Dermal Fillers

What are Dermal Fillers?


Fillers such as JUVÉDERM® Ultra, JUVÉDERM® Ultra Plus, Restylane®, Perlane®, Radiesse® and Artefill® are all types of dermal fillers that offer immediate and lasting wrinkle correction. These fillers are safe and natural cosmetic products that correct moderate facial wrinkles and folds such as the smile lines, vertical lip lines, “marionette” lines at the corners of the mouth and tear troughs, depressions under the eyes. These fillers can also be used to volumize the face and create a non-surgical lift.

At MediSpa Maui, we offer both absorbable and non-absorbable dermal fillers. There are 3 types of absorbable (temporary) fillers that we use on a regular basis, Hyaluronic Acid fillers (Juvederm Ultra, Juvederm Ultra Plus, Restylane and Perlane), Calcium Hydroxyappetite fillers such as Radiesse and lastly, Sculptra (Poly-L-Lactic Acid) which works less as an immediate filler and more as a gradual collagen stimulater that fills over time. Artefill® is the first FDA approved, non-absorbable (permanent) dermal filler. It is composed polymethylmethacrylate (PMMA) bovine collagen and lidocaine. PMMA microspheres are not degraded, are not absorbed, and therefore provide a long-lasting wrinkle correction. These treatments are a cornerstone to facial rejuvenation allowing years to be erased without surgery.

Dr. Stolley is a master of using these fillers alone or in concert with Botox/Dysport and Lasers to dramatically rejuvenate your skin.

Hyaluronic Acid


Hyaluronic Acid is a large molecule that is naturally found in the human body and almost all living organisms. The HA found in JUVÉDERM® and other products on the market come from bacteria. The main difference between the HA found naturally in your body and those found in fillers such as JUVÉDERM® Ultra, JUVÉDERM® Ultra Plus, Restylane, Perlane and Radiesse is that the latter are cross-linked to each other via a glucuronidate molecule. The body has natural enzymes called hyaluronidases that breakdown the HAs to sugar and water. The HA fillers as a whole are the most versatile fillers available.

Available Hyaluronic Acid Treatments:
  • JUVÉDERM® Ultra
  • JUVÉDERM® Ultra Plus
  • Restylane®
  • Perlane®
  • Radiesse®

Calcium Hydroxyappetite


These fillers consist of calcium microspheres surrounded by a methylcellulose carrier. Over 3-4 months, the methylcellulose carrier or vehicle is absorbed leaving the calcium microspheres behind to stimulate collagen growth. Radiesse is often used over bony areas due to its firm nature and its whitish color. A benefit of Radiesse is the relatively large amount in the syringes, roughly 50% more than the amount of other fillers. This allows for more volumization per syringe and some savings financially. The negative regarding Radiesse is the firmness of the product, the whitish color and some longevity issues. The firmness and whitish color limit the product, in my opinion, to a deeper plane of injection and thus I often use the product in the cheeks or the jaw line. Regarding longevity, the company is allowed by the FDA to say that it can last “Up to 1 Year”. I find this overly generous for a single injection. Longevity of a year to 18 months can be achieved but it requires augmenting the correction at 3-4 months with more filler. Radiesse is also an ideal product for hand rejuvenation.

Available Calcium Hydroxyappetite Treatments:
  • Radiesse®

Poly-L-Lactic Acid


These fillers are made from a synthetic material that when injected, stimulates the body’s own production of collagen. These small particles are mixed with sterile water and injected into areas to stimulate collagen growth and thus a thickening of the tissue in that area. In some areas, they are used deep over the bone and in others such as the lateral face and lower cheeks, they can be used under the skin. The benefit of Sculptra is its longevity. After a series of several treatments, the product can last for 2 or more years. The downside is the cost, though the cost of the product has come down recently.

Available Poly-L-Lactic Acid Treatments:
  • Sculptra®

PMMA


Polymethylmethacrylate (PMMA)

Artefill is different from temporary injectable wrinkle fillers. Temporary injectable wrinkle fillers are made of different kinds of natural or synthetic materials that are broken down and eventually absorbed by your body. As a result, wrinkle correction is only temporary and you may need repeat injections several months after the initial treatment to maintain your wrinkle correction. Artefill corrects wrinkles differently. The unique microspheres are not absorbed by your body and provide the support your skin needs for natural, long lasting results. Most people get the results they want with one or two treatments, depending on the depth of their wrinkles and folds. Artefill is injected deep in the skin, underneath the wrinkle and just above the skin’s fat layer. The collagen works right away, reducing the appearance of the line or wrinkle, then the microspheres provide a support matrix for natural, enduring wrinkle correction.

Available Polymethylmethacrylate (PMMA) Treatments:
  • Artefill®

What are the Possible Complications with Fillers?


Dermal fillers are a great tool to use to helping patients create a smoother, more youthful appearance. The right filler can be used in the right place to fill in bothersome lines and wrinkles and/or to lift and volumize the facial areas, giving back what time has taken away. Though fillers are a great tool, they are not without their issues and potential complications.

Bruising – any time you enter the skin and soft tissue with a needle or other sharp object, bruising is possible. Bruises can take up to a week to 10 days to go away. Less often, a bruise can leave what is called a hemosiderin stain. This is when the iron from the blood remains in the skin for some time after the initial bruise has resolved. Hemosiderin stains almost always go away, but they can sometimes take months.

Infection – I have never had a patient get an infection from a dermal filler, but anytime the skin is broken, an infection is possible. Infections can be problematic with dermal fillers because as long as the filler is present, the bacteria has a home to live in and can be difficult for antibiotics to reach it at high enough concentrations to destroy it. The risk of injection is very small and is limited by use of alcohol or other tissue disinfectants. If a patient has a history of recurrent skin infections, a consideration of pretreatment with antibiotics may be considered and screening or treatment for Staph aureus colonization should be considered. Please ask your doctor about pre-treatment for Staph aureus colonization if you have a history of recurrent skin injection such as boils, superficially abscesses or recurrent folliculitis.

Visible Product – One relatively common problem with fillers is that the product can be visible from the surface of the skin either as a bluish hue with HA fillers or whitish with Radiesse or as a lumpy/bumpy area with any of the products. As we mentioned earlier, a benefit of the HA fillers is that problems can be removed relatively easily with extrusion of the product or via the use of hyaluronidase. With Radiesse, the product can be removed via extrusion at times or broken up by injecting saline to the area or left to dissolve over time.

Arterial Compromise – Though rarely an issue, the most serious complication of a dermal filler is arterial compromise or the shutting off of arterial blood flow the distal tissue. This is rarely an issue for 2 reasons: 1) arteries are rarely hit or compromised and 2) most of the facial tissue benefits from collateral flow; that is, the area is fed by more than one artery. Only a few areas of the face have limited blood flow and include some mid-line regions such as the mid-forehead and nasal regions.

As an expert injector, I am always looking for the signs and symptoms of arterial compromise and ready to treat if needed. Treatment would include firstly recognizing the issue, then treating with massage to the area. This can be flowed by administering aspirin, injecting hyaluronidase into the area to break up the HA filler (if one was used) and administering Nitroglycerin paste to the areas to help to open up the blood vessels. I have only had one episode when arterial compromise was a concern and it resolved promptly with the above treatments leaving a happy patient with a small bruise who came back in a week later for a bit more filler in the area. One important warning sign to watch for from a patient’s perspective is severe pain or tenderness minutes to hours after the treatment in the area treated or near-by tissue. This is an important sign that cannot be ignored. It is a sign of tissue ischemia (lack of oxygen) and it is your skin screaming out to you to do something. If you experience extreme pain in the area or adjacent areas minutes to hours after your treatment, call your doctor. And on that note, make sure you do have an after-hours number available to call.

Complications with dermal fillers are rare but can happen. At MediSpa Maui, we are always available for complimentary consultations prior to any treatment. We educate all of our patients on the appropriate pre/post care instructions that can limit the possible side effects of a treatment.

Results


Photos Courtesy of Brian Stolley, MD ~ Individual results may vary.


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