Dermal Fillers – What, Where, Why and How? The VISAGE difference

There are about 14 dermal fillers of non-animal origin available in the US yet there are over 200 fillers in use around the World. Many of unavailable to us fillers are from the makers of our Juvederm, Restylane and Radiesse.

The Galderma’s Restylane line is 27 products-long but we have only 5; Allergan, the company behind the Juvederm line, makes as many as 16 products abroad with only 6 here.

Since each FDA approved fillers have a specific indications, the majority of them are not really related to their original intended use but to aesthetically and medically irrelevant factor – the availability.

Therefore, most of the fillers we use are only relatively indicated for approved applications making the term “off-label” nearly obsolete.

The problem of FDA approvals is not only an administrative issue but, more importantly, an ethical dilemma of high magnitude! (more details in next blog entry).

Is there an advantage of having more products to choose from? Yes, and No.

No, because in reality one could do almost everything that is considered a “standard” with just few products.

Yes. Having more options gives us wider range of intricate possibilities from simple skin hydration, nourishment and rejuvenation to treatment of large volume deficits. More choice you have, more minute details can be addressed the more likely you will find a filler that will be optimal for your own specific needs, that may last longer, be more compliant with skin movement and stretching or will provide your skin with additional benefits such as the antioxidants and/or vitamins.


Difference between the fillers

Over 95% of all dermal fillers are made of hyaluronic acid, a natural component of our skin that makes it “springy” and “plump”. Hyaluronic acid in filler is capable of easy tissue integration, attracting and binding water to expand and provide volume .

The non-hyaluronic acid fillers are composed of various ingredients with Radiesse being the most attractive and safest option. The permanent or semi-permanent fillers are not advisable due to their known long-term inflammatory response, tender nodules and irreversible disfigurement.

These very controversial and unpredictable fillers were removed from the markets in many countries including Canada. They should not be used or offered to patients without a full disclosure of their history and potential harmful effects.


Hyaluronic Acid Fillers

The hyaluronic acid fillers differ in concentration and the level of bonding between the molecules. In general, thicker fillers last longer and should be implanted in much deeper plane to replace volume while fillers designed to correct more superficial structures are thinner and have shorter longevity.

The available hyaluronic acid fillers includes:                                    

Juvederm Line   –   Juvederm Ultra, Juvederm Ultra Plus, Juvederm Voluma, Juvederm Volbella, Juvederm Vollure

Restylane Line   –   Restylane L, Restylane Lyft, Restylane Silk, Restylane Defyne, Restylane Refyne,

Belotero   Line   – Belotero is only one of many available from this line.


For large volume losses, cheeks, chin, temples and jaw re-contouringJuvederm Voluma, Radiesse   or Restylane Lyft are the best options.

For lips – Juvederm Ultra, Juvederm Ultra Plus, Juvederm Volbella or Belotero are most frequently used.

The “tear troughs” are much more demanding and challenging. It has been known for some time that many hyaluronic acid fillers can induce an unpredictable reaction with swelling, frequently occurring   months after the injection and not always in all injected areas. The true mechanism of this side effect is still poorly understood with theories ranging from excessive water retention to partial blockage of the lymph outflow. This side effect is frequently associated with Juvederm line of products. The safest of the available fillers for “tear troughs” are Restylane or Belotero.

In practice, the assigned indications for the hyaluronic acid fillers are not absolute. If longevity of the “lip filler” is disappointing one should consider longer lasting Restylane Lyft or Juvederm Voluma .

Strict adherence to approved indications eliminates many great options and, in a long run, could be much more expensive.

Non-Hyaluronic Acid Fillers 

There are 4 non-hyaluronic acid fillers available in the US: Radiesse, Sculptra, Artefill and the newest product – Allofill.

Radiesse is made of Calcium Hydroxylapatite, a substance similar to the matrix of our bones. It is quite viscous and is best used for deep injections and larger volume replacement. The major ingredient works by stimulating local production of new collagen which, in time, adds volume to the injected area. It is fully reabsorbable but not dissolvable. Radiesse can be implanted in nearly any area except for lips.

Sculptra, chemically a Poly-L-Lactic Acid, was initially approved for treatment of facial lipoatrophy, a troubling side effect of anti-retroviral therapy. It is assumed that the ingredient is stimulating production of new collagen. As opposed to all other fillers, the results are not visible immediately but it takes few months for collagen to accumulate .

Few years ago, Sculptra received additional FDA approval for all aesthetic indications even though its side effects were known from its previous use.

Allofill, the newest product, deserves a special introduction – the subject of the next blog. Briefly, it is the most natural of all fillers that is derived from fat tissue obtained from donors. This is the only filler with potential to remain in place for years.

By far, the most common question related to fillers is: “How long does it last?

In all honesty, there is no answer to this question and if you believe the marketing you have a good chance of being disappointed. There are many factors that may change the lifespan of every filler, many of them are unknown, others may even defy logic.

In general, thicker fillers last longer. The level of activity and your own basic metabolism will affect the longevity of many fillers, sun exposure may shorten the effect of Radiesse while thyroid disfunction can alter the process of filler degradation. There is always a possibility that certain medications or supplements could contribute to filler’s duration.



The technique of filler injection is one of the most critical issues in successful aesthetic enhancement. The standard techniques of injections as well as post-injection handling of tissue may have significant effect on the outcome. The depth of injection will impact filler duration, injection in one area may influence the effect in remote areas and excessive and inappropriate “massaging” or “molding” is known to shorten filler’s lifespan.

The effect of filler placement that is most frequently neglected is a subject to physical laws for liquids. It was elegantly displayed in the work of Wayne Carrey, M from the McGill University in Montreal. His   proposed unusual technique of injection results not only in spectacular sculpting of the upper face, cheeks and under-eye area but has achieved significantly longer durability of the fillers reaching, in some cases, up to 5 years!.

As ingenious as it is, only very few are familiar here with this technique and even fewer are skilled enough to perform it. The reason is that the injection trainers from the manufacturers are mostly unaware of it nor will discuss the technique that could potentially decrease the frequency of injections. It is not difficult to guess why?


VISAGE difference.

What do we do differently at VISAGE? Nearly everything! First, our filler recommendations are not based on their indications but on particular circumstances including history of previous use. Personally, I almost never use the syringes or needles supplied by the manufacturers which, by the way, were redesigned few times due to their inherited flaws. Because of their physical characteristics, the syringes preclude the use of the smallest needles; the needles provided in each package are relatively large bore causing unnecessary trauma. Therefore, we transfer fillers to a different syringes that, based on laws of physics, are much more effective when used with small needles.

In 2007, the first flexible cannula for filler injection was introduced in France. It added great versatility to the technique of injection and, more importantly, have nearly eliminated the most severe, sometimes devastating, complications of needle injection. We begun using cannulas in 2008, long before the device became available on the market.

Even though the introduction of cannula 10 years ago have eliminated many safety concerns and was widely accepted around the world, it remains a relative rarity in the US. The reasons are few: the cost of disposable cannulas and lack of knowledgeable trainers. The manufacturers of fillers offer rather basic injection courses and only for needle injections. It is difficult to understand why Allergen, the maker of Judder Volume, does not teach cannula injections in this country when the same product in Canada and other countries contains cannula in the package!

We suggest particular fillers for less common injection sites, use micro-injections and, on occasion we may mix different fillers in order to achieve particular aesthetic goals. Our injection process is nearly always little longer; it allows us to pay attention to every detail and…enjoy conversations, frequently unrelated!

Each injection is a separate project that requires attention and judgement. Regardless of the technique, the key is injector’s artistic imagination, the ability to see the final outcome before it begins. Every single injection point brings effect that must be seen in the context of totality. The reference and injection points reside only in imagination but must not be random. The outcome of unimaginative injection is always predictably bad – fish or duck lips, overblown cheeks, loss of proportions and fake appearance. It takes more than knowledge of anatomy and ability to empty the syringe. It takes something that can not be mastered by reading a textbooks – the ability to use artistic perception, judgement and incorporate them into dexterity.

And, on occasion, to say “no”.

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