Signs of aging have long been a thorn in the side of many. With the variety of non-invasive cosmetic treatments available on the market, more and more individuals are opting for fillers to maintain the plump and smooth skin of their youth.
Fillers are non-invasive procedures which result in minor improvements on the surface of the skin and are often an attractive alternative to other cosmetic procedures which require you to go under the knife to achieve a desired aesthetic change. Many fillers deliver gratifying results in next to no time, are more cost effective (cheaper) and involve less downtime (recovery) than plastic surgery.
Fillers (often referred to as soft tissue, wrinkle, dermal, cosmetic, injectable implants or injectable fillers) temporarily soften the appearance of wrinkles (rhytides), creases, lines and even scars (shallow or deep) when substances, such as collagen, are injected into the skin (dermis) of the face and back of the hand. How long the effect of a filler lasts depends on what type of filler is used and the type of wrinkle or crease being treated.
Some fillers are approved for the restoration and / or correction of lipoatrophy (facial fat loss), often experienced by people with the human immunodeficiency virus (HIV). Soft tissue filler can also be used for lip augmentation, cheek augmentation and hand augmentation (increasing size or volume).
Fillers cannot, however, be used for breast augmentation (increasing the breast size and shape), increasing the size of the buttocks, fullness of the feet or as an implant into bone, tendons, ligaments or muscles.
Effects can be semi-permanent (up to several months or a year) or more short-lived, again depending on the type of filler used. Most fillers require repeat injections and can cause some minor swelling, bruising and inflammation. More serious side effects are typically rare and are largely impacted by the quality of the product used and the professional administering the treatment.
Why are fillers done?
Fillers are an option, mostly, for aesthetic purposes. We, as human beings, desire healthy-looking and youthful skin, especially as we age. For many, the longer we can retain a semblance of youthfulness to our physical appearance, the better.
The cosmetic market has seen an ever-increasing desire for this youthfulness, as well as an increase in the demand for ‘lunch-time procedures’ (those that take next to no time at all). It is one of the fastest growing segments of cosmetic treatments. Plastic surgeons and specialists now have an increasing number of options to meet the demands of the cosmetic patient visiting their aesthetic clinics.
Skin is normally held by three vital components: collagen (which makes up approximately 80% of the skin’s deeper layer, the dermis), hyaluronic acid and elastin. These three components ensure the tight and smooth texture of the skin by combining to form a firm, spongy meshwork beneath the surface.
As we age, the meshwork gradually loses its integrity and the underlying support structure weakens. The skin surface begins to lose its youthful ‘baby-skin’ smoothness.
An injectable filler helps to fill out the thinning meshwork, plumping up the tissue beneath the surface of the skin. As the filler shrinks wrinkles (folds, ridges or creases), the texture of the skin improves to look firmer, smoother and younger-looking.
Types of fillers
Injectable fillers can enhance the appearance of facial skin, giving it a more youthful look for a fraction of what a traditional facelift can cost. Wrinkle fillers have a cosmetic purpose, filling hollows, lines and wrinkles, and are often done in less than 30 minutes.
Fillers are essentially ‘volumisers’ that plump and lift facial features – cheeks, chins, jawlines, temples, thin lips and even sagging skin around the hands.
Fillers are injected beneath the skin to make it fuller or plumper. The materials injected work to make the skin appear younger by shrinking wrinkles. The oldest and best-known cosmetic filler is collagen. There have been advancements over the years to introduce other types of natural and synthetic products that offer longer-lasting and even semi-permanent results (between 4 months to more than a year).
Any filler used comes with its own set of advantages and disadvantages, so it is best to ensure that you are well informed by your dermatologist, plastic (cosmetic) surgeon or otolaryngologist (physicians trained in the medical and surgical management and treatment of ear, nose and throat disorders - ENT, as well as related structures of the head and neck) before opting to have a filler treatment.
Cosmetic / injectable wrinkle fillers available include:
- Bovine Collagen Fillers: As the name suggests, bovine collagen is processed from the skin of cows. It has been widely used as a cosmetic filler for the effective treatment of wrinkles. These injected fillers are often less expensive than other treatments. It is possible to have adverse reactions to the injected material. Allergy skin testing is highly recommended before any treatments begin as at least two to four injections per year will be required to maintain results. Testing is usually done by injecting [milliletres:0.1] of Zyderm into the surface of the skin in the arm. The body also naturally breaks down the injected collagen and is another reason why numerous injections are required if you wish to maintain the results.
- Human Collagen Fillers: Since around 2002, cultures of human cells have been formulated to produce human collagen fillers, primarily for the treatment of wrinkles. Human collagen has been found to result in far less allergic reactions than bovine collagen and have a more natural looking result. For this reason, skin testing is not as essential. The downside is that it does tend to be a more expensive treatment than bovine collagen, and injections are required every three to six months.
- Porcine Collagen fillers: An alternative to bovine and human collagen is Evolence, which comes from pigs (pig tendons). It is more similar to human collagen than bovine. One benefit of this is that is does not require allergy testing. This filler is effective for the treatment of moderate-to-deep facial wrinkles and folds. Results are virtually immediate, with little or no downtime and can last up to six months.
- Hyaluronic Acid Fillers (Juvederm, Restylane, Perlane, Prevelle Silk, Elevess, Belotero): A natural part of the skin is hyaluronic acid (HA). As we age, the skin produces less of it. HA injections work to fill the space between the collagen and elastin fibres within the skin. These fibres normally replenish the skin’s natural volume, which is gradually lost with aging. There are various natural and synthetic product variations available where the HA molecule is modified to breakdown at a slower rate. This means that results can last for longer periods (up to nine months or longer with less tissue injury or inflammation). Some materials are thicker and can provide significant structure and volume, while others are thinner and able to flow more consistently. There have been very few allergic reactions to this type of injectable filler. These fillers are effective in filling shallow areas, such as the deeper folds around the nose, the fine lines above the lips and ‘marionette lines’ (creases that run downward from the corners of the mouth). HA injections also restore volume to cheeks, add definition to a slackening jawline, plump up thinning lips and fill hollows under the eyes or forehead lines. HA fillers pose no risk of infection and help to attract and bind water in the skin, which maintains fullness where it is injected. Repeated treatments are required to maintain results. Results do vary and it is possible that you may not be satisfied. HA fillers can be reversed with an injected enzyme, hyaluronidase.
- Fat Injection (Autologous) Fillers: These fillers offer us an opportunity to do what so many would (jokingly) wish for: taking fat from an unwanted part of the body and using it for positive effects elsewhere. Fat (in small amounts) is removed from problem areas such as thighs, stomach (belly) or buttocks, treated (fat purification) and then injected under the surface of the skin of the face. This means that two procedures are required with this treatment, but are done in one visit. The additional fat purification process done in the lab can be time-consuming and costlier. Results vary but this procedure can help to shrink the appearance of wrinkles by expanding the skin. As the fat is your own tissue, there are usually no adverse reactions and results can last for quite some time. Several injections may be required to maintain lasting results.
- Poly-L lactic Acid (Sculptra) Fillers: Poly-L lactic acid (PLLA) is a non-toxic, bio-degradable synthetic material that is injected under the skin to replace lost facial fat. PLLA stimulates skin cells to produce collagen and has been approved as a cosmetic treatment of certain skin conditions in people with HIV. Synthetic polymer material has also been used in dissolvable stitches and bone screws for many years. PLLA doesn’t provide instant plumping and volume. It gradually stimulates the body to produce its own collagen instead. It is most effective in filling deep creases around the mouth and plumping up hollowed or sunken cheeks. It can also be effectively used to treat wrinkles with semi-permanent results (lasting a few months or years) as it promotes the body’s ability to produce collagen. Three to six injections sessions, approximately a month apart, may be required for results lasting up to two years.
- Calcium Hydroxylapatite (Radiesse) Fillers: This injectable filler is made of the materials that give bone its strength and texture. Minerals are ground into tiny particles and then suspended in a water or aqueous gel solution. This product is then injected beneath the surface of the skin to increase soft tissue and reduce even the most severe of wrinkles. Thicker than Hyaluronic Acid, this filler is most effective where volume is needed. Typical areas that can benefit from this treatment include a weak chin or jawline, sunken cheeks, and the filling of deep wrinkles. Results have been found to work significantly better than collagen injections and last for a longer period of time. This filler is a collagen stimulator which improves the surface texture of the skin, enabling the effects of the product to last longer.
- Polymethyl Methacrylate (PMMA) Fillers: This semi-permanent cosmetic filler was first used by medical professionals as a ‘cement’ during bone surgery. Unlike more biological materials, PMMA does not readily break down, thus producing a semi-permanent result. PMMA microspheres are tiny round, smooth plastic particles that aren’t absorbed by the body, Natural sources of these beads or microspheres are used to add volume. Synthetic microspheres made from 80% cow’s collagen and 20% PMMA microspheres (marketed as Bellafill) are used to improve the skin folds around the nose and lips.
Alternative injectable options to improve the appearance of wrinkles are:
- Botulinum toxin (Botox Cosmetic, Xeomin and Dysport): Botulinum toxin A is not an actual wrinkle filler as such, but does improve the underlying cause of lines and wrinkles by relaxing the muscle beneath. It has been successfully used to improve eyebrow furrows, crow’s feet and forehead creases. The toxin is injected into the facial muscles to immobilise the underlying causes of wrinkles and facial creases, but does not actually fill them.
- Platelet-rich plasma injections: This is another type of autologous filler or volumiser, often referred to as the ‘vampire facelift’. Blood is drawn from the arm, treated to form platelet rich plasma (PRP) and then injected into the face. Results can last for between 12 and 18 months.
Risk factors and complications
Filler treatments are relatively quick and simple, but there are some disadvantages. Some of these can include:
- A risk of an allergic reaction (hypersensitive reactions): In severe cases, this has resulted in anaphylactic shock, which requires immediate medical assistance (it is regarded as a life-threatening emergency).
- Non-hypersensitive reactions: These can include ecchymosis, beading, cysts, abscesses, bacterial infections and herpes (trauma to skin where the virus is present but dormant can cause it to flare-up).
- Skin cells may die (necrosis): This is very rare but can happen if wrinkle fillers are not used properly.
- The formation of tiny bumps under the skin on the face or hand (some bumps may be permanent, and can be both seen and felt. In rare cases, these can be surgically removed.)
- Inflammation, swelling, itchiness, rash and bruising at the injection site (this can last up to a few weeks)
- Migration (movement) of filler material from the site of injection.
- Leakage or rupture of filler material at the injection site or through the skin, which can occur as a result of a tissue reaction or infection.
- Difficulties with performing every day activities: This can happen when a filler is injected into the back of the hand.
- The Tyndall effect (a bluish skin discolouration which can last for several months)
- Scarring (which can be permanent)
- Blindness or vision impairment, stroke and nerve paralysis: This is also rare but can happen if fillers are inadvertently injected into blood vessels. Signs to be aware of include changes in vision, symptoms of stroke, blanching (white or pale appearance) of the skin, or unusual pain during or shortly after the treatment.
- Disfigurement (caused by synthetic fillers that include lab-made substances)
- Sores at the injection site, and open or draining wounds
Immediate medical attention will be required if you experience:
- Unusual pain
- Vision changes
- White appearance of skin near the injection site
- Signs of a stroke (sudden difficulties with speaking, numbness, weakness in the face, arms or legs, difficulties walking, severe headaches, face drooping, confusion and dizziness)
Fillers that tend to have longer-lasting effects are typically those that cause more side effects or complications. Not every filler is right for every type of wrinkle. Generally, the filler with the least amount of risk and best result comes from using the correct type for the right purpose.
It is highly advisable to only have fillers injected by a board-certified doctor, dermatologist, plastic surgeon or otolaryngologist with ongoing, specialised training. Severe side effects and complications are mostly seen in instances where an inferior product, sub-standard process or unqualified technician handles the treatment.
The safety of fillers is not entirely known when used during pregnancy, while breastfeeding or in people under the age of 18, as well as for those who are prone to keloids (excessive scarring) and / or hypertrophic scars (thick scarring). A specialist may advise against treatments if any of the aforementioned are applicable to you.
If needles tend to make you feel like you will experience some degree of pain, you can take comfort in knowing that many are often mixed with lidocaine (a mild anaesthetic, also often used by dentists), which will help to minimise any discomfort. A numbing cream is also often applied to help reduce any effects of discomfort or pain in the area being injected.
Ways you can minimise risk and increase your odds of a pleasing result and overall treatment safety include:
- Not letting cost be your guide or deciding factor: It is likely that some serious compromises have been made if the filler treatment costs far less than an above-board specialist would normally charge for a treatment. The skill of the provider, as well as the quality of the product are vitally important. The risk for sometimes irreversible complications is higher with an inferior set of skills and product quality, and not worth the risk when it comes to your face, and overall health.
- Be wary of a treatment not offered in a medical setting with sterile instruments: It is strongly advisable to only commit to a treatment that is done in a medical setting and not in homes, hotels, spas or even resorts, regardless of the professional who may be performing them. If, for instance, you suffer an allergic reaction, medical facilities (a sterile environment) run by trained medical professionals may be necessary to safely treat the problem that arises and reduce further medical complications. A filler treatment should be regarded as more of a medical procedure than a simple cosmetic treatment at your local beauty salon.
- Know what you are being injected with and where it’s come from: Is the filler approved and has it been purchased directly from the maker? If your doctor, dermatologist or plastic surgeon isn’t forthcoming about this type of information, it is best not to take a chance. There have been reports of industrial-grade silicone and even baby oil being used as ‘filler’ treatments.
- Use sunscreen: Used daily, a sunscreen can help to preserve the effects of the filler and protect against post-inflammatory pigment changes (which can often happen due to the needle sticks caused by injections).
- Discontinue blood thinners at least 10 days before treatment: These include aspirin, nonsteroidal anti-inflammatories, vitamin E or warfarin.
What is collagen?
A key part (up to 80%) of the skin’s structure, collagen forms a network of fibres within the skin (acting like a framework).
Skin remains intact, moisturised and elastic during our younger years. As we age, this support structure weakens and the skin loses its elasticity and tone.
Movement, particularly the use of facial muscles (smiling, frowning, squinting etc.) to express ourselves does place a degree of stress on collagen in the skin. Over time a build-up of this kind of stress contributes to wrinkles and other facial lines and creases.
Can collagen creams smooth wrinkles?
Collagen creams are not formulated to be absorbed and only work on the skin’s surface (they cannot deeply penetrate the skin).
No cream containing collagen can undo the effect of collagen loss and make wrinkles disappear. Creams essentially work by slowing the rate of water loss from the skin, thus keeping it supple.
How do I know if I am an ideal candidate for wrinkle fillers?
If you are interested in a filler treatment you should consult with a qualified, certified and specifically trained dermatologist, plastic (cosmetic) surgeon, doctor or otolaryngologist. You and your specialist will discuss your medical history to determine if there are any flags or possible conditions that could lead to certain side effects or complications with a filler treatment.
You will also discuss the areas you wish to have treated and the type of results you are expecting. In some cases, certain lines, creases and scars may not be sufficiently treated with a filler and may need Botox instead. Your specialist should be able to assess whether you are an ideal candidate for fillers at this stage of your consultation.
As with any cosmetic treatment or procedure it is very important to have realistic expectations from the very beginning. This way you are more likely to be happy with the final result. Your specialist can also help you to understand what can be realistically achieved, and support their explanation with visuals of their previous work. One treatment may not be enough, and depending on the type of filler used, several treatments may need to be committed to, to achieve the results you desire.
A good tip is to decide on the area’s most important to you and from there, discuss how many treatments may be necessary to produce the result you would most like. Cost will be a factor, and should be discussed with your specialist. You will need to keep in mind that most cosmetic procedures are not covered by medical health insurance. It is advisable to have a very clear idea about all costs involved and if there are any payment options available to you before going ahead with treatment.
What will rule me out as a candidate for a filler treatment?
A specialist will likely advise against any filler treatment if:
- Your skin is inflamed or infected (if you have an inflammatory condition such as cysts, acne, rashes or hives)
- You have a bleeding disorder
- You already have severe allergies (especially to collagen, eggs or egg-derived products, animal products, bacteria or bacteria fermentation or lidocaine which can form part of the filler material) or have a history of anaphylaxis (acute allergic reactions).
- You have a joint, tendon or vascular disease affecting the hand.