Facial dermal filler injections guide

hyaluronic acid treatment areas

Dermal fillers, also known as injectable soft tissue fillers, are the second most popular minimally invasive procedure in the field of cosmetic medicine and surgery, the first one being botulinum toxin injections (Botox). Dermal fillers are mainly used for facial rejuvenating purposes to fight the signs of aging, such as lines and wrinkles, but are also often used to enhance facial features, to replace lost volume both in the face and in the hands and to overall restore a youthful appearance.

What are dermal fillers?

Dermal filler is a broad term that includes many different substances used to achieve the same goal. These substances can be natural, such as hyaluronic acid, derived from our own bodies such as PRP and autologous fat, or synthetic like PLLA and PMMA. They can be temporary treatment, long lasting biodegradable treatments or permanent non-biodegradable substances. They work in different ways and not all of them are right for each indication and injection area; for this reason, a plastic surgeon may prefer using one over another to provide the results that meet the expectations of the patient. 

Indications of dermal fillers

Injectable soft tissue fillers have many different cosmetic indications and are used to improve the look and appearance in several different ways. Dermal fillers can:

  • Smooth fine lines on the face, like crow’s feet and vertical lip lines (smoker’s lines).
  • Fill wrinkles, like the horizontal forehead lines and the frown lines.
  • Soften creases and skin folds on the face, like the nasolabial fold and marionette lines.
  • Fill hollows, such as the under-eye hollows that cause black circles and a tired appearance or the submalar hollow when cheek volume is loss due to aging.
  • Reshape features, such as the chin and the nose
  • Augment features, such as lips and cheeks
  • Restore lost volume, in many facial areas but also in the aging hands
  • Improve the look of scars, such as acne scars and other depressed scars

Types of dermal fillers

The main types of dermal fillers are:

  1. Hyaluronic acid fillers (HA)
  2. Collagen fillers
  3. Autologous Fat
  4. Platelet-rich plasma (PRP)
  5. Poly-L-lactic acid fillers (PLLA)
  6. Calcium Hydroxylapatite (CaHA)
  7. Polymethylmethacrylate (PMMA)
  8. Polycaprolactone (PCL)

Beware of black-market substances, unlicensed providers and non-FDA approved products.

There are reports of patients who received all kind of dangerous injections for cosmetic purposes: from silicone, to animal fat, glycerin, non-medical-grade products to even cement and motor oil.

How do dermal fillers work?

Depending on the specific substance injected, dermal fillers work in different ways.

Hyaluronic acid fillers

Hyaluronic acid (HA) is a natural occurring molecule in the human body. It is also found in the skin where it keeps it plump and hydrated. HA has the ability to bind 1000 times its weight in water, helping to retain it in the skin. Photodamaged and aging skin in general see a decrease in concentration of hyaluronic acid due to its degradation and reduced synthesis resulting in loss of volume, wrinkling and altered elasticity. Hyaluronic acid as an injectable filler may be chemically modified (crosslinked) to make it last longer in the body.

There are several different brands marketing different hyaluronic acid products each with its own slightly different formulation, characteristics and applications. The main ones are:

  • Belotero®: Balance.
  • Captique®
  • Esthélis®
  • Elevess®
  • Hylaform®
  • Juvederm®: Ultra, Ultra Plus, XC, Ultra XC, Volbella XC, Vollure XC, Voluma XC
  • Perlane®
  • Prevelle®: Silk
  • Puragen®
  • Restylane®: L, Lyft, Silk, Refyne, Defyne
  • Teoxane Teosyal®: RH1, RH2, RH3, RH4, Kiss

Collagen fillers

Collagen is a naturally occurring and most abundant protein found in the human body. Collagen is a major component of the skin giving it strength and support. Collagen deteriorates over time and is easily damaged and degrades when hit by UV rays. There are different collagen products on the market, some are derived from animal sources (bovine and porcine) and other are derived from human sources (cadaveric skin or lab cell cultures). The main ones are:

  • Alloderm®
  • Cosmoderm®
  • Cosmoplast®
  • Cymetra®
  • Evolence®
  • Fibrel®
  • Zyderm®
  • Zyplast®

Autologous Fat Graft

Fat grafting is a procedure that utilizes autologous fat as filling material. Fat grafting is also known as fat transfer, fat transplant or lipofilling. Fat is another component of the subcutaneous tissue that is loss due to the aging process and its loss contributes to sagging and wrinkling skin as we age; this loss happens in the face and hands mainly while fat storage is increased in other areas of the body such as the waist in women and the abdomen in men. Fat is usually obtained through liposuction of the lower abdomen and after centrifugation and processing it is ready for reinjection. Not all transplanted fat cells will survive, and the survival rate varies greatly depending on the surgical techniques used and the ability of the surgeon. The damaged cells and those that can’t receive blood and nutrient supply in the recipient area will be resorbed with time. The survival rate ranges 10-90% and the use of PRP in conjunction with fat grafting seems to be promising in guaranteeing a higher survival rate of the fat cells.

Platelet-rich plasma (PRP)

PRP injections to the face are also known as “vampire lift”. Blood is drawn from the arm and after centrifugation and processing the PRP is separated from the other blood components and is ready for reinjection. PRP is rich in growth factors which increase fibroblast proliferation; fibroblasts are cells that synthetize the extracellular matrix (ECM) which is composed by proteins such as collagen and elastin, and by other molecules such as hyaluronic acid, all of which are lost due to the aging process. By increasing fibroblast and their production of ECM components, PRP effectively rejuvenates the skin, decreasing the signs of aging and increasing elasticity and volume.

Poly-L-lactic acid (PLLA)

Polylactic acid is a synthetic but resorbable dermal filler used for many years in the medical field such as in dissolvable stitches. PLLA works by stimulating the tissue to synthetize new collagen over several weeks while slowly being resorbed. It is marketed under the following brand names:

  • Sculptra®
  • Sculptra Aesthetics®

Calcium Hydroxylapatite (CaHA)

Calcium hydroxylapatite is a biodegradable substance naturally found in human bones and teeth. As a filler, CaHA is made in the lab as microspheres suspended in a soluble gel which is resorbed and helps in the dispersion of the microspheres. Calcium hydroxylapatite stimulates collagen production, increasing volume over several months in the areas where it was injected, and it is eventually resorbed. It is marketed under the following brand name:

  • Radiesse®

Polymethylmethacrylate (PMMA)

PMMA is a biocompatible but permanent filler. Microspheres of PMMA are suspended in a collagen gel which helps for an even distribution of the product. While collagen is quickly resorbed, PMMA microspheres stimulate our own collagen production providing volume in the treated areas. It is marketed under the following brand names:

  • Artefill®
  • Bellafill®

Polycaprolactone (PCL)

PCL is a biocompatible and biodegradable polymer. Microspheres of PCL are suspended in an aqueous gel and injected in the desired area. The aqueous gel provides immediate volume restoration and is then resorbed over 2 to 3 months. The PCL microspheres stimulate collagen production overtime providing a longer lasting effect. It is marketed under the following brand name:

  • Ellansé®

How long do dermal filler lasts?

Different classes of fillers have different duration of the effects. Different formulations of the same class of fillers also have different duration. Duration is also affected by the site of injection, technique used for the injection, amount of product injected, patient’s metabolism and individual characteristics, and if it is the first treatment or a follow-up treatment.

This is how long, on average, dermal filler last:

  • Hyaluronic acid fillers HA (Juvederm®, Restylane®, …): effects lasting 6-18 months
  • Collagen fillers (Cosmoderm®, Zyplast®, …): effects lasting 1-4 months
  • Autologous Fat: some fat cells will be resorbed during the first few months, after about 6 months the effects should be stable and last several years (5-15 years).
  • Platelet-rich plasma (PRP): full effects visible in 2-3 months and lasting up to 12-18 months
  • Poly-L-lactic acid fillers PLLA (Sculptra®): full effects visible in 2-3 months and lasting about 2 years.
  • Calcium Hydroxylapatite CaHA (Radiesse®): effects lasting 12-18 months
  • Polymethylmethacrylate PMMA (Bellafill®): full effects seen after 3-6 months and lasting over 5 years.
  • Polycaprolactone PCL (Ellansé®): Effects from the water gel carrier are immediate and fade in 6-12 weeks, while full effects of PCL are seen after about 12 weeks and last 12-48 months depending on the formulation used.

Facial dermal fillers cost

As per the duration, there are many variables influencing the cost of dermal fillers: it will depend on the surgeon and clinic where the treatment is performed, the country, the formulation, the brand, …

On average, the cost of face dermal filler treatment is:

  • Hyaluronic acid fillers HA (Juvederm®, Restylane®, …): 500-1,500 USD per syringe
  • Collagen fillers (Cosmoderm®, Zyplast®, …): 300-450 USD per syringe
  • Autologous Fat: 2,500-8,000 USD per treatment
  • Platelet-rich plasma (PRP): 500-2,500 USD per treatment
  • Poly-L-lactic acid fillers PLLA (Sculptra®): 800-1,000 USD per syringe
  • Calcium Hydroxylapatite CaHA (Radiesse®): 800-1,000 USD per syringe
  • Polymethylmethacrylate PMMA (Bellafill®): 1,000 USD per syringe
  • Polycaprolactone PCL (Ellansé®): 450-650 USD per syringe

You may expect to save about 30-70% by undergoing treatment in plastic and cosmetic surgery clinics in Bangkok, Thailand.

Risks and side effects of dermal fillers

Dermal filler injections are generally a safe treatment but do carry some risks, like any other medical or surgical procedure.

To minimize such risks, it is of utmost importance to have the procedure carried out in a medical setting by a qualified and experienced professional using products purchased from a reputable source.

The face has a great number of blood vessels and nerves and if a filler is injected in the wrong spot or in the wrong amount or with the wrong technique it can cause complications, sometimes irreversible and potentially even death.

Over the years, due to dermal fillers being a very remunerative industry, doctors from all specialties and background started providing dermal filler injections. While a plastic surgeon, or dermatologist, or cranio-facial surgeon has extensive knowledge of the facial and soft tissues anatomy, a dentist, a GP, or a nurse are not as trained as them. Sometimes doctors qualify themselves as aesthetic doctors. Aesthetic medicine is not a recognized medical specialty and it is a title often awarded after attending a 1-2 days course on how to perform injections or how to use a medical (cosmetic) device such as lasers.

Moreover, cosmetic surgery is also an art. To achieve a harmonious, pleasing, natural looking result doesn’t just require medical knowledge but also artistic sense.

Each filler has a different risk profile, which also depends on the area treated and on the characteristics of the patient. Your provider will inform you of the specific risks related to the procedure you want performed.

In general, these are the potential risks and side effects of dermal filler treatment to the face

Common risks of dermal fillers include

  • Bruising
  • Swelling
  • Minor bleeding
  • Redness
  • Itching
  • Discomfort or pain for a few days

Uncommon risks of dermal fillers include

  • Asymmetry of the face
  • Infection at the injection site
  • Scarring
  • Lumps
  • Redness of the skin and itching
  • Skin discoloration
  • Numbness
  • Allergic reactions
  • Systemic infection
  • Blisters
  • Migration of the filler to another area
  • Skin necrosis
  • Blindness and cardiovascular complications if injected into a blood vessel

It is generally better to start with hyaluronic acid injections before committing to a long-lasting or permanent filler injection. Hyaluronic acid is also the only type of filler than can be reversed by injecting an enzyme known as hyaluronidase which dissolves the filler if you are unhappy with the results.

I advise against the use of permanent PMMA fillers (Bellafill®) and Polyacrylamide fillers (Aquamid®).


Sources
  • Skin ageing and its treatment.
    L Baumann – Journal of Pathology, 2007
  • “Saving Face”: An Online Study of the Injecting Use of DIY Botox and Dermal Filler Kits.
    R Brennan, JSG Wells, M Van Hout – Plastic Surgery, 2018
  • A Review of Dermal Fillers in Facial Plastic Surgery.
    D Bray, C Hopkins, DN Roberts – Current Opinion in Otolaryngology & Head and Neck Surgery, Aug 2010
  • Fat, Stem Cells, and Platelet-Rich Plasma.
    IB James, SR Coleman, JP Rubin – Clinics in Plastic Surgery, 2016
  • Update in minimally invasive periorbital rejuvenation with a focus on platelet-rich plasma: A narrative review.
    M Kassir, G Kroumpouzos, P Puja – Journal of Cosmetic Dermatology, Mar 2020
  • ArteFill® Permanent Injectable for Soft Tissue Augmentation: I. Mechanism of Action and Injection Techniques.
    G Lemperle, TR KNAPP, NS Sadick – Aesthetic Plastic Surgery, Jun 2010
  • Polycaprolactone: How a Well-Known and Futuristic Polymer Has Become an Innovative Collagen-Stimulator in Esthetics.
    MO Christen, F Vercesi – Clinical Cosmetic and Investigational Dermatology, Jan 2020
  • Managing Complications of Fillers: Rare and Not-So-Rare.
    E Haneke – Journal of Cutaneous and Aesthetic Surgery, Oct 2015
  • Overview of Deep Dermal Fillers.
    MH Liu, DP Beynet, NM Gharavi – Facial Plastic Surgery, Jun 2019
  • U.S. Food & Drug Administration (FDA)
  • American Society of Plastic Surgeons (ASPS)
  • American Academy of Dermatology (AAD)

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