Summary

The two principal categories of temporary fillers approved by the U.S. Food and Drug Administration for facial rejuvenation are hyaluronic acid and calcium hydroxylapatite. The selection of HA implant is based on the indication and site of placement. For lifting and restoring volume, improving the structural foundations and facial contour, a high-density HA implant is injected deeply into the supraperiosteum. To treat medium-deep depression, we used a mid-density hyaluronic acid filler injected subdermally. For treating the periorbital area and the area around the lip, giving finished facial refinements, a low-density hyaluronic acid filler is selected with a water-like consistency filler. The most significant limitation of a filler compared with fat transfer is the potential cost compared with the latter as each syringe can be pretty expensive. The greatest benefit of a filler is accuracy. The other benefit is that a filler is bioinert and does not increase with patient’s weight gain but obviously may not look good when a patient does gain or lose weight as the filler has been injected to match a person’s current weight status.

Nothing is more gratifying for cosmetic patients than immediate wrinkles or scars because of filler injection. Fillers are flexible substances that can be injected into the skin to improve the appearance of fine lines and wrinkles, plump lips, fill hollow cheeks, repair various facial imperfections, improve scars, and elevate deep folds. The result is a smoother, more youthful appearance with minimal “downtime” and maximum safety.

Skin Rejuvenation Filler vs. Botox Injections

The simple rule? “Lines of expression need botulinum toxin. Lines at rest need filler.” Prof. Moawad says that while Botox is an excellent choice for hitting those “crease points” where muscles contract, fillers are best for deep lines present even when facial muscles are not contracting.

Who is the Ideal Skin Rejuvenation Filler Injection?

The ideal filler should be well tolerated by tissues and composed of materials that are not toxic, antigenic, carcinogenic, or teratogenic. The administration of injection should be simple, reproducible, consistent, without migration, and safe. Patients should have predictable outcomes, minimal side effects, and minimal downtime. The product should also be easily stored, versatile, durable, and affordable. The perfect filler does not exist now, and there is some debate on what defines the “perfect filler.” Some insist on non-permanent filler enhancements due to the ever-changing facial structures as a person ages. Thus, the possibility of permanent filler becoming out of proportion or migrating over time. Some argue that a permanent filler “mistake” is a lifelong mistake that is difficult, if not in some cases impossible, to remedy without surgical intervention. On the other side, advocates of permanence point to a growing phenomenon coined “injection fatigue” to support the need for permanent filler injection. It is noted that many patients drop out over time and tire of the regular needles and associated discomforts.

Additionally, many drop filler therapies due to economic reasons, as costs mount with continuous treatments required to keep the aesthetic enhancement. A growing number of patients have experienced temporary positive results, like what they see, and want to keep these enhancements permanently without ongoing treatments and expense. This “try before you buy” concept is reasonable, and a need for sustained long-term improvements has a place in the hands of expert physicians.

In the world of injectable filler injection, there is a wide range of substances being used. Despite what you might have read or heard, there isn’t the best filler; all have risks, though rare ones. Which filler substance is considered “best” or “preferred” for you depends on the doctor’s technique, skill, experience, training, facial needs, and risk tolerance? It has nothing to do with headlines in the media; these are often a result of the company’s marketing efforts that make the filler, though this information is usually downplayed, so the piece comes across as unbiased. It is essential to realize that over the past 20 years, many filler injections that were once highlighted in fashion magazines or touted by doctors (and often heralded by studies paid for by the manufacturer) have since been dropped for a variety of reasons. Getting headlines doesn’t always make for beautiful results!

Who Need Skin Rejuvantion Filler Injections?

You can choose not to undergo any cosmetic corrective procedure. Still, then without question, the deep lines between your brows, the lines from your nose to your mouth (nasolabial folds), and even your drooping jawline will not look younger the way you want. Simply put, there are no skincare products that can work as well as Botox or filler injection. It’s not that great skincare can’t make a massive difference in the appearance of your skin (believe us, we know the remarkable benefits a state-of-the-art skincare routine can provide). Still, age, muscle movement, fat loss, gravity, and sun damage, among other factors, will eventually take their toll, and your face will start looking older around the age of. Left alone, it is inevitably a downhill ride. Filler injection is one way to get a lot of your youthful appearance back. When celebrities, models, and women all over the world age 45 or older have facial skin that looks smooth and young, you can bet a big part of the reason is that they have had filler injections. If you can get over the fear of needles (no injections are pleasant) and are done wasting money on the wrinkle or so-called “lifting” creams that did not work, then perhaps you should consider filler injection.

Which Skin Rejuvenation Filler Injection is Right for Me?

The aging process causes volume loss as the underlying collagen, hyaluronic acid, and elastin fibers deteriorate, and fat stores in the face decrease. This most commonly occurs around the eyes, mouth, cheeks, jawline, brow, and bridge of the nose, producing crow’s feet, laugh lines, folds, and furrows on the forehead, and “hills and valleys” on the lower third of the face. By directly injecting a naturally-derived or synthetic material into the frown lines between your brows, the deep lines from the corners of your nose to the edges of your mouth, depressions along the jawline, the recessed areas under your eyes, or the hollowed regions of your face, wrinkles and lines immediately become filled-in and skin is plumped up to the point where the crease, depression, or fold is gone. Filler injection has the unique ability to fill and contour these changes and improve facial scarring from acne or injury. This improvement can last from 3 months to 2 years or even longer depend on the type of filler used, how you take care of your skin, and how your face continues to age. Don’t confuse filler injection with how Botox works. Although both procedures involve injections, Botox is injected around the forehead and wrinkles around the eyes (crow’s feet) to stop muscle movement that results in lines. It has nothing to do with the plumping smoothing effect filler injection has. Many people get both Botox and filler injections because the combination can produce a remarkably younger-looking face.

How are Filler Injections Done?

Dermatologists have developed various filler substances to address a wide range of cosmetic flaws and other needs of the individual patient. Each filler brings subtle, distinctive benefits. Sometimes I may use more than one filler to achieve the best results. One fill provides longer-lasting results; others allow for more precision with fine lines, and still, others can gradually bring the face into better balance, creating an overall rejuvenated appearance. Filler injection is often considered the first line in treating aging skin and is used in combinations or with other techniques for facial rejuvenation. The ideal material varies by indication. A permanent and immobile substance may be proper for an iatrogenic scar. A soft, resorbable, and non-inflammatory element might be more suitable for wrinkles that change with age. At MSI, we do our best to make your sessions as painless as possible. Numbness of the treated area may vary from merely the applications of topical cream, air, and contact cooling, local anesthesia, nerve blocks to sedation. The new filler injection is already mixed with anesthesia to make the injection less painful and more comfortable.

Prof. Moawad uses various filler injections, including hyaluronic acid and autologous fat (one’s fat). Since filler substances do not involve major surgery and are cost-effective, men and women use these youth-enhancing techniques more than ever. With the increasing desire for people to achieve a more youthful appearance, the aging baby boomer population, and the increased demand for “lunch-time procedures,” the pharmaceutical market has responded by providing the cosmetic surgeon with an increasing number of options to meet the needs of the cosmetic patient. Thus, this segment of cosmetic surgery has been the fastest growing for the past decade worldwide. Considerable advances in technology have given cosmetic surgeons an array of filler options. Still, no one filler can address every patient’s concern.

Filler injection can be classified in a variety of ways. They can be found according to their source: autologous, biological, or synthetic. They can also be classified according to risk profile, level of ability needed for injection, or depth of dose. We choose to find these products as filler injection instead of filler injection because they are not placed exclusively into the dermis. More commonly, filler injection is classified according to its effect longevity: short, long-lasting,semi-permanent, and permanent. These durations can be defined as less than six months, six months to 2 years, 2 to 5 years, and more than five years, respectively.

Filler injection is used for various cosmetic purposes, from filling fine lines and wrinkles to augmenting facial contour and projection. Replacement filler injection, or temporary filler injection, are filling agents that are injected into and occupy space for a variable period until they are either degraded by the body or naturally dissipate. Hyaluronic acid (HA) products, calcium hydroxyapatite (CaHA), marketed as Radiesse, and collagens form this category. Bio-stimulatory filler injection, by contrast, runs by inducing new collagen formation. These agents have either long-lasting or permanent effects. Poly- L-lactic acid (PLLA), marketed as Sculptra, and polymethylmethacrylate (PMMA), marketed as Bellafill, form this category.

Temporary Filler injection

Collagen

Collagen is the major structural part of the skin. Replenishing the dermis with more collagen seems a natural extension. By the end of 2010, all the collagen filler injections will no longer be available in the United States, as they have been voluntarily withdrawn from the US market.

Hyaluronic Acid (HA) Filler injection

Hyaluronic acid is a part of all connective tissue, including the skin. Hyaluronic acid is chemically the same for all species and has a low risk of allergic reactions. Therefore, skin testing is not needed. HA is hydrophilic and supplies a matrix to keep moisture within the dermis where collagen may develop. Hyaluronic acid potently binds to water. One gram of HA can bind up to 6 L of water. When injected into the skin, it volumizes, softens, and hydrates the skin. In addition to these benefits, it plays a role in cell growth, membrane receptor function, and adhesion. Hyaluronic acid stabilizes intercellular structures and produces the viscoelastic network for collagen and elastin fibers to bind together. As seen with photoaging, these connections fail, thus resulting in disorganized clumps of collagen and elastin. Hyaluronic acid has a heparin effect, thus resulting in a higher incidence of bruising.

Restylane/Perlane

This filler is produced by fermentation in bacterial cultures. This filler has been used to correct the nasolabial folds, marionette lines, tear troughs, glabellar frown lines, lip enhancement, and cheek augmentation. Other clinical uses include the correction of the jowls and nasal deformities. In general, most patients can expect six months of revision, if not longer.  Perlane filler is identical to Restylane except that it consists of larger gel particles. This filler is suitable for correcting deeper folds, such as the nasolabial folds, and works well for cheek enhancement. Most patients can expect 6-12 months of revision with Perlane.

Juvederm (Juvederm Ultra/Juvederm Ultra Plus)

In 2006, the FDA approved Juvederm, which is also a non-animal stabilized hyaluronic filler. In the United States, only two types of Juvederm filler injection are FDA approved. Both Juvederm Ultra and Juvederm Ultra Plus hold 24 mg/mL of hyaluronic acid, but Juvederm Ultra Plus has a higher proportion of cross-linking than Juvederm Ultra. Juvederm is a homologous gel with the highest degree of cross-linking of any hyaluronic acid filler injections and thus has a smooth consistency. Juvederm Ultra and Juvederm Ultra Plus have indications like those of Restylane and Perlane, respectively, and do not require refrigeration or skin tests before use.

Juvederm (Voluma, Volift, and Vobella)

Voluma is the first filler approved by the FDA to claim it can “temporarily correct age-related volume loss in the cheek area of adults over the age of 21.” One of the early signs of aging is volume loss in that part of the face from a combination of fat and bone absorption, which results in sagging skin and hollowing that increases slowly over time. Another quality unique to Voluma is that it can last for two years—exceptional longevity for an HA—and something that makes it particularly appealing to patients who dislike returning for frequent refills. The concepts of lift, volume replacement, molding, quickly spreading, direct line filling, and improved glowing appearance is all within this agent’s province. For cases of significant volume depletion where either lift or feature augmentation is needed, Voluma is the product of choice.  The milder volume change induced by Volift is designed for a more subtle difference, such as in the perioral and brow/forehead regions. In contrast, the very spreadable texture presented by Volbella is a more critical filler characteristic for superficial placement for lines and for those indications where minimum volume is required.

Hyaluronic Acid for Fine Lines (Belotero Balance)

Fine lines and creepy skin are manifestations of multilevel, age-related volume loss. It is, therefore, logical to combine intradermal volumetric for fine lines with subcutaneous volumetric for contours. This publication supplies evidence- and experience-based rationales for applying cohesive polydensified matrix hyaluronic acid filler (Belotero Balance). For an excellent line filler, the relative contributions of space-filling, water binding, and neocollagenesis to the mechanism of action have implications for efficacy— both quantitatively and qualitatively, and in the immediate and long term. The rheologic profile of Belotero Balance supplies a scientific rationale for its ability to address fine lines and crepe skin. Its design as a cohesive, soft, spreading filler that flows through tissue and integrates homogeneously allows it to carry out ongoing 3-dimensional tissue expansion, with the dual potential for structural and dynamic restoration. Clinical study data show that Belotero Balance is efficient, durable, and well-tolerated for intradermal and superficial subcutaneous implantation.

Prevelle Silk

Injection into the mid-to-deep dermis. This filler was FDA approved for use in the United States in 2008 and was the first hyaluronic acid filler to hold lidocaine, which reduces pain upon injection in the USA. Prevelle Silk is shown to treat moderate-to-severe facial wrinkles, although it may be better suited for fine lines.

Elevess

Elevess is approved for injection into the mid to deep dermis to correct moderate to severe facial wrinkles and folds, such as nasolabial folds. ELEVESS is supported in the EU to correct contour deficiencies, such as wrinkles, folds, and acne scars, and enhance the appearance of lips. ELEVESS is approved in Canada to correct contour deficiencies of the face, such as wrinkles, folds, and acne scars.

Matridex /Reviderm Intra

This is a new resorbable gel suspension filler composed of a mixture of non-animal stabilized hyaluronic acid, cross-linked hyaluronic acid, and dextranomer microspheres (Matridex and Reviderm intra). It has been used for the aesthetic treatment of facial lines.

LONG-LASTING FILLER INJECTION

POLY-L-LACTIC ACID (PLLA) (SCULPTRA OR NEW FILL)

Poly-L-lactic acid (PLLA) is a biodegradable, non-toxic, synthetic, inactive material derived from corn starch. It has been used in suture material, stents, and other biomedical implants. Due to the extensive biostimulation effects of this product, it is considered a semi-permanent filler. The clinical results can be seen for up to 2 years. The FDA approved Sculptra in 2004 for human immunodeficiency virus (HIV)- related facial lipoatrophy. It holds PLLA microspheres in a powdered form.  A common finding with this product is palpable but usually nonvisible subcutaneous “micronodules.” More recent studies of PLLA using a diluted suspension of the product have resulted in a dramatically decreased rate of micronodule formation. Many practitioners use six ccs of sterile water for reconstitution, and in areas such as the hands and chest, even larger dilutions are used. Longer reconstitution times are also recommended, with reconstitution occurring at least 8 hours before injection of the product. I should take care to inject the product in the superficial fat and not in the mid dermis, and the clinician should be careful not to insert the residue at the end of the syringe.

RADIESSE OR RADIANCE

Calcium hydroxylapatite (CaHA) is the mineral part of the bone; therefore, it should not stimulate an immune response, making it biocompatible. This material has been used previously in dental, orthopedic, urologic, and vocal cord applications. It acts as a scaffold for collagen ingrowth. The FDA approved Radiesse in 2006 for the correction of facial wrinkles and folds and HIV-associated facial lipoatrophy. In 2009, it received FDA approval for cosmetic use in non-HIV patients as well. Administration of CaHA supplies immediate 1: 1 correction and does not expand beyond what was injected. Over time, the carrier gel is absorbed, and new collagen is formed around the microspheres. The result is a longer-lasting implant with characteristics close to natural tissue.  The longevity of correction ranges from 10 to 18months. Most Radiesse is used for the correction of nasolabial folds, atrophic cheeks, and temporal wasting. The clinical results may last for 12 months or longer, although the carrier gel lasts no longer than six months, thus often resulting in a slight decrease in correction at that time. Because of the pain associated with injection, Radiesse was released, which has lidocaine to reduce pain upon injection.

Treatment of the lips has resulted in cyst formation holding the carrier gel. For this reason, most cosmetic surgeons avoid treating the lips with Radiesse. I must take extreme care to avoid injection while withdrawing the needle out of the skin, which will result in the deposition of material into the dermis. In addition, it should be administered with caution to the tear trough region. In general, the overall rate of nodule formation with CaHA is meager, and no granulomas or nodules have been reported when the product is injected into areas other than the lips. If visible nodules occur, these can be treated by puncturing the buds with a no. 11 blade or needle and then expressing the contents.

Permanent Filler injection

Fat transfer, Fat injections, Fat grafting, Micro-lipo-injection

Various names know fat transfer: fat injection, fat injections, fat grafting, micro-lipo injection, and autologous fat grafting. The word autologous means material (fat) is harvested from one area and donated to another in the same individual. Although fat transplantation has been utilized in medicine for more than 100 years, the concept of injecting human fat back into the patient as an effective means to fill in wrinkles and loss of tissue throughout the body and face has been accessible only since the mid1980s. Autologous fat transfer has become an increasingly important method of facial rejuvenation both as a standalone procedure and in combination with traditional rejuvenation methods, like face-lifting, brow lifting, and blepharoplasty.

Fat transfer is particularly suited for restructuring the proportion of the face. Typical facial structures can also be aided by adding constructive elements to correct a broad range of perceived facial deficiencies. For example, a stronger jawline creates a youthful, more powerful-looking face; ending the hollowness of lower lids helps reduce that tired, sad appearance, and fuller lips create a more youthful, attractive appearance. Fat transfer is also used for augmenting body contours, such as the breasts or buttocks. In certain respects, fat grafting stands in contradistinction to earlier efforts at rejuvenation in which the face is augmented with tissue rather than subtracted by lifting, pulling, and excising. A simple analogy to understand the benefits of fat grafting is looking at a whole and the ripe grape that becomes prune-like (wrinkled, puckered) over a period like a convex, youthful face that undergoes contraction and involution with age. It would be better to re-inflate that tiny raisin back into a grape rather than remove what appears to be excess tissue and transform that raisin into a pea. The minimally invasive technique using autologous fat transplantation has become a standard procedure in facial rejuvenation. It is simple, inexpensive, permanent, and valuable. It is considered safe because of its autologous property and fat graft longevity. Other indications include congenital, traumatic defects, or surgical defects and scars.

Autologous fat grafting meets all the fundamental criteria of ideal augmentation materials: availability, low antigenicity, minimal donor morbidity, reproducible, predictable results, and avoids non-auto graft disease transmission or incompatibility, not likely to elicit an immune response, most minor reported complications, and longer survivability. Fat transfer provides a very appealing resource for volume augmentation in both small and large volumes. Other areas where fat grafting techniques are considered superior to synthetic filler injection in terms of the total amount required to perform more substantial aesthetic corrections include the buttocks and breasts. Prof. Moawad and many others insist on the unique dynamic quality of fat as it will age as we age. This exceptional fat quality is perfect in augmentation since facial structures change as we age, and a permanent filler will be out of proportion if used.

Furthermore, fashion and trends change, and what is accepted now as beautiful may not be allowed later. The best of all is fat grafting is forgivable while the mistake of permanent filler is permanent,” Prof Moawad says. The only relative drawback of fat injection has been the resorption of some of the fat grafts. However, with proper technique, 30–70% of the fat is retained, Prof Moawad says. The Disputes about longevity and the technique variation has postponed the announcement of fat as the perfect filler, added Prof. Moawad.

Nevertheless, its use stays limited compared to commercial filler injection. It also appears that surgically trained and oriented cosmetic practitioners are far more likely to use fat and complement other surgical procedures such as face–neck lifts and blepharoplasty. In sheer numbers, less surgically aggressive dermatologists, and now a wide array of non-surgically trained “cosmetic practitioners,” not to mention non-physician “extenders” such as physician assistants and nurse practitioners, and even simple registered nurses – inject the bulk of commercial filler. While synthetic filler injection can smooth out wrinkles and folds, it cannot restore fullness that is naturally lost as fat and bone diminish, and it is not for everyone. Some individuals are allergic to synthetic materials and may develop an allergic reaction. Furthermore, due to high cost, I cannot use synthetic materials in large quantities to restore body deformities, augment breasts or buttocks, or even hands, making fat grafting a much more desirable and economical treatment choice.

Patient choice plays a vital role in the success or failure of any procedure. It never pays to run on patients with unrealistic expectations, as they are never satisfied with the outcome. It is vital to have a detailed history, including their past, personal, and psychiatric history. In people with severe depression, facial outlook acts only as a part of the problem and will only help but not treat the cause of depression. It is noticed during the consultation that some patients are not sure what the most proper procedure is for them. I should explain the process to those and others in nonmedical terms and its potential complications and alternatives. An ideal candidate will be an individual in good health, with no current or preexisting medical condition, who is not on any immunosuppressive or anticoagulation therapy, and has realistic expectations. Fat grafting could be considered ideal for those areas where you need a lot of filler, such as in those patients who have full-face lipoatrophy. Individuals who are allergic to bovine collagen (animal origin) or other synthetic materials, but want youth-enhancing results, are good candidates for fat transplantation. People with “contour deformities” may receive help from fat transplantation as well. By contour deformity, we mean a large surface area of skin sunken or otherwise uneven due to a traumatic injury or surgery, for example, after liposuction. Another indication could be the atrophy typically seen in the aging dorsum of the hands, Prof Moawad says, offering a more lasting treatment solution for this cosmetic thorn.

Patients with a history of underlying current infection, smoking, anticoagulants, coagulation disorders, herpes simplex, and significant acne scarring are not ideal candidates for fat transfer. Patients with gross wrinkles and poor skin tone will need added procedures for optimum results. One must be careful in dealing with patients having a history of poor or delayed wounds. People with bleeding disorders, or those who have diabetes, are not suitable candidates for the procedure. Additionally, fragile people with inadequate donor fat sites should not undergo this procedure.

Silicone (Silikon 1000, Adatosil 5000, Bioplastique)

Silicone, in the currently FDA-approved “off-label” filler substances SILIKON 1000 and ADATO SIL-OL 5000. In elastomer (solid) form, silicone is extensively used in medicine, such as intravenous fluid tubing and implanted prosthetic devices. Silicone gel is used for breast reconstruction and breast enlargement. The suspension should be injected into the subcutaneous tissue and has been chiefly used to correct facial rhytids and lip augmentation. The large size of the silicone particles prevents them from being engulfed by immune cells. Therefore, they stay at the injected site, producing local fibrosis, contributing to the filling effect.

Liquid injectable silicone readily fulfills most of the criteria for an ideal filling substance. It is a clear, odorless, tasteless, colorless, and stable substance. Liquid injectable silicone does not harden or soften, still is unaltered within the range of human body temperature, and is chemically unchanged by exposure to air, most chemicals, and sunlight. It can be stored for long periods at room temperature and does not allow for the growth of microorganisms. Although not entirely biologically inert, liquid injectable silicone has been shown to have the least physiologic reactivity of most foreign materials. Additionally, it lacks mutagenic, carcinogenic, and teratogenic effects; no true allergies to silicone have been documented. Although the technique is dependent, the advantages of liquid injectable silicone over other liquid injectable filler substances are its precision and permanence.

Despite concerns about its long-term safety and adverse inflammatory reactions, the long-term experience of physicians skilled in administering liquid injectable silicone has shown it to be safe and efficient for augmentation. With depressed, broad-based acne scars, the 1,000-centistoke viscosity liquid silicone is used exclusively with a 27-gauge 1/2-inch needle. Using the microdroplet, multiple-injection approach, small amounts of silicone are injected at the correct depth in the tissue at monthly intervals, usually requiring only a few treatments. Allowing about a month between treatment sessions enables the scar to stretch, reconfigure, or accommodate the presence of the liquid silicone.

Concerns about its long-term safety and adverse tissue reactivity have been raised in many articles. Silicone has been implicated in a variety of local and systemic adverse inflammatory reactions. Treatment-site reactions, including redness, pain, tissue hardness, discoloration, ecchymosis, excessive tissue elevation, and migration of the injected material to local and distant areas, have been reported—more severe complications, including subcutaneous bumps, lumps, ulceration, and regional lymph node enlargement. Following large amounts of silicone injections, physicians have reported tissue destruction and scarring, lung and liver inflammation. None of those mentioned earlier reports have associated such side effects or complications with silicone for acne treatment. Only tiny volumes of the material are employed.

Artefill, Artecoll, Arteplast, Bellafil (PMMA)

Polymethylmethacrylate (PMMA) is an acrylic plastic that has been used in many medical applications for years, including bone cement, lenses, dental work, and pacemakers. Because this filler contains lidocaine, the injection is less painful than other filler injections that do not contain lidocaine. This filler is shown to correct the nasolabial folds, although used for acne scars and forehead furrows. PMMA supplies support for human collagen deposition. Suppose placed too superficially, leading to lumps. Most practitioners prefer a threading injection technique. Unlike the other filler injection, this filler should be considered a permanent filler. Because results are lasting, it is often best not to achieve full correction in one session but to carry out the desired effect over several treatment sessions.

Bellafill (previously known as Artefill) has been marketed and sold in the United States as a permanent filler to correct nasolabial folds since 2007 and received FDA approval for acne scarring in December 2014. With this new indication, Bellafill is currently the only “on-label” filler approved by the FDA to treat moderate to severe, atrophic, distensible facial acne scars on the cheeks of patients older than 21.

Evolution

This filler is composed of a suspension of 6% polyvinylhydroxide microspheres suspended in 2.5% polyacrylamide gel and has been used chiefly for lip augmentation. Several adverse effects (AEs) have been reported with this product, including local tissue necrosis, granuloma formation, chronic inflammation, and infection. A unique complication associated with this product is the development of stiffness, lymphedema, and nodules after-treatment of the lips. Skin testing is mandatory before using this agent, and PMMA is contraindicated in patients with either one positive response or two equivocal responses. Furthermore, a contraindication is extended to patients with a history of severe anaphylaxis, those with an allergy to bovine collagen or sensitivity to lidocaine.t is therefore not recommended in patients with a susceptibility to either keloid or hypertrophic scarring. It is not written down for lip augmentation.