Wrinkles form with ageing and the loss of elasticity of the skin causes sagging and deeper folds. A wide range of commercial injectable fillers exist – reputable practitioners would almost always use temporary resorbable fillers which are the subject of this information sheet.
Dermal fillers – Hyaluronic Acid
Overview of the rationale for treatment:
It is important that your treatment is tailored to you by a specialist with knowledge of the wide range of potential solutions for wrinkles / sagging – from botox injections, injectable fillers, chemical peels, laser therapy, facial implants, fat transfer to surgical procedures such as blepharoplasty, brow lifts or face-lifts.
What is hyaluronic acid?
The key component in most dermal fillers – such as Juvederm® or Restylane®, is hyaluronic acid, is a naturally occurring, biodegradable complex sugar found in the human body and in all mammals. The hyaluronic acid can be made by clinical fermentation from streptococci bacteria in a pharmaceutical laboratory environment. Among other things, hyaluronic acid hydrates the skin and adds volume, contributing to the overall appearance of the skin. Hyaluronic acid is a normal constituent of skin tissue. The ability of cells to produce hyaluronic acid diminishes with age, often resulting in the formation of facial wrinkles and folds as the skin loses volume.
Dermal filler is biodegradable and has demonstrated its safety and effectiveness in patients of all skin colours. Studies have demonstrated no increased risk of hyperpigmentation or hypertrophic scarring of all skin colours.
They can be administered in a smooth-flowing injection, providing your doctor with a high level of control for individualized, tailored wrinkle treatment and for achieving a smooth and natural look.
Only products with approval of the European Union (CE marked) and United States of America Food and Drug Administration and should be used and should be administered by trained and qualified practitioners.
How does it work?
Dermal fillers are administered in small doses by intradermal injection directly into moderate to severe facial wrinkles and folds, such as nasolabial folds (along the side of the nose and mouth), temporarily filling and augmenting the treated area. The folds are made more smooth as the underlying tissue is given greater volume or filled-out. They may be used in conjunction with other products such as botulinum toxin type A (Botox) injections because some deep or long-standing wrinkles may have ‘memory’ still be visible (like creases in a straightened out shirt) after Botox treatment. In these circumstances, the best result may be gained with additional dermal filler injections to plump out such wrinkles.
How is the treatment delivered?
It is a safe and simple procedure when delivered by an appropriately trained practitioner. Precise amounts of hyaluronic gel are injected with a very fine needle into the tissue under the fold. These injections are associated with only a little pain and some dermal fillers such as Juvederm and some Restylane products contain local anaesthesia e.g. 0.3% lidocaine (a local anaesthetic agent used by your dentist). You may well develop slight bruising at the injection sites and require cover make-up although every effort is made to reduce this risk to a minimum. There may be a pinky-red flushing of the skin for an hour or so as a reaction to the needle itself.
The filler injections can be placed incrementally into one side. You can then review the outcome in a mirror to judge the degree of correction achieved – and then can be replicated on the opposite side. You will feel more comfortable if you bring a good friend with you – to affirm any judgements being made between yourself, Mr Blackburn (and your friend) about an adequate volume and natural look. You will inevitably be a little nervous so a friend can be a great support for your first time.
What sites can be treated?
Nasolabial folds, frown (glabellar) lines, oral commissures and marionette lines (marionette is the French word for puppet / ventriloquist’s doll; the vertical folds down from the corners of the mouth), tear trough lines, crows feet / laughter lines, radial lip lines, to volumize thin lips, chin wrinkles and cheek augmentation.
How long does the treatment last?
This kind of treatment is a temporary solution because the gel disappears over time. This has the benefit of allowing the first treatment to be a more subtle trial as is preferred by some clients. The Juvederm and Restylane dermal fillers can last about 6 months and some clients report up to 12 months of satisfactory treatment.
Who cannot have dermal fillers or for whom there are increased risks?
You cannot be breast-feeding or pregnant or under the age of 18 when receiving dermal filler treatment. Those with a history of anaphylaxis, multiple severe allergies or a history of allergy to gram-positive bacterial proteins should not have the injections. Clients who take aspirin, clopidogrel, dipyridamole, warfarin and non-steroidal analgesics such as ibuprofen are at increased risk of bruising. Those taking immunosuppressive therapy are at greater risk of infection from any injection and should be considered with caution. Dermal fillers have not been tested on those with a history of excessive scarring – keloid or hypertrophic – or those with pigmentation disorders.
You should ensure you inform the consulting practitioner of your full medical history. People with a history of cold sores may experience a recurrence after the treatment, although this can be minimized by the use of antiviral medicines. I agree to consult with my doctor if I have a history of cold sores or shingles prior to this treatment. Dermal fillers should not be administered directly after laser treatment, chemical peeling or microdermabrasion as the skin surface is not intact and there is a greater risk of infection.
What must I do / not do after the treatment?
You must inform any medical practitioner who may prescribe you medication that you have had the injection treatment for up to 3 months after the treatment. After treatment, you should not exercise vigorously or have a hot bath for 12 hours. It is best to leave the area to settle for 1-2 days before considering any gentle massage to smooth any small collections of the filler into the tissues – this proposed delay is to theoretically minimise any risk of infection via the needle-track.
Can the product be removed?
It dissolves away over time, but if necessary (this would be very unusual) this could be hastened by the injection of an enzyme hyaluronase into the product within the tissues.
A holistic healthy approach?
No-one ‘needs’ cosmetic treatments, however, many thousands of these types of treatments are safely performed each year and it has become established as a reliable and exciting mainstream treatment for improving the visible effects of ageing. Of course, the best long-term holistic approach for healthy youthful skin includes not smoking, protection from sun-radiation, keeping well hydrated, a healthy diet, exercise and plenty of sleep.
What are the reported adverse effects?
In studies, for those clients reporting an adverse effect – these were usually mild to moderate lasting 7 days or less and included temporary injection site reactions like redness, pain, firmness, swelling and bumps.
Reactions may occur to needle injections such as infection, itching, redness, pain, discoloration and tenderness.
Keloid or hypertrophic scar formation can occur in relation to any injury or invasive skin procedure including dermal filler injections. You must inform the clinician of any history of abnormal scar formation.
Sculptra® – a poly-L-lactic acid microbead suspension.
This product can increase the volume of the facial tissues over time by stimulating new collagen deposition around the microbeads as the microbeads dissolve over time. Usually, sculptra is injected on 3 separate occasions at 4 week intervals and the maximum effect is not seen until about 6 months later. However, the effects can last up to 18-24 months and some clients are happy for up to 3 years before requesting a repeat treatment.
Some clients require more than 3 treatments. It is important to realise that the amount of augmentation cannot be accurately predicted such that there may be some clients who would have wanted even more volume than is ultimately achieved.
This is a useful treatment for cheek augmentation, deep nasolabial folds, and to disguise early jowl formation.
Infection can occur after any injection. Small palpable (but rarely visible) nodules may form beneath the dermis of the skin (subdermal papilloma formation) and more recent developments in product preparation and technique of injection have reduced the incidence from 10-15% to the order of 3%.
Autogenous fat transfer / lipoaugmentation / Coleman fat transfer
This is the closest to a permanent, transfer of your own fat tissue from your abdomen / thighs to the face to increase and sculpt the volume of the face.
The fat is harvested with aseptic technique with sterile liposuction apparatus under general anaesthesia, processed via a multi-step method including centrifuging the harvested cell suspension and separating the fluid / cellular layers before carefully injecting the required volume of fat tissue into the face.
The best results are gained in the malar triangles (mid-cheek to cheek bone area) where excellent cosmesis and improved skin tone can be achieved transferring a fat suspension –which contains a high concentration of stem cells and natural growth factors.The technique has been described and used for many facial zones and eye sockets but certain areas – such as the lower eyelids or tear trough zones are seen to have less predictably good outcomes.
The fat transfer is followed by a degree of resorption of the transferred cells. The amount of transferred fat that remains in the face ranges from as little as 5% up to 100% in the reported literature with an average of about 40%. This means that a) more than one fat transfer may be required for the best results and b) one should be careful not to excessively allow for resorption by overcorrecting because it is possible that there will be no resorption i.e. 100% retention of the transferred volume. It is possible over the years for further resorption to occur in some cases, but generally gives the longest lasting volume rejuvenation. It needs to be placed carefully and the anatomical subsite selection for this technique is important – it should only be placed where fat deposits are normally located.
Donor site – abdomen. Dimpling or contour deformity at the site of liposuction can occur. The small incisions for liposuction access form permanent scars. There is a risk of infection or bruising with any invasive procedure. There is a rare risk of perforation of the bowel or intra-abdominal structures has been reported in the literature.
Recipient site – the very small incisions for needle lipoaugmentation made at the junctions of cosmetic units form tiny scars. There is a risk of infection or bruising. The transferred fat my resorb (disappear) to a variable degree after treatment and further repeat procedure(s) may be required.
Other injectable temporary fillers
Other methods have been described but have not emerged into the mainstream practice i.e. not demonstrated widespread reliable and safe use. They may include: collagen implants; bovine preparations; human preparations of collagen / elastic fibres; autologous preparations of collagen suspension; injectable fibroblasts.
Permanent dermal fillers
It could be argued that these have no place in routine practice. They have been described and performed in the past but can prove to cause adverse tissue reactions which are difficult to treat. Permanent fillers include methylmethacrylate, polyacrylamide gel and silicone injections.