Dermal Fillers, Lip Fillers - Hyaluronic Acid Injections Information

Dermal fillers are made of various kinds of natural and man-made or synthetic materials that have been developed over the years for injection into the skin.

This is not a new treatment. As early as the 1890s, doctors could take fat from patients’ arms and inject it into their faces. In fact, fat is still a popular substance used by some practitioners today who can move fatty tissue from an area of the body where it is not required and inject it somewhere else. If you would like to find out more about this treatment, please go to our fat transfer section.

In the mid 1900s, doctors were using paraffin and then silicone as a filler in the skin, with some reported problems regarding safety that prevented them being used widely.

In the U.S.A. in the 1980s, scientists discovered a type of collagen (a filler material) which occurs naturally in cows’ skin that proved to be safe in humans. At this point, the use of fat as a filler material was overtaken by this new collagen.  

According to Statistics from the American Society for Aesthetic Plastic Surgery, (ASAPS), collagen injections were the 14th commonest aesthetic procedure in the U.S. with more than 53,000 treatments in 2010 (last recorded data). Between 2005 and 2008 there was a continued decline in the use of collagen based dermal fillers in the USA, with a slight rise of 1.4% in 2009, followed by another sharp decrease of 9.5% in 2010. From 2011, ASAPS stopped gathering data on the use of collagen based dermal fillers due to this decrease in usage and many manufacturers have also discontinued the production of various collagen based brands during 2010 & 2011.

This can be attributed to rises in the use of predominantly hyaluronic acid based dermal fillers and others which are now growing steadily having received FDA approval for use in the USA in recent years (i.e. calcium hydroxlapatite, poly-l-lactic acid and polymethyl methacrylate dermal fillers).

The hyaluronic acid based dermal fillers (including FDA-approved brands Restylane® , Juvéderm® & Belotero®) are now the 2nd commonest aesthetic procedure in the U.S. with 749,409 treatments in 2019, a drop of 7.5% on 2018. With calcium hydroxlapatite (Radiesse™) accounting for 34,776 dermal filler procedures (an increase of 9.3% in its use compared to 2018), poly-l-lactic acid (Sculptra®) 28,100 (an increase of 0.2% from 2018), and Polymethylmethacrylate (Artefill/Artecoll) accounting for just over 4,400 treatments in 2013 when data was last reported.

Although similar statistics are not yet available in the U.K., there has been tremendous growth in the use of collagen and other dermal fillers in this country. More people than ever are having this treatment because it works, it is not as expensive as a face lift and it doesn’t involve any surgery.
 
As the use of these products has grown, so has the choice of different filler substances. Since the late 1990s, some manufacturers have been claiming that their products last longer than older fillers, and even that their effects can be permanent.
 
If you are considering a dermal filler procedure, the following information will give you a basic understanding of what's involved. It can't answer all your questions, since a lot depends on the individual patient and the practitioner. Please ask a practitioner about anything you don't understand.

As the skin ages, it gradually loses some of its collagen and fat. These are the materials that prevent the skin from becoming saggy. Thus, as we age, our skin can become thinner and more wrinkled and lined.

Dermal fillers help to restore our skin to its former youthful appearance. Material is injected into the skin in areas where it needs to be plumped up again and made to look firmer.

Fillers come in different thicknesses, and in general, the thicker the product, the deeper it is injected into the dermis (middle layer of the skin - see diagram below) to help plump out fine to deep lines and wrinkles.

Background image provided courtesy of Q-med Limited.

Dermal fillers tend to be broadly classified as being either non-permanent or permanent in their effect by both manufacturers and practitioners using these products.

Non-permanent or resorbable dermal fillers

In 1981, Collagen was the first filler approved in the U.S. for soft-tissue filling by injection. It is made from bovine (derived from cows’ skin) collagen and is currently known in the U.K. as Collagen Instant Therapy.

The collagen is taken from the cow and then purified to such a degree that it resembles the collagen which occurs naturally in our own skin. It is necessary to have a skin test before this treatment, however, as some patients may be allergic to bovine collagen.

Collagen instant therapy comes in different thicknesses, depending on the depth of your wrinkles or loss of firmness in your skin. You will sometimes hear Collagen Instant Therapy called by the brand names Zyderm® and Zyplast®. Unfortunately due to a decrease in popularity these brands were discontinued in 2010.

Evolence®, a porcine (derived from pigs) based collagen product was available in the UK from 2005 to 2009 when it was discontinued for commercial not safety reasons.

Other collagen only based fillers include Cymetra, collagen derived from human skin. This is rarely used these days.

The leading dermal filler used by most UK practitioners is a hyaluronic acid based product. This particular brand is manufactured using bacteria. Again, this product comes in different thicknesses and is called Restylane®.

Hyaluronic acid is a naturally occurring substance found in the spaces between the cells of body tissues in all animals. It has already been used widely in general medicine to help eye surgeons perform cataract operations, and for injection into arthritic joints to aid movement. It is estimated that 30 million patients around the world have been treated with some form of hyaluronic acid. Hyaluronic acid has now largely replaced collagen as the favourite filler of U.K. cosmetic experts. This is because it is more likely to be compatible with our bodies than collagen, and so people are less likely to be allergic to it and do not require a test prior to use.

Other hyaluronic acid only based products include:

Hylaform® and Hylaform Plus® - Manufactured from cockerel combs. This is being discontinued by the manufacturer in favour of other products.

Juvederm® ULTRA, Belotero®, Teosyal®, Matridur® and Hydrafill are examples of other Hyaluronic acid based brands derived from non-animal sources.

A newer filler using polylactic acid is promoted under the brand name Sculptra® (formerly New-Fill®). According to the manufacturer, Sculptra®, as the name suggests, is used more as a sculpting agent rather than just a wrinkle filler (see injectable tissue stimulators) and larger areas can be treated with a longer lasting result.

Another product new to the UK market in 2004 is calcium hydroxylapatite, the key component of Radiesse™. Calcium hydroxylapatite has been safely used in the body for many reasons including dental applications where bone build-up is needed for reconstruction and also in block form for cosmetic applications such as cheek, jaw, cranial and chin implants.

Radiesse is marketed as a long lasting dermal filler and facial sculpting agent where results can last for 2 years or longer.

Most of the ingredients of available non-permanent or temporary fillers have been widely used and clinically tested for safety and effectiveness.

Permanent or non-resorbable dermal fillers

These are fillers that can give a longer lasting effect, or even a permanent effect, and may be recommended in some cases by a practitioner.

These products are currently not widely used, but include the following brands:

Artecoll® - Rounded PMMA beads in bovine collagen.

Aquamid™ - Polyacrylamide.

Matridex® - Hyaluronic acid with Dextran microspheres.

Collagen treatment has been widely used to increase the size and volume of lips in women for a number of years, and this is still the most popular use for most dermal fillers.

However, these products are also very effective in both men and women in helping to fill out lines around the lips, the lines from the nose to the corners of the mouth (nasolabial lines), smile lines on the cheeks, as well as crow’s feet and forehead wrinkles.

Thicker fillers can also be used to add volume to sunken cheeks and weak chins, reshape the tip of the nose, as well as filling out deeper acne or other scars. In addition, fillers can be used to help reduce the appearance of veins and bones in aged hands with thin skin.

Usually, if you need to have fillers in the upper part of your face for movement lines associated with expression i.e., crow’s feet, forehead and general wrinkle lines, it is usually recommended that the fillers are used alongside injections of botulinum toxin (or Botox®).

Some fillers can be used to treat larger skin defects in other areas of the body.

More recently dermal filler products have  begun to be used for ear lobe rejuvenation to help plump up the lobe and restored the fullness and shape which is often elongating and saggng with the natural ageing process, allowing a more youthful look and a better cosmetic appearance when earring jewellery is worn in the ear.

Similarly dermal fillers, specifically hyaluronic acid based ones, can also be used to address issues in relation to the female genitalia, such as g-spot treatments for enhanced sexual pleasure or to address issues of vaginal atrophy where there is a loss of elasticity and volume in the outer labia which can lead to vaginal dryness and other symptoms. Treatment for this is available specifically using a brand called Desirial. This treatment is sometimes marketed as 'labial puff'.

Depending on the area treated, and the depth of wrinkles or scars or sagginess of the skin, your practitioner may recommend that different combinations of types of fillers are used in order to achieve the best results.

During your first visit to a clinic, you should explain what you expect from a dermal filler treatment and how you would like to look afterwards. Your practitioner should discuss any potential problems connected with the treatment, such as allergies. You must discuss which filler is best for you and how much it will cost.

For instance, if bovine collagen is recommended, you will be advised to have a skin test where a small amount of collagen is injected into your forearm to see if you have an allergic response. This skin test is only currently recommended for products containing bovine collagen which has limited use nowadays. Other dermal fillers can be used without a skin test. The area injected will be checked after 2 - 3 days and again after 4 weeks to see if there is any swelling or tenderness. Around 3% of people will have a positive skin test preventing them from having treatment with bovine collagen.

The practitioner should take a medical history to make sure that there are no reasons why you shouldn’t have the treatment. Then you will usually be asked to read detailed information and sign a consent form which means that you have understood what the treatment may do, along with any potential side effects from the filler(s) being used.

Photographs may also be taken by the practitioner for a “before and after” comparison of the treatment.

The consultation, skin test (if appropriate), or maybe even an initial treatment might happen in your first visit, if your skin suits the filler recommended and you are comfortable in going ahead with the treatment. If not, you will simply be given a second appointment to begin your procedure.

For treatment of lines and wrinkles, an anaesthetic cream is sometimes applied to the area 20 minutes or so prior to injection. This helps to numb the area to be treated and reduces pain when the needle is inserted into the skin.

Before injections in the lips, a dental or lip block may be used, where a small amount of lignocaine/lidocaine (an anaesthetic like the ones used by dentists) is injected into the lip area to help to numb them prior to treatment.

However, as dermal filler products have developed in recent years, we now find that many hyaluronic acid based gels are available with the addition of 0.3% lidocaine combined with the gel in the syringe. This provides an instant relief from pain upon injection and removes the need for a separate nerve block or topical anaesthesia.

Different injection techniques are used depending on the type of filler and the area being treated.

For filling out wrinkles, the two main techniques are:

linear threading technique, where the full length of the needle is inserted into the middle of the wrinkle and the material is then injected while pulling the needle slowly backwards;

serial puncture technique, where several injections are made in a line along the wrinkle or fold to lift the wrinkle;

for plumping out the face, or filling larger areas such as hollow cheeks, either a fan technique or cross hatching technique is employed.

Follow-up treatment

Depending on the type of filler used, and the area treated, top up treatments are usually required to maintain the effect.

Depending on the area treated, and which filler is used, treatment times can vary from around 30 minutes to an hour, and recovery time can be from a few hours to a few days. However, most people find that they can return straight back to work after treatment with dermal fillers.

Depending on the area injected and the type of filler or pain control used, patients may find the procedure relatively painless to mildly uncomfortable. Treatments around the nose or lip areas are usually more painful.

The obvious, immediate and most common side effect is slight bleeding after the needle has been inserted into the skin. Other risks include mild bruising, tenderness, redness and swelling that may also occur around the site of injection. These signs may take 2 - 3 days to vanish completely, especially around the lips where there is little flesh and the skin is tender.

Rarely, allergic type reactions can occur after treatment with some fillers. These include prolonged redness, swelling, itching and or hardness and bumps in the skin. Such signs may appear at some or all of the points of injection. Sometimes, they can last for several months or longer, but this is extremely unusual.

If you have a history of cold sores, or fever blisters in the treated area, filler injections may cause them to break out again. In these cases, your practitioner may recommend that you take an anti-herpes medicine before treatment to help reduce the likelihood of an outbreak of cold sores.

Very occasionally, delayed side effects can occur many months after the first treatment. These side-effects usually appear as red lumps showing up underneath the skin. Sometimes, these may be permanent. There is some evidence that these may be more common and more difficult to treat with some of the permanent fillers.

It has been reported in clinical journals that very rarely the use of dermal fillers can lead to blindness due to incorrect placement of the product and/or migration. The study by Lazzeri published in April 2012 entitled 'Blindness following cosmetic injections of the face' compared the data from twenty-nine clinical articles which described 32 patients in which blindness was a direct consequence of a cosmetic injection procedure of the face. In 15 patients, blindness occurred after injections of adipose tissue (from fat transfer); in the other 17, it followed injections of various materials, including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate (PMMA), hyaluronic acid, and calcium hydroxyapatite.

It is important that you follow the advice of your practitioner carefully after dermal filler treatment. This will help you to gain maximum effect from the procedure and reduce the risk of complications.

Post-treatment advice may include:

• iced water soaks or ice packs to help to reduce swelling (although this is generally not required);
• the use of pain-killers such as paracetamol, if required for a few days after treatment;
• arnica (a homeopathic remedy) cream or tablets are sometimes recommended a few days before and a few days after treatment as there is some evidence that this can reduce bruising;
• bruising and swelling should go down after a couple of days, but if you continue to experience very painful swelling and bruising, or if any blistering occurs, you should contact your practitioner;
• similarly, if you experience any delayed reactions such as lumpy redness occurring any time after treatment, you should contact the person who treated you immediately.

As in any treatment to the skin, injections should be avoided in areas where the skin is swollen or where infections are present – e.g. active acne. This will reduce the risk of infection at the injection site after the treatment.

If you have even the slightest allergic reaction to a particular filler, it cannot be used and you will need to use a different brand. Dermal fillers have not been tested in pregnant women, so their use would normally be not advised by practitioners if you are expecting a child.

If you have suffered from a disease of the auto-immune system, you are likely to be allergic to bovine collagen and so it cannot be used. You need to give your doctor a detailed medical history to avoid such outcomes. Conditions which are not suited to the use of bovine collagen include: rheumatoid arthritis; psoriatic arthritis; systemic or discoid lupus erythematosus; or polymyositis.

Dermal fillers are categorised by the UK medical authorities as medical devices. This means that practitioners do not need to write a prescription to use these treatments.

Manufacturers recommend that only medically qualified practitioners should use collagen and hyaluronic acid or other dermal filler treatments. Thus you will find many nurses, as well as general practitioners, cosmetic doctors, dermatologists, plastic surgeons, ophthalmologists (eye specialists) and private dentists offering one or a range of dermal filler options.

Manufacturers do not recommend that beauticians or any other person outside the medical profession use these treatments.

As there are many different fillers on the market that can be used to treat a variety of problems, please ensure that your practitioner has undergone proper certificated training for both the use of the specific filler, and the area that they are treating.

Costs vary depending mostly on the type of dermal filler used and the degree of filling to the skin required.

Generally prices for dermal fillers are based upon the estimated number of syringes needed to obtain the required result.

Deeper lines and wrinkles tend to require more filler than shallow lines.

In addition, fillers used more for facial sculpting, contouring and addition of volume will tend to me more expensive than those just used for treating single lines.
 
A combination of fillers may also be recommended, and for certain areas additional treatments with other agents such as botulinum toxin (Botox®) may also be suggested, (especially for lines in the upper part of the face).

In addition, differnt filler brands such as Restylane, Perlane, Radiesse and Juvederm differ in price to clinics and practioners who purchase them from the respective manufacturers.

Hence, overall prices may vary from £150 to over £750 per treatment session.

Remember, using less filler than is actually required to fill out a line or improve the contour of the face properly will generally produce a less pleasing and less long lasting effect than opting for a proper (and more expensive) treatment.

We do not know exactly how many treatments using dermal fillers, or indeed what type of fillers, are currently being used in this country. We do know, however, that they are an increasingly popular cosmetic procedure.

As fillers are technically regarded as “medical devices” in the U.K., there are few restrictions to prevent them being used.

Some members of the medical profession are concerned about the recent growth in new fillers available in the U.K. and feel that more studies should be performed on them to see how safe they are and how long their effects can last.

The most widely used products in the U.K. are the non-permanent hyaluronic acid fillers, such as Restylane and Juvederm and are used by thousands of practitioners on millions of patients across the world. Their results are generally safe and very effective.

The final result, however, is dependent upon the type of filler which the practitioner uses, the problems you want treated, and the skill of the practitioner.

Make sure that they are experienced with the filler that they are using, and ensure that your idea of a pleasing aesthetic result, particularly when these products are used for lip enhancement, is the same as yours!

Nasolabial lines before (left) and after (right) treatment with Restylane®.

Photographs provided courtesy of Q-med Limited.

Thin lips and lip lines lines improved with Restylane®.

Photographs provided courtesy of Q-med Limited.

Glabellar frown lines before (left) and after (right) treatment with Restylane® injections.

Photographs provided courtesy of Q-med Limited.

Subtle reshaping of the cheeks with Restylane SubQ
(Images taken using MediZen's VECTRA 3D imaging system)

Images provided courtesy of Dr David Eccleston at MediZen

Female, décolletage (area between next and breasts) before (left) and 6 weeks post (right) treatment with Belotero®.

Images provided courtesy of Dr.Geoff Fairris, Dermatologist at the Wessex Skin Clinic.

Female nose before (left) and after (right) nose reshaping with Restylane® Perlane.

Images provided courtesy of Dr Marc Armangué, Medical Aesthetics Ltd.

Thin skin and loss of fat revealing veins and bones in the hand.

Improvement in appearance following treatment with Radiesse.

Images provided courtesy of MediZen Clinics Ltd

All before and after photographs are real patients, your results may differ.