Dermal Fillers
Classification
1) Temporary
2) permanent fillers
Subclassification
1) Alloplast
2) Allograft
3) Xenograft
4) Autologous tissue
Alloplast options
Requirements
1. biocompatible - inert
2. Non-toxic
3. nonallergenic
4. noncarcinogenic
5. non-inflammatory
6. non-mutagenic
7. does not migrate
8. feel soft, smooth
9. long lasting
10. should be adaptable for any cosmetic defect
11. result has to be predictable and permanent
12. sterilisable
Temporary fillers
Poly-l-lactic acid (NewFill/Sculpta)
 injected intradermal where a fibrous response is elicited – stimulates
neocollagenosis
 only product that 'plumps up' thin skin and restores fullness to the face
 Lasts longer than most temporary fillers - persistence of up to 2 years
 Usually from 2 for moderate depressions Ranging to 5 for more widespread
volumising of face. Then usually 1 treatment top-up every 12 - 18 months
 Only facial filler to be approved by the FDA for the reconstructive management of
HIV-associated facial lipoatrophy.
Hyaluronic acid(Perlane, Restylane)
 derived from streptococcal bacterial fermentation (Perlane, Restylane)
 Hylaform derived from rooster combs of domestic fowl
 no allergy test required for any of these
 Perlane is a more robust form of Restylane for use in the deep dermis and at the
dermal-fat junction.
o Perlane for deeper folds and volume augmentation of lips
o Restylane for moderate wrinkles and lip enhancements
 less risk of clumping and go in more smoothly than collagen
 Overcorrection is not needed
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Usually 2 treatments 1 month apart then 1 treatment every 4-8 months
Effects noted to be 82% at 3 months and 33% at 1 year
Lindqvist PRS Jan 2005 - "Optimal cosmetic result" was achieved with a smaller
volume of Perlane than Zyplast with less local injection-site reactions
Injectable bovine collagen
 rapid enzymatic degradation within 3 to 6 months
 The more mobile the area injected, the quicker the resorption time of the
collagen implant
 hypersensitivity rate of 3-5% (usually within first 1-2 weeks)
 requires skin testing in the forearm 4 weeks prior to injection
 contraindicated in patients with autoimmune diseases.
 Usually 2 treatments, 1 month apart. Then 1 treatment every 4 to 6 months.
Treatment intervals often increase over time.
 Treatment for hypersensitivity may include topical tacrolimus 0.1% twice daily,
systemic cyclosporine, systemic steroids, intralesional steroids, and time.
 Types
1. Zyderm 1
o 95-98% type I collagen, and the remainder type III
o 3.5% bovine dermal collagen by weight
o injected into the papillary dermis
o Overcorrection by approximately 100% is required
o For fine surface lines, around eye area and for those with very fine skin.
2. Zyderm II
o identical to Zyderm I except that it is 6.5% bovine collagen by weight
o injected into superficial reticular dermis
o Overcorrect by 50%
o For moderate surface lines, areas of high muscle stress and overlaying
etched lines after Botox or Newfill.
3. Zyplast
o 3.5% bovine dermal collagen cross-linked by glutaraldehyde
o less immunogenic than Zyderm I or Zyderm II, and it is more resistant to
degradation
o injected into mid-deep reticular dermis
o No overcorrection required.
o For deeper lines, wrinkles, scars and lip enhancement.
o It is often layered with Zyderm I or Zyderm II for more dramatic, longerlasting results.
Injectable human collagen (Cosmoderm, CosmoPlast)
 Purified collagen derived from cultured human fibroblasts
 considered to be safer than bovine-derived collagen.
 Low risk of adverse immune reaction – no skin test required
 CosmoDerm is used for minor skin defects; CosmoPlast is used for defects that
are more serious.
 Last 3-9 months
 Overcorrection required
 Combined with hyaluronic acid injection for best results
Dextran micro-beads (Reviderm Intra) – not available in Australia
 40- to 60-m dextran beads suspended in hyaluronic acid of non-animal origin
 Intradermal injection without overcorrection
 Stimulates fibrosis
Polyvinyl alcohol (Bioinblue) – not available in Australia
 composed of synthetic high purity polyvinyl alcohol (8%) and water (92%)
 metabolised, lasts for 12months
Permanent fillers
Silicone Oil
 Permanent
 Microdroplets injected subdermally – induces fibrosis
 Characterised by foreign body low grade chronic inflammatory reaction
 Complicated by migration, late infections, granulomas, and palpable masses
 Withdrawn by FDA
Solid Silicone Particles (Bioplastique)
 solid silicone particles(permanent) suspended in a polyvinylpyrrolidone
carrier(absorbed)
 large doplet size and texturing prevents migration
 elicits low grade inflammatory response
 not approved for lip augmentation in the US
Polymethylmethacrylate microspheres (Artecoll)
 Permanent filler
 polymethylmethacrylate microspheres suspended in bovine collagen
 collagen serves as a vehicle for injection and is eventually degraded, leaving
behind permanent implantation of the beads
 mixture is injected without overcorrection
 Injected into dermal-subdermal junction
 must be tested for allergy to bovine collagen prior to administration.
 company recommends a single skin test 14-21 days prior to treatment.
 Avoid in patients with thin, flaccid skin because of the risk of permanent surface
irregularities.
Polyacrylamide hydrogel (Aquamid)
 Polyacrylamide used in contact lens - molecule is not dissolved in water, but
"swollen" like a sponge. The gel is in dynamic equilibrium with the surrounding
tissue, but still the polymer retains its ability to hold water and remains elastic
over an extended time giving the implant a soft and natural feel.
 nontoxic, stable, nonresorbable sterile watery gel consisting of approximately
2.5% cross-linked polyacrylamide and nonpyrogenic water.
 Used extensively in Russia/Ukraine for breast augmentation (direct injection) and
other aesthetic procedures
 Seems to only evoke a thin capsular response
 Oppenheimer effect observed in rats
Alkyl-imide gel polymer (Bio-Alcamid)
 Synthetic gel polymer comprised exclusively of networks or alkyl-imide groups
(approximately 4%) and non-pyrogenic water (approximately 96%). Alkyl-imide
belongs to the family of acryl-derivatives and its polymeric structure does not
contain free polymers.
 Once implanted, Bio-Alcamid, becomes covered by a very thin collagen capsule
(0.02 mm) which completely surrounds the gel, isolating it from the host tissues
 Popular in Europe (used since 2001) – has been used to correct significant tissue
loss such as facial atrophy (facial wasting, sunken cheeks etc.), Poland's
syndrome, Pectus excavatum, gluteal (buttock) atrophy.
 Touted as being removable
Gore-Tex (PTFE threads)
 Permanent filler
 composed of nodules of solid PTFE interconnected by thin fibrils of PTFE
characterized by a microporous structure.
 Also comes as tubes (SoftForm)
 most bioinert material available, is noncarcinogenic, causes no allergic reaction,
and causes very little foreign body granulomatous reaction (has been reported)
 subdermal implantation
 Disadvantage: very difficult thread removal, lack of incorporation into the wound
bed, concerns over long-term effects such as palpability, capsular formation,
contraction, and lip distortion
Calcium hydroxylapatite (Radiance, Radiesse)
 mild fibrous response is deposited around the CaHA particles, stabilizing the
implants and adding further bulk
 Can cause nodules, not recommended for lip augmentation
Allograft
Additional Requirements
1. no risk of transmitted diseases
Acellular human cadaveric dermis (Alloderm/Cymetra)
 allogeneic human dermis that is freeze-dried to remove all immunogenic cells
while maintaining the structural integrity of the extracellular matrix
 elicits neither a cellular-specific immune response observed with transplantation
of allogeneic tissue nor a nonspecific foreign-body reaction seen with placement
of alloplastic material
 This lack of an induced inflammatory response may imply long-term persistence
of the graft and minimize the risk of reactive fibroplasia and subsequent capsular
formation.
 80-85% persistence rate (higher risk of resorption with smokers)
 Cymetra is the micronized, injectable form of AlloDerm.
 No allergy testing required
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Cymetra not recommend for use in the glabellar region because of the risk of
arterial occlusion. If injected periorbitally, these viscous soft tissue fillers can
cause overcorrection, local skin necrosis, or retinal artery thrombosis.
Autologous bioengineered options
Additional Requirements
1. mimimal donor site morbidity
Injectable autologous dermal collagen(Autologen)
 available through the processing of patient skin that otherwise would be discarded
 benefits: does not require skin testing and that it lasts longer than bovine collagen
 no long-term results
 drawbacks include small quantity and high expense.
 requires careful timing of the procedure since it must be used within several hours
of delivery
Injectable autologous fibroblasts (Isolagen)
 3-mm punch biopsy obtained from the patient
 Processing usually takes 6 week, test dose administered in the meantime
 needs to be injected into multiple levels of the dermis for best results
 must be given within 24 hours after delivery
Summaries
Skin testing required for
1) Bovine collagen – Zyderm, Zyplast, Artecoll
2) Isolagen
Complications
Allergic
1) Allergy
2) Hypersensitivity
3) Swelling
Nonallergic
1) Bruising
2) Infection, abscess
3) Overcorrection
4) Undercorrection
5) Granulomas, foreign body reaction
6) Fibrosis - hardening
7) Nodules, lumps
8) Extrusion (Silicone, Goretex) – difficult problems to treat
9) Skin necrosis (0.09% of collagen injections)
10) Arterial embolisation
a. embolization and occlusion of the ophthalmic artery led to partial
visual loss after an attempted correction of wrinkles in the glabellar
area with bovine collagen in 1 patient (Dermatol Surg Oncol 1988)
b. A case of unilateral blindness was reported after using autologous fat
injection as a filler into the glabellar area (Stroke 1993)