Patient Information — Fillers for the Treatment of Wrinkles, Lines, Etc.

A host of various different fillers, referred to as dermal fillers, soft tissue augmentation materials and implants, are described in literature about the treatment of wrinkles, lines and skin folds. We have provided you below with brief descriptions of the key attributes of the different materials frequently used.

What are non-permanent fillers?

Non-permanent fillers are made of substances that naturally occur in organisms. They are referred to as biological fillers because the body breaks down (absorbs) these materials as time goes on. The time required by the body to break down these dermal fillers depends on the specific character and composition of the material. Usually, it is limited to several months, i.e. the effect provided by non-permanent fillers begins to diminish after several months.

Suitable non-permanent materials include substances obtained from patients’ own bodies, such as fat cells and Plasmagel®. In addition, synthetic biocompatible compounds, like hyaluronic acid, collagen and polylactic acid are available for injection. A new product that has been in use for a while in the USA, where it has produced a good deal of satisfaction among patients, is calcium hydroxylapatite.

Hyaluronic acid

Hyaluronic acid, a substance present in large quantities in human organisms, in particular, the skin, is frequently used as tissue filler under wrinkles, lines and creases. It is manufactured synthetically or from animal protein. Hyaluronic acid has been used to treat wrinkles for a long time and it has a long history of being safe and effective. Today’s hyaluronic acids exhibit much longer longevity with a year and longer being quite common.

In the last few years, different hyaluronic acids have been developed that distinguish themselves significantly with regards to the extent of their cross linking and the resulting “thickness” of the individual particles. While completely pure, non-cross linked hyaluronic acids are usually used to treat very fine, surface lines or larger areas to restore a youthful look to the skin (e.g. Hyalsystem®, Jalupro® or Restylane vital®), highly cross linked hyaluronic acids (e.g. Belotero®, Hydrafill®, Juvederm®) are recommended for deeper wrinkles and creases. With the use of special injection techniques, very highly cross-linked products can be placed in deep layers of the skin, enabling contouring of the entire face. Volume lifts restore the volume lost through ageing due to the natural loss of subcutaneous fat for a youthful natural look. Currently, hyaluronic acid is the most unproblematic tissue filler, i.e. it is the filler with the least number of negative side effects.

Collagen (Zyderm®)

Collagen (Zyderm®), a preparation that has long been in use as a soft filler to combat wrinkles, plays an important role in the deeper layers of the human skin with regards to texture and tightness. It is produced from collagen obtained exclusively from cows in carefully monitored herds. Since there exists the danger of allergization with the use of this preparation, patients are tested prior to injection. New on the market is a collagen product derived from porcine collagen (Evolence®). It is very similar to human collagen and doesn’t require pre-tests. Collagens last between 3 and 6 months on the average.

Polylactic acid (polylactate)

Polylactic acid (polylactate) occurs everywhere naturally in human organisms and can be produced synthetically today (Sculptra®). It offers the advantages of improved compatibility and long lasting effect, the latter a quality that led to it being approved as a semi-permanent filler. This agent is especially suitable for smoothing out nasolabial folds (run from the sides of the nose to the corners of the mouth) and lifting the corner of the mouth. Since large quantities can be injected without concern in a single session, it is especially suitable for larger area treatments, such as sunken cheeks, etc. Usually, the treatment takes place in two sessions, 1 — 2 months apart. Once the desired effect has been achieved, it can be expected to last for a half to an entire year. Particularly, with polylactic acid, the placement of the substance in the appropriate skin layer is of utmost importance to avoid complications. 

Due to its longevity, Radiesse® (Calcium Hydroxylapatite), a relative newcomer on the German market, is also considered a semi-permanent filler. It is manufactured from a very slowly resorbing bioceramic material of calcium phosphate particles, which upon injection form a type of framework that the patients own tissue can infiltrate, i.e. the body’s tissue gradually replaces the excipient gel. Comparable to polylactic acid, Radiesse® is suited for the filling of deep wrinkles, creases and folds or extended, sunken areas or filling and contouring of chin and cheek areas, etc. This treatment is also successful only if the injection is performed properly.

Autologous fat cells

Autologous fat is a non-permanent dermal filler produced from one’s own fat. It is particularly suitable for large volume filling of sunken, haggard looking cheeks. In addition, it is also very useful for the direct filling of medium and larger facial wrinkles and creases. The autologous fat is obtained in a minor outpatient procedure from an area of the patient’s body that is precisely defined in pre-procedure consultation. Local anaesthetic is used. The procedure is called Lipotransfer, because autologous lipoids are taken from one spot and transferred via injection to another location of the same body. Very important in this procedure is that with the extraction of the fat the performing physician is careful to leave the affected tissue, so that the location is symmetric, proportionately smoothed to the body’s contours and without any trace of hollowness or dimpling.

Still another procedure is Liporecycling, which Dr. Sommer played a decisive role in developing. It involves the extraction of autologous fat from areas on the patient’s body where it is not desired by means of liposuction. It is then prepared as required for the ensuing procedure in which it is injected under the wrinkle or crease or frozen and stored for later use. Autologous fat can be kept for up to three years when it is frozen.

Are there are other autologous materials that are suitable for the cosmetic treatment of wrinkles, lines and folds?

Plasmagel®, developed in South America, has been available for quite a while in Europe. Also an autologous product, it is used for the filling of wrinkles and occasionally for the shaping of soft parts. The preparation is specifically produced for each patient. Blood, taken from the patient, is “spun” to separate the solid components of the blood, such as red and white blood cells, from the liquid portion of the blood, namely the plasma, which is required for the production of small injections of Plasmagel®. In the plasma, there are still quite a few soluble blood components, among others, the coagulation factors. Careful warming of the plasma in the injection causes it to take on a jelly-like consistency. If desired, additives, such as local anaesthetics, sodium chloride solution, etc. may be added to the plasma before it is warmed. The gel obtained is then suitable for the filling of wrinkles or correction of soft parts.

Based on clinical results and experience, the material’s longevity is similar to that of collagen products, which means the effect can be expected to last 4 to 6 months.

What advantages do autologous dermal fillers offer?

Autologous materials offer the advantage that they are very patient-compatible and cause no allergic reactions because the body is very familiar with them already. The best known is patient-derived fat. It is the most tried and tested of all the dermal fillers on the market today. The disadvantage associated with such materials is the time, effort and cost (obtaining of fat and blood and their preparation) required to produce the substances. The longevity of the autologous materials differs greatly from agent to agent with the speed with which the materials break down being different from patient to patient.

When is botulinum toxin the best choice to treat wrinkles?

Due to conscious or unconscious use of specific facial muscles, the face, particularly the forehead and the areas around the eyes contract. Typical lines and creases are the dynamic wrinkles that occur with time on the forehead (frown lines, brow furrows) and around the eyes (crow’s feet).
Botulinum toxin, an injectable drug is a “muscle tension blocker” that blocks the transmission of impulses from the nerves to the muscles for approximately 3 to 5 months. It is derived from clostridium botulinum via gene technology under very strict safety regulations. Minute amounts of very diluted botulinum toxin are injected only into the specific area to be treated. Besides a few, very tiny punctures, which are visible for a couple of minutes, the treatment leaves no traces. The effects of the treatment become noticeable within 2 — 7 days. For further details, see the Patient Information section on Botulinum Toxin.

What can you tell me about permanent fillers?

Permanent fillers provide long-lasting effects. This is only possible because the body cannot break down the materials out of which the fillers, such as acrylic pearls, are made. In other words, the foreign material that is implanted in the body remains! Upon the first glance, the lasting effect is very appealing, however, there are distinct disadvantages, including:

With relative frequency, side effects occur, such as the development of allergic reactions and shifting of the liquid materials. Since the body is incapable of breaking these substances down, the undesirable side effects can be eliminated only by means of operation, which is, as is imaginable, usually very difficult and sometimes even impossible.
As our bodies age, the overall subcutaneous fat tissue diminishes, which means that, in spite of satisfactory material compatibility, continuing active effects may have negative consequences. For example, after several years, the receding height of the skin leaves an unnatural, inconsistent looking ridge, which is the permanent implant, elevated above the rest of the surface, like the saddle of a mountain range when the snow melts in spring.

Besides liquid permanent dermal fillers, there are also implants manufactured from solid materials, such as Gore-Tex®, which the body is unable to break down and metabolize. An advantage offered by non-liquid permanent implants compared to their liquid counterparts is that they are easier to remove in the event that side effects occur.

Due to the problems presented here, Dr. Sommer complies with the recommendation of numerous professional associations and does not offer treatments with permanent liquid dermal fillers!