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                             Different Types of Dermal Fillers

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The hyaluronic acid filler RESTYLANE  revolutionized the injectables market when it was FDA approved in 2004. Since then, the options of hyaluronic acid fillers have grown substantially, and also some have left the market. Restylane had the market cornered until the introduction of Juvederm in 2006. In the year 2007, Perlane was finally approved, which is essentially the same as Restylane, although it’s higher density makes it more appropriate for deeper wrinkles and creases, as well as restoring volume to the mid-face and cheeks.



                                    Restylane Filler                                Juvederm Filler


                                                                   Images courtesy of Allergan, Inc.


Hyaluronic Acid is capable of holding 1,000 times its weight in water, naturally occurring hyaluronic acid is responsible for binding moisture in the skin. It does this by filling in the space between collagen and elastin fibers in the skin – which hence will hold in moisture and maintain skin’s volume.

Naturally occurring hyaluronic acid in the skin decreases over time due to aging, sun exposure and other environmental factors. When hyaluronic acid is injected under the epidermis, it temporarily replenishes the skin’s volume by replacing deteriorated support layers of the skin. The longevity of a hyaluronic acid filler is determined by the amount of cross-linking of the gel molecules. The more solidly (or cross-linked) a hyaluronic acid product is the longer it will last. The absolute amount of hyaluronic acid in a syringe does not translate into more of the product remaining in an injected area. Only the actual cross-linked amount of hyaluronic acid in the syringe will actually remain in the body. The non-cross-linked product will be dissolved in a few days.


Hyaluronic Acid Concentration:  The higher the hyaluronic acid concentration, the larger the needle and greater the force required to inject.

Particle size:  Larger particles can last longer. Larger particles can create a firmer result so are usually reserved for deeper dermal use. Smaller particles are reserved for more superficial indications, and may dissipate earlier.





The fillers that are available to us today have the ability to plump up fine lines and wrinkles on the spot with immediate improvement. Some can also offer us longer staying power as well. As many patients or consumers are realizing, many times the areas of concern are better addressed by volume restoration versus pulling the skin and muscles tighter as in a face lift.  Volume loss under the eye area (tear trough) is a  common concern  for both men and women, and injection with a hyaluronic acid filler seems to correct the problem better than actually surgery sometimes.

Many physicians have found that the hyaluronic acid fillers – like Juvederm and Restylane can restore volume loss under the eyes.  Although, this area remains an area with controversy with whether or not a filler should be applied there, this simple and almost painless procedure can make a huge difference. The tear trough or hollowing under the eyes, sometimes extending onto the cheek, is created by fat loss or sagging of the surrounding tissue. 








This hollow alone can create a shadowing effect that leads to dark circles under the eyes.  The dark circles can also be caused by many superficial vessels in this area.  The dark circles are best improved when caused by shadowing but can also alleviate those cause by superficial vessels.  The "Tyndall Effect" comes about when hyaluronic acids (such as Restylane, Juvederm, Hydrelle) are placed too superficially - or close to the skin surface.  The deeper these fillers are placed the less likely for the Tyndal Effect (bluish tint) to happen. 

As with all fillers today, many are concerned about what is going to happen to my face if I stop getting the injections. Most plastic surgeons and dermatologists agree that there is some evidence that the hyaluronic acid fillers and also other types can actually increase your own collagen to some degree, which may give a longer duration of wrinkle softening.

If a lump should occur with any of the hyaluronic acid fillers, such as Restylane, Perlane, Juvederm, etc. an injection of Hyaluronidsase or commonly called Wytase (off label use of Hyaluronidsase) can dissolve lumps or granulomas that might occur.


This treatment although it is used off label and not FDA approved for this application, is very well documented and widely used when needed.





Varying hydration levels of the hyaluronic acid fillers have an impact on their performance overall. Where Hylaform Plus and Captique have concentrations, of 5.5 mg hyaluronic acid, Restylane has 20 mg of hyaluronic acid, and Juvéderm has 24 mg of hyaluronic acid cross-linked per ml of water. The newly named "Hydrelle" or (Elevess) contains the highest amount of hyaluronic acid - at 28 mg.

It is these properties make them extremely hydrophilic, which results in more swelling upon injection of the product, as tissue fluids get absorbed by the higher concentration product.





The brand names of Hyaluronic acid are the following:

  • Restylane

  • Perlane

  • Captique

  • Hylaform

  • Hydrelle

  • Prevelle

  • Silk
  • Juvederm




    Advantages of Hyaluronic Acid Fillers:

  • These fillers provide instant results

  • No allergy testing needed – injection can be given the same day

  • If there is a misapplication of hyaluronic acid-based filler - this can be often corrected by

  • Injecting hyaluronidase, an enzyme that breaks down hyaluronic acid.


    Disadvantages of Hyaluronic Acid Fillers:



                                                      Images of subcutaneous nodules

                                                  Subcutenous Nodules complication of too much dermal filler




    How long does it last:  Depending on where these fillers are injected, the longevity of the filler can range from 3 - 9 months.

    How is it injected: These fillers are injected after you receive a topical or local anesthetic to minimize any discomfort you might have. Either a topical anesthetic cream may be applied or a local anesthetic agent may be injected to numb the region. If you decide to get a dental/nerve block (local anesthetic), there is more swelling after the procedure; however this will wear off within two hours.

    Pain relief during injection:  Nerve blocks deaden the area and prevent the pain associated with this procedure.






    You can get bruising and swelling from hyaluronic acid (Juvederm, Restylane, and Perlane) however the bruising is not directly caused by the type of filler but rather:

  • By the size of the needle used to inject the filler

  • The amount of tissue trauma during injection

  • Trauma to the arteries and veins around the injection site

  • The patient's propensity to bleed


    Common Causes of Bleeding and Bruising:

  • Family history of bleeding disorders

  • Ingestion of aspirin, ibuprofen, coumadin, or other herbal medications that may thin out the blood and impair proper coagulation

  • Medication to Avoid






    Avoid doing the following prior to your next injection:

  • Make sure to avoid taking aspirin, ibuprofen, or other blood thinners for three weeks before your injection. 

  • Make sure to place compression with or without ice packs immediately after injection. 

  • Sinecch and Arnica are also known to minimize the duration of the bruising.




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