Comparing Fillers

I’ve been around awhile in dermatology, and there have been lots of changes in fillers since I started injecting in 2003.  Yes, that’s over 15 years, how can it be, when I am only 30?  But I digress…

When I first starting injecting fillers in residency, we were using collagen, first of bovine, then human origin, which was difficult due to a need for allergy testing.  Then, suddenly there was this amazing product called Restylane, which quickly rocked the world of fillers, sending collagen to the bottom of the barrel.  Restylane, and most of our conventional fillers are made of hyaluronic acid and was synthesized in a lab, eliminating the need for allergy testing and the risk of allergy.

For years I usually used Restylane and its counterpart Perlane in the office.  Then a study came out that Juvederm lasted a little longer.  One study demonstrated 75% of effect remaining at six months vs. 60% of effect at 6 months with Perlane, so I switched for years to solely using the Juvederm family of products.  So, what do I use now? A little bit of everything!

Over the past few years, thankfully a number of independent studies have now looked at properties of the fillers and tried to define how they are different independent of drug company claims and marketing.  Currently, there are a number of different variables that make all the fillers different and few tests to determine how those variations impact performance, functional ability, and results.  This discussion will specifically focus on hyaluronic acid fillers.

Properties:

Concentration – How many filler particles per a given volume.

Particle Size – As a simplification, those with smaller particle size are placed more superficially and used for more fine lines

Crosslinking – Refers to how the particles are connected and suspended within the solution.

Water absorption – Some of the fillers naturally draw water to themselves, some much more than others, this can lead to fluctuation of result depending on the hydration of the filler once in the skin.

 

Tests of Functional Ability:

G Prime (G’) – Also know as the elasticity coefficient, refers to the ability of the filler to maintain shape and structure.

Viscosity, Flexibility or X Strain – Refers to Flexibility and refers to the ability of the filler to move well with your skin and to withstand shearing forces.

 

The chart below shows the best illustration I have found of all of this.  This chart really helped me a lot.  As you can see, on the G Prime axis, Restylane is all the way to the right giving the most structure and support.  I now primarily use Restylane Lyft for Marionette lines for this reason.  On the other axis, I usually still prefer Juvederm Ultra as a great well-rounded filler and I often use it for fine lines and filling more superficial areas and lips.  After many years, I don’t feel there is a huge difference in the longevity of the different hyaluronic acid fillers, so I choose more on the scientific performance than anything else.

 

Admittedly, if you talk to a hundred injectors, you will have a hundred different approaches to this.  Some injectors even use multiple syringes of different types of filler on the same patient to achieve more specialized results.  The fact of the matter is, most of my patients can’t afford to use multiple different syringes of filler at a given appointment.  So, I have really been challenged over the years to make one syringe work as much as possible.  I try to always fully correct the area that is of most concern to the patient using the filler that scientifically has been shown to be most likely to meet their desired effect.

Below are some older before and afters from my early days of using Restylane and Perlane.  I need some new pictures, so if you are in for filler and want to be a model, let me know!

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