Filler Injections. Your Quick Fix

The two principal categories of temporary fillers approved by the U.S. Food and Drug Administration for facial rejuvenation are hyaluronic acid and calcium hydroxylapatite. The selection of HA implant is based on the indication and site of placement. For lifting and restoring volume, and improving the structural foundations and facial contour, a high-density HA implant is injected deeply into the supra-periosteum. To treat medium-deep depression, we used a mid-density hyaluronic acid filler injected sub-dermally. For treating the periorbital area and the area around the lip, giving finished facial refinements, a low-density hyaluronic acid filler is selected with a water-like consistency filler. The most significant limitation of a filler compared with fat transfer is the potential cost compared with the latter as each syringe can be expensive. The greatest benefit of a filler is accuracy. The other benefit is that a filler is bioinert and does not increase with patient’s weight gain but obviously may not look good when a patient does gain or lose weight as the filler has been injected to match a person’s current weight status.


The two principal categories of temporary fillers approved by the US Food and Drug Administration for facial rejuvenation are hyaluronic acid and calcium hydroxylapatite. The selection of HA implant is based on the indication and site of placement. A high-density HA implant is injected deeply into the supra-periosteum to lift and restore volume and improve the structural foundations and facial contour.

To treat medium-deep depression, we used a mid-density hyaluronic acid filler injected subd-ermally. For treating the periorbital area and the area around the lip, giving finished facial refinements, a low-density hyaluronic acid filler is selected with a water-like consistency filler.

The most significant limitation of a filler compared with fat transfer is the potential cost compared with the latter, as each syringe can be expensive. The greatest benefit of a filler is accuracy. The other benefit is that a filler is bioinert and does not increase with the patient’s weight gain but may not look good when a patient gains or loses weight as the filler has been injected to match a person’s current weight status.

Patients find nothing more gratifying than immediate wrinkles or scars because of filler injection. Fillers are flexible substances that can be injected into the skin to improve the appearance of fine lines and wrinkles, plump lips, fill hollow cheeks, repair various facial imperfections, improve scars, and elevate deep folds—a smoother, more youthful appearance with minimal “downtime” and maximum safety.

Who is the Ideal Skin Rejuvenation Filler Injection?

The ideal filler should be well tolerated by tissues and composed of materials that are not toxic, antigenic, carcinogenic, or teratogenic. The injection administration should be simple, reproducible, consistent, without migration, and safe.

Patients should have predictable outcomes, minimal side effects, and minimal downtime. The product should also be easily stored, versatile, durable, and affordable. The perfect filler does not exist now, and there is some debate on what defines the “perfect filler.”

Some insist on non-permanent filler enhancements due to the ever-changing facial structures as a personage. Thus, the permanent filler may become out of proportion or migrate over time. Some argue that a permanent filler “mistake” is a lifelong mistake that is difficult, if not in some cases impossible, to remedy without surgical intervention.

On the other side, advocates of permanence point to a growing phenomenon coined “injection fatigue” to support the need for permanent filler injections. It is noted that many patients drop out over time and tire of the regular needles and associated discomforts.

Additionally, many drops filler therapies due to economic reasons, as costs mount with continuous treatments required to keep the aesthetic enhancement. Many patients have experienced temporary positive results, like what they see, and want to keep these enhancements permanently without ongoing treatments and expense. This “try before you buy” concept is reasonable, and a need for sustained long-term improvements has a place in the hands of expert physicians.

In injectable filler injection, a wide range of substances is used. Despite what you might have read or heard, there isn’t the best filler; all have risks, though rare ones. Which filler substance is considered “best” or “preferred” for you depends on the doctor’s technique, skill, experience, training, facial needs, and risk tolerance?

Getting headlines doesn’t always make for beautiful results! It has nothing to do with headlines in the media; these are often a result of the company’s marketing efforts that make the filler, though this information is usually downplayed, so the piece comes across as unbiased. It is essential to realize that over the past 20 years, many filler injections that were once highlighted in fashion magazines or touted by doctors (and often heralded by studies paid for by the manufacturer) have since been dropped for a variety of reasons.

Who Needs Skin Rejuvenation Filler Injections?

You can choose not to undergo any cosmetic corrective procedure. Still, then without question, the deep lines between your brows, the lines from your nose to your mouth (nasolabial folds), and even your drooping jawline will not look younger the way you want. It’s not that great skincare can’t make a massive difference to the appearance of your skin (believe us, we know the remarkable benefits a state-of-the-art skincare routine can provide). Simply put, there are no skincare products that can work as well as Botox or filler injection.

Still, age, muscle movement, fat loss, gravity, and sun damage, among other factors, will eventually take their toll, and your face will start looking older around the age of. A filler injection is one way to get a lot of your youthful appearance back. Left alone, it is inevitably a downhill ride.

When celebrities, models, and women all over the world age 45 or older have facial skin that looks smooth and young, you can bet a big part of the reason is that they have had filler injections. If you can get over the fear of needles (no injections are pleasant) and are done wasting money on the wrinkle or so-called “lifting” creams that did not work, perhaps you should consider a filler injection.

Which Skin Rejuvenation Filler Injection is Right for Me?

The aging process causes volume loss as the underlying collagen, hyaluronic acid, elastin fibers deteriorate, and fat stores in the face decrease. This most commonly occurs around the eyes, mouth, cheeks, jawline, brow, and nose bridge, producing crow’s feet, laugh lines, folds, furrows on the forehead, and “hills and valleys” on the lower third of the face.

By directly injecting a naturally-derived or synthetic material into the frown lines between your brows, the deep lines from the corners of your nose to the edges of your mouth, depressions along the jawline, the recessed areas under your eyes, or the hollowed regions of your face, wrinkles and lines immediately become filled-in and skin is plumped up to the point where the crease, depression, or fold is gone.

Don’t confuse filler injection with how Botox works. Filler injection has the unique ability to fill and contour these changes and improve facial scarring from acne or injury. This improvement can last from 3 months to 2 years or even longer, depending on the filler used, how you take care of your skin, and how your face continues to age.

Many people get both Botox and filler injections because the combination can produce a remarkably younger-looking face. Although both procedures involve injections, Botox is injected around the forehead and wrinkles around the eyes (crow’s feet) to stop muscle movement that results in lines. It has nothing to do with the plumping smoothing effect filler injection has.

How are Filler Injections Done?


Dermatologists have developed various filler substances to address a wide range of cosmetic flaws and other needs of the individual patient. Each filler brings subtle, distinctive benefits. One filling provides longer-lasting results; others allow for more precision with fine lines, and still, others can gradually bring the face into better balance, creating an overall rejuvenated appearance. Sometimes I may use more than one filler to achieve the best results.

Filler injection is often considered the first line in treating aging skin and is used in combinations or with other techniques for facial rejuvenation. The ideal material varies by indication. A permanent and immobile substance may be proper for an iatrogenic scar. A soft, resorbable, and non-inflammatory element might be more suitable for wrinkles that change with age.

Numbness of the treated area may vary from merely the applications of topical cream, air, and contact cooling, local anesthesia, and nerve blocks to sedation. The new filler injection is already mixed with anesthesia to make the injection less painful and more comfortable. At MSI, we do our best to make your sessions as painless as possible.

What are the Types of Skin Rejuvenation Filler Injections?


Prof. Moawad uses various filler injections, including hyaluronic acid and autologous fat (one’s fat). Since filler substances do not involve major surgery and are cost-effective, patients use these youth-enhancing techniques more than ever.

With the increasing desire for people to achieve a more youthful appearance, the aging baby boomer population, and the increased demand for “lunch-time procedures,” the pharmaceutical market has responded by providing the cosmetic surgeon with an increasing number of options to meet the needs of the cosmetic patient.

Thus, this cosmetic surgery segment has been the fastest growing for the past decade worldwide. Considerable advances in technology have given cosmetic surgeons an array of filler options. Still, no one filler can address every patient’s concern.

Filler injection can be classified in a variety of ways. According to their source, they can be found autologous, biological, or synthetic. They can also be classified according to risk profile, level of ability needed for injection, or depth of dose. We choose to find these products as filler injections instead of filler injections because they are not placed exclusively into the dermis.

More commonly, filler injection is classified according to its effect longevity: short, long-lasting, semi-permanent, and permanent. These durations can be defined as less than six months, six months to 2 years, 2 to 5 years, and more than five years.

Filler injection is used for various cosmetic purposes, from filling fine lines and wrinkles to augmenting facial contour and projection. Replacement filler injection, or temporary filler injection, are filling agents that are injected into and occupy space for a variable period until they are either degraded by the body or naturally dissipate.

Hyaluronic acid (HA) products, calcium hydroxyapatite (CaHA), marketed as Radiesse, and collagens form this category. These agents have either long-lasting or permanent effects. Bio-stimulatory filler injection, by contrast, runs by inducing new collagen formation. Poly- L-lactic acid (PLLA), marketed as Sculptra, and polymethylmethacrylate (PMMA), marketed as Bellafill, form this category.

Temporary Filler injection


Collagen is the major structural part of the skin. Replenishing the dermis with more collagens seems a natural extension. By the end of 2010, all the collagen filler injections will no longer be available in the United States, as they have been voluntarily withdrawn from the US market.

Hyaluronic Acid (HA) Filler injection

Hyaluronic acid is a part of all connective tissue, including the skin. Hyaluronic acid is chemically the same for all species and has a negligible risk of allergic reactions. Therefore, skin testing is not needed. HA is hydrophilic and supplies a matrix to keep moisture where collagen may develop within the dermis. Hyaluronic acid potently binds to water. One gram of HA can bind up to 6 L of water.

When injected into the skin, its volume softens and hydrates the skin. In addition to these benefits, it plays a role in cell growth, membrane receptor function, and adhesion. Hyaluronic acid stabilizes intercellular structures and produces the viscoelastic network for collagen and elastin fibers to bind together. As seen with photo-aging, these connections fail, thus resulting in disorganized clumps of collagen and elastin. Hyaluronic acid has a heparin effect, thus resulting in a higher incidence of bruising.


This filler is produced by fermentation in bacterial cultures. This filler has been used to correct the nasolabial folds, marionette lines, tear troughs, glabellar frown lines, lip enhancement, and cheek augmentation. Other clinical uses include the correction of the jowls and nasal deformities. Most patients can expect six months of revision, if not longer.

Perlane filler is identical to Restylane except that it consists of larger gel particles. This filler is suitable for correcting deeper folds, such as the nasolabial folds, and works well for cheek enhancement. Most patients can expect 6-12 months of revision with Perlane.

Juvederm (Juvederm Ultra/Juvederm Ultra Plus)

In 2006, the FDA approved Juvederm, a non-animal stabilized hyaluronic filler. Juvederm is a homologous gel with the highest degree of cross-linking of any hyaluronic acid filler injections and thus has a smooth consistency. In the United States, only two types of Juvederm filler injection are FDA approved.

Both Juvederm Ultra and Juvederm Ultra Plus hold 24 mg/mL of hyaluronic acid, but Juvederm Ultra Plus has a higher proportion of cross-linking than Juvederm Ultra. Juvederm Ultra and Juvederm Ultra Plus have indications like those of Restylane and Perlane, respectively, and do not require refrigeration or skin tests before use.

Juvederm (Voluma, Volift, and Vobella)

One of the early signs of aging is volume loss in that part of the face from a combination of fat and bone absorption, which results in sagging skin and hollowing that increases slowly over time. Voluma is the first filler approved by the FDA to claim it can “temporarily correct age-related volume loss in the cheek area of adults over the age of 21.” another quality unique to Voluma is that it can last for two years—exceptional longevity for an HA—and something that makes it particularly appealing to patients who dislike returning for frequent refills.

The concepts of lift, volume replacement, molding, quickly spreading, direct line filling, and improved glowing appearance is all within this agent’s province. For cases of significant volume depletion where either lift or feature augmentation is needed, Voluma is the product of choice.

The milder volume change induced by Volift is designed for a more subtle difference, such as in the perioral and brow/forehead regions. In contrast, the very spreadable texture presented by Volbella is a more critical filler characteristic for superficial placement for lines and for those indications where minimum volume is required.

Hyaluronic Acid for Fine Lines (Belotero Balance)

Fine lines and creepy skin are manifestations of multilevel, age-related volume loss. It is, therefore, logical to combine intradermal volumetric for fine lines with subcutaneous volumetric for contours. This publication supplies evidence- and experience-based rationales for applying cohesive polydensified matrix hyaluronic acid filler (Belotero Balance).

For an excellent line filler, the relative contributions of space-filling, water binding, and neocollagenesis to the mechanism of action have implications for efficacy— both quantitatively and qualitatively, and in the immediate and long term.

The rheologic profile of Belotero Balance supplies a scientific rationale for its ability to address fine lines and crepe skin. Its design as a cohesive, soft, spreading filler that flows through tissue and integrates homogeneously allows it to carry out ongoing 3-dimensional tissue expansion, with the dual potential for structural and dynamic restoration. Clinical study data show that Belotero Balance is efficient, durable, and well-tolerated for intradermal and superficial subcutaneous implantation.

Prevelle Silk

Injection into the mid-to-deep dermis. This filler was FDA approved for use in the United States in 2008 and was the first hyaluronic acid filler to hold lidocaine, which reduces pain upon injection in the USA. Prevelle Silk is shown to treat moderate-to-severe facial wrinkles, although it may be better suited for fine lines.


Elevess is approved for injection into the mid to deep dermis to correct moderate to severe facial wrinkles and folds, such as nasolabial folds. ELEVESS is supported in the EU to correct contour deficiencies, such as wrinkles, folds, and acne scars, and enhance the appearance of lips. ELEVESS is approved in Canada to correct contour deficiencies of the face, such as wrinkles, folds, and acne scars.

Matridex /Reviderm Intra

This is a new resorbable gel suspension filler composed of non-animal stabilized hyaluronic acid, cross-linked hyaluronic acid, and dextranomer microspheres (Matridex and Reviderm intra). It has been used for the aesthetic treatment of facial lines.



Poly-L-lactic acid (PLLA) is a biodegradable, non-toxic, synthetic, inactive material derived from corn starch. It has been used in suture material, stents, and other biomedical implants. Due to the extensive biostimulation effects of this product, it is considered a semi-permanent filler. The clinical results can be seen for up to 2 years. The FDA approved Sculptra in 2004 for human immunodeficiency virus (HIV)- related facial lipoatrophy. It holds PLLA microspheres in a powdered form.

A common finding with this product is palpable but usually nonvisible subcutaneous “micronodules.” More recent studies of PLLA using a diluted suspension of the product have resulted in a dramatically decreased rate of micronodule formation. Many practitioners use six ccs of sterile water for reconstitution, and in areas such as the hands and chest, even larger dilutions are used.

Longer reconstitution times are also recommended, with reconstitution occurring at least 8 hours before injection of the product. I should take care to inject the product in the superficial fat and not in the mid dermis, and the clinician should be careful not to insert the residue at the end of the syringe.


Calcium hydroxylapatite (CaHA) is the mineral part of the bone; therefore, it should not stimulate an immune response, making it biocompatible. This material has been used previously in dental, orthopedic, urologic, and vocal cord applications. It acts as a scaffold for collagen ingrowth. The FDA approved Radiesse in 2006 to correct facial wrinkles and folds and HIV-associated facial lipoatrophy.

In 2009, it received FDA approval for cosmetic use in non-HIV patients. Administration of CaHA supplies immediate 1: 1 correction and does not expand beyond what was injected. Over time, the carrier gel is absorbed, and new collagen is formed around the microspheres. The result is a longer-lasting implant with characteristics close to natural tissue.

Most Radiesse is used to correct nasolabial folds, atrophic cheeks, and temporal wasting. The longevity of correction ranges from 10 to 18months. The clinical results may last for 12 months or longer, although the carrier gel lasts no longer than six months, thus often resulting in a slight decrease in correction. Because of the pain associated with injection, Radiesse was released, which has lidocaine to reduce pain upon injection.

Treatment of the lips has resulted in cyst formation holding the carrier gel. For this reason, most cosmetic surgeons avoid treating the lips with Radiesse. I must take extreme care to avoid injection while withdrawing the needle out of the skin, which will result in the deposition of material into the dermis.

In addition, it should be administered with caution to the tear trough region. In general, the overall rate of nodule formation with CaHA is meager, and no granulomas or nodules have been reported when the product is injected into areas other than the lips. If visible nodules occur, these can be treated by puncturing the buds with a no. Eleven blades or needles and then express the contents.

Permanent Filler injection


Fat transfer, Fat injections, Fat grafting, Micro-lipo-injection

Although fat transplantation has been utilized in medicine for more than 100 years, injecting human fat back into the patient as an effective means to fill in wrinkles and loss of tissue throughout the body and face has been accessible only since the mid1980s.

A fat transfer includes various names: fat injection, fat injections, fat grafting, micro-lipo injection, and autologous fat grafting. The word autologous means material (fat) is harvested from one area and donated to another in the same individual. Autologous fat transfer has become an increasingly important method of facial rejuvenation both as a standalone procedure and in combination with traditional rejuvenation methods, like face-lifting, brow lifting, and blepharoplasty.

Fat transfer is particularly suited for restructuring the proportion of the face. Typical facial structures can also be aided by adding constructive elements to correct a broad range of perceived facial deficiencies. For example, a stronger jawline creates a youthful, more powerful-looking face; ending the hollowness of lower lids helps reduce that tired, sad appearance, and fuller lips create a more youthful, attractive appearance.

Fat transfer is also used for augmenting body contours, such as the breasts or buttocks. In certain respects, fat grafting stands in contradistinction to earlier efforts at rejuvenation in which the face is augmented with tissue rather than subtracted by lifting, pulling, and excising. A simple analogy to understand the benefits of fat grafting is looking at a whole and the ripe grape that becomes prune-like (wrinkled, puckered) over a period like a convex, youthful face that undergoes contraction and involution with age.

It would be better to re-inflate that tiny raisin into a grape rather than remove excess tissue and transform it into a pea. The minimally invasive technique using autologous fat transplantation has become a standard procedure in facial rejuvenation. It is simple, inexpensive, permanent, and valuable. It is considered safe because of its autologous property and fat graft longevity. Other indications include congenital, traumatic defects, or surgical defects and scars.

Autologous fat grafting meets all the fundamental criteria of ideal augmentation materials: availability, low antigenicity, minimal donor morbidity, reproducible, predictable results, avoids non-auto graft disease transmission or incompatibility, not likely to elicit an immune response, most minor reported complications, and longer survivability. Fat transfer provides a very appealing resource for volume augmentation in small and large volumes.

Prof. Moawad and many others insist on the unique dynamic quality of fat as it will age as we age. This exceptional fat quality is perfect for augmentation since facial structures change as we age, and a permanent filler will be out of proportion if used. Other areas where fat grafting techniques are considered superior to synthetic filler injection in terms of the total amount required to perform more substantial aesthetic corrections include the buttocks and breasts.

The Disputes about longevity and the technique variation have postponed the announcement of fat as the perfect filler, added Prof. Moawad. Furthermore, fashion and trends change, and what is accepted now as beautiful may not be allowed later. The best of all is fat grafting is forgivable while the mistake of permanent filler is permanent,” Prof Moawad says. The only relative drawback of fat injection has been the resorption of some fat grafts. However, with proper technique, 30–70% of the fat is retained, Prof Moawad says.

Nevertheless, its use stays limited compared to commercial filler injection. In sheer numbers, less surgically aggressive dermatologists, and now a wide array of non-surgically trained “cosmetic practitioners,” not to mention non-physician “extenders” such as physician assistants and nurse practitioners, and even simple registered nurses – inject the bulk of commercial filler. Surgically trained and oriented cosmetic practitioners are far more likely to use fat and complement other surgical procedures such as face–neck lifts and blepharoplasty.

While synthetic filler injection can smooth out wrinkles and folds, it cannot restore fullness that is naturally lost as fat and bone diminish, and it is not for everyone. Some individuals are allergic to synthetic materials and may develop an allergic reaction. Furthermore, due to high cost, I cannot use synthetic materials in copious quantities to restore body deformities, augment breasts or buttocks, or even hands, making fat grafting a much more desirable and economical treatment choice.

Patient choice plays a vital role in the success or failure of any procedure. It never pays to run on patients with unrealistic expectations, as they are never satisfied with the outcome. It is vital to have a detailed history, including their past, personal, and psychiatric history.

In people with severe depression, facial outlook acts only as a part of the problem and will only help but not treat the cause of depression. It is noticed during the consultation that some patients are not sure what the most proper procedure is for them. In nonmedical terms, I should explain the process and its potential complications and alternatives to those and others.

An ideal candidate will be an individual in good health, with no current or preexisting medical condition, who is not on any immunosuppressive or anticoagulation therapy and has realistic expectations. Fat grafting could be considered ideal for those areas where you need a lot of filler, such as in those patients who have full-face lipoatrophy. Individuals who are allergic to bovine collagen (animal origin) or other synthetic materials, but want youth-enhancing results, are good candidates for fat transplantation. People with “contour deformities” may also receive help from fat transplantation.

By contour deformity, we mean a large surface area of skin sunken or otherwise uneven due to a traumatic injury or surgery, for example, after liposuction. Another indication could be the atrophy typically seen in the aging dorsum of the hands, Prof Moawad says, offering a more lasting treatment solution for this cosmetic thorn.

Patients with a history of underlying current infection, smoking, anticoagulants, coagulation disorders, herpes simplex, and significant acne scarring are not ideal candidates for fat transfer. Patients with gross wrinkles and poor skin tone will need added procedures for optimum results. One must be careful in dealing with patients with poor or delayed wounds. People with bleeding disorders, or those who have diabetes, are not suitable candidates for the procedure. Fragile people with inadequate donor fat sites should not undergo this procedure.

Silicone (Silikon 1000, Adatosil 5000, Bioplastique)

Silicone, in the currently FDA-approved “off-label” filler substances SILIKON 1000 and ADATO SIL-OL 5000. In medicine, silicone is extensively used in elastomers (solid) form, such as intravenous fluid tubing and implanted prosthetic devices. Silicone gel is used for breast reconstruction and breast enlargement. The suspension should be injected into the subcutaneous tissue and has been chiefly used to correct facial rhytids and lip augmentation. The enormous size of the silicone particles prevents them from being engulfed by immune cells. Therefore, they stay at the injected site, producing local fibrosis and contributing to the filling effect.

Liquid injectable silicone readily fulfills most of the criteria for an ideal filling substance. It is a clear, odorless, tasteless, colorless, and stable substance. Although the technique is dependent, the advantages of liquid injectable silicone over other liquid injectable filler substances are its precision and permanence. Liquid injectable silicone does not harden or soften, is unaltered within the range of human body temperature, and is chemically unchanged by exposure to air, most chemicals, and sunlight.

It can be stored for extended periods at room temperature and does not allow for the growth of microorganisms. Although not entirely biologically inert, liquid injectable silicone has been shown to have the least physiologic reactivity of most foreign materials. Additionally, it lacks mutagenic, carcinogenic, and teratogenic effects; no true allergies to silicone have been documented.

Despite concerns about its long-term safety and adverse inflammatory reactions, the long-term experience of physicians skilled in administering liquid injectable silicone has shown it to be safe and efficient for augmentation. With depressed, broad-based acne scars, the 1,000-centistoke viscosity liquid silicone is used exclusively with a 27-gauge 1/2-inch needle.

Using the microdroplet, multiple-injection approach, lesser amounts of silicone are injected at the correct depth in the tissue at monthly intervals, usually requiring only a few treatments. Allowing about a month between treatment sessions enables the scar to stretch, reconfigure, or accommodate the presence of liquid silicone.

Silicone has been implicated in various local and systemic adverse inflammatory reactions. Concerns about its long-term safety and adverse tissue reactivity have been raised in many articles. Treatment-site reactions, including redness, pain, tissue hardness, discoloration, ecchymosis, excessive tissue elevation, and migration of the injected material to local and distant areas, have been reported—more severe complications, including subcutaneous bumps, lumps, ulceration, and regional lymph node enlargement.

Following copious amounts of silicone injections, physicians have reported tissue destruction, scarring, and lung and liver inflammation. None of those mentioned in earlier reports have associated such side effects or complications with silicone for acne treatment. Only tiny volumes of the material are employed.

Artefill, Artecoll, Arteplast, Bellafil (PMMA)

Polymethylmethacrylate (PMMA) is an acrylic plastic that has been used in many medical applications for years, including bone cement, lenses, dental work, and pacemakers. This filler is shown to correct the nasolabial folds, although used for acne scars and forehead furrows. Because this filler contains lidocaine, the injection is less painful than other filler injections that do not contain lidocaine.

PMMA supplies support for human collagen deposition. Suppose placed too superficially, leading to lumps. Most practitioners prefer a threading injection technique. Unlike the other filler injection, this filler should be considered permanent. Because results are lasting, it is often best not to achieve full correction in one session but to carry out the desired effect over several treatment sessions.

Bellafill (previously known as Artefill) has been marketed and sold in the United States as a permanent filler to correct nasolabial folds since 2007 and received FDA approval for acne scarring in December 2014. With this new indication, Bellafill is currently the only “on-label” filler approved by the FDA to treat moderate to severe, atrophic, distensible facial acne scars on the cheeks of patients older than twenty-one.


This filler is composed of a suspension of 6% polyvinylhydroxide microspheres suspended in 2.5% polyacrylamide gel and has been used chiefly for lip augmentation. It is not written down for lip augmentation. Several adverse effects (AEs) have been reported with this product, including local tissue necrosis, granuloma formation, chronic inflammation, and infection. A unique complication associated with this product is the development of stiffness, lymphedema, and nodules after-treatment of the lips.

Skin testing is mandatory before using this agent, and PMMA is contraindicated in patients with either one positive response or two equivocal responses. Furthermore, a contraindication is extended to patients with a history of severe anaphylaxis, those with an allergy to bovine collagen or sensitivity to lidocaine.t is therefore not recommended in patients with a susceptibility to either keloid or hypertrophic scarring.

What Are My Risks/Complications of Skin Rejuvenation Filler Injection?


All medical procedures carry some risk. Besides an allergic reaction to the injected substance, side effects are few and typically due to the local injection. However, soft tissue fillers are considered safe and effective.

The outcome of treatment with Injectable is never wholly predictable. Still, individuals vary in anatomy, physical reactions, and healing abilities. Risks unrelated to allergies include infection, abscesses, open sores, skin peeling, scarring, and lumpiness, which may persist over the treated area.

We suggest that they are classified as early, late, and delayed. These time frames should be defined as less than 14 days, 14 days to 1 year, and more than one year. Early complications are considered inflammatory. Late complications are secondary to granuloma formation. Delayed complications may be due to biofilms.

Technical Aesthetic Complications

As with any complication in medicine, avoidance is far preferable to management. Fillers are classified by the US Food and Drug Administration (FDA) as devices, not medications. Therefore, the same precautions with other implantable devices apply to dermal fillers. However, the occurrence of post-treatment complications in some patients is inevitable. I can address the following difficulties efficiently if they result from reversible fillers:

Volume: too much or too little filler

Depth of treatment: filler injected too superficially or too deep.

Location: unfavorable anatomic location or asymmetry, or injection into the incorrect anatomical location.

I can quickly treat problems with reversible fillers such as Hyaluronic acid with Hyaluronidase to dissolve or remove undesired or insufficient volume may be addressed by adding more product. Still, I cannot easily remove irreversible fillers. Problems with irreversible filters are much more challenging to manage, especially if vital structures have been treated.

Even in the best hands, complications may occur, requiring extreme caution, especially when injecting the product around vital facial structures. Therefore, Prof. Moawad strongly recommends that they not be considered a first-line choice and should be used only by clinicians with substantial training and experience with these filler agents.

Swelling and Bruising

Swelling and bruising are both technique-dependent and patient-dependent variables that contribute to the degree of these expected side effects. I can minimize swelling and bruising by avoiding aspirin compounds, nonsteroidal anti-inflammatory drugs (NSAIDs), and vitamin supplements for 7–10 days before the procedure. Swelling mediated by inflammatory cascade due to trauma or injection may also occur. Pre-treatment and post-treatment with ice can decrease the swelling and bruising response associated with cosmetic filler injection.

Lumps and Nodules

Lumps and nodules can be caused by almost any filler when too much is injected into a small area for assorted reasons, including incorrect dilution, reconstitution, or inaccurate placement or technique. The resulting lump or nodule is usually easily treated with a simple incision and drainage using a sharp disposable needle. If nodules due to excess products are multiple or profound within vital anatomic structures, a formal incision and drainage may not be feasible. In such cases, HA products can be treated with HYAL.

Capsular contracture around tissue fillers is quite rare. Hyaluronidase may be administered to clean up whatever remains behind. A small amount of local anesthesia may be needed to pass a larger bore needle or 16-gauge Luer-Lok syringe to break through the capsule and aspirate the material within. Hyaluronidase should be used with caution if an infection is suspected since this may spread the infection to surrounding areas.

Tyndall Effect

The Tyndall effect (bluish discoloration) results from the injection of HA fillers too close to the skin’s surface. It can readily treat bluish discoloration with HYAL.

Around the Eyes Filler Injection Complications

As filling the infraorbital region has become more popular, side effects, such as the appearance of eye bags, worsening of existing eyebags, or persistent upper cheek swelling, occur more frequently. This may occur when the injector treats too high, operates too close to the infraorbital rim, injects too deep, accidentally penetrates the septum, or injects too much product.

Those injected with Radiesse; may be treated with injections of sterile water or saline (with or without lidocaine for local anesthesia) and massage to help dilute the material mechanically. Careful injection of HYAL into the area and subsequent massage to diffuse the HYAL and bring it into contact with the injected filler. It is also important to remember that particulate forms of HA derivatives (such as the Restylane family of products) respond faster than the monophasic types (such as Juvéderm).

Persistent skin redness and Spider Veins

Persistent redness and spider veins that continue beyond two weeks after the injection may occur with any of the dermal fillers. After filler injection, redness and spider veins have also been treated successfully using Lasers or light.

Angry red bumps (granulomas)

Foreign body granulomas are the body’s attempt to remove foreign material. Therefore, granuloma formation can occur with any of the injectable dermal fillers. Nodule formation tends to occur as a delayed adverse reaction from the implantation of a filler. No red bumps that develop after injection immediately occur because of the uneven distribution of the product.

In an exact granulomatous process, all sites initially injected with filler material appear adversely affected at the same time. Infection may present clinically as single or multiple nodules, often with associated signs of inflammation, such as redness and pain. In addition, nodules secondary to a hypersensitivity reaction can present identically to those due to infection. They should be treated as infectious until a diagnosis of hypersensitivity has been established through thorough skin testing.

The treatment of granulomatous inflammation should begin with investigating what agents have been injected. From there, the physician must decide the best pathway to success. Unfortunately, removing the product that has been diffusely injected into vital structures such as the lips is neither practical nor desirable. The options, then, consist of methods to control the inflammation and halt the process.

Once the diagnosis of granulomatous inflammation has been made because of treatment history, physical, and, if possible, tissue biopsy, options for treatment are serial injection with cortisone or trials with various drugs. Prof. Moawad has successfully treated these lesions with graduated injections of triamcinolone acetonide. He starts with doses of 0.1 mL of a 10-mg/mL solution and then increases the concentration to 20 mg/mL and 40 mg/mL with repeated injections until valid.

Treatment should occur every four weeks, and the amount injected should be carefully controlled to prevent post-treatment soft tissue atrophy. Prednisone in doses up to 60 mg/day has improved some patient signs and symptoms. Another approach is to discourage unusual cell growth by injecting 5-fluorouracil plus corticosteroids. Surgical excision is the most effective and definitive approach for well-circumscribed nodular granulomas.


The death of most or all the cells in the injection site (necrosis)due to injection is a rare but potentially overwhelming severe side effect with soft tissue fillers. Decay typically occurs due to either interruption of vascular supply due to compression or natural obstruction of vessels by direct injection of the material into a vessel. The glabellar region carries the highest risk of necrosis, presumably because of the small-caliber vessels supplying this region.

An additional risk from intravascular injection in the glabellar area is blindness. This catastrophic complication occurs from the injected filler flowing backward to the retinal artery. An increased risk of this event arises when a large volume bolus is inserted, such as greater than 0.1 mL of material. PMMA carries the most significant risk of this complication of all the dermal fillers.

I should take several precautions to avoid necrosis. These precautions include knowing the anatomy of the vasculature in the injection area, aspirating before injection, not using an excessive volume of the product, and not using extreme pressure during the injection. If necrosis is suspected, treatment options include applying warm clothes to facilitate local vasodilation and applying nitroglycerin paste – at the first sign of blanching – to promote further vasodilation.

For cases in which an HA filler was employed, there has been a report of impending necrosis being successfully treated after injection of Hyaluronidase and the distribution of the underlying vessel and adjacent violaceous skin. In this case, it is thought that Hyaluronidase removed some of the products and decompressed the vessel.

Therefore, it is recommended to inject the affected area with Hyaluronidase if an intravascular injection is suspected, with 75–one hundred units of the product. There is some evidence to suggest using Hyaluronidase for impending necrosis, even if the dermal filler used was not an HA.

The theory in this context is that the Hyaluronidase may also disperse the other material, allowing for revascularization. For severe or unresponsive cases of necrosis, deep subcutaneous injections of low-molecular-weight heparin into the affected area may benefit.

Gentle wound care and ointment application to the necrotic skin are also recommended. In cases of tissue loss, no reconstruction should be employed for several months, or at least until the eschar has fallen off and healthy circulation and tissue integrity have been restored.


Several infectious disease concerns have been associated with soft tissue fillers. The most common viral infection in the skin after injection is herpes simplex. It may be caused by bacterial, viral, and Candida species, and it may sometimes occur as a polymicrobial infection.

Patients with a strong history of cold sores or fever blisters may be pretreated with acyclovir, famciclovir, or valacyclovir to reduce the severity and duration of cutaneous herpes infections. If there is any question of ocular infection, consultation with an ophthalmologist is recommended since it may require surgical debridement of the cornea. Patients should be initiated on broad-spectrum antibiotics, such as a tetracycline plus a macrolide, to limit the emergence of resistant bacteria.

Other antibiotic regimens include clarithromycin, quinolone, and minocycline, often for 4–6 weeks to cover for atypical mycobacterial infection, which may not grow well in culture. Reevaluation of the site should occur after 48 hours of antibiotic therapy, and if the fluctuance continues, incision and drainage and repeat culture should be sent.

If no response to treatment occurs over several days, I should consider a biopsy for tissue culture and an adjustment of antibiotics. When there are multiple inflamed swellings in various sites corresponding to the injection sites, contaminated products should be suspected. The recommended management is the same as employed for single inflamed swellings, including incision and drainage, culture, and empiric antibiotics.


Some bacteria secrete a self-made, highly protective “slime layer”—or biofilm that acts as a form of a shell, blocking out the local environment to the point that antimicrobial drugs are no longer valid. Once a biofilm has developed, the bacteria have a “safe room,” and neither the immune system nor drugs or medication can penetrate the protective layer.

Thus, bacteria can lie dormant for exceptionally extended periods, only to reawaken and cause more problems once the environment is favorable again. As a result, they can cause angry bumps, boils, lumps, and even full-blown recurrent infections when they arise from their planktonic state. These may be present on dental plaques, making the intraoral injection of soft tissue filler a higher risk of secondary infection from these highly antibiotic-resistant bacteria.

A further risk occurs when injection occurs soon after a dental procedure, disrupting the biofilm and increasing the number of circulating bacteria. Any implant, including all fillers, significantly reduces the threshold at which contaminating bacteria can cause infection.

Furthermore, the punctures of repeated injections may reactivate inflammation. Until the foreign body is completely removed, it is difficult, if not impossible, to remove the biofilm; the bacteria are irreversibly bound to the foreign material. With solid implants, such as hip or knee joint prostheses, it is impossible to clean the devices ex vivo thoroughly, and I must replace them.

New strategies for addressing this issue in solid implants include drug-eluting implant coatings, and future permanent fillers may utilize this strategy. Excision may be the only recourse available with permanent fillers (e.g., PMMA). If permanent implants are used in vital structures like the lips or eyelids, clinical options are limited, and I must make difficult choices. The clinician should consider these issues carefully when selecting permanent or long-lasting fillers in such critical structures.

The simplicity of removing HA fillers with HYAL is a considerable benefit. To optimally prevent injection site infection, recommendations are as follows: properly sterilize the treatment area with either alcohol or chlorhexidine, never inject over areas of active infection, such as acne, herpes simplex, or impetigo, avoid intraoral injection, avoid injecting over an existent implant, and avoid injecting in patients who have undergone a recent dental procedure.

There is no proof that a simple alcohol swab prep and non-sterile gloves are insufficient in preventing granulomas or filler infections. Still, Prof. Moawad believes that transferring surgical expertise in sterile techniques to the clinic treatment room may further reduce the prevalence of these complications.

What is Hyaluronidase (HYAL)? What is Used For?

In the uncommon circumstance when an undesirable outcome occurs with hyaluronic acid, correction is possible with the injection of commercially available Hyaluronidase, which breaks down the unwanted hyaluronic acid dermal filler. Clinicians are encouraged to have it readily available to treat asymmetry or unfavorable cosmetic outcomes after HA injection, especially in emergencies such as impending necrosis due to vascular compromise.

Hyaluronidase for this purpose is not FDA approved and is considered off-label use. It may be injected directly and slowly into the affected site to initiate hydrolysis of the previously injected HA. In many cases, 10- 30 units of unpreserved Hyaluronidase is enough to achieve the desired correction. I can perform additional corrections, although complete corrections may take up to 4 weeks to fully appreciate. Injecting a small amount of appropriate local anesthesia will facilitate massage, which is essential in obtaining the therapeutic effect.

The nature and quality of the dermal HA filler product are essential considerations for the effectiveness of HYAL. For example, the non-cross-linked HA fraction responds immediately (in seconds to minutes) to HYAL, allowing it to surround the tiny particles. Suppose a particulate form of dermal filler is used like Restylane. In that case, HYAL can quickly surround the granules of heavily cross-linked HA and hydrolyze the material over a broad surface area, several orders of magnitude larger than that of monophasic products like Juvéderm.

With the Juvéderm family of products, HYAL can only affect the outermost surface of the aliquot, taking far longer to break down the HA. In Prof Moawad’s opinion, massage is essential to mechanically mix the HYAL with the HA and promote hydrolysis in the clinical setting.

Complementary Procedures to Filler Injections

Various techniques have been used to improve cutaneous changes seen with photo-aging to complement the effects of filler injection. Topical applications of tretinoin and alpha-hydroxy acids lead to increased collagen and diminished wrinkles.

Increased deposition of new collagen has been reported after CO2 laser resurfacing, dermabrasion, and chemical peels. In recent years, wounds and new collagen depositions have been shown by non-ablative skin resurfacing. Laser, light, and other energy-based technology such as radiofrequency or ultrasound treat skin wrinkling and sagging non-ablative.

In non-ablative tissue tightening, the epidermal injury is minimized, and thermal energy is directed into the reticular dermis and subcutis, where immediate tissue contraction and delayed remodeling cause skin tightening collectively.

The attractive features of non-ablative skin tightening are limited post-procedure healing time, ability to return to work or social engagements, reduced risk of adverse events compared with ablative resurfacing or face-lift, and less need for physician oversight.

With careful assessment, appropriate intervention can be identified and employed to correct the inevitable effects of aging on appearance. Filler injection is an excellent medium for targeting individual areas for improvement, but adjunctive treatments can be great utility when treating the entire face.

Botox Injection VS. Filler Injection

skin rejuvenation botox injectionprocedure

The simple rule? “Lines of expression need botulinum toxin. Lines at rest need filler.” Prof. Moawad says that while Botox is an excellent choice for hitting those “crease points” where muscles contract, fillers are best for deep lines present even when facial muscles are not contracting.

While technically not a filler, very tiny amounts of Botox are injected into specific facial muscles to immobilize or relax the underlying cause of lines and wrinkles. It is commonly used to improve forehead creases, furrows between the eyebrows, and crow’s feet. Using Botox and filler injection in the same area may achieve longer-lasting results. Prof. Moawad uses BTX-A as adjunctive therapy with soft-tissue augmentation to make more effective, longer-lasting results, especially in some facial regions (i.e., deep glabellar furrows or lip augmentation).

Platelet Rrich Plasma (PRP)


Platelet-rich plasma (PRP) is an autologous concentration of human platelets in a small plasma volume. Many alternative terms to PRP are used in the literature, including autologous platelet gel, plasma-rich growth factors, and autologous platelet concentrate.

The use of growth factors permeates many fields of medicine and surgery, including facial rejuvenation and plastic surgery, maxillofacial surgery, dentistry, oral surgery, tissue engineering, research and development, cardiovascular surgery, orthopedic surgery, and sports medicine, gastroenterology, and urology. Platelet preparations have applications in operation and are especially useful for the bony reconstructions met in facial plastic and reconstructive surgery.

Their use in these situations has been associated with decreased operative time, the need for drains and pressure dressings, and the incidence of complications. Platelet-rich plasma has been applied to wounds, supplying hemostasis, adhesion, and enhanced wound healing—possible recent use for improving wound healing after ablative fractional CO2 laser resurfacing.

Concentrated platelets are a rich source of seven fundamental protein growth factors actively secreted by platelets during the initiation of wound healing. Human growth factors have been investigated extensively, and clinical applications of individual growth factors such as keratinocyte growth factors and platelet-derived growth factors are used to treat oral mucositis and non-healing diabetic wounds. PRP production has been simplified to use in the office and operating room.

Subcision Surgery


The term “subcision” denotes a method that involves cutting under a depressed scar, wrinkle, or contour using disposable needles inserted under the skin through a needle puncture. The procedure attempts to raise the base of the defect to the level of the surrounding skin surface. The integrity of the skin surface is minimally compromised, just as with a routine needle puncture.

The effectiveness of subcision for correcting several types of skin depressions depends on two distinct phenomena. First, surgically releasing the skin from its attachment to deeper tissues results in skin elevation. Second, the introduction of a controlled trauma initiates wound healing with consequent formation of connective tissue, resulting in augmentation of the depressing site.

Hyaluronic acid (HA)-based filler injections are widely used to fill lines and compensate for volume loss. Recent clinical observations prove the persistence of the filling effect is longer than the biological availability of the filler injection.

Stimulation of new collagen by cross-linked HA and up-regulation of elastin has been suggested to explain this observation and supported experimentally and cross-linked HA substitutes for fragmented collagen in restoring extracellular matrix required for regular activity of fibroblasts, such as collagen and elastin production.

Several monthly sessions are needed. Boosting facial and non-facial skin through fibroblast activation is a new indication for HA-based products. Injectable HA has also been recently registered in Europe as an agent specific for improving skin quality (Restylane Skin boosters). Fat transfer, injectable filler injections, and alloplastic implants.

By understanding these issues, a surgeon can better discuss what would be ideal for a patient. Fat grafting offers the most cost-effective solution to a patient with enough volume loss. Injectable filler injections supply a natural, predictable, and correct non-surgical alternative that is scalable in cost.

Alloplastic implants are ideally used in individuals with skeletal rather than soft-tissue deficiencies or in younger patients where the soft-tissue envelope is enough to mask the implant. The use of injectable products for cosmetic enhancement is increasing rapidly.

This is due to the full range of practical options, decrease in social stigma, and the excellent safety profile of these products. However, complications do occur, and therefore, an awareness of the potential complications and how to best avoid or manage them will help maximize the success of these valuable therapeutic tools.

The emerging objective of injectable treatment is facial harmonization rather than rejuvenation. Joint therapy is now a standard of care. Its use will increase further as we refine the concept that aspects of aging are intimately related and that successful treatment entails finding and addressing the primary causes of each.






The Art of non-surgical Facial Skin Rejuvenation

The Art of Non-surgical Facial Skin Rejuvenation