Dermal Facial Fillers & Lip Fillers

Hyaluronic acid (HA) is a natural material found throughout the human body. It has a simple chemical structure that is know as a glycosaminoglycan. In other words, it is simply made of two slightly different sugar molecules that repeat themselves in long chains and form particles of various sizes. The chains connect themselves with chemical bonds known as cross-linking.

Cross-linking is an important characteristic of HA, since without it, the HA will rapidly disappear if it is injected in the body. Think of the cross-linking between the chains of sugar molecules as the “glue” that keeps the HA stable. Companies that manufacture HA can also select various particle sizes. In general, bigger particles are useful when heavy lifting is necessary under a deep crease or in a hollow cheek, while smaller particles are more useful closer to the skin surface.

The configuration of the HA chains is also important. Some fillers are more “stretchable” than others, which may offer advantages in specific facial zones.

Although HA is found in many tissues in the body, we will concern ourselves predominantly with the HA that is found in the skin. The skin can be viewed as having two main layers, an outer cellular layer (the epidermis) that protects us from the external environment and a deeper structural layer (the dermis) that provides resiliency, tone, and support.

The dermis is largely made up of bundles of collagen and elastic fibers that run through a squishy pudding of HA. The dermis also contains fibroblasts, which are cells that manufacture collagen and other materials, including hyaluronic acid. As we age, our fibroblasts can’t make as much of these good materials, so the skin becomes thinner.

A clinician has quite a few choices available for soft tissue augmentation in the United States—and an even greater range of options in other countries. This is one of the reasons Dr. Cook has spent significant time traveling to medical conferences and visiting clinicians in European countries. In Europe, an almost Darwinian struggle goes on between all of the possible materials that compete for a doctor’s limited attention. In many ways, this is quite good, since the beneficial and useful materials tend to gain market share, while the ones with problems or disadvantages tend to fade away. Since medical materials and drugs come to market much quicker in Europe than in the United States, an American physician who can speak some French or German can monitor the Europeans and predict future developments in the United States. It’s hard for Dr. Cook to say which knowledge has been of greater benefit to his patients: knowing what will probably turn out to be useful or knowing what to avoid at all costs. He has certainly seen plenty of examples of both. Many years ago, he noticed that European doctors were abandoning other injectable dermal and lip fillers and were moving to HA products. As he learned from his European colleagues and began to develop his own injection technique, he was struck by certain advantages inherent in the hyaluronic products:

First of all, they are soft. There is less of a problem with lumpiness or palpability than with many of the other injectable dermal or lip fillers. A pair of lips may look beautiful, but if you feel a firm ridge when you kiss them, they lose much of their appeal.

A second advantage that springs from this softness is the remarkable versatility of HA dermal and lip fillers. With many other materials, the clinician is limited to a small number of sites that be safely injected: lip borders, nasolabial creases, and other facial grooves and furrows. With HA injectables, a highly experienced clinician can actually build up three-dimensional structures in certain facial zones, especially around the lips. This allows for more of a sculptural approach. At the Whole Beauty^® Institute, we use a variety of HA dermal and lip fillers to restore deep volume to the cheeks, the temples, the chin, and other areas that have become hollow from the aging process or from weight loss.

A third advantage is durability. HA injectables persist for months longer than many other forms of soft tissue fillers. To the patient, this means fewer trips to the doctor for restoration.

The fourth advantage, their temporary nature, may at first seem paradoxical. Why wouldn’t it be better just to inject something that will persist for years? After all, there are products out there that supposedly will do just that. There are two powerful reasons why a temporary duration is a desirable characteristic. First of all, if the patient doesn’t care for the result, it will eventually melt away. To achieve their true potential, HA injectables require a highly skilled and visually sophisticated clinician on the other end of the syringe. If a patient is treated by someone who lacks these characteristics, the filler will eventually diminish.

An even more important advantage to non-durability came to Dr. Cook during a visit to one of the European medical congresses. He noticed that physicians with a high level of experience and skill who had used non-temporary injectables in the past were warning others not to do so in their lectures. In each case, the reason was the same: delayed granulomas. No matter what the material, the message was remarkably similar: At first, the doctors loved using a type of injectable, but after several years they began to notice that in a certain percentage of patients, changes began to appear in the skin above the area of injection. These changes consisted of granulomas, which are itchy, raised, red bumps that do not go away. As he looked into the record of these injectable materials, Dr. Cook was struck by the similarity of the pattern:

Stage I: The physician thought he or she had found a lasting injectable that didn’t cause long-term problems.

Stage II: Aggressive marketing on the part of the company that manufactures the injectable material led to uncritical acceptance on the part of certain physicians.

Stage III: Several years later, the physicians discovered delayed granulomas. Since hyaluronic acid is a material that naturally occurs in the body and is broken down through normal turnover, granulomas should be extremely rare. As a practical measure, the team at the Whole Beauty^® Institute has performed thousands of injections with various HA products, and we have seen only a tiny number of nodules, which have responded well to treatment.

The aging process continues after a person has been injected with a filler. With a lasting filler, this may become a problem, since the shifting and settling of facial structures might move the material to a lessdesirable area. This problem is largely avoided with HA fillers, which have the additional advantage of reversibility. Hyaluronidase is an enzyme the body uses to break down HA in tissues. This enzyme is available for clinical use. If for some reason too much HA has been injected, so that an area is fuller than a patient desires, it is possible for the clinician to inject hyaluronidase into that area and melt the HA down to a desired size.

The fact that hyaluronic acid is naturally present throughout the body has great appeal. The simplicity of its structure and its gradual natural breakdown in the tissues are added benefits.

When it comes to facial injectables, there truly is safety in numbers. The more patients who have been treated with a given material and the longer the treatment experience, the more intelligently one can talk about safety. For anyone considering treatment with a dermal or lip filler, a good first question to ask is, “How many people have been treated with this material?”

It is reassuring that millions of facial soft tissue augmentations have been carried out with HA injectables. At the Whole Beauty^® Institute, our team has performed thousands of treatments with hyaluronic acidbased fillers. Our extensive experience works to our patients’ advantage.

Although there is a more limited range of fillers available to patients in the United States than in other advanced countries, patients and physicians have better choices than they did a few years ago. Each dermal and lip filler has a range of applications where it works best. Some are thick and relatively good for lifting tissue. Others are thin and better for very fine lines. Some are of intermediate consistency.