Recent advances in understanding facial aging indicate that the typically aged face represents a combination of changes on many levels, including bony structures, subcutaneous fat, muscle strength and skin integrity. These structural changes can completely reshape the three-dimensional contours of the face over time, by altering balance, volume and proportions. Our advanced understanding, in combination with the advent of newer products and technologies, has dramatically increased our ability to address the aging face without having to rely exclusively on surgical interventions.

Volume replacement by means of fillers and muscle modulation through botulinum toxin injections, although not a substitute for conventional surgery, may delay or enhance cosmetic surgical procedures and is becoming ubiquitous in the field of aesthetics. As with any medical intervention, complications can occur. In a rather unregulated market where state regulations vary greatly with regards to who can inject fillers and what type of fillers can be used, experience and knowledge can greatly affect the results.

The term ‘dermal fillers’ is often thrown around in the media but little is explained about the different types and what their purpose and place is when it comes to restoring volume in the face. Fillers or volumizing agents can be categorized in two types: hyaluronic acid fillers and biostimulatory fillers.

Hyaluronic Acid Fillers

The average human body contains roughly 15 grams of Hyaluronic Acid, one third of which is degraded and synthesized on a daily basis. Almost half of the body’s HA is located in the dermis and by the time we reach the mid-40’s, the synthesis declines by up to as much as 50%.

With a gel-like, water-retaining property, Hyaluronic Acid fillers can replace one of the key structural components (glycosaminoglycans GAGs) of the human face and replenish volume and restore symmetry and youthfulness in the face. In fact, no other biological agent can retain as much water as HA, resulting in increased smoothness and softening of facial wrinkles.

Scientific studies have shown that HA not only maintains skin elasticity but also stimulates collagen production and works as a free radical scavenger and antioxidant. The unique ability of the Hyaluronic Acid fillers, beyond their immediate volumetric properties and their versatility, is its reversibility; their effect can be modified or even reversed which makes them a much safer and predictable option for non-surgical facial shaping.

Biostimulatory fillers

The primary function of a biostimulatory filler is to enhance volume through the induction of neocollagenesis: production of new collagen fibers responsible for structural support of the dermis. Currently, the active components of these shaping agents, which both have FDA approval, are: Poly L Lactic Acid (Sculptra) and Calcium Hydroxylapatite (Radiesse).

Biostimulatory fillers employ the host’s response in achieving the desired end result. By activating cell metabolism and collagen production by a cell population named fibroblasts, soft tissue augmentation and dermis remodeling is achieved.

Their effect is not immediate as with hyaluronic acid fillers; it occurs over a period of time offering the advantage of a gradual and natural change. Repeat sessions might be necessary depending on the targeted areas, volume deficit and the patient’s age which affects the inherent biostimulatory potential.

As expertise has been gained with these products over the past decade, it is now widely recognized to be safe and versatile agents that can be used in a manner that is both predictable and reproducible. Clinicians’ experience, methodology and simple yet critical technical considerations are essential to optimize results.