Dermal Fillers: Narrowing the Field

Stock the right mix of fillers for your patients' concerns.
Narrowing the Field

With more than 20 dermal fillers currently on the market in the United States and several more in the FDA pipeline, the question for practitioners is no longer, “Are my patients interested in these procedures?” Rather, the question has become, “How many of these fillers do I need to stock, and which ones offer the best results and value for my patients?”

Each filler offers its own unique characteristics. But, generally speaking, dermal fillers fall within categories based on their thickness—or G Prime—and mechanism of action as a volumizer or stimulator.

Volumizers and Stimulators

Sculptra Aesthetic (poly-L-lactic acid, Valeant) and LaViv (Fibrocell Science), which uses the patient’s own tissue to create an injectable that encourages collagen production, are stimulators. Hyaluronic acid fillers, which physically fill areas that need volume, are considered volumizers.

“If you tell people, ‘I can inject something that will turn your own body on, and it’s going to build collagen and elastin,’ that’s very appealing, in abstract,” says Anthony P. Sclafani, MD, FACS, of the Center for Facial Plastic Surgery in Chappaqua, New York. “But then you have to tell them that it is not an instantaneous effect; they have to wait several weeks, and it may require several injection sessions. That works well if you’re in your 30s and have only a shadow of a wrinkle. But if you’re severely volume depleted, that’s a big commitment that really needs to be discussed.”

There is evidence that HA fillers can perform double duty as both volumizers and stimulators, but the amount of long-term improvement tends to be minimal. “Most of these will also stimulate—the question is, what can you expect of that stimulation?” says Dr. Sclafani. “Dermal needling is popular and can lead to dermal collagen deposition. So when I inject an HA filler, the process of passing the needle back and forth through the skin may stimulate some collagen. There’s also pretty good evidence that the microenvironment around the deposition of hyaluronic acid will stimulate collagen production. How much? In most patients, very little. It’s on more of a cellular level.”

Radiesse (calcium hydroxyapatite, Merz Aesthetics) and ArteFill (polymethylmethacrylate, Suneva Medical) are true combination volumizers and stimulators, featuring tiny beads in a gel carrier. As the body absorbs the carrier, it is replaced by fibrosis around the beads. “In most people’s hands, Radiesse and ArteFill are one-to-one corrections—what you see is what you’re going to get—even though the carrier is absorbed, because you’re also developing some fibrosis around those beads,” says Dr. Sclafani.

Within the category of volumizers, fillers are categorized based on their G prime or thickness. Products with a low G prime have some spread, while those with a high G prime—such as Voluma XC (Allergan)—hold their shape. “Voluma is unique in that the cross-links in the molecules are bound very tightly and very densely, so they stack up on top of each other,” says Lorrie Klein, MD, OC Dermatology in Laguna Niguel, California. “It’s almost like one of those magnet paperweights. When I picture Voluma working, I picture little towers I’m putting in that actually push the skin up, rather than just raising the tide, which is what the other fillers do.”

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