In the ever-growing world of anti-aging products and procedures, cosmetic facial fillers are gaining popularity among men and women alike. Atlanta-based plastic surgeon Nelson Castillo, MD, discusses how fillers work and answers frequently asked questions. 1. Q: What are cosmetic fillers? A: Cosmetic fillers are the second most popular minimally invasive procedure in plastic surgery practices. Whether used to support the soft tissues of the face, enhance a patient’s facial anatomy, restore soft tissue volume loss, or lift tissues that gravity and age have caused to thin and sag, fillers help create a more youthful shape and contour to the face, often delaying the need for surgery. Cosmetic fillers are not the same as neuromodulators, like Botox, Dysport, or Xeomin, which prevent muscle contraction and, thus, wrinkle development–though they all certainly contribute to facial rejuvenation and a younger appearance. When I ask patients if they are more concerned about wrinkles or sagging, thin skin, 99% will say sagging, thin skin–and that’s where fillers come in. Fillers work directly on tissues by filling in thin lips, “laugh lines” around the mouth, lower eyelid hollowing, and the apples of the cheeks. And, in fact, cosmetic fillers are not just for women, as professional men like executives and salesmen are one of the fastest growing consumer markets for filler use. When administered properly, fillers allow men to maintain a masculine, yet youthful appearance while projecting a greater overall sense of self-confidence. 2. Q: What are the different types of fillers available? A: The several different types of fillers available vary by their chemical composition, degree of gel thickness, and anticipated duration of effects. The most commonly used fillers today are comprised of hyaluronic acid, or HA, a naturally occurring substance found throughout the skin and connective tissues of the body. HA filler brand names include Juvederm, Voluma, and Restylane. The thicker, gel versions of these fillers are typically injected deeper into the skin in areas like the cheek, jawline, or chin, while thinner fillers are placed closer to the skin surface and are good for the areas around the eyes and the lips. The chance of an allergic reaction to HA fillers is small, and many patients find comfort in the fact that if they do not like their post-procedural result, the effects of HA fillers are fully reversible. In contrast to the immediate effects seen with HA fillers, poly-L-lactic acid fillers achieve results subtly over time by stimulating the body’s natural production of collagen, the protein in skin that keeps us looking young. Composed of the same synthetic compound plastic surgeons have used for years in solid suture material, Sculptra is the only poly-L-lactic acid filler available in the United States. Patients typically require three Sculptra treatment sessions spaced over a few months, but results can last for two years or more. The third and final type of filler I often use in my practice is derived from calcium hydroxylapatite, a mineral-like compound found in human bone that has been converted into a filler by placement into a gel carrier. Commonly known in the U.S. as Radiesse, this cosmetic filler uses calcium hydroxylapatite particles as a support system for collagen to grow, and because of its thicker composition, is best placed in deeper portions of the face like the cheeks. Recently, Radiesse also received Food and Drug Administration approval for hand rejuvenation, as it can help hide the veins and tendons that become more noticeable with time. 3. Q: How long do fillers last? A: Filler duration depends on a number of factors inherent to both filler and patient. For example, the effects of Juvederm, a hyaluronic acid (HA) filler, may last three to four months in some patients, yet six months or longer in others. Sculptra, with its collagen stimulating properties, can produce results anywhere from 18 months to more than two years, while Radiesse tends to last for 9 to 15 months. Why the wide time range? For one, fillers that are placed into areas of the face that move more–lips and smile lines, for example–will tend to dissolve faster than those in parts of the face that move less, like the cheeks or under eyes. Additionally, some patients metabolize fillers more quickly than others and will dissolve them at a faster rate. And finally, because the composition and viscosity of the gel used to make fillers varies drastically from brand to brand, the absorption rate of each looks quite different. Unfortunately, patients who research fillers online often find conflicting information about their anticipated duration, which can be very confusing for someone evaluating his or her cosmetic options. Given the aforementioned factors, it is important to choose an experienced plastic surgeon or dermatologist who can ensure a positive result. Selecting a provider based on price alone may end up costing you greater time, expense, and frustration, so be sure to do your research–and ask lots of questions! 4. Q: What are the side effects or risks? A: Cosmetic fillers are administered safely through office-based, low-risk procedures if performed by board-certified plastic surgeons or dermatologists. It is important to know, however, that patients can occasionally experience side effects after receiving fillers due to the skin’s natural reaction to the injections. Irritation, infection, redness, soreness, swelling, bleeding, and occasional bruising are most common but do subside with time, while other risks like lumps, bumps, asymmetry, and contour irregularity are inherent to the fillers themselves. Patients should avoid strenuous exercise after treatment, as it may worsen the local skin reactions, but otherwise, they can return to their daily activities with little evidence of treatment. Because of the potential for side effects, it is important to plan your treatment and allow enough time to fully heal before major events. Recently, for example, I had one patient who wanted fillers two days prior to her wedding day photographs, but I advised against it because of the possibility of her developing bruising. I also advise against fillers for pregnant women, because even though no studies have proven them to be harmful, this is a case of “better safe than sorry.” 5. Q: Why is proper injection technique so important? A: Proper injection technique is extremely important to minimize the risks of complications and maximize patient results. Injectors must have an intimate knowledge of facial anatomy to avoid major arteries and nerves of the face; they must also place fillers in the appropriate areas to lead to balanced results. To provide a comfortable, pain-free experience for each of my patients, I first offer them a range of different pain-minimizing techniques, including icing of the skin, the application of numbing creams, and creating nerve blocks; these preventive measures often complement the local anesthetic that is premixed into many fillers. I then degrease each patient’s skin with an alcohol solution before I administer the first injection. Just before I inject the filler, I pull back on the plunger of the syringe to ensure that the needle was not inadvertently placed into a blood vessel where an injection may cause a blockage. Finally, I place the filler material in the desired facial region to enhance or restore a patient’s anatomy. After I’ve completed the injections, I apply gentle pressure and cold compresses to the treatment areas to minimize swelling and bruising. Most patients end up leaving the office without any visible signs of treatment.