Dermal Fillers: Just the Facts, No Hype

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Ads for wrinkle creams sometimes assert they are better than dermal fillers or Botox without the need for "painful injections". Dermal fillers work differently than Botox but we'll explain that more in a moment. These ads usually show a picture of a woman about to get injected and then explain how you don't need to go through the pain of needles since you can just use their product instead. Don't believe the hype!
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The Case for Dermal Fillers

You can absolutely choose to not undergo any cosmetic corrective procedure, but then without question the deep lines between your brows, the lines from your nose to your mouth (nasolabial folds), and even your drooping jaw line will not look younger the way you really want. Simply put, there are no skin-care products that can work as well as Botox or dermal fillers.

It's not that great skin care can't make a huge difference in the appearance of your skin (believe us, we know the remarkable benefits a state-of-the-art skin-care routine can provide) but age, muscle movement, fat loss, gravity, and sun damage among other factors will eventually take its toll and your face will start looking older around the age of 40-45. Left alone, it's inevitably a downhill ride from there; none of us are Benjamin Button.

Dermal fillers are one way to truly get a lot of your youthful appearance back. In fact, when celebrities, models, and women all over the world age 45 or older have facial skin that looks really smooth and young, you can bet a big part of the reason is that they have had dermal filler injections.

If you can get over the fear of needles (no injections are pleasant) and are done wasting money on wrinkle or so-called "lifting" creams that didn't work, then perhaps you should consider dermal fillers.

Once you've decided this cosmetic corrective treatment may be right for you, the next question is which dermal filler is the best one. How do you begin to choose given the vast number of fillers available? Talk about decision paralysis! Weighing out the pros and cons is important and the information may surprise you! After reading this you will have a much better understanding of what is possible, what the risks are, and how not to get duped by misinformation about fillers.

How Dermal Fillers Work

Dermal fillers have a very specific function unrelated to other medical corrective procedures. By directly injecting a naturally derived or synthetic material into the frown lines between your brows, the deep lines from the corners of your nose to the corners of your mouth, depressions along the jaw line, the sunken areas under your eyes, or the hollowed areas of your face, wrinkles and lines immediately become filled-in and skin is plumped up to the point where the wrinkle, depression, or fold is gone. This improvement can last from 3 months to 2 years or even longer depending on the type of filler used, how you take care of your skin, and how your face continues to age.

Don't confuse dermal fillers with how Botox works. Although both procedures involve injections, Botox is injected around the forehead and wrinkles around the eyes (crow's feet) to stop muscle movement that results in wrinkles. It has nothing to do with the plumping smoothing effect dermal fillers have. Many people get both Botox and dermal fillers because the combination can produce a remarkably younger-looking face.

There Really Isn't a Best Dermal Filler

In the world of injectable dermal fillers, there is a wide range of substances being used. Despite what you might have read or heard there really isn't a best dermal filler; all have risks, albeit rare ones. Which filler substance is considered "best" or "preferred" for you depends on the doctors technique, skill, experience, training, your facial needs, and risk tolerance. It has nothing to do with headlines in the media; these are often a result of marketing efforts from the company that makes the filler, though this information is usually downplayed so the piece comes across as impartial.

It's important to realize that over the past 20 years many dermal fillers that were once showcased in fashion magazines or touted by doctors (and often heralded by studies paid for by the manufacturer) have since been discontinued for a variety of reasons. Getting headlines doesn't always make for beautiful results!

Synthetic and Natural Dermal Fillers

There are two primary groups of dermal fillers: synthetic and natural.

Naturally-derived fillers (the most widely known is hyaluronic acid) have a much smaller risk of causing an allergic reaction but reactions can occur. Results are immediate but will only last from just 3 to 18 months and occasionally up to 2 years because the filler eventually breaks down, taking the results, for better or worse, with it. Once the filler starts to dissipate you need to go back in and get more filler injected to maintain results. Most people who get fillers will need at least one follow-up injection within a year.

Aside from allergic reactions fillers also have risks of lumping and migration although this happens infrequently. On the other hand, because the results last a short period of time so do the potential problems.

Synthetic fillers last much longer than naturally-derived ones and are considered semi-permanent though there many who would call them permanent because they really don't dissipate. The wrinkles start to return only because your face continues to age or you continue to get sun damage due to being lax about protecting skin with sunscreen daily.

As with all fillers, synthetic fillers have risks which are pretty much the same as for naturally-derived fillers except the difference is because synthetic fillers are "permanent" the potential problems can be "permanent" as well and are harder to correct.

Reviews of Dermal Fillers

As you will see from the list below, there are lots of dermal fillers to consider, even those harvested from your own body or from someone else's (yes, that does have its own gross-out factor). Each filler has its own pros and cons from unique complications to cost and how long it lasts.

What all is said and done, given the small percentage of risks and the truly younger appearance fillers create (and assuming you find a skilled practitioner), this is one procedure not to frown at just yet.

As you go through these, keep in mind that your dermatologist may recommend more than one filler for you, depending on your specific areas of concern. For example, one type of filler may be used for lines around your mouth, while another is used to correct wrinkles elsewhere on the face. It is unusual for a single filler to correct every concern—but some doctors take this approach and get great results, so be open to the suggestion.

Alloderm is processed from donated human cadaver tissue prepared in such a way that it retains its underlying structure but without any cells that could cause rejection. It has been used for a variety of surgical reconstructive procedures to replace lost, damaged, or diseased tissues. For wrinkles, it is considered stable and may last from 1 to 2 years, though there are no controlled studies substantiating that claim (Sources: Annals of Plastic Surgery, May 2013, pages 587-94; www.emedicine.com/ent/topic43.htm; and www.emedicine.com/ent/topic377.htm).

A micronized form of Alloderm, called Cymetra is also available. This material is rehydrated with lidocaine in the physician's office before injection so the procedure is considered less painful.

Artefill consists of a synthetic ingredient known as polymethyl methacrylate (PMMA) mixed with animal-derived collagen. It's considered to be semi-permanent to permanent. Because of its potential permanence, injecting Artefill requires greater skill. Risks include lumping of the product after injection; inflamed, hardened, grain-sized nodules at the injection site; and migration of the filler. Unlike fillers that dissipate over a year or two.

Artefill sticks around almost indefinitely. That means any problems last as well unless the filler is removed which is not an easy process. The tradeoff for potential long-term side effects is, not surprisingly, long terms results. And because Artefill lasts, you don't need to adhere to a regular maintenance schedule as you would for naturally-derived dermal fillers such as hyaluronic acid.

Autologous Fat (Fat Grafting) is produced from fat taken from a part of your body via liposuction. No allergy testing is required because you won't reject material taken from your own body. Harvesting fat is an involved, complicated process but is done regularly now right in the doctor's office. There is no consensus on longevity (which is true for most injectables as they vary from person to person) but generally it lasts from 12 to 24 months. The major risk is migration; the injected fat can move and "bunch" creating a lumpy appearance. Even though the fat material is taken you're your own body when you have problems they are not easily corrected. (Source: Plastic Reconstructive Surgery, April 2013, pages 589-596)

CosmoDerm 1 and 2 or CosmoPlast is human-derived collagen and is considered to be safer than cow-derived collagen. CosmoDerm is used for superficial wrinkles and CosmoPlast is used for deeper wrinkles. Overcorrection (injecting more of the dermal filler substance than what is typically needed to produce a positive outcome) is usually needed to achieve ideal results as well as touch-ups through the year.

Whether you have CosmoDerm or CosmoPlast, results last about 3 to 9 months which is on the short side of injectables available today. As a result, these fillers aren't used as often as they once were.

Juvederm Ultra and Juvederm Ultra Plus are popular fillers derived from lab-synthesized hyaluronic acid. The differences between Juvederm Ultra and Juvederm Ultra Plus is that the Ultra Plus is made for deeper and more depressed folds of skin while Juvederm Ultra is for plumping up finer surface lines.

Both fillers can last between 6 months and up to 2 years in some instances depending on how your face continues to age, how you take care of your skin and how much of the product was injected. There is also Juvederm Ultra XC and Juvederm Ultra Plus XC. Both of these are made up of the same filler material with the anesthetic lidocaine added to the formula to reduce pain as it is being injected into wrinkles.

Juvederm Voluma differs from the Ultra versions above in that it is a much thicker hyaluronic acid gel which is used for filling in age-related volume loss that occurs in the cheekbone and chin areas. It is not meant to be used around the eyes, frown lines, or lips. Results can last up to 18 months.

Perlane is a sister product to Restylane. Both are composed of transparent, viscous gel particles of hyaluronic acid derived from bacteria grown in a lab. Perlane is injected into facial tissue to provide volume in or just under the skin. This smooths wrinkles and folds, especially around the nose, mouth and under the edges of the mouth (areas known as nasolabial folds and oral commissures). Because Perlane's particle size is larger than Restylane it is considered better for deeper wrinkles and depressions in skin. Perlane can last for 6 months to a year.

Radiesse is a synthetic material made up of calcium hydroxyapatite (30%) suspended in a cellulose gel carrier (70%). Calcium hydroxyapatite is a type of "bone cement" and has been used for years to repair many types of skeletal defects. It has been shown to have stable results, ease of use, and is easily adapted for use as a dermal filler. Because Radiesse is a thicker substance it's used for deeper wrinkles rather than superficial ones. Radiesse is considered a semi-permanent filler.

Restylane is a form of hyaluronic acid lab-derived from bacteria. It's used for more superficial wrinkling but research has also shown it can be used for overall filling of deeper winkles and to build volume. Its sister product Perlane is meant for use on deeper wrinkles. Restylane can last from six months to one year. A dermatologist may use Restylane and Perlane depending on your concerns and which filler will work best in key areas.

Sculptra is not technically a filler because it does not add volume but rather stimulates collagen production in the areas where it is injected. Sculptra is a synthetic filler derived from poly-L-lactic acid (PLLA) which is distantly related to alpha hydroxy acids (AHAs). It can be used for wrinkles and indented, "ice pick"-type acne scars as well as for general improvement in facial depressions especially where fat loss is problem. Results are not immediate and usually require multiple, biweekly treatments to obtain the desired improvement and then routinely to maintain the appearance.

Zyderm I, Zyderm II, and Zyplast are different combinations of cow-derived collagen. Zyderm was the first injectable filling material to be approved by the FDA. It has been used for more than 20 years and the injection technique has been standardized. All these materials are absorbable and, therefore, overcorrection is necessary to maintain results. Duration is limited, ranging from 3 to 9 months. Allergy testing is mandatory because about 5% of patients may experience hypersensitivity to injectable bovine (cow) collagen.

Risks from Dermal Fillers

After all is said and done, the major issue for fillers is one of longevity, followed by risk of migration and lumping, and ultimately the skill of the doctor in placing the right amount of filler in exactly the right place. Regardless of the material, there is a learning curve to injection techniques as well as understanding how the varying substances affect skin. That means you need to find a doctor who has been injecting dermal fillers for some time, and who has loads of experience, preferably with more than one type of filler.

There is every reason to consider dermal fillers to correct signs of aging that are beyond what skin-care products (including sun protection) can do. Of course, as with any cosmetic corrective procedure, daily use of well-formulated skin-care products and sun protection (even when it's cloudy) are part of the anti-aging package that will keep your skin looking younger and healthier for a very long time.

Additional sources for this article include: Journal of Drugs in Dermatology, April 2013, pages 470-475; Aesthetic Surgery Journal, March 2013, pages 414-420; Plastic and Reconstructive Surgery, April 2013, pages 589-596; Journal of the American Medical Association Facial Plastic Surgery, March 2013, pages1-6; Aesthetic Surgery Journal, May 2013, pages 561-575); Head and Neck Pathology, March 2013; Facial Plastic Surgery Clinics North America, August 2012, pages 245-264; Cosmetic Dermatology, Second Edition, Baumann Leslie MD, 2009, pages 191-209; Journal of the American Academy of Dermatology, July 2011, pages 92-96; Facial and Plastic Surgery, February 2004, pages 21-29; Journal of Drugs in Dermatology, May 2010, pages 446-450; Aesthetic Surgery Journal, March 2010, pages 235-238; Facial Plastic Surgery, May 2009, pages 100-105; Clinical Interventions in Aging, March 2008, pages 161-174).

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About the Experts

Paula Begoun is the best-selling author of 20 books on skin care and makeup. She is known worldwide as the Cosmetics Cop and creator of Paula's Choice. Paula's expertise has led to hundreds of appearances on national and international television including:

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The Paula's Choice Research Team is dedicated to helping you find the absolute best products for your skin, using research-based criteria to review beauty products from an honest, balanced perspective. Each member of the team was personally trained by Paula herself.

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