12/18/2008 05:12 am ET | Updated May 25, 2011

New Fillers For Those Stubborn Wrinkles

If the stress of the economy is starting to show more lines on your face, don't worry because help is on the way. I recently attended the American Society for Dermatological Surgery's annual conference in Orlando, learning about the latest advances in aesthetic medicine. One of the recurrent themes of the conference was that facial aging is caused by global volume loss as well as the appearance of fine lines, wrinkles and discoloration. As we age, resorption (i.e., breakdown) of facial fat and skeletal bone gives the face a hollow appearance and causes the facial skin to droop. We see this as the skin starts to sag in a clockwise direction, resulting in a fallen brow, turned down nasal tip and hanging skin along the jowls. The best analogy I heard for this phenomenon compared the facial skin to a tablecloth covering the underlying table of fat and bone. As that supporting table shrinks, the skin tablecloth remains unchanged and starts to hang over the face. Replacing this support structure with new generations of injectable fillers can restore the scaffolding underlying the skin and thus give a more youthful appearance.

Injectable fillers have come a long way since bovine collagen was first approved by the FDA in 1981. The latest generation of fillers has been shown to stimulate collagen growth in order to replace the underlying skin scaffolding and create softer and more natural contours. Almost all currently available dermal fillers eventually are broken down by the body's natural enzymes but several fillers have been shown to last at least a year. Fillers that are placed deep into the fat and just above the facial bones are termed "stimulatory" fillers since they promote the restoration of the deeper facial structures. More superficial fillers are placed higher in the skin to fill wrinkles and create more youthful face contours.

Deeper stimulatory fillers include:

Calcium Hydroxylapetite

Microspheres of calcium hydroxyl appetite found in the Radiesse product can be used to correct deep wrinkles and folds. The skin creates lasting collagen scaffolding around this substance, which gives improved appearance to wrinkles for up to a year.

Poly-L-lactic acid

Poly-L-lactic acid found in Sculptra injections is a longer-lasting alternative for cases with more significant volume loss. A series of injections performed over several months can help restore a youthful appearance in those experiencing a loss of facial fat. Clinical studies have demonstrated results lasting up to 2 years.

More superficial contouring fillers include:

Hylauronic Acid Fillers

Hylauronic Acid fillers are composed of natural sugar substances which bind to water and give the skin a natural plumpness. Sugars are attached to each other by various crosslinks to make smaller and larger size particles that respectively target finer and deeper wrinkles.

There are several brands of hylauronic acid fillers including:
Restylane for fine lines and Perlane for deeper lines.

Restylane was recently shown to last up to 18 months in 97 % of patients undergoing initial treatment followed by re-treatment 4-9 months later for the lines around the mouth.

Juvederm Ultra and Juvederm Ultra Plus are used to fill fine and deep wrinkles respectively.
Juvederm is the only hylauronic acid filler that has been FDA approved to last up to 1 year after a single injection.
Prevelle Silk is a new hylauronic acid filler indicated for the treatment of moderate to deep
folds. It contains the anesthetic lidocaine to minimize the pain of injections.


Because collagen makes up a significant portion of the skin, the first filler substances were made from animal collagen. While the earlier versions were reabsorbed quickly and have been associated with allergic reactions, the newest generation of collagen fillers last longer and do not require allergy testing. Collagen fillers tend to give a softer natural look without the swelling which is sometimes seen with hylauronic acid fillers.

There are several different kids of collagen fillers including:

Cosmoderm and Cosmoplast are highly purified forms of human collagen, which are used to treat fine and deep wrinkles respectively. These fillers tend to last 2-3 months.

Evolence is the most recently FDA approved collagen filler that uses sugar crosslinks to improve its duration. It lasts up to 6 months and has natural blood clotting properties that minimize bruising after injections. Although it is made from pigs, it requires no allergy testing.

While filler injections can give you a more youthful appearance, all fillers have potential side effects that can include bruising, swelling and occasionally nodules. The FDA just released a report based on post-market surveillance of all FDA approved fillers in 2002-2007 that documents 930 side effects. While the majority of events including swelling, inflammation, and redness are well known and can be contained, the report highlights very rare and potentially serious occurrences of anaphylactic shock and hospitalizations for infections requiring extended antibiotic therapy. The report does not identify which fillers were associated with the most severe reactions, but it does note that many of the described incidents were caused by "injections of dermal implants performed by untrained personnel or in settings other than health clinics or doctors offices."

Although the adverse effects in the FDA report represent only a small fraction of the millions of filler procedures that are performed each year, it is important to consider this possibility of serious adverse effects and take steps to minimize their occurrence. Patients can minimize their risks by seeking treatment from experienced dermatologists with extensive training in injection techniques, and only use fillers with at least 5 years of data demonstrating safety. Also, many physicians, including myself, are hesitant to use more permanent dermal fillers, as these have been associated with non-reversible complications such as permanent disfigurement. The pursuit of a more youthful appearance shouldn't compromise your safety and health!