Skip to main content

Dermal Fillers: An Update

Abstract

Injection of dermal fillers is the second most frequent nonsurgical cosmetic procedure performed in the USA. Dermal fillers are an option in the treatment of volume deficiency, scars, and rhytides; facial sculpting; facial contouring; and augmentation of specific anatomical sites such as the lips. The number of injectable dermal fillers available on the market increases yearly. Dermatologists and cosmetic surgeons should regularly review treatment options to provide patients with safe and effective filler options. This paper extensively reviews the properties of the available fillers, such as their rheology, longevity, and adverse effects, and how these properties affect the choice of filler agent for a particular patient or a particular site. Also, trends in dermal filler injections are discussed.

This is a preview of subscription content, access via your institution.

References

  1. American Society of Plastic Surgeons. 2013 cosmetic plastic surgery statistics report of the American Society of Plastic Surgeons. Available at: http://www.plasticsurgery.org/Documents/news-resources/statistics/2013-statistics/plastic-surgery-statistics-full-report-2013.pdf. Accessed 9 Feb 2015.

  2. US Census Bureau. An aging nation: the older population in the United States. US Census Bureau. Issued May 2014. Available at: http://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed 9 Feb 2015.

  3. Fitzgerald R, Graivier MH, et al. Update on facial aging. Aesthet Surg J. 2010;30:11S–24S.

    Article  PubMed  Google Scholar 

  4. Brandt FS, Kaufman J, Green JB, Ballin AC, Cazzaniga A. Hyaluronic acid fillers. In: Nouri K, editor. Dermatologic surgery: step by step. Oxford: Wiley-Blackwell; 2012. p. 259–85.

    Google Scholar 

  5. Vleggaar D, Fitzgerald R. Dermatological implications of skeletal aging: a focus on supraperiosteal volumization for perioral rejuvenation. J Drugs Dermatol. 2008;7(3):209–20.

    PubMed  Google Scholar 

  6. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plastic Reconstr Surg. 2007;119:2219–27.

    Article  CAS  Google Scholar 

  7. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with Artecoll: 10-year history, indications, techniques, and complications. Dermatol Surg. 2003;29(6):573–87.

    PubMed  Google Scholar 

  8. Kontis TC. Contemporary review of injectable facial fillers. JAMA Facial Plast Surg. 2013;15(1):58–64.

    Article  PubMed  Google Scholar 

  9. Conejo-Mir JS, Sanz Guirado S, Angel Munoz M. Adverse granulomatous reaction to Artecoll treated by intralesional 5-fluorouracil and triamcinolone injections. Dermatol Surg. 2006;32:1079–81.

    CAS  PubMed  Google Scholar 

  10. Lemperle G, Gauthier-Hazan N, Wolters M, Eisemann-Klein M, Zimmermann U, Duffy DM. Foreign body granulomas after all injectable dermal fillers: part 1. Possible causes. Plast Reconstr Surg. 2009;123:1842–63.

    Article  CAS  PubMed  Google Scholar 

  11. Lemperle G, Knapp TR, Sadick NS, Lemperle SM. ArteFill permanent injectable for soft tissue augmentation: I. Mechanism of action and injection techniques. Aesthetic Plast Surg. 2010;34(3):264–72.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Sclafani AP, Fagien S. Treatment of injectable soft tissue filler complications. Dermatol Surg. 2009;35(Suppl 2):1672–80.

    Article  CAS  PubMed  Google Scholar 

  13. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;12(6):295–316.

    Google Scholar 

  14. Suneva Medical, Inc. Protocol for the post-approval study of Artefill for correction of nasolabial folds. Available at: https://clinicaltrials.gov/ct2/show/record/NCT00778531?term=artefill&rank=4. Accessed 10 Feb 2015.

  15. Karnik J, Baumann L, Bruce S, Callender V, Cohen S, Grimes P, Joseph J, Shamban A, Spencer J, Tedaldi R, Werschler WP, Smith SR. A double-blind, randomized, multicenter, controlled trial of suspended polymethylmethacrylate microspheres for the correction of atrophic facial acne scars. J Am Acad Dermatol. 2014;71(1):77–83.

    Article  CAS  PubMed  Google Scholar 

  16. Goldberg D, Guana A, Volk A, et al. Single-arm study for the characterization of human tissue response to injectable poly-l-lactic acid. Dermatol Surg. 2013;39:915–22.

    Article  CAS  PubMed  Google Scholar 

  17. Vleggaar D. Facial volumetric correction with injectable poly-l-lactic acid. Dermatol Surg. 2005;3:1511–7.

    Article  Google Scholar 

  18. Brandt FS, Cazzaniga A, Baumann L, Fagien S, Glazer S, Kenkel JM, Lowe NJ, Monheit GD, Narins RS, Rendon MI, Rohrich RJ, Werschler WP. Investigator global evaluations of efficacy of injectable poly-l-lactic acid versus human collagen in the correction of nasolabial fold wrinkles. Aesthet Surg J. 2011;31(5):521–8.

    Article  PubMed  Google Scholar 

  19. Fitzgerald R, Vleggaar D. Facial volume restoration of the aging face with poly-l-lactic acid. Dermatol Ther. 2011;24:2–27.

    Article  PubMed  Google Scholar 

  20. Rossner F, Rossner M, Hartmann V, Erdmann R, Wiest LG, Rzany B. Decrease of reported events to injectable polylactic acid after recommending an increased dilution: 8-year results from the Injectable Filler Safety Study. J Cosmet Dermatol. 2009;8(1):14–8.

    Article  PubMed  Google Scholar 

  21. Woerle B, Hanke CW, Sattler G. Poly-l-lactic acid: a temporary filler for soft tissue augmentation. J Drugs Dermatol. 2004;3(4):385–9.

    PubMed  Google Scholar 

  22. Alessio R, Rzany B, Eve L, Grangier Y, Herranz P, Olivier-Masveyraud F, Vleggaar D. European expert recommendations on the use of injectable poly-l-lactic acid for facial rejuvenation. J Drugs Dermatol. 2014;13(9):1057–66.

    CAS  PubMed  Google Scholar 

  23. Palm MD, Goldman MP. Patient satisfaction and duration of effect with PLLA: a review of the literature. J Drugs Dermatol. 2009;8(10):s15–20.

    PubMed  Google Scholar 

  24. Smith S, Busso M, McClaren M, Bass LS. A randomized, bilateral, prospective comparison of calcium hydroxylapatite microspheres versus human-based collagen for the correction of nasolabial folds. Dermatol Surg. 2007;33(Suppl 2):S112–21 (discussion S121).

    CAS  PubMed  Google Scholar 

  25. Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg. 2007;33(Suppl 2):S144–51.

    CAS  PubMed  Google Scholar 

  26. Moers-Carpi MM, Tufet JO. Calcium hydroxylapatite versus nonanimal stabilized hyaluronic acid for the correction of nasolabial folds: a 12-month, multicenter, prospective, randomized, controlled, split-face trial. Dermatol Surg. 2008;34(2):210–5.

    Article  CAS  PubMed  Google Scholar 

  27. Bass LS, Smith S, Busso M, McClaren M. Calcium hydroxylapatite (Radiesse) for treatment of nasolabial folds: long-term safety and efficacy results. Aesthet Surg J. 2010;30(2):235–8.

    Article  PubMed  Google Scholar 

  28. Graivier MH, Bass LS, Busso M, Jasin ME, Narins RS, Tzikas TL. Calcium hydroxylapatite (Radiesse) for correction of the mid-and lower face: consensus recommendations. Plast Reconstr Surg. 2007;120(6 Suppl):55S–66S.

    Article  CAS  PubMed  Google Scholar 

  29. Daley T, Damm DD, Haden JA, Kolodychak MT. Oral lesions associated with injected hydroxyapatite cosmetic filler. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(1):107–11.

    Article  PubMed  Google Scholar 

  30. Tzikas TL. A 52-month summary of results using calcium hydroxylapatite for facial soft tissue augmentation. Dermatol Surg. 2008;34(Suppl 1):S9–15.

    CAS  PubMed  Google Scholar 

  31. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-based review and discussion of current concepts (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345–54.

    CAS  PubMed  Google Scholar 

  32. Sadick NS. A 52-week study of safety and efficacy of calcium hydroxylapatite for rejuvenation of the aging hand. J Drugs Dermatol. 2011;10(1):47–51.

    PubMed  Google Scholar 

  33. Marmur ES, Al Quran H, De Sa Earp AP, Yoo JY. A five-patient satisfaction pilot study of calcium hydroxylapatite injection for treatment of aging hands. Dermatol Surg. 2009;35(12):1978–84.

    Article  CAS  PubMed  Google Scholar 

  34. US Food and Drug Administration. Laviv cell therapy. Available at: http://www.fda.gov/BiologicsBloodVaccines/CellularGeneTherapyProducts/ApprovedProducts/. Accessed 3 Feb 2015.

  35. Weiss RA. Autologous cell therapy: will it replace dermal fillers? Facial Plast Surg Clin N Am. 2013;21(2):299–304.

    Article  Google Scholar 

  36. Smith SR, Munavalli G, Weiss R, Maslowski JM, Hennegan KP, Novak JM. A multicenter, double-blind, placebo controlled trial of autologous fibroblast therapy for the treatment of nasolabial fold wrinkles. Dermatol Surg. 2012;38(7 Pt 2):1234–43.

    Article  CAS  PubMed  Google Scholar 

  37. Weiss RA, Weiss MA, Beasley KL, Munavalli G. Autologous cultured fibroblast injection for facial contour deformities: a prospective, placebo-controlled, phase III clinical trial. Dermatol Surg. 2007;33(3):263–8.

    CAS  PubMed  Google Scholar 

  38. Fibrocell Science, Inc. Azficel-T (laViv) package insert. Fibrocell Science, Inc.; 2011. Available at: http://www.fda.gov/downloads/BiologicsBloodVaccines/CellularGeneTherapyProducts/ApprovedProducts/UCM260489.pdf. Accessed 20 Dec 2014.

  39. Kablik J, Monheit GD, Yu L, et al. Comparative physical properties of hyaluronic acid dermal fillers. Dermatol Surg. 2009;35:S302–12.

    Article  Google Scholar 

  40. Sundaram H, Voigts B, Beer K, Meland M. Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol Surg. 2010;36:1859–65.

    Article  CAS  PubMed  Google Scholar 

  41. Edsman K, Nord LI, Ohrlund A, Lärkner H, Kenne AH. Gel properties of hyaluronic acid dermal fillers. Dermatol Surg. 2012;38(7 Pt 2):1170–9.

    Article  CAS  PubMed  Google Scholar 

  42. Tezel A, Fredrickson GH. The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther. 2008;10:35–42.

    Article  PubMed  Google Scholar 

  43. Flynn TC, Sarazin D, Bezzola A, Terrani C, Micheels P. Comparative histology of intradermal implantation of mono and biphasic hyaluronic acid fillers. Dermatol Surg. 2011;37(5):637–43.

    Article  CAS  PubMed  Google Scholar 

  44. Cohen JL, Dayan SH, Brandt FS, Nelson DB, Axford-Gatley RA, Theisen MJ, Narins RS. Systematic review of clinical trials of small- and large-gel-particle hyaluronic acid injectable fillers for aesthetic soft tissue augmentation. Dermatol Surg. 2013;39(2):205–31.

    Article  CAS  PubMed  Google Scholar 

  45. US Food and Drug Administration. Summary of safety and effectiveness data of Belotero. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf9/P090016b.pdf. Accessed 28 Feb 2015.

  46. Narins RS, Coleman WP III, Donofrio LM, et al. Improvement in nasolabial folds with a hyaluronic acid filler using a cohesive polydensified matrix technology: results from an 18-month open-label extension trial. Dermatol Surg. 2010;36(Suppl 3):1800–8.

    Article  CAS  PubMed  Google Scholar 

  47. Kühne U, Imhof M, Kirchmeir M, Howell DJ. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients. J Drugs Dermatol. 2012;11:1032–5.

    PubMed  Google Scholar 

  48. Downie JB, Grimes PE, Callender VD. A multicenter study of the safety and effectiveness of hyaluronic acid with a cohesive polydensified matrix for treatment of nasolabial folds in subjects with Fitzpatrick skin types IV, V, and VI. Plast Reconstr Surg. 2013;132(4 Suppl 2):41S–7S.

    Article  CAS  PubMed  Google Scholar 

  49. Goh AS, Kohn JC, Rootman DB, Lin JL, Goldberg RA. Hyaluronic acid gel distribution pattern in periocular area with high-resolution ultrasound imaging. Aesthet Surg J. 2014;34(4):510–5.

    Article  PubMed  Google Scholar 

  50. Prager W, Wissmueller E, Havermann I, et al. A prospective, split-face, randomized, comparative study of safety and 12-month longevity of three formulations of hyaluronic acid dermal filler for treatment of nasolabial folds. Dermatol Surg. 2012;38(7 Pt 2):1143–50.

    Article  CAS  PubMed  Google Scholar 

  51. Lorenc ZP, Fagien S, Flynn TC, Waldorf HA. Review of key Belotero Balance safety and efficacy trials. Plast Reconstr Surg. 2013;132(4 Suppl 2):33S–40S.

    Article  CAS  PubMed  Google Scholar 

  52. Sundaram H, Cassuto D. Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications. Plast Reconstr Surg. 2013;132(4 Suppl 2):5S–21S.

    Article  CAS  PubMed  Google Scholar 

  53. Lorenc ZR, Fagien S, Flynn TC, Waldorf HA. Clinical application and assessment of Belotero: a roundtable discussion. Plast Reconstr Surg. 2013;132(4S-2):69S–76S.

    Article  CAS  PubMed  Google Scholar 

  54. Jones D, Murphy DK. Volumizing hyaluronic acid filler for midface volume deficit: 2-year results from a pivotal single-blind randomized controlled study. Dermatol Surg. 2013;39(11):1602–12.

    Article  CAS  PubMed  Google Scholar 

  55. Carruthers J, Carruthers A, Tezel A, Kraemer J, Craik L. Volumizing with a 20-mg/mL smooth, highly cohesive, viscous hyaluronic acid filler and its role in facial rejuvenation therapy. Dermatol Surg. 2010;36(Suppl 3):1886–92.

    Article  CAS  PubMed  Google Scholar 

  56. US Food and Drug Administration. Summary of safety and effectiveness data of Juvederm Voluma XC. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf11/P110033b.pdf. Accessed 10 Feb 2015.

  57. Raspaldo H. Volumizing effect of a new hyaluronic acid sub-dermal facial filler: a retrospective analysis based on 102 cases. J Cosmet Laser Ther. 2008;10(3):134–42.

    Article  PubMed  Google Scholar 

  58. Philipp-Dormston WG, Eccleston D, De Boulle K, Hilton S, van den Elzen H, Nathan M. A prospective, observational study of the volumizing effect of open-label aesthetic use of Juvéderm® Voluma® with lidocaine in mid-face area. J Cosmet Laser Ther. 2014;16(4):171–9.

    Article  PubMed  Google Scholar 

  59. US Food and Drug Administration. Summary of safety and effectiveness data of Restylane® Silk injectable gel. http://www.accessdata.fda.gov/cdrh_docs/pdf4/P040024S072b.pdf. Accessed 2 Feb 2015.

  60. Micheels P, Sarazin D, Besse S, Sundaram H, Flynn TC. A blanching technique for intradermal injection of hyaluronic acid Belotero. Plast Reconstr Surg. 2013;132(4 Suppl 2):59S–68S.

    Article  CAS  PubMed  Google Scholar 

  61. Ballin AC, Cazzaniga A, Brandt FS. Long-term efficacy, safety and durability of Juvéderm® XC. Clin Cosmet Investig Dermatol. 2013;6:183–9.

    PubMed Central  PubMed  Google Scholar 

  62. Levy PM, Boulle K, Raspaldo H. Comparison of injection comfort of a new category of cohesive hyaluronic acid filler with preincorporated lidocaine and a hyaluronic acid filler alone. Dermatol Surg. 2009;35:332–7.

    Article  CAS  PubMed  Google Scholar 

  63. Weinkle SH, Bank DE, Boyd CM, Gold MH, Thomas JA, Murphy DK. A multi-center, double-blind, randomized controlled study of the safety and effectiveness of Juvéderm injectable gel with and without lidocaine. J Cosmet Dermatol. 2009;8(3):205–10.

    Article  PubMed  Google Scholar 

  64. Marmur E, Green L, Busso M. Controlled, randomized study of pain levels in subjects treated with calcium hydroxylapatite premixed with lidocaine for correction of nasolabial folds. Dermatol Surg. 2010;36(3):309–15.

    Article  CAS  PubMed  Google Scholar 

  65. Tetzlaff JE. The pharmacology of local anesthetics. Anesthesiol Clin N Am. 2000;18(2):217–33.

    Article  CAS  Google Scholar 

  66. Busso M, Voigts R. An investigation of changes in physical properties of injectable calcium hydroxylapatite in a carrier gel when mixed with lidocaine and with lidocaine/epinephrine. Dermatol Surg. 2008;34(Suppl 1):S16–24.

    CAS  PubMed  Google Scholar 

  67. Hesxel D, Soirefmann M, Porto MD, Siega C, Souza JS, Brum C. Double-blind, randomized, controlled clinical trial to compare safety and efficacy of a metallic cannula with that of a standard needle for soft tissue augmentation of the nasolabial folds. Dermatol Surg. 2012;38(2):207–14.

    Google Scholar 

Download references

Disclosure

No funding was received to prepare this manuscript.

Annelyse Ballin and Alex Cazzaniga report no conflicts of interest.

Fredric Brandt is a consultant to and/or has received grants from Allergan, Galderma, Medicis, and Merz Aesthetics.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Annelyse Cristine Ballin.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ballin, A.C., Brandt, F.S. & Cazzaniga, A. Dermal Fillers: An Update. Am J Clin Dermatol 16, 271–283 (2015). https://doi.org/10.1007/s40257-015-0135-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40257-015-0135-7

Keywords