Cosmetic dermal fillers include Restylane and Perlane (from the same manufacturer), Juvederm and Radiesse. These injectables help contour deep folds, furrows and depressed scars. They can improve and even eliminate creases in the skin. They can also be used to add volume and contour the lips, cheeks and chin. All have different characteristics. I will try to explain these differences and show examples of how I use each of these materials to its best advantage. It should be emphasized that these materials are not magic and it may require more than one syringe to produce the optimal result. These agents also have their limits and will not replace surgical procedures in situations where there is significant sagging and redundancy of skin and deeper tissues. Finally, for larger areas and volume needs, fat injection, in which fat is borrowed from another part of the body and injected, may be a better natural option and has much longer lasting results.

To increase patient comfort during the injection, I usually pretreat the area with a little local anesthetic. The anesthetic injection will create a bit of a pinch, but once the site is numb, the patient will experience no discomfort from the filler injection. I find that precise placement of the material is facilitated when the patient is comfortable.

Since all of these materials are synthetically made, no skin test is required before injection as was the case with Collagen.

Juvederm, Restylane and Perlane are made of Hyaluronic Acid which is naturally found in skin and joints. The Hyaluronic Acid in the injectables is synthetically manufactured. This material is usually injected directly in the skin to improve creases and make the skin thicker. These substances can be placed below the skin but will be absorbed quickly and hence the duration of their effect would be shorter than when placed in the skin. Once injected in the skin, the results can be expected to last six months and sometimes longer. The manufacturers are now promoting effects lasting up to 18 months but the key words are "up to". While I have seen patients with effects lasting more than a year these results are not consistent. These agents are the first Hyaluronic Acid products to enter the American market. Other manufacturers have entered the U.S. market and others are trying to obtain FDA clearance. The last count I know of found over 140 companies in Europe. I have yet to find any newer product that offers any advantage over the agents mentioned above. Depending on location, these agents can be combined with Botox or Radiesse to maximize their enhancement in non-surgical facial contouring.

Restylane was the first Hyaluronic Acid filler to enter the American market. Overnight it virtually replaced Collagen. Restylane is denser and firmer than Juvederm. Perlane is also from the makers of Restylane and is even firmer and denser than Restylane. Perlane was introduced after Juvederm. It seems that rather than compete against Juvederm, which is softer, they chose to create the firmest Hyaluronic Acid injectable. These agents add volume to the skin to lift folds and furrows. They also improve and sometimes eliminate skin creases. The creases that form around the lips, the crows feet area and the cheek/lip (nasolabial) folds are the most common sites for Restylane. Restylane is also injected along the very edge of the lip (vermilion) to give a slight augmentation and increased definition to the lips. Because of their denser composition, Restylane and Perlane resist spreading so they do a good job of raising deep creases and depressions in individuals with thick or tough skin.

The makers of Botox wanted their own injectable so they purchased the U.S. distribution rights from a European Hyaluronic Acid manufacter and named it Juvederm. It became the second Hyaluronic Acid product to enter the American market. Juvederm is softer (the manufacturer says it is "whipped") and spreads out more than Restylane when injected. I feel it is best used in individuals with thin or soft skin. It is especially useful when it is desirable to treat wide areas. Because of its tendency to spread, it is not as good for areas where deep but narrow filling is desired such as deep creases or a tight deep facial folds. It should be avoided near the eyelids where it can diffuse into the soft tissues of the eyelid and create a puffiness that is not attractive.

Radiesse, formally called Radiance, is the only agent not made of Hyaluronic Acid. Radiesse consists of Hydroxyapatite, another synthetically-made naturally occurring material. The material is thicker and denser than even Perlane. Therefore it is injected below the skin and it should be used where the skin is relatively thick. Because it is denser it will resist spreading out and will do the best job of pushing up deep folds. This lifting of deep folds is further enhanced because the subcutaneous tissue can hold more material in one location than the skin can. These two factors make Radiesse the most useful agent for individuals with very deep cheek/upper lip (nasolabial) folds. Radiesse can also be used to add volume in the chin and mid-cheeks areas. It is not as effective for treating skin creases as hyaluronic acid agents which are injected directly into the skin. Radiesse will also feel firmer after injection but as long as it is injected under thick skin it will be felt and not seen. If Radiesse is injected where the skin is thin such as the eyelids and lips, visible lumps are possible. Radiesse typically lasts about nine months and up to two years.