time if the anatomy around the filler changes. So the fact that reapplication is needed every several months to a year allows placement of the filler to be adjusted to match the ever-changing needs and anatomy of one’s face. With continued advancement of filler technology, longer lasting, non-permanent fillers are likely to be developed which hopefully reach that “sweet spot” of duration where a longer effect can be enjoyed, but not so long that the changes in the face cause them to become a problem eventually. In my opinion that sweet spot would be 2-3 years of duration—a time frame which I suspect will soon be attainable as research progresses in this area.
- Experience counts. The most important factor that predicts successful filler treatment is the experience and skill of the injector. As aesthetic office procedures become more and more popular, more practitioners are getting into the game. As a patient seeking treatment, one should seek a medical practice with treatment performed or overseen by a board certified physician with specific training and experience in the cosmetic field. There are many skilled non-physician injectors who are capable of performing beautiful work. But I believe it is safest if such non-MD injectors conduct their practice within the scope of safe, physician supervised, medical setting.
