What are Dermal Fillers?
Fillers such as JUVÉDERM®
Ultra Plus, Restylane, Perlane, Radiesse and Artefill®
are all types of dermal fillers that offer immediate and lasting
wrinkle correction. These fillers are safe and natural cosmetic
products that correct moderate facial wrinkles and folds such as the
smile lines, vertical lip lines, “marionette” lines at the corners
of the mouth and tear troughs, depressions under the eyes. These
fillers can also be used to volumize the face and create a
At MediSpa Maui, we offer both absorbable and non-absorbable dermal
fillers. There are 3 types of absorbable (temporary) fillers that we
use on a regular basis, Hyaluronic Acid fillers (Juvederm Ultra,
Juvederm Ultra Plus, Restylane and Perlane), Calcium Hydroxyappetite
fillers such as Radiesse and lastly, Sculptra (Poly-L-Lactic Acid)
which works less as an immediate filler and more as a gradual
collagen stimulater that fills over time. Artefill®
is the first FDA approved, non-absorbable (permanent) dermal filler.
It is composed polymethylmethacrylate (PMMA) bovine collagen and
lidocaine. PMMA microspheres are not degraded, are not absorbed, and
therefore provide a long-lasting wrinkle correction. These
treatments are a cornerstone to facial rejuvenation allowing years
to be erased without surgery.
Dr. Stolley is a master of using these fillers alone or in concert
with Botox/Dysport and Lasers to dramatically rejuvenate your skin.
Hyaluronic Acid (JUVÉDERM®
Ultra Plus, Restylane, Perlane, Radiesse)
Hyaluronic Acid is a large molecule that is naturally found in the
human body and almost all living organisms. The HA found in JUVÉDERM®
and other products on the market come from bacteria. The main
difference between the HA found naturally in your body and those
found in fillers such as JUVÉDERM®
Ultra Plus, Restylane, Perlane and Radiesse is that the latter are
cross-linked to each other via a glucuronidate molecule. The body
has natural enzymes called hyaluronidases that breakdown the HAs to
sugar and water. The HA fillers as a whole are the most versatile
Calcium Hydroxyappetite (Radiesse)
These fillers consist of calcium microspheres surrounded by a
methylcellulose carrier. Over 3-4 months, the methylcellulose
carrier or vehicle is absorbed leaving the calcium microspheres
behind to stimulate collagen growth. Radiesse is often used over
bony areas due to its firm nature and its whitish color. A benefit
of Radiesse is the relatively large amount in the syringes, roughly
50% more than the amount of other fillers. This allows for more
volumization per syringe and some savings financially. The negative
regarding Radiesse is the firmness of the product, the whitish color
and some longevity issues. The firmness and whitish color limit the
product, in my opinion, to a deeper plane of injection and thus I
often use the product in the cheeks or the jaw line. Regarding
longevity, the company is allowed by the FDA to say that it can last
“Up to 1 Year”. I find this overly generous for a single injection.
Longevity of a year to 18 months can be achieved but it requires
augmenting the correction at 3-4 months with more filler. Radiesse
is also an ideal product for hand rejuvenation.
Poly-L-Lactic Acid (Sculptra)
These fillers are made from a synthetic material that when injected,
stimulates the body's own production of collagen. These small
particles are mixed with sterile water and injected into areas to
stimulate collagen growth and thus a thickening of the tissue in
that area. In some areas, they are used deep over the bone and in
others such as the lateral face and lower cheeks, they can be used
under the skin. The benefit of Sculptra is its longevity. After a
series of several treatments, the product can last for 2 or more
years. The downside is the cost, though the cost of the product has
come down recently.
Polymethylmethacrylate (PMMA) Artefill®
Artefill is different from temporary injectable wrinkle fillers.
Temporary injectable wrinkle fillers are made of different kinds of
natural or synthetic materials that are broken down and eventually
absorbed by your body. As a result, wrinkle correction is only
temporary and you may need repeat injections several months after
the initial treatment to maintain your wrinkle correction. Artefill
corrects wrinkles differently. The unique microspheres are not
absorbed by your body and provide the support your skin needs for
natural, long lasting results. Most people get the results they want
with one or two treatments, depending on the depth of their wrinkles
and folds. Artefill is injected deep in the skin, underneath the
wrinkle and just above the skin’s fat layer. The collagen works
right away, reducing the appearance of the line or wrinkle, then the
microspheres provide a support matrix for natural, enduring wrinkle
What are the Possible Complications with Fillers?
Dermal fillers are a great tool to use to helping patients create a
smoother, more youthful appearance. The right filler can be used in
the right place to fill in bothersome lines and wrinkles and/or to
lift and volumize the facial areas, giving back what time has taken
away. Though fillers are a great tool, they are not without their
issues and potential complications.
Bruising – any time you enter the skin and soft tissue with a
needle or other sharp object, bruising is possible. Bruises can take
up to a week to 10 days to go away. Less often, a bruise can leave
what is called a hemosiderin stain. This is when the iron from the
blood remains in the skin for some time after the initial bruise has
resolved. Hemosiderin stains almost always go away, but they can
sometimes take months.
Infection – I have never had a patient get an infection from
a dermal filler, but anytime the skin is broken, an infection is
possible. Infections can be problematic with dermal fillers because
as long as the filler is present, the bacteria has a home to live in
and can be difficult for antibiotics to reach it at high enough
concentrations to destroy it. The risk of injection is very small
and is limited by use of alcohol or other tissue disinfectants. If a
patient has a history of recurrent skin infections, a consideration
of pretreatment with antibiotics may be considered and screening or
treatment for Staph aureus colonization should be considered. Please
ask your doctor about pre-treatment for Staph aureus colonization if
you have a history of recurrent skin injection such as boils,
superficially abscesses or recurrent folliculitis.
Visible Product – One relatively common problem with fillers
is that the product can be visible from the surface of the skin
either as a bluish hue with HA fillers or whitish with Radiesse or
as a lumpy/bumpy area with any of the products. As we mentioned
earlier, a benefit of the HA fillers is that problems can be removed
relatively easily with extrusion of the product or via the use of
hyaluronidase. With Radiesse, the product can be removed via
extrusion at times or broken up by injecting saline to the area or
left to dissolve over time.
Arterial Compromise – Though rarely an issue, the most
serious complication of a dermal filler is arterial compromise or
the shutting off of arterial blood flow the distal tissue. This is
rarely an issue for 2 reasons: 1) arteries are rarely hit or
compromised and 2) most of the facial tissue benefits from
collateral flow; that is, the area is fed by more than one artery.
Only a few areas of the face have limited blood flow and include
some mid-line regions such as the mid-forehead and nasal regions.
As an expert injector, I am always looking for the signs and
symptoms of arterial compromise and ready to treat if needed.
Treatment would include firstly recognizing the issue, then treating
with massage to the area. This can be flowed by administering
aspirin, injecting hyaluronidase into the area to break up the HA
filler (if one was used) and administering Nitroglycerin paste to
the areas to help to open up the blood vessels. I have only had one
episode when arterial compromise was a concern and it resolved
promptly with the above treatments leaving a happy patient with a
small bruise who came back in a week later for a bit more filler in
the area. One important warning sign to watch for from a patient’s
perspective is severe pain or tenderness minutes to hours after the
treatment in the area treated or near-by tissue. This is an
important sign that cannot be ignored. It is a sign of tissue
ischemia (lack of oxygen) and it is your skin screaming out to you
to do something. If you experience extreme pain in the area or
adjacent areas minutes to hours after your treatment, call your
doctor. And on that note, make sure you do have an after-hours
number available to call.
Complications with dermal fillers are rare but can happen. At
MediSpa Maui, we are always available for complimentary
consultations prior to any treatment. We educate all of our patients
on the appropriate pre/post care instructions that can limit the
possible side effects of a treatment.
Before and After Photos
Click Photos to Enlarge
HERE for more images.
Photos Courtesy of Brian Stolley, MD