Cosmetic medicine has been revolutionized by non-surgical treatments over the last few decades, and one of the most important and versatile is the dermal filler. This diverse group of prescription-only injectable products can help reverse the signs of facial ageing by adding volume, smoothing lines and gently recontouring the face with minimal downtime. These powerful biomedical tools require skill and a sound scientific understanding to be used safely and effectively, as there are real risks if treatment is not done correctly. This article aims to provide an overview of the most important aspects of dermal fillers: the science behind them, how and where they are used and, most importantly, how to choose a safe and reliable practitioner.
The complex biological process of facial ageing has both intrinsic genetic and extrinsic environmental causes such as UV exposure and lifestyle. The most recognizable signs are lines and wrinkles, but the more profound change is the loss of volume and descent of facial tissues. After our late twenties, there is a progressive decline in the production of structural proteins—collagen and elastin—in the skin, and the fat pads in the face that provide youthful contours become smaller and descend. This results in the jawline softening and becoming less defined, the cheeks and temples hollowing, the folds from the nose to the mouth (nasolabial folds) and from the corners of the mouth to the chin (marionette lines) deepening and the lips thinning. In reality, this is a process of loss of support and scaffolding from within the face and not just wrinkling of the skin. Dermal fillers are the tool of choice to correct this and help restore a youthful appearance.
The most common fillers are biocompatible gels that integrate with the tissues of the face and are used to replace lost volume. The gold-standard material is a sugar molecule called hyaluronic acid (HA), a naturally occurring substance found throughout the human body, particularly in the skin, joints and eyes. In nature, the body can create its own hyaluronic acid and it is continuously degraded and replenished. The most important property of HA is that it has the unique ability to bind water, with one gram of HA able to hold up to six litres of water. This makes it the most potent hydrator we know of. The synthetic HA used in dermal fillers is made from a bacterial fermentation process to produce a non-animal stable gel that is chemically identical to naturally occurring HA in the body, but cross-linked to give it a predictable resistance to immediate breakdown. It is this slow metabolism that makes the filler provide volume for weeks or months at a time until it is gradually and safely metabolized and absorbed. HA fillers are very safe as it is a natural substance found throughout the body, so the chance of an allergic reaction is almost zero. If a patient is unhappy with their treatment, it is also a significant advantage that there is a hyaluronidase enzyme that can rapidly reverse an HA filler. In the hands of a competent and trained practitioner, the safety and outcomes for HA fillers are excellent.
One of the true skills of dermal filler treatment is the ability of the practitioner to choose the most appropriate product for each area of the face. Fillers are carefully engineered with different levels of cross-linking (firmness and longevity) and particle size, which creates products with a wide range of consistencies, from thin and flowing to thick and cohesive. The skilled practitioner is like a sculptor, with an in-depth understanding of the product toolbox. The thinner, more flowing gels are used to subtly hydrate superficial lines, for example, around the eyes, or to soften the edges of a treated area. Medium-density products are used to correct mild folds and add volume to lips. The thickest and most robust fillers are the structural fillers. The dense cross-linked matrix is used to provide lift and contour to the mid-face by adding volume to the cheekbones, to redefine a jawline and project the chin. The placement of strategic lifts of supportive filler can subtly lift sagging tissues to provide a non-surgical facelift effect by providing an underlying scaffold to recreate the youthful architecture of the face.
Dermal fillers have many uses, including much more than just filling lines. Their primary use is in restoring volume in areas that have been lost with age. Placed deeply on or over the bone or injected into the fat compartments, fillers are injected deep onto the bone or into the fat compartments to rebuild the support. The first step is to rebuild lost volume in the cheeks and temples to lift the lower face and soften deep folds. This has the effect of restoring a more heart-shaped facial profile. Lip augmentation remains a popular treatment, but now the emphasis is on lip enhancement and balance rather than on pure volume. This can include border definition, creating a slight upwards lift at the corners and adding proportional volume to the middle of the lip. Fillers are also used to help regenerative aesthetic effects. Injection of HA has been shown to stimulate the skin’s fibroblast cells to produce new collagen (neocollagenesis). The clinical term for this process is “pre-conditioning effect”. The new collagen created as a result of HA filler injections will remain even after the filler is absorbed, giving long-term benefits and thicker skin beyond the mechanical effect of the filler.
Another recent development in filler techniques is the holistic “liquid facelift” concept. This is where practitioners look at the whole face rather than isolated lines. They will strategically place different types of filler into multiple areas such as the cheeks, jawline, chin and temples to rebalance proportions, restore harmony and provide a global rejuvenation effect that appears completely natural. The aim is to help people look like the best versions of themselves by turning back the clock. This involves a thorough knowledge of anatomy, a skilled aesthetic eye and a gentle hand, and it should be remembered that a small amount of filler goes a long way.
The importance of safety and practitioner qualification must be emphasized. Dermal fillers are prescription-only medicines, and their injection is a medical procedure, with the potential for complications. The market’s popularity and visibility has seen a rise in non-medical practitioners offering cheap treatments using unregulated or counterfeit products, which is putting patients at extreme risk. The most serious risk, albeit rare, is vascular compromise from accidental injection into a blood vessel, which can lead to blocked blood flow and tissue necrosis (skin death) or, worse, blindness. Only a medically trained individual (doctor, dentist or nurse prescriber) will have the detailed anatomical knowledge to safely navigate the complex vasculature of the face and avoid these complications. A qualified and legitimate practitioner will have the detailed training and expertise to undertake an adequate consultation and medical history, obtain informed consent and set patient expectations appropriately. They will only use approved products from reputable sources and perform the treatment in a hygienic clinical environment.
Treatment is a personal choice and the post-treatment experience is also an important factor for patients to consider. Dermal filler is minimally invasive, and the most common side effects are local redness, swelling, tenderness and bruising. These are temporary and usually last a few days to one week. The results are instant, though the final result will take a few days to settle as swelling subsides and the product blends into the tissue. Results can last from six to eighteen months, depending on the product, area and individual metabolism. As the effects are temporary, repeat treatment is needed to maintain the desired effect, and patients are free to choose how often they do this.
Fillers are becoming increasingly destigmatized and are becoming a normal part of our culture. The modern focus is on a natural refreshed look, an ever-elusive “done but not over-done” aesthetic. The more evolved the public perception, the more people see these products as tools to enhance rather than completely alter their features. This is supported by improved product technology and more sophisticated injection techniques that provide subtle but powerful results.
In conclusion, dermal fillers are an amazing combination of biomedical science and artistic medicine. They provide a safe, targeted, effective and non-surgical way to counteract some of the most significant signs of facial ageing: volume loss and structural descent. By carefully and thoughtfully restoring what has been lost, dermal fillers can help people feel more confident and empowered. But with great power comes great responsibility. The key to a successful and safe outcome is in the hands of a qualified, experienced and ethical medical professional. Dermal filler treatment should be seen as a medical art form to be enjoyed by both the patient and the practitioner and, when performed in this way, it is a highly safe and effective way to enhance and restore the natural architecture of the face.
