'Filling In' the Wrinkles

Problem: I am considering an injectable dermal filler to help plump up my wrinkles, but there are so many options available, I don't know where to begin. Each product I read or speak to cosmetic surgeons about is supposedly the "best" option currently available! Which one really is best?

Solution: As we grow older, the effects of sun damage, aging, and smoking result in loss of collagen and fat. These factors, combined with muscle movement, cause wrinkles and folds to occur on the face, particularly around the lips, nasal-labial folds (the lines from the nose to the mouth), and frown lines between the eyes. To "plump" or "fill" out these areas, various materials are available that a dermatologist or plastic surgeon can inject directly into the depression, creating a more youthful appearance.

In the world of injectable dermal fillers, there is a wide range of substances being used. Despite what you might have read or heard there isn't a "best" material to choose. For the most part, claims are not based on comparative studies or independent research. Which substance is considered "best" or "preferred" is often determined by whatever the newest procedure happens to be, what is receiving attention in fashion magazines, or, more often than not, what company is actively marketing their product. What's disconcerting about all this is that most dermal fillers are so new they have no long-term safety data of any kind and there is little, if any, published research available. Without published research, there is no real way to assess what the risks, problems, or possible outcomes can be.

There are two primary groups of dermal fillers: synthetic and natural. Synthetic fillers tend to last much longer and are often considered semi-permanent to permanent but are considered a higher risk for lumping and migration. Natural fillers last from just 6 months to 2 years, with some risk of lumping and migration (Sources: Journal of Oral Pathology and Medicine, February 2004, pages 115-120; and Dermatologic Surgery, October 1997, pages 871-877).

As you will see from the list below, there are lots of natural dermal fillers, even those harvested from your own body, that are not automatically the preferred option. In the formidable list of injectable dermal fillers, each one has its own pros and cons (Source: Facial and Plastic Surgery, February 2004, pages 21-29).

Alloderm (FDA-approved for cosmetic corrective use) is processed from donated human cadaver tissue prepared in such a way that it retains its underlying structure. It has been used for a variety of surgical reconstructive procedures to replace lost, damaged, or diseased tissues. For wrinkles, it is considered stable and may last from 1 to 2 years, though there are no controlled studies substantiating that contention (Sources: www.emedicine.com; www.emedicine.com/ent/topic43.htm; and http://www.emedicine.com/ent/topic377.htm). A micronized form of Alloderm, termed Cymetra (see below), is also available. This material is rehydrated with lidocaine in the physician's office before injection so the procedure is far less painful. Because it is human derived, no skin test is required by the manufacturer. Clinical trials of 200 patients to date show no evidence of allergic reactions, however, transient bruising, redness, and swelling occurred at a rate of 2.1%, side effects that are true for most dermal fillers (Source: http://www.emedicine.com/plastic/topic439.htm).

Artecoll (FDA approval for cosmetic corrective use is pending) has been used in Canada and other countries since 1994. The material is polymethyl methacrylate (PMMA) mixed with collagen and is considered to be semi-permanent to permanent. Because of its potential permanence, injecting Artecoll requires greater skill. Risks include lumping of the product after injection; inflamed, hardened, grain-sized tissue at the injection site; and migration of the material (Sources: American Society of Plastic Surgeons, www.plasticsurgery.org; American Journal of Dermatopathology, June 2001, pages 197–202; and Aesthetic Plastic Surgery, September-October 1998, pages 356–365).

Autologen (does not require FDA approval for cosmetic corrective use) is collagen harvested and reformulated from the patient’s own skin so allergic reactions are considered impossible. Theoretically, it should last longer than other biological fillers. It can last from nine months to one year (Source: Clinical Plastic Surgery, October 2000, pages 507–513). The company manufacturing Autologen is no longer in business.

Autologous Fat, Fat Grafting (does not require FDA approval) is produced from the patient's own fat via liposuction. No allergy testing is required. Harvesting the fat is an involved, complicated process. There is no consensus on longevity, but most experts agree it lasts from 3 to 6 months (Sources: www.emedicine.com; and http://www.plasticsurgery.org).

Bioplastique (not FDA-approved for cosmetic corrective use) uses synthetic beads of hard silicone in a gel of polyvinylpyrrolidone (PVP). Some research shows it may be permanent. There is concern that it can pose problems similar to the silicone used previously in breast implants, but there is research showing this is unfounded because the particle size for Bioplastique is such that it does not migrate and absorption does not occur (Sources: www.emedicine.com; www.facialplasticsurgery.net; and Plastic and Reconstructive Surgery, November 1997, pages 1570-1574).

CosmoDerm or CosmoPlast (FDA-approved for cosmetic corrective use) is human-derived collagen and is considered to be safer than bovine-derived collagen. CosmoDerm is used for minor skin defects; CosmoPlast is used for defects that are more serious. Overcorrection (injecting more of the dermal filler substance than what is typically needed to produce a positive outcome) is needed to achieve ideal results. Lasts 3 to 9 months.

Cymetra (FDA-approved for cosmetic corrective use) is a micronized version of Alloderm (see above). Cymetra is not recommended for use between the eyes or around the eye area but is effective for nasal-labial folds and lip enhancement (Source: Archives of Facial and Plastic Surgery, October-December 2002, pages 252-257).

Dermal Grafting (does not require FDA approval for cosmetic corrective use) is tissue harvested from a patient and reinjected as a filler. It usually results in a scar at the graft site (where the tissue was removed).The grafted skin is then processed and formed to fit the area where it will be injected. A tiny point in the wrinkle or line is opened to create an area where the skin implant is placed. Because it is a graft, far less reabsorption occurs than with other dermal fillers such as collagen or fat.

Endoplast-50 (not FDA-approved) consists of solubilized elastin peptides with bovine collagen, which stimulates the skin to produce collagen. Results are reported to last as long as 12 months (Source: www.emedicine.com).

Fascian (does not require FDA approval for cosmetic corrective use) is a type of collagen derived from cadavers. Fascian is firm, yet pliable. Duration is about six months to one year, the same as for other collagen-type injections. There is little research showing this to be an effective filler.

Fibrel (FDA-approved for cosmetic corrective use) has been in use as a dermal filler since the 1980s. However, this animal-derived collagen was complicated to use and could be painful for the patient. Subsequently, it has been refined and simplified so it is easier for the physcian to use and now contians 1% lidocaine to reduce discomfort. Results can last up to 2 years (Source: www.emedicine.com).

Formacryl, different forms of this substance are known as BioFormacryl, Argiform, and DermaLive (not FDA-approved for cosmetic corrective use), is a synthetic polyacrylamide gel and is considered to be one of the longest-lasting and potentially permanent fillers available, with low risk of complications, though it requires skill to administer it properly (Source: Aesthetic Plastic Surgery, July-August 2001, pages 249–255). There is concern that the material used may be problematic for the health of skin in the long term (Source: www.facialplasticsurgery.net).

Gore-Tex, also known as SoftForm and UltraSoft (FDA-approved for cosmetic corrective use), is polytetrafluoroethylene (ePTFE), a nonabsorbable, synthetic material used for soft tissue augmentation and considered to be permanent. It is considered to be more of a synthetic implant than a classic injectable material. If not placed correctly during the procedure, the material can be felt under the skin (Sources: Dermatologic Surgery, October 2002, pages 901–908; and www.emedicine.com). In case you’re wondering, yes, this is the same Gore-Tex material used in the company's outerwear products.

Hylaform, also known as Hylan-B Gel (FDA-approved for cosmetic corrective use) is a form of hyaluronic acid, a substance found in human skin, although this version is derived from rooster combs (rooster combs are the stiff feathers along a rooster's back, extending to its hindquarter area). It is considered to be somewhat longer-lasting than collagen, though, and supposedly poses less risk of clumping or allergic reaction. It can last for up to 1 year (Sources: www.emedicine.com; and Journal of the American Academy of Dermatology, December 2001, pages 930–933 ).

Isolagen (not FDA-approved) is a method of harvesting your own collagen, purifying the material, and packaging it in a suspension for injection into the skin. Because the material is from the patient's body, little risk of allergic response exists. Clinical trials are taking place in hopes of obtaining FDA approval. Research has shown it to be effective and it can last for up to 4 years (Sources: www.emedince.com; Annals of Plastic Surgery, May 2000, pages 536-542; and Archives of Facial and Plastic Surgery, July-September 1999, pages 165-170).

New-fill (See Sculptra)

Perlane (See Restylane)

Radiance (FDA-approved for certain bone-related surgeries, but not for cosmetic corrective use) is a form of calcium hydroxyapatite. Calcium hydroxyapatite is bone cement and has been used for years to repair many types of skeletal defects. It has been shown to have stable results, ease of use, and excellent adaptability; however, there is minimal research concerning its success for wrinkles (Source: British Journal of Plastic Surgery, January 2000, pages 24–29).

Restylane and Perlane (FDA-approved for cosmetic corrective use) are similar to Hylaform in that they are forms of hyaluronic acid. Restylane is derived from bacteria and is used for more superficial wrinkling. Perlane is meant for use on deeper wrinkles. Overcorrection (injecting more of the dermal filler substance than what is typically needed to produce a positive outcome) is generally not needed with these substances, as it is for collagen or fat injections. Restylane and Perlane can last from six months to one year. One of the main advantages for hyaluronic acid fillers is that they do not pose an allergy risk (Sources: American Academy of Dermatology, www.aad.org; Journal of the American Academy of Dermatology, December 2001, pages 930–933; and www.emedicine.com/derm/topic515.htm).

Reviderm Intra (not FDA approved in the United States for any use) are dextran beads suspended in hylan gel of nonanimal origin. One study of 274 patients reported permanent results (Source: www.emedicine.com).

Sculptra (FDA-approved to restore or correct facial fat loss (lipoatrophy) in people with AIDS) is nonanimal-derived poly-L-lactic acid (PLLA) and is related to alpha hydroxy acids. It is not approved for wrinkles or general cosmetic use in the US but it has been used in 30 other countries as a dermal filler for several years. It can be used for wrinkles and acne scars as well as for general improvement in facial and lip contour. Results are not immediate and usually require multiple, biweekly treatments. It can last up to 2 years but usually requires touch-ups (Sources: American Academy of Dermatology, www.aad.org; Journal of Drugs in Dermatology, July-August 2004, pages 385-389; American Society of Plastic Surgeons, www.plasticsurgery.org).

Silikon 1000 (FDA-approved for certain eye-related injections, but not for cosmetic corrective use) is injectable silicone used off-label as a permanent dermal filler. The two greatest risks are that the silicone will migrate to areas where you don't want it, and that it will form hard granules under the skin (Source: Dermatological Surgery, March 2003, pages 211–214).

Zyderm I, Zyderm II, and Zyplast (FDA-approved for cosmetic corrective use) are different combinations of cow-derived collagen. Zyderm was the first injectable filling material to be approved by the FDA. It has been used for approximately 20 years and the injection technique has been standardized. All these materials are absorbable and, therefore, overcorrection is necessary to maintain results. Duration is limited, ranging from 6 to 9 months. Allergy testing is mandatory because about 5% of patients may experience hypersensitivity to injectable bovine (cow) collagen (Sources: www.emedicine.com; and www.emedicine.com/derm/topic515.htm ).

After all is said and done, aside from the fact that research for most fillers is limited, the major issue for fillers is one of longevity, followed by ease of use, and—ultimately—the skill of the doctor. Regardless of the material, there is a learning curve to injection techniques as well as understanding how the varying substances affect skin. That means you need to find a doctor who has been injecting dermal fillers for some time, and who has loads of experience, preferably with more than one type of filler.