Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Facts on Facial Fillers


 Introduction to Injectable Fillers


The use of Injectable facial fillers is one of the fastest growing areas in the field of cosmetic surgery.  Many advances in have been made in the last 5 years that have led to safer, more predictable and longer lasting fillers.


Historically, surgeons have injected substances into the face and lips for over a century.  For the past 25 years, the choice of FDA approved fillers was very limited and basically was the use of bovine collagen (obtained from cows) products such as Zyplast and Zyderm.  While these fillers were effective, they required allergy testing and a one month wait for injection after a negative allergy test.  In addition, the did not produce lasting augmentation and the results were often gone at 3 months or less.


In December of 2003, the FDA approved Restylane for treating facial folds and wrinkles.  Restylane represented a new type of filler and is made from hyaluronic acid which is a naturally occurring carbohydrate that is found in the skin and other tissues of all mammals.  This substance is a clear gel with similar consistency as hair gel.  Since it is not made from animal products, there is no need for allergy testing which is a huge advantage as the patient can come to an office and have same day filler injection.  In addition, the hyaluronic acid fillers have a chemical process known as “cross linking” which prolongs their effect in the body, giving augmentation that can last 8-12 months.  Medicis, the company that makes Restylane also has a more robust filler known as Perlane which was FDA approved in 5-07.  This is a thicker filler that is used for smile lines (nasolabial folds) and other areas and provides a firmer support and lasts longer than Restylane.


Since the FDA approval of Restylane, Allergan Inc. (the makers of Botox) have had 2 injectable fillers approved by the FDA in 2006.  Juvederm Ultra is a hyaluronic acid filler similar to Restylane and Juvederm Ultra Plus is a larger particle, more robust filler, similar to Perlane.  The hyaluronic acid based fillers (Juvederm and Restylane) currently remain the most popular filler choices.


Hylaform, Hylform Plus are animal based hyaluronic acid fillers FDA approved in 2004,  formerly marketed by Inamed (now Allergan) that have declined in popularity with the newer non-animal derived hyaluronic acid fillers. Captique (also marketed by Allergan) is an additional non-animal hyaluronic acid filler that was FDA approved in 2004.


There is a continued effort to develop longer lasting fillers.  Although a permanent filler may sound like a perfect thing, if a patient has complications such as over fill or asymmetry, then permanent may not be a good thing!  In experienced hands, the longer lasting fillers work well and their lasting effect is appreciated by both surgeons and patients.


There are numerous fillers that claim to last longer than the hyaluronic acid fillers.  One of these FDA approved fillers is Radiesse.  This filler is made from a substance that has similar properties to the organic matrix in bone or sea coral.  These fillers have a consistency similar to tooth paste and due to their composition, can last up to 18 months.  Radiesse is most often used in the nasolabial folds and for cheek augmentation, but may be used in the lips by some injectors.  Since this is a thicker filler, it is generally used in deeper areas of the skin so there are not irregularities in the superficial skin.


Another new, longer lasting filler is Artefil.  This filler consists of microscopic plastic beads that look like pearls under a microscope.  The beads are mixed in a collagen carrier for injection.  Since the beads are plastic, they will remain in place permanently and thus provide a lasting augmentation.  One drawback to this filler is that since it contains collagen, it requires allergy testing one month before injection. 


With the previously described fillers, they work by filling the lip or wrinkle with volume and are gradually digested by the body.  Basically, when these fillers are injected, “what you see is what you get”.  There exists another class of injectable fillers that work in a different manner than simple augmentation.  Silicone and Sculptra work by an alternate method.  These fillers are injected into the deeper skin and they cause the body to make new collagen.  When these fillers are injected, they cause the collagen reaction that actually causes the area to grow over a 3-4 week period.  This means that when Silicone of Sculptra are injected, there may be little noticeable result at first, but over the next month, the body will produce collagen in the injected areas and the augmentation will actually grow.  With Silicone, very small micro droplets are injected into the lips or wrinkles and over the next month these tiny droplets of silicone will become surrounded with collagen and enhance the augmentation.  Since the Silicone will “grow” it is injected in very small volumes on a monthly basis until the desired result is achieved.  Silicone is considered a permanent filler as it stays in place and the body does not digest it.


Sculptra is substance known as L-Poly Lactic Acid which is similar to the material used to make a type of suture that is used to close lacerations.  This material, similar to Silicone, will cause the body to make new collagen in the area where the filler is injected.  Due to this, the reaction (like Silicone) is not immediate but increases over the next 3-4 weeks after injection.  Sculptra is popular for injection into the nasolabial folds and for cheek augmentation.  Some surgeons may also inject Sculptra in the lips and other regions of the face.  Sculptra, like Silicone does not require allergy testing.

Since the science of fillers is so prolific, we will see new fillers introduced on a regular basis.  In Europe, cosmetic surgeons have over 70 choices of various injectable filler products.  Several very recent FDA approved fillers include Evidence, Elevess, and Prevelle.


Elvess is a hyaluronic acid filler that contains local anesthetic (0.3% lidocaine) and was FDA approved in 12-07.  By combining a local anesthetic with the filler, the injection process is more comfortable for the patient, although most surgeons use local anesthetic injection routinely before filler administration.  Prevelle Silk is another hyaluronic acid filler with local anesthesia marketed by Mentor and is representative of the process of adding lidocaine to the actual filler product.


Evolence is a filler that is made from porcine collagen (derived from pig tissue) and claims to last up to a year when injected into the nasolabial folds.  Evolence has the consistency of a paste, does not require allergy testing and is yet another exciting example of the new generation of fillers.




Who is a Candidate for Injectable Fillers?



Facial fillers are administered over a wide age range.  Younger patients may seek filler injection for lip plumping and fillers are used in the lips and other areas on aging patients.  Men are also candidates for injectable fillers and are one of the fastest growing filler patient populations. Since filler injection is basically a simple and safe procedure most patients are candidates for injectable fillers if they want to plump their lips or wrinkles.  Fillers should only be injected by appropriately trained personnel that can manage any potential complications. 



Who is not a Candidate for Injectable Fillers?


Patients with significant allergies should check with their doctor before having any filler injected.  Also patients taking aspirin or any medication that could affect blood clotting should notify their surgeon prior to injection to avoid hematoma, bleeding or severe bruising.



What is the Intended Result of Filler Injection?



Fillers are intended to plump lips and soften wrinkles.  Different patients have different areas in need of improvement for their lips.  Younger patients may only need some slight plumping to augment their already youthful lips while older patients may need plumping, outlining (restoration of the youthful border of the lips) and injection of lipstick lines.


For wrinkles and folds, fillers are intended to “soften” the wrinkle or fold, not to eliminate them.  It is important that the patient has reasonable expectations prior to the treatment as not to be disappointed.  If you consider the wrinkle a depression in the skin, the filler will plump up the depression to make it less severe, but will not make it completely disappear.  Having realistic expectations is very important.



How Long Can I expect the Filler to Last?


Filler longevity is extremely variable and depends upon the type of filler used, the area it was placed and the metabolism of the individual patient.  Fillers generally do not last as long in areas of extreme movement such as the lips as compared to less mobile areas like the cheekbones.



How is the filler administered?


Every surgeon has a different way of injection filler.  Most surgeons will use a topical anesthetic cream and also administer local anesthetic injections (dental injections) prior to injecting fillers.  Ice is also applied before and after injection.  Injection generally only takes several minutes and some fillers cause immediate swelling so the patient may appear “over treated” at first.  This swelling generally resolves in several hours.  A follow up appointment several weeks after filler injection is a good idea so the surgeon can evaluate the result and touch up any areas in need.



What is the Recovery for Filler Injection?


For most patients, fillers can be injected in the lips or wrinkles and they can return to work the next day.  Occasionally some patients will swell dramatically, especially in the lips, so for a first time patient; they may want to schedule the initial injection on a Friday.  Occasionally patients will bruise from lip or wrinkle filling and this can usually be covered with makeup, but it is a good idea not to schedule filler injection right before an important social function in the event the patient experiences unusual bruising.



What are the Possible Complications of Injectable Filler Injection?


Like any procedure, filler injection can cause complications, but fortunately they are generally rare and minor.  The most common post injection complications are swelling and bruising, both of which generally are short lived and self limiting.  Over correction or under correction are also possible.  For under correction, more filler can be added.  In cases of over correction, sometimes the excess filler can be expressed out of the lip or wrinkle through a small needle puncture.  Hyaluronidase is a medication that will dissolve the hyaluronic acid fillers and can be used to reduce areas of over treatment.  Asymmetry is another possible complication where one side may be different from the other and again, requires filling of the deficient side.


In rare case allergic or foreign body reactions have been known to occur with fillers, but this is extremely rare.  All of the above potential complications should be thoroughly discussed with your doctor before injecting fillers.





Injectable facial fillers have broadened the scope of minimally invasive cosmetic facial surgery and provided increased rejuvenative options for both doctors and patients.  The represent an exciting and rapidly expanding part of anti-aging treatment and hold much promise for new fillers on the horizon.  What used to require surgery can now, oftentimes be accomplished in several minutes with minimally invasive injectable facial fillers.


For more information on injectable facial fillers and other cosmetic facial surgery click on




Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

May 9, 2008 Posted by | Lip and Wrinkle Fillers | , , , , , | 1 Comment

Tell Me About Injectable Lip and Wrinkle Fillers

If you asked a doctor about injectable fillers 20 years ago, the answer would have been easy…..collagen.  Bovine collagen (from cows) was about the only FDA choice for plumping lips and wrinkles.  It worked pretty well, didn’t last very long and required allergy testing a month before injection.  Hard to believe that surgeons and patients put up with it for so long!  Meanwhile, overseas, many filler options were popular.  In about 2002 Restylane was given FDA approval and started the filler revolution in the USA.

Restylane (a filler made by Medicis) is a sugar derivative that is called hyaluronic acid and is found naturally in many body tissues.  Since it is a non animal product, no allergy testing is necessary and this option ushered in the new age of fillers.  Medicis also has FDA approval for Perlane which is a thicker, longer lasting and more robust hyaluronic acid filler.  Restylane pretty much owned the filler market until Allergan obtained FDA approval for Juvederm.  Juvederm Ultra is another hyaluronic acid filler and is currently giving Restylane a run for its money.  Many people feel that Juvederm is easier to inject, hurts less, is softer feeling and lasts longer.  Others feel that it is very similar to Restylane, like Coke is to Pepsi.  Personally, I use both depending upon whom and where I am injecting the filler.  In some respects I am a filler “bartender” as I offer many brands of fillers for different applications and patients.  Allergan also sells Juvederm Ultra Plus, which like Perlane is a thicker (larger particle) filler.  These more robust fillers usually last longer and are more frequently used in deeper folds or wrinkles, but they can also be used in the lips.  The hyaluronic acid fillers constitute 90% of my filler practice.  These fillers generally last 6-12 months, depending upon on the patient’s metabolism and where they are injected.  Areas like the lips which are continually moving to not last as long when filled as less mobile areas such as the cheekbone regions.

Although bovine collagen (Zyplast and Zyderm) have largely fallen out of popularity, Allergan offers human collagen fillers called Cosmoplast and Cosmoderm.  These fillers are not quite as popular as the hyaluronic acid fillers and do not last as long.  They are very forgiving and work well for fine lines and lipstick lines.  I only use these fillers when a patient requests them.

Radiesse is popular filler that is made from synthetic calcium which is similar to a ground up bone paste with the consistency of tooth paste.  This filler is more for deeper folds or wrinkles and I do not use it in the lips.  Radiesse is popular for smile lines (nasolabial folds) or cheek plumping.  The advantage of Radiesse is that it lasts for up to 18 months.

Sculptra is synthetic filler that is FDA accepted for facial filling in HIV patients.  It is also used for cosmetic applications.  This filler is injected and stimulates the body’s collagen to increase, which contributes to the filling.  I have used Sculptra and see no significant advantage over the hyaluronic acid fillers such as Juvederm Ultra or Restylane, although some of my colleagues favor it.

Permanent fillers exist and this can be good or bad.  If the treatment result is positive and if the patient likes it, being permanent is a positive thing, but if there is a treatment problem or the patient does not like it, there can be big problems.

Liquid Silicone (Silikon 1000) is permanent filler.  In the past silicone has gotten a bad rap because surgeons were injecting non medical grade silicone into the body and it caused many problems.  In addition they were injecting large amounts of silicone at a single treatment.  Silicone is actually a very naturally feeling and safe filler and I use it for lips, wrinkles folds and acne scars on patients with whom I am well acquainted and have experienced resorbable fillers (those that go away) in the past.  Silicone has been safely used for 50 years, and when using medical grade silicone (which is FDA approved) with the proper technique, it is safe, natural feeling and predictable.  The key to successful silicone injection is called the micro drop technique.  In this technique, extremely tiny drops of silicone (smaller than a pin head) are injected.  The volume may be so small that it is not very noticeable on the first treatment.  When the small droplets of silicone are injected, the body will surround them with the patient’s natural collagen.  This causes an increase in the tissue and produces bigger lips or fills wrinkles.  Silicone is generally injected on a monthly basis until the desired effect is almost reached (since the silicone will grow after the last injection).  After this, touch up injections may be done once a year.  The results of silicone injection last for many years and should only be given by experienced injectors. 

Artefill is the newest permanent filler to obtain FDA approval.  In February of 2008, I injected the first Artefill patient in Richmond, Virginia.  This filler contains microscopic plastic beads that fill the wrinkles and like silicone, stimulate the body’s collagen to increase the filling.  Since the beads are permanent, the result can last for many years, which is a good thing if it is done correctly.  I use Artefill on the smile lines for patients that request it or desire a permanent option.  Since this filler also contains animal collagen, the patient must be allergy tested a month before treatment.  This is a bit of a drawback.

Human fat is also a filler option and although I used to perform a lot of fat transfer, I do it much less since the availability of new fillers.  In fat transfer, I harvest fat from around the belly button and inject it in the lips and face.  Fat is nice because it is the patient’s own tissue but in my experience, most of it gets dissolved with time and it requires several injection sessions to achieve a lasting result.  Another drawback of fat injection is that the area must be over corrected since much of the injected fat will go away.  Due to this, patients will have an extended recovery until the over correction adjusts.


The above descriptions don’t cover every single filler but is a synopsis of the most common available FDA fillers in this country.  Each year new fillers will be introduced.  I recently went to the Cayman Islands to become certified as a trainer and inject a new filler called Evolance (made by Johnson & Johnson).  This will also be promising filler once the FDA approves it for use in this country, which will be soon.

Since every patient is different and every area is also different, many options occur for plumping the lips and filling out wrinkles and scars.  Experienced injectors should be able to guide the patient to the best filler for their particular needs.  To find out more about injectable click the link below.


Lip implants are also an option for permanent lip filling and will be discussed in a future blog entry. To learn more about lip fillers select the following link.


March 19, 2008 Posted by | Lip and Wrinkle Fillers, Lip Augmentation | , , , , | 1 Comment