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Actas Dermosifiliogr. 2010;101(5):381393

ISSN: 0001-7310

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Biosimilares o biosecuelas en Dermatologa
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Incidencia del cncer de piel
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Epidemiologa de la dermatitis de contacto

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REVIEW

Dermal Fillers: Types, Indications, and Complications

I. Snchez-Carpintero,* D. Candelas, and R. Ruiz-Rodrguez
Unidad de Dermatologa, Clnica Rber, Madrid, Spain
Manuscript received November 10, 2009; accepted for publication January 21, 2010

KEYWORDS
Dermal fillers;
Rejuvenation;
Hyaluronic acid;
Collagen;
Poly-L-lactic acid;
Calcium
hydroxylapatite

PALABRAS CLAVE
Material de relleno;
Rejuvenecimiento;
cido hialurnico;
Colgeno;
cido polilctico;
Hidroxiapatita
de calcio

Abstract
There are many types of dermal fillers currently used for cosmetic and medical indications
in routine clinical practice. Fillers can be classified as temporary, semipermanent,
or permanent depending on the length of time the substance remains in tissue. They
can also be classified by the composition of the product. Materials can be based on
collagen (bovine, porcine, and human), hyaluronic acid, poly-L-lactic acid, calcium
hydroxylapatite, polymethyl methacrylates, and polyacrylamide gels, among others.
Temporary fillers are the products most often used for cosmetic purposes, in particular
hyaluronic acid. This is due to the ease of application of fillers based on this substance,
the good results obtained, and their safety profile. This review presents an overview of the
techniques used for the correct placement of dermal fillers and the most common clinical
indications for these procedures. It also covers the nature, properties, and mechanisms
of action of the principal temporary, semipermanent, and permanent dermal fillers as
well as the indications for each type of material. Finally, we describe the most common
complications encountered and their treatment.
2009 Elsevier Espaa, S.L. and AEDV. All rights reserved.
Materiales de relleno: tipos, indicaciones y complicaciones
Resumen
Existen numerosos materiales de relleno utilizados en la prctica clnica diaria con fines
cosmticos y mdicos. Se pueden clasificar, en funcin de su duracin en el tejido, en
temporales, semipermanentes y permanentes. Tambin pueden clasificarse de acuerdo
con la composicin del relleno: colgeno (bovino, porcino y humano), cido hialurnico,
cido polilctico, hidroxiapatita de calcio, polimetilmetacrilatos y geles de poliacrilamida, entre otros. Los rellenos temporales son los ms empleados con fines estticos, especialmente el cido hialurnico. Este hecho se debe al perfil de seguridad que tienen, a la
facilidad en su aplicacin y a los buenos resultados encontrados. En esta revisin se exponen las diferentes tcnicas descritas para su colocacin correcta y las indicaciones

* Corresponding author.
E-mail address: [email protected] (I. Snchez-Carpintero).
0001-7310/$ - see front matter 2009 Elsevier Espaa, S.L. and AEDV. All rights reserved.

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382

I. Snchez-Carpintero et al
clnicas ms frecuentes. Tambin se describe la naturaleza, las propiedades, los mecanismos de accin y las indicaciones de los principales materiales de relleno, tanto temporales como semipermanentes o permanentes. Finalmente se describen las complicaciones
ms comunes y su tratamiento.
2009 Elsevier Espaa, S.L. y AEDV. Todos los derechos reservados.

Introduction
Many types of dermal fillers are currently used in routine
clinical practice for cosmetic and medical purposes.
The different types of materials on the market and the
brand names of some of the most widely used products
are shown in Table 1. Not all dermal fillers are approved
for cosmetic use. In many cases, European and American
regulations differ. The main indication for these products
in dermatology is facial rejuvenation. Medical indications,
such as for facial lipoatrophy, are less common.
Depending on the length of time they remain in tissue,
dermal fillers are classified as temporary, semipermanent
(when the longevity is at least 18 months), or permanent.
They can also be classified by product composition. Primary
ingredients include collagen (bovine, porcine, or human),

animal or synthetic hyaluronic acid (HA), poly-L-lactic acid,

calcium hydroxylapatite, polymethyl methacrylate, and
polyacrylamide gel.1-3 The differences between these types
of fillers are in their diverse modes of action and the length
of time the filler material remains in tissue before it is
absorbed. Temporary fillers are the type most often used for
cosmetic purposes and there is a logical explanation for this
choice. Aging is a dynamic process, making it inadvisable to
permanently correct a defect at a specific point in time. The
best strategy is to apply fillers as necessary to deal with the
signs of aging as they appear. According to data published
by the American Society of Aesthetic Plastic Surgery, more
than 85% of dermal filler procedures are performed with HA
derivatives.4 The widespread use of this type of filler is due
to its excellent safety profile, ease of application, and the
good results achieved.

Table 1 Types of Dermal Fillers and Some of the Commercially Available Products of Each Type
Material

Brand Name

Autologous fat

Hyaluronic acid
Restylane, Restylane Perlane, Restylane Lipp,

Restylane Touch, Restylane Vital

Macrolane 20, 30

Juvederm Ultra 1, 2, 3, Juvederm Voluma

Hylaform, Hylaform Plus, Hylaform Fineline

Others: Rofilan Forte, Matridur, Puragen, Glytone,

Isogel, Prevelle, etc

Collagen
Zyplast/Zyderm (bovine)

Cosmoderm/Cosmoplast (human)

Evolence, Permacol, Fibroquel (porcine)

Calcium hydroxylapatite
Radiesse

Poly-L-lactic acid
Sculptra/New Fill

b-tricalcium phosphate
Atlean
with hyaluronic acid

Polyacrylamide gel
Aquamid

Bio-Alcamid

Polymethyl methacrylate
Arteplast, Artecoll, Artefill


Dermalive/Dermadeep
Dimethylsiloxane polymers

Silicone

Duration and Biodegradability

Temporary and biodegradable
Temporary and biodegradable

Temporary and biodegradable

Semipermanent and biodegradable

Semipermanent and biodegradable
Semipermanent and biodegradable

Permanent and not biodegradable

Semipermanent and not

biodegradable

Permanent and not biodegradable

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Dermal Fillers: Types, Indications, and Complications

The first section of this review is a description of the
techniques used to inject dermal fillers. We then go on to
discuss the most common indications for these materials
and their less common uses. The following section describes
the principal temporary, semipermanent, and permanent
dermal fillers, with a review of the nature, properties,
mode of action, and indications of each one. A number
of dermal fillers only recently launched on the market
are also included. Finally, we describe the most common
complications and their treatment.

Injection Techniques for Dermal Fillers

Pretreatment Preparation and General
Recommendations
Pretreatment preparation is important to minimize risks
and unwanted side effects. Patients must be properly
informed to ensure that their expectations are realistic.
Written informed consent must always be obtained, and
pretreatment photographs should be obtained when
possible. A complete medical history is always necessary
and should cover allergic or hypersensitivity reactions to
any substance, including anesthetics. Dermal fillers are
contraindicated during pregnancy and breastfeeding and
are not recommended in immunocompromised individuals,
patients with autoimmune diseases or receiving certain
drugs, such as interferon.5 Patients should be instructed
not to take any medication that might increase the risk
of bleeding during the 10 to 14 days prior to treatment.
Nonsteroidal anti-inflammatory drugs and vitamin
complexes containing vitamin E should also be avoided.6
Permanent and semi-permanent fillers should not be used
in individuals with a history of keloid or hypertrophic scars.
A skin allergy test prior to treatment is only necessary when
bovine collagen fillers are used. Particular attention must
be paid to avoiding overcorrection. The strategy of many
authors is to carry out an initial treatment session followed
by a second visit a few weeks later to refine the results and
achieve the desired final outcome. Topical anesthetics or
a nerve block will be used depending on the patients pain
threshold. Some dermal fillers contain lidocaine, which
helps the patient to tolerate the injections.

Injection Techniques
A certain amount of practice and experience is required
to inject dermal fillers. It is essential to choose the filling
agent best suited to each patient and anatomical site,
and to determine the appropriate amount of filler to
be injected. Another crucial aspect in achieving a good
outcome with dermal fillers is the depth at which the
material is implanted. Most dermal fillers are injected into
the deep dermis or the fatty tissue.7 A number of different
injection techniques have been described.8

Linear Threading or Tunneling

In the linear threading technique the needle is introduced
along the length of the fold or line and a thread of filler is

383
then gradually deposited as the needle is withdrawn. This
technique is mainly used to correct isolated rhytides or
folds, such as the nasolabial fold.

Serial Puncture
Serial puncture involves multiple injections along the
wrinkle or fold. These must be placed close enough
together to prevent irregularities, and massaging the area
will help to distribute the product evenly.

Radial Fanning
In the radial fanning technique, threads of filler are
deposited using the tunneling technique. However, before
the needle is completely withdrawn, it is reinserted in a
radial pattern and another thread is deposited along the
new axis. This is repeated as necessary until the desired
effect is achieved. This technique is used to augment
volume in the malar region.

Crosshatching
Crosshatching is another variation on the tunneling
technique. Several parallel lines of filler are created
across the treatment area followed by a second set of
parallel threads perpendicular to the first set forming a
grid pattern. This technique is used to correct marionette
lines and the prejowl sulcus.

Indications for Dermal Fillers

The main indication for the use of dermal fillers is
facial rejuvenation. Their use, often in combination with
botulinum toxin injections, produces very satisfactory
results with a very low incidence of side effects.9 Ideal
subjects are patients with early signs of aging.
The nasolabial fold becomes accentuated with age,
forming an increasingly pronounced furrow. In this area,
dermal fillers should be injected deeply (Figure 1). The
techniques most often used are tunneling and serial
puncture. The injection is usually made parallel and medial
to the fold, with the initial insertion point at the lower
end. The desired effect can usually be achieved with 0.5
to 2 mL of filler per side.7,10

Figure 1 Patient treated with hyaluronic acid filler in the

nasolabial folds before (A) and after (B) treatment. (Image
supplied by Q-Med, Spain, S.L.).

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384

I. Snchez-Carpintero et al

Dermal fillers are also used to correct volume deficiencies

and improve facial contours.8 Another area that can be
improved is the tear trough located below the lower eyelid in
the transition area between the eye and the malar region.11
This deformity usually develops late in life as a result of
herniation of the infraorbital fat pillows and flattening or
sagging of malar fat. The loss of natural convexity between
the lower eyelid and the malar region gives rise to a tired
look and a more aged appearance, with the formation
of a depression and an unsightly shadow. Tunneling and
serial puncture are the preferred techniques for correcting
tear trough deformity. Permanent fillers are not usually
recommended for this purpose because poor technique can
easily give rise to surface irregularities in this area. The
initial insertion point is lateral and the needle is introduced
in a medial direction. Filler should not be deposited closer
than 2 to 4 mm from the nasal wall to avoid creating the
appearance of a broad nose. To avoid eye damage, the
injection should be made below the infraorbital rim. Filler
is injected supraperiosteally, and a volume of 0.5 to 1 mL
per side is usually sufficient. To augment the volume of the
malar region and create a more convex appearance, the
radial fanning technique is generally used to deposit 1 to
2 mL of filler in the subperiosteal plane. The injection is
made a few millimeters from the lateral superior aspect of
the malar eminence.
Considerable improvement can also be achieved in
the perioral region, in particular in the lips, marionette
lines, and prejowl sulcus (Figure 2). 8 In young patients,
increased volume in the central part of the lips is
all that is needed. The filler is injected into the lip
mucosa along the transition line between mucosal
tissue and skin. The outline of the cupids bow can
also be improved. Temporary fillers are usually used
for this purpose (Figure 3). The injection techniques
used are tunneling and serial puncture. The filler
should be injected into the submucosa above the
orbicularis oris muscle. If the patient wishes to enhance
the transition between the mucosa and the skin, the
needle should be introduced into the space between
the vermilion and white parts of the lip to deposit the
filler. When the needle is correctly positioned, filler
can be injected without resistance and elevation of the
edge of the lip is immediately apparent. The overall
appearance of the lips can be enhanced by shaping
the philtral columns through injection of filler into
the mid dermis starting from the base of the columns.
In older patients, the entire length of the lip must be

Figure 2 Patient treated with hyaluronic acid in the perioral

region before (A) and after (B) treatment. (Image supplied by
Q-Med, Spain, S.L.).

Figure 3 Patient treated with hyaluronic acid in the lips before

(A) and after (B) treatment. (Image supplied by Q-Med, Spain,
S.L.).

treated and the correction of vertical lip lines should

also be considered. Since these lines are superficial,
collagen filler is the recommended treatment. Another
treatment option is to increase the volume of filler at
the edge of the lips. Since this is where the vertical
lines originate, they are reduced or become less visible
when the lip is expanded.
Another indication for dermal fillers is the treatment of
marionette lines, the folds that extend downwards from the
corners of the mouth and give rise to an aged appearance
and an unhappy expression. The injection techniques
usually used in this case are tunneling and serial puncture.
If the area is affected by an overall loss of volume, the
crosshatching technique may also be used. Finally, the
contour of the jaw line can become deformed over time
as a result of bone resorption and sagging skin, giving rise
to a shadow called the prejowl sulcus between the lower
jaw and the chin. This area is often treated at the same
time as the marionette lines. Dermal fillers can improve
this defect, giving the patient a younger appearance by
restoring the transition between the chin and the posterior
jaw line. Between these 2 areas some 2 to 3 mL is normally
injected.8
Nose remodeling with dermal fillers is a very attractive
alternative to conventional surgery. The tip, bridge and
root of the nose can all be projected or raised. Temporary
fillers are normally used for this purpose. To prevent
lateral spread of filler, the skin should be pinched during
the procedure. The injections should be deep, and small
volumes (0.5 to 1 mL) are usually sufficient to achieve the
desired effect.12
The glabellar region is usually treated with a combination
of filler and botulinum toxin.3 Once paralysis has been
achieved, dermal filler can be used to correct persistent
depressions. The use of fillers that must be injected into
the deep dermis is not advisable in this area because of the
possibility of serious complications, including cutaneous
necrosis. Consequently, some authors recommend the
exclusive use of fillers that are injected very superficially
in this area.6
Dermal fillers can also be used in the periocular
region. Before any decision is made concerning the
areas to be treated, an initial evaluation of the patient
is essential. Candidate areas include the lower eyelids,
the infraorbital groove, the upper eyelids, the brow, and
the transition area between the glabellar region and the
root of the nose. Some authors recommend the exclusive
use of temporary fillers (such as HA) and, within this

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Dermal Fillers: Types, Indications, and Complications

group, the products with greater viscosity are preferred
as this property facilitates better control of the dose and
placement of the filler, and the incidence of inflammation
and edema associated with treatment is lower. 13 The
filler should be injected deeply. The most common
complications are overcorrection and the appearance of
lumps, bruises, and localized edema. Only experienced
practitioners should undertake this procedure because
this is one of the most complicated and delicate
treatment areas. Isolated cases of blindness following
treatment have been reported, probably caused by poor
technique.14 The likelihood of such a complication can
be minimized by administering nerve block anesthesia
with epinephrine, which produces vasoconstriction. The
recommended technique is to use 30-gauge needles to
slowly inject small amounts of filler.

Less Common Indications for Dermal Fillers

Scarring
Although, no studies in the literature have demonstrated
any long-term benefits associated with the treatment of
scars with dermal fillers, the injection of HA can improve
the patients appearance, especially in the case of atrophic
acne scars. Small amounts of filler should be injected
over a number of sessions.3 Good long-term results have
also been reported with poly-L-lactic acid,15 and porcine
collagen has also been used.16

Chin Shaping in Patients With Implants

In patients with chin implants, contouring with HA can
improve the transition between the implant and the
adjacent soft tissue. To obtain the best results, these
treatments are usually combined with botulinum toxin
treatment.3

Earlobe Treatment
With age, the earlobes tend to sag and create folds, and the
injection of fillers such as HA can improve their appearance.
The effects of treatment last longer in the earlobes than
elsewhere, probably because it is metabolically inactive
tissue that moves very little.3

Hand Rejuvenation
Hands can also be improved with dermal fillers, although
this application is not very widespread. Stabilized HA fillers
are a good choice.17 Other fillers that have been used in
the hand include calcium hydroxylapatite18 and bovine
collagen.19

Temporary Dermal Fillers

Autologous Fat
Subcutaneous fat is distributed across independent

385
compartments separated by fibrous septa. In the youthful
face, the transition between these subcutaneous fat
compartments is subtle, but aging gives rise to abrupt
changes of contour between these spaces, whether due
to loss of volume or fat misplacement. One example
is orbital fat, which tends to herniate and create bags
around the eyes. The use of the patients own fat as a
filler is a safe and natural method. One drawback of this
technique is that it must be performed in an operating
theater environment with local anesthesia and sedation;
specific instruments and materials are also required. Fat
is extracted from areas such as the thighs or abdomen
using special cannulas. The harvested fat is then purified
by centrifugation. Using a different type of cannula, the
processed fat is then injected into the treatment areas
depending on the needs of the patient (forehead, brow,
cheeks, suborbital region, perioral areas, jaw line, etc). Fat
is injected at different depths (subdermal, intramuscular,
and subperiosteal) and in different quantities depending
on the patient and the anatomical area treated.20,21 The
longevity of injected autologous fat ranges from 8 months
to several years.

Hyaluronic Acid
Under normal circumstances, HA is present in the human
body as a component of the extracellular matrix. It is a
polysaccharide (a glycosaminoglycan disaccharide composed
of an alternating and repeating unit of D-glucuronic acid
and N-acetyl-D-glucosamine) with hydrophilic properties
(a very high affinity for attracting and binding water
molecules).22 Owing to their hydrophilic properties, HA filler
materials can achieve substantial soft tissue augmentation
after injection. The initial filling effect is directly related
to the volume of the exogenous HA injected, but it has
been shown that HA also has an indirect effect in that,
once deposited in the dermis, it activates the dermal
fibroblasts.23 HA is a temporary injectable filler. However,
unlike collagen fillers, which only remain in tissue for a
few weeks or months, HA can last for as long as 6 to 9
months or sometimes longer, depending on the type of
HA filler used. When an appropriate volume is correctly
placed, this material cannot be detected either visually or
by palpation.
Most of the HA products on the market are synthetic,
sourced from stabilized nonanimal HA. This makes
pretreatment skin testing unnecessary since there is
no possibility of an allergic reaction. To further its
longevity in tissue, the HA is manipulated using a process
called crosslinking that involves the use of substances
such as divinyl sulfone, 1,2,7,8-diepoxyoctane, and
butanediol-diglycidyl-ether. The differences between
the types of HA on the market are due in part to
the degree of crosslinking and the agent used in this
process. Crosslinking modifies the solubility of HA, and
the degree of crosslinking is directly related to the
viscosity of the gel. Any allergic reaction produced by
such products is thought to be caused by the agent used
in the crosslinking process. 24
The main indications for some of the HA products most
commonly used in clinical practice are listed below. There

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386
are so many such products on the market that it would be
impossible to mention all of them in this review.

Restylane
Restylane (Sub-Q, Uppsala, Sweden) was the first HA
product sold in the United States. The gel has a particle
size of 400 m. The areas that respond best to treatment
with this product are the nasolabial folds, the lips, and
the oral commissures. It can also be used for cheek
augmentation and to improve deformities of the chin and
prejowl sulcus. It is not generally recommended for the
treatment of fine lines.

Perlane or Restylane Perlane

Perlane (Sub-Q, Uppsala, Sweden), like Restylane, is a
stabilized HA of nonanimal origin. It has a larger particle
size (1000 m) and is used to treat moderate to severe
rhytides and folds. The product contains 0.3% lidocaine.

Juvederm
The chief advantage of Juvederm (Allergan Inc, Santa
Barbara, CA, USA) over Restylane is that it is softer and
produces fewer lumps in the skin when injected close to
the surface. Juvederm is very useful for correcting slight
or moderate nasolabial folds in patients with fine skin. It is
also used for lip enhancement and to treat minor defects in
facial contours. In general, this product is less well known
than Restylane.

Restylane Lipp
Restylane Lipp (Sub-Q, Uppsala, Sweden) is a compact and
cohesive HA gel specifically designed for lip augmentation.
The gel must be homogeneously distributed. Care should
be taken not to inject excessive volume since the material
cannot be effectively massaged or redistributed. The
tunneling technique is usually used to inject this product,
whose effect lasts about 12 months.
Other HA products on the market include Hylaform
(Allergan Inc, Santa Barbara, California, USA), Rofilan
Hylan Gelv (Rofil Medical International, Breda,
Netherlands), AcHyal (Tedec-Meiji Farma S.A. Madrid,
Spain), Matridur (Biopolymer, Siershahn, Germany),
Hyal System (Merz Pharma GmbH, Frankfurt, Germany),
Puragen (Mentor Corp, Santa Barbara, California, USA),
and Restylane Vital and Vital Light (Sub-Q, Uppsala,
Sweden), among others (Table 1).
Depending on the anatomical region and defect to be
treated, it may be more appropriate to use one type
of HA or another. For example, the following can be
used in the nasolabial folds: Juvederm Ultra or Ultra
Plus, Restylane, Perlane, and other HA products. The
treatment of facial lines is generally more complex,
and Juvederm Ultra may be more useful in such cases.
When the problem to be treated requires a more
substantial increase in volume, such as very flat cheeks
or the prejowl sulcus, an HA product with a harder gel,
such as Restylane, Perlane, or Juvederm Ultraplus,

I. Snchez-Carpintero et al
is recommended. For areas that require remodeling
with large volumes, Juvederm Voluma may a better
choice. In general, the different types of HA can also be
used in patients with high phototypes (IV-V), since no
complications have been reported in such cases.25

Collagen Fillers
Collagen makes up 70% to 80% of the dermis. With age,
dermal collagen is lost and becomes fragmented, as the
transformation from new and complete collagen (type I) to
fibrotic collagen (type III) gives rise to the appearance of
rhytides and folds. Collagen fillers can be bovine, human
or porcine in origin. One of the advantages of collagen
fillers over HA is that they are less viscous and can be more
useful for the correction of fine lines and wrinkles because
they are less likely to produce irregularities when injected
superficially.

Bovine Collagen
The 2 bovine collagen products most used are Zyderm
and Zyplast (Allergan Inc, Santa Barbara, California,
USA). Bovine collagen, a temporary and biodegradable
filler, was the first collagen to be sold as a filler.
Pretreatment skin testing is necessary. Some authors
even recommend administering 2 skin tests separated
by an interval of 2 to 4 weeks.26 The incidence of local
hypersensitivity reactions in patients tested prior to
treatment is estimated to be between 3% and 5%. Zyderm
is indicated for superficial rhytides and Zyplast for
deeper rhytides or defects. Zyplast should never be used
in the glabellar region because cases of local cutaneous
necrosis caused by intra-arterial injection of the product
have been reported.27 A shorter duration of effect in the
treatment of nasolabial folds than that obtained with
HA fillers has been reported.28 These products remain in
tissue between 2 and 6 months.

Human Collagen
Human collagen is produced from human dermal fibroblast
cell lines using bioengineering techniques. No pretreatment
skin test is required. The two most frequently used dermal
filling products are Cosmoderm and Cosmoplast (Allergan
Inc, Santa Barbara, USA). Both products are biodegradable
and therefore temporary and have a duration of effect
from 3 to 7 months.29 Cosmoderm is indicated for
superficial and Cosmoplast for deep rhytides or defects,1
and both contain the anesthetic agent lidocaine. Collagen
can also be obtained from the tissue of human cadavers.6
Products that contain collagen of human origin include
Fascian (Fascia Biosystems LLC, Los Angeles, CA, USA) and
Cymetra (LifeCell Corp, Branchburg, NJ, USA).

Porcine Collagen
Porcine collagen is also temporary and biodegradable and
has a duration in tissue of around 12 months. A number of
products on the market contain porcine collagen, including
Evolence and Evolence Breeze (ColBar LifeScience,

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Dermal Fillers: Types, Indications, and Complications

Herzliya, Israel). The porcine collagen in these products
is crosslinked using natural sugar, a technology called
Glymatrix. Collagen extracted from porcine tendons
is broken down using enzymes and the crosslinking is
then reconstituted using the Glymatrix system. Since
this proprietary technology does not involve the use of
chemical crosslinking agents, it eliminates all potentially
antigenic compounds that might induce allergic reactions.
No pretreatment skin test is required. The particles are
incorporated into the recipient tissue and neovascularization
occurs. The product is broken down over time by enzymatic
mechanisms. Another advantage of this type of filler is the
low incidence of edema and hematomas following injection
because of the hemostatic properties of collagen.30 Other
porcine collagen products on the market include Fibroquel
(Aspid, Mexico City, Mexico) and Permacol (Tissue Science
Labs, Aldershot, United Kingdom).
Evolence is indicated for moderate to deep lines,
wrinkles, and folds, and for the correction of contour
defects. It is not used in the lips because of the
possibility of nodule formation. Evolence Breeze
is used to fill fine lines and for lip enhancement.
Although the information available is not extensive,
it would appear that Evolence is less immunogenic
than bovine collagen. The studies in the literature
show it to be a very safe dermal filler, at least for 1
year after implantation. 31 From the clinical standpoint,
some studies have reported that this product is more
effective than bovine collagen in the treatment of
nasolabial folds. 32 However, no significant differences
have been observed with respect to HA fillers. 28

Poly-L-lactic Acid
Poly-L-lactic acid is a temporary dermal filler composed
of a biocompatible and biodegradable synthetic
polymer. No pretreatment skin test is required. The
only commercially available product of this type is
marketed in the United States under the brand name
Sculptra (Dermik Laboratories, Berwyn, PA, USA) and
in Europe as New Fill (Sanofi Aventis, Paris, France).
Poly-L-lactic acid belongs to the category of fillers
that produce their effect by stimulating new collagen
formation through fibroblast activation.33 As a result,
the volume increases in the treated area over time. This
effect has been studied in a murine model and has been
described in isolated cases in humans in series reported
in the literature. The amount of collagen present has
been found to continue to increase on follow-up at 3
and 6 months; after a longer interval, between 8 and 30
months, breakdown of the poly-L-lactic acid is observed
but type I collagen continues to increase.34 The poly-Llactic acid continues to break down 9 to 24 months after
its introduction. Degradation is not enzymatic but rather
involves metabolism into water and carbon dioxide. The
de novo collagen may, however, remain in tissue, and
its presence has been detected up to 24 months after
treatment.34,35 As the effect develops over a prolonged
period, reinjection is not advisable when no immediate
clinical effect is observed following initial treatment. The
efficacy of this filler material in the treatment of facial

387
lipoatrophy in patients with human immunodeficiency
virus (HIV) infection has been clearly established.36 The
cosmetic results are also satisfactory.34,37

Calcium Hydroxylapatite
The calcium hydroxylapatite filler is Radiesse (Bioform
Medical, San Mateo, CA, USA), a product formerly marketed
under the brand name Radiance FN. Although Radiesse
is a temporary filler, it has a longer duration of effect
than either HA or collagen fillers, leading some authors
to classify it as semipermanent.1 Radiesse is composed
of microspheres of synthetic calcium hydroxylapatite (a
chemical composition identical to that found in teeth
and bone) suspended in a water-based carboxymethyl
cellulose gel carrier. The microspheres are very smooth
and vary in size from 25 to 45 m. As the product is totally
biocompatible, no pretreatment skin test is required. In
addition to the direct volumizing effect produced by the
presence of the filler itself, this product also stimulates
endogenous collagen production, an effect that can be
observed months after treatment as a consequence of
the attempts of macrophages to break down the calcium
hydroxylapatite; macrophages have been observed to
engulf the calcium hydroxylapatite microspheres.38 This
filler remains in tissue for as long as 1 year or even 18
months in some studies,40 exceeding the longevity of HA,
It is indicated for the correction of moderate to severe
facial wrinkles and oral and maxillofacial defects and
for the treatment of HIV-associated facial lipoatrophy.
Radiesse is also used for radiographic tissue marking and
vocal cord augmentation. The incidence of associated
complications is low, and there are no reports of
calcification or osteogenesis at injection sites.

Permanent Dermal Fillers

Polymethyl Methacrylate Microspheres
Polymethyl methacrylate microspheres can be suspended
in either bovine collagen (Artecoll and Artefill) or HA
(Dermalive and Dermadeep). The characteristics of each
of these 2 types of dermal fillers are detailed below.

Polymethyl Methacrylate Microspheres

in Bovine Collagen
The 2 most widely known fillers in this group are Artecoll,
a second generation product, and, more recently Artefill,
a third generation product. Arteplast, the original
polymethyl methacrylate filler, is no longer in use.
Artefill (Suneva Medical Inc, San Diego, CA, USA) is
composed of polymethyl methacrylate microspheres
suspended in a bovine collagen matrix mixed with 0.3%
lidocaine. Consequently, pretreatment skin testing is
required if this product is chosen. Artefill, unlike the
other polymethyl methacrylate products, has highly
uniform microspheres and less than 1% of particles are
smaller than 20 m, a characteristic that gives rise
to a lower rate of adverse effects compared to other

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388
polymethyl methacrylate fillers.41 Once injected, the
microspheres act as a matrix, stimulating the patients
own fibroblasts to produce collagen and encapsulate each
microsphere. The bovine collagen, in addition to being
the carrier of the polymethyl methacrylate microspheres,
prevents the needle from becoming obstructed during
injection and has the effect of stimulating the growth of
tissue in which it is deposited. This product is mainly used
as a filler for nasolabial folds.

Hydroxyethyl Methacrylate in Hyaluronic Acid

The products based on a combination of hydroxyethyl
methacrylate and HA are Dermalive and Dermadeep
(Dermatech, Paris, France). Dermalive is a mixture of 60%
crosslinked HA fluid produced by fermentation in bacterial
culture and 40% hydroxyethyl methacrylate and ethyl
methacrylate particles. The particles have an irregular
surface and vary in size from 45 to 65 m. This filler must
be implanted in the deep dermis and is not indicated
for the treatment of superficial rhytides. Dermadeep
must be implanted even more deeply, in the hypodermis
or periosteum. The use of these materials is not very
widespread because of the high incidence of associated
adverse effects.

Polyacrylamide Gel
The 2 most widely known polyacrylamide gel products are
Bio-Alcamid and Aquamid. Bio-Alcamid (Polymekon,
Milan, Italy) is composed of 96% water and 4%
polyalkylimide. It is generally used for the treatment
of deep defects. Aquamid (Contura International,
Copenhagen, Denmark) is a hydrogel, composed of 2.5%
polyacrylamide and 97.5% water, that is not absorbed.
This product is also used to correct deep defects. Since
Aquamid has a high complication rate and its use is often
associated with the formation of granulomas, its use
is increasingly rare.2 Other products in this group have
different molecular weights and, therefore, different
levels of viscosity. They include Interfall (Interfall Ltd.,
Kiev, Ukraine), Formacryl and Argiforn (Bioform, Moscow,
Russia), Outline (ProCytech, Bordeaux, France), and
Amazing Gel (FuHua Ltd, ShenZhen, China).

Silicone
Injectable liquid silicone was one of the permanent fillers
most used in the past. There are various products on the
market, including Adato SIL-OL 5000 (Bausch & Lomb,
Rochester, NY, USA), Silikon 1000 (Alcon Laboratories,
Fort Worth, TX, USA), and SilSkin 1000 (Richard-James
Development Corp, Peabody, MA, USA). There is also a
product, marketed under the brand name Bioplastique
(Uroplasty BV, Netherlands), that consists of solid silicone
particles suspended in a polyvinylpyrrolidone carrier. All
these materials must be implanted in the deep dermis or on
the dermis-panniculus adiposus plane. As well as affording
an immediate effect due to the volume of the injected
silicone, these products also induces the formation of
fibroplasia in the long term However, since complications

I. Snchez-Carpintero et al
are frequent, these products are now rarely used for facial
rejuvenation.

Other Permanent Products

Other permanent products on the market include Metacrill
(Nutricel Laboratories, Ro de Janeiro, Brazil), composed
of polymethyl methacrylate spheres suspended in a
carboxygluconate gel; Advanta (Atrium Medical Corporation,
NH, USA), containing expanded polytetrafluoroethylene;
and Profill (Laboratoires Filorga, Paris, France), composed
of polyoxyethylene and polyoxypropylene.

New Dermal Fillers

Current research into new dermal fillers is focused on
obtaining products with a longer duration of effect that
provide better cosmetic results without complications.
Some of the most recently developed fillers are discussed
below.

Atlean
Atlean, formerly marketed by ABR Development in
France and currently owned by Stiefel Laboratories, is
classified as a dermal filler and volumizer. It contains HA
and tricalcium phosphate particles that are biodegradable
and biocompatible and thus cause no allergic reactions.
There is prior experience of this product in the literature
related to its use in the regeneration of fractured bones.
The HA component produces an immediate clinical effect
and tissue subsequently forms around the particles,
with formation of new collagen. Atlean is injected
subcutaneously or supraperiosteally and has the advantage
over other dermal fillers that the injection is less painful.
The material remains in tissue from 12 to 15 months.30 It
is used in the nasolabial folds, marionette lines, facial
contour remodeling, chin folds, cheekbone remodeling,
and lipoatrophy.

Laresse
Laresse (FzioMed, Inc, London, United Kingdom) is a
biodegradable and biocompatible filler composed of a
polymer of carboxymethyl cellulose and polyethylene
oxide. It is used to treat nasolabial folds, marionette
lines, and lip lines, and in cheek contouring. One of the
advantages of Laresse over HA is that superficial injection
of the product does not leave a blue discoloration. The
material remains in tissue for about 6 months.30

Easy Agarose
Easy Agarose (Dermacare Aps, Denmark) is a polymer
composed of D-galactose and 3,6 anhydro-L-galactose.
Two preparations are available: Easy Agarose L.D. (low
density) is used to treat superficial rhytides, and Easy
Agarose H.D. (high density) is used to treat deeper lines
and folds and to correct volumes. The duration of action
is 8 to 11 months.30

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Dermal Fillers: Types, Indications, and Complications

Esthlis
Esthlis (Laboratorios Anteis, Geneva, Switzerland) is
manufactured using cohesive polydensified matrix (CPM)
technology, a crosslinking process that produces a totally
homogeneous, cohesive, and elastic HA gel of different
densities. The 2 formulations of Esthlis on the market
differ in the degree of crosslinking and the percentage of
high and low density areas. The AH CPM Basic version has
an HA concentration of 22.5 mg/mL and a high percentage
of high density areas with double crosslinking, while AH
CPM Soft formulation has a lower concentration of HA (20
mg/mL) and a higher percentage of single crosslinking. The
chief advantage of HA gels obtained using CPM technology
is their excellent dermal biointegration and the more
natural clinical effect they obtain, including a certain
lifting effect because the larger spaces in the dermis are
filled with the high density part of the gel and the smaller
interfibrillar spaces with the low density material. The risk
of formation of aggregates is very low. AH CPM Basic is
injected into the reticular dermis and is indicated for deep
lines, while AH CPM Soft is implanted below the papillary
dermis and is indicated for periocular lines.30

Macrolane
Macrolane (Q-Med AB, Uppsala, Sweden) is a stabilized,
biocompatible and resorbable HA product indicated for
improving body contours and augmenting the volume of
areas of larger dimensions. It is used to treat atrophic
defects caused by liposuction and to correct concave body
deformities. It is currently being used experimentally
for breast tissue augmentation.30 The product remains
in tissue for approximately 12 months. The 2 available
formulations are Macrolane 20 and Macrolane 30, the
latter having a higher density. The filler material must
be implanted deeply in the subcutaneous or subperiosteal
tissue. Large volumes of up to 120 mL are injected per
treatment area.30

Complications Associated with Dermal Fillers

Unlike permanent filler materials, temporary dermal fillers
are associated with a very low incidence of complications.12,42
Most complications are mild and of limited duration. A
potential complication common to all dermal fillers is
an asymmetrical appearance caused by the injection of
different amounts of material on either side. Each patient
must be individually assessed because facial asymmetry
may be present before treatment. Alternatively, one area
may be overtreated or undertreated. As a general rule,
undertreatment is preferable to overtreatment since the
latter is more difficult to correct.

Complications Associated with Temporary Fillers

Complications that may appear immediately are local
redness, inflammation, and bruising.6,42 Both erythema
and edema are due to inflammation after trauma
caused by the injections but may also be related to the

389
hygroscopic properties of the injected material. While
erythema usually resolves within a few hours, edema
may persist for 2 to 3 days. The risk of edema can be
minimized by limiting the number of percutaneous
punctures, by using anesthetics containing epinephrine,
by applying ice or cold compresses after the procedure,
and by avoiding treatments during menstruation. 43
Bruising is caused when a vessel is accidentally punctured
by the needle or when pressure is exerted on the
vessel by the filler. In many cases, bruising appears
immediately after the injection; it resolves within 5 to
10 days. To reduce the incidence of this complication,
it is important to have the appropriate side lighting and
to clean the treatment area with alcohol. If a vessel
breaks, immediate compression with a dressing on the
area can reduce the size of the hematoma. Very rarely,
a larger vessel may be punctured , making cauterization
necessary. Some HA products incorporate an anesthetic,
such as lidocaine. Owing to the vasodilator effect of this
ingredient, such products may be associated with more
bleeding and subsequent hematomas. In any case, none
of these immediate complications will affect the final
cosmetic result.
Another complication seen in the short and medium
term is the presence of visible filler material in the form
of whitish papules or palpable or visible nodules. This
complication is usually caused by poor technique, when
the filler material is injected very superficially. It has
also been suggested that nodules may develop later as a
result of local inflammation or an inflammatory foreign
body response. Filler visibility occurs very rarely with
HA formulations but may be associated with a bluish
discoloration.44 In the case of poly-L-lactic acid fillers,
the incidence of nodules can be greatly reduced by
reconstituting the product in at least 5 mL of sterile
water at room temperature and leaving the preparation
to stand for 2 hours before use.45 The injection of
small amounts of filler (0.1-0.2 mL at a time) using the
tunneling technique is recommended. Some authors add
0.1% lidocaine with epinephrine to the filler, shaking
the mixture just before injection.46 Nodules may also
appear after treatment with calcium hydroxylapatite,
particularly in the lips, making the use of this type of
dermal filler in the lips inadvisable.47 All types of nodules
can be treated by firmly massaging the tissue. If the
problem does not resolve, nodules can be pricked with a
needle and drained42,48 or injected with corticosteroids. If
they persist despite these measures, systemic treatment
with corticosteroids can be considered. Treatment with
oral allopurinol has been shown to be effective in isolated
cases.49 If nodules should appear after treatment with
an HA filler, hyaluronidase can be injected to attempt to
eliminate them.50 Hyaluronidase is sold by the following
companies: Amphastar Pharmaceuticals (Amphadase;
Rancho Cucamonga, CA, USA) and Ista Pharmaceuticals
Inc (Vitrase; Irvine, CA, USA). In any case, most nodules
are more palpable than visible, and they will resolve
spontaneously without treatment. Surgical excision should
only be used as a last resort.
It is not clear whether a hypersensitivity reaction can
be produced by the implantation of temporary dermal

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390
fillers or whether the complications observed are local
irritations due to the volume of the product injected or
poor placement of the filler material. Temporary fillers
are generally biocompatible and rarely cause this type of
reaction. HA has the best safety profile and very rarely
gives rise to this complication. When such a reaction
occurs it could be due to the crosslinking agent rather
than HA. Isolated cases have been described of delayed
hypersensitivity reactions characterized by inflammatory
nodules, induration, and facial edema.51 In some studies,
a localized cutaneous reaction has also been reported in
humans following a skin test with HA.52,53 Finally, serum
antibodies against certain types of HA have been found,
although these have not been associated with any apparent
clinical manifestations.52 Improvements in the processes
used to purify the different types of HA have reduced the
incidence of this type of reaction, making its occurrence
highly unlikely.12 Other fillers, such as bovine collagen,
are associated with a high incidence of allergic reactions,
making a prior skin test always necessary when these
products are used.
Necrosis at the injection site is a rare but severe
complication.6,54,55 It may occur when the material is
injected into the angular artery of the nasolabial fold or the
supratrochlear artery in the glabellar region. Compression
of the supratrochlear vessels during injection of the
filler could, hypothetically, minimize this complication.
Since necrosis in the glabellar region has been reported
after the implantation of bovine collagen27 and calcium
hydroxylapatite, the use of these materials in this region is
not recommended. Exceptionally, isolated cases of necrosis
with HA have been described.6,55 A violet discoloration
and pain are immediately observed in the area and this is
followed by subsequent erosion and ulceration. Because
of its vasodilatory properties, topical nitroglycerin could
reduce necrotic spread.6,42 If this complication occurs
after injection of HA, hyaluronidase can be injected.56
Subcutaneous injection of low molecular weight heparin has
also been used successfully in a case of severe necrosis.55
Other reported complications, such as headache,
sinusitis, and respiratory symptoms, are difficult to relate
to the use of dermal fillers. More infrequently, isolated
cases have been reported of facial paralysis and collagen
disease.42 One case in the literature reports generalized
scleromyxedema, which took the form of a generalized
papular eruption with thickening of the skin secondary
to the injection of HA some 9 months earlier.57 Infections
caused by herpes simplex, local infections, changes in
pigmentation, and small scars may occur at injection
sites.12 Antiherpetic prophylaxis is recommended only in
patients undergoing lip treatment who have a history of
recurrent herpes simplex.

Complications Associated With Permanent Dermal

Fillers
Granulomatous reactions are much more frequent after
treatment with permanent filler materials than following
the use of temporary fillers; in the latter case granulomas
only develop in exceptional cases (Figures 4 and 5). The
development of granulomas may be delayed, for example

I. Snchez-Carpintero et al
coming as late as 14 to 24 months after treatment
with polymethyl methacrylate microspheres58,59 or the
injection of methacrylate fillers, such as Dermalive.60,61
A granulomatous reaction can be defined as a chronic
inflammatory response that appears at all injection sites
at the same time at least 2 months after treatment;
it can persist for at least a further 2 months.62 The
real incidence of this complication is estimated to be
about 0.1%.12 Histologic findings can sometimes help to
determine the type of filler used.63 Reports describe various
types of granulomas: cystic (palisading or inflammatory);
edematous (lipogranuloma) and sclerosing.62 It appears that
the development of these granulomas does not depend on
the volume of material injected or the biocompatibility
of the compound, but rather on its chemical properties,
surface structure, and the greater or lesser presence of
impurities.62 For example, granulomatous reactions are
found more frequently in association with fillers that have
an irregular surface, in which cases giant foreign body
cells have been observed.64 The dermis is known to be
highly susceptible to immunogenic provocation, however,

Figure 4 A and B, Patient with an intense inflammatory reaction

caused by permanent dermal filler. C and D, The histologic
hematoxylineosin stain reveals a granulomatous reaction with
foreign body giant cells in the subcutaneous tissue (hematoxylin
eosin, original magnification 1.25, 10). E and F, Polygonal
material can be seen, consistent with the presence of Dermalive
deposits (hematoxylineosin, original magnification 20, 40).

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Dermal Fillers: Types, Indications, and Complications

391
with HIV-associated facial lipoatrophy, excellent results
and no serious complications were reported using this
technique.71
A final controversial question is whether exposure
to certain laser or radiofrequency procedures could in
some way affect injected dermal fillers. In one study
no alteration of the properties or disposition of HA or
calcium hydroxylapatite was observed when monopolar
radiofrequencies were applied 2 weeks after injection of
these fillers.72 Likewise, in another study using a variety
of different laser and radiofrequency procedures following
injection of HA dermal filler, no clinical or histologic
changes were found.73

Our Personal View

Figure 5 A and B, A patient who developed an intense

inflammatory response a few months after treatment with a
permanent dermal filler in whom the condition had not improved
despite 3 years of treatment with oral corticosteroids. C and D,
A very satisfactory response was obtained only 1 month after
starting treatment with oral allopurinol.

meaning that the deeper the material is implanted, the less

likely there is to be a granulomatous reaction.62 Although
the pathogenesis is poorly understood, it has been reported
that the development of granulomas is associated with the
occurrence of a serious infection in the preceding months.
It is therefore recommended that all patients with implants
of permanent filler materials should take antibiotics during
infections that develop in the 10 years following the
implantation of the material.62
The initial treatment for granulomas is intralesional
injection of corticosteroids.65 The number of treatments
required will depend on individual response. In resistant
cases, intralesional interferon can also be injected.
Intralesional injection of 5-fluorouracil combined with
betamethasone or triamcinolone has also been used.66
Other treatment options include oral corticosteroids or
oral antibiotics such as minocycline or doxycycline.67 Other
drugs that have been used successfully in isolated cases
are allopurinol49, colchicine,68 and isotretinoin69 (Figure
5). Since few patients have been treated, guidelines and
specific recommendations are not available for these
drugs in this setting. Surgical excision of granulomas is not
recommended except as a last resort.65
The incidence of complications associated with silicone
fillers can be high when large quantities of material are
used or the type of silicone used contains impurities.
Cases of migration of the material to other areas of the
body, cellulitis, and even death have been reported.70
The microdroplet injection technique is recommended to
minimize the complication rate. This technique involves
the injection of 1 or 2 drops of the product into each
one of a series of punctures. In a recent study of patients

Dermal fillers, together with botulinum toxin treatment

and certain laser procedures, have become key tools in the
prevention and treatment of facial aging. An understanding
of the nature of the different filler materials, their
indications, and the associated complications and their
respective treatments, is essential to the achievement of
optimum results. To ensure a good result, treatment should
always be individualized, precise indications should be
established on a case-by-case basis, and the physician must
inform the patient about the results that can realistically
be achieved.
Dermal fillers have been used for many years to
improve the appearance of lines and wrinkles by making
two-dimensional changes. Today, we also use them to
correct loss of volume in certain areas of the face. This
volumizing effect is responsible for the increased use
of fillers in recent years. Our experience with dermal
fillers is aimed at achieving a natural result with few side
effects. Consequently, of all the dermal fillers available
to dermatologists, the material we use in most cases is
HA in different densities. When facing industry pressure
in this field, it is vital to follow the medical maxim that
admonishes to read up on the latest development but use
the one just before that.

Acknowledgments
The authors would like to thank Dr Rosario Serrano
and Dr Ana Beln Enguita for their histologic study and
microphotographs, and Gloria Gmez for her assistance in
the preparation of the illustrations.

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