Choosing a filler: Considerations and concerns increase with products' longevity

October 1, 2008

When choosing among temporary, semipermanent and permanent dermal fillers, increased longevity may also mean increased risks, an expert says.

Key Points

Colorado Springs - The longer a filler lasts, the more cautious one must be in using it, an expert says. However, some permanent fillers can provide satisfactory results in carefully selected patients.

In general, dermal fillers approved by the Food and Drug Administration (FDA) are extremely safe, says David M. Duffy, M.D., a Torrance, Calif., board-certified dermatologist who holds teaching appointments at the University of California, Los Angeles, and the University of Southern California.

However, Dr. Duffy says, "The key is that as fillers last longer, one must be much more careful when selecting patients."

These fillers also may negatively interact with certain drugs or inflammatory processes even years after injection, Dr. Duffy adds.

Such complications don't occur commonly in good hands, "But when they do, nobody understands the mechanism underlying them or the best way of treating them," Dr. Duffy explains.

Adverse events commonly associated with temporary and semipermanent fillers include beading, bruising, clumping, erythema, short duration and patient disappointment.

"We see a lot of bruising - it's hard to believe how many compounds contain aspirin or other anticoagulants. I have a list of about 100 that I discuss with patients preoperatively," Dr. Duffy tells Dermatology Times.

Temporary fillers

Patients and physicians must understand that filler longevity varies substantially from patient to patient and is based upon volume employed in what time frame, location, type of filler and individual patient characteristics.

Manufacturers' optimistic predictions are based upon the use of unlimited volumes of product during their studies, Dr. Duffy says. "In real life, most patients can't afford the several thousand dollars that such liberal use of fillers would necessitate."

Nevertheless, temporary fillers, such as collagen and hyaluronic acid, offer advantages, including versatility, safety, instant gratification and the knowledge that "if the patients don't like the results, the results are going to go away," he says.

Moreover, Dr. Duffy says, temporary fillers are technique-forgiving, and overcorrection creates only temporary problems. Additionally, temporary fillers work well for superficial defects.

In contrast, he says, "Longer-lasting fillers are more viscous and must be injected more deeply; while overcorrection is generally to be avoided," Dr. Duffy says.

He also says that temporary fillers rarely cause permanent problems, such as amaurosis or tissue necrosis when intra-arterial injection occurs.

Technique

Technique is particularly important when using permanent fillers.

Superficial injection into inflexible tissues can result in beading (most commonly seen when treating horizontal forehead wrinkles), or "doughnutting," which denotes an elevation at the periphery of rigid ice-pick scars, Dr. Duffy says.

To avoid nodularity after the use of temporary fillers, Dr. Duffy stretches the treated area with his fingers to make sure the filler isn't visible. He also discusses the fact that when using temporary fillers, the deeper the injections are placed, the shorter duration of the fillers.

Conversely, the more superficially these fillers are injected, the more tendency there is toward nodules or lumps.

Dr. Duffy will sometimes give patients large Q-tips to take home, instructing them that if they feel lumps or bumps three or four days after treatment, they can smooth out the area by firmly pressing it with the unpadded end of the Q-tip. He combines this method with hyaluronidase for persistent nodules following the use of hyalurons.

"Don't be afraid to reach inside the mouth and feel the area where you've injected," he says. If one can feel lumps and bumps after injection, patients will feel them as well, and they can be treated with firm compression.

This is a particular problem when treating the oral commissures and melolabial rhytides, Dr. Duffy says.

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