Hyaluronic Acid Fillers

Importance of Hyaluronic Acid Fillers
The hallmark of the aging face is loss of associated subcutaneous volume over time. Clinically, with this loss, one commonly finds the signs most clinicians see routinely when confronted with a patient concerned with the aging face – an increase in facial vasculature and pigment alterations, as well as an increase in the lines and wrinkles of the skin. This is associated histologically with a thinning of the epidermis and with dermal atrophy and loss of the elastic tissues present within the dermis and with actinic changes with loss of dermal collagen. The treatment for this change over time can be multiple, from skin care products, to energy based therapies (lasers, light sources, and radiofrequency devices) to fillers and toxins. HA fillers play an integral part in the correction of changes associated with aging; especially those associated in the lower one-half of the face, from the nasolabial folds, to the vertical lip lines of the lips, the marionette lines around the mouth, and in the thinning of the lip itself. They also can be used for volume enhancement of the cheeks. The concept of an ideal filler has been debated for a number of years. Without question, everyone wants the ideal filler to be easy to inject, produce reproducible results, and have longevity (lasting between 1 and 2 years). Further, the ideal filler would be painless on injection and nonallergenic (no skin tests required), noncarcinogenic, nonteratogenic, and we would expect it not to migrate once injected into the skin. We would like the ideal filler to be stored at room temperature, have a long shelf-life, and be free from all transmittable diseases. Further, we would want this ideal filler to have few, if any local adverse events, and be affordable to both the patient and the physician.

The Main Differentiators for Hyaluronic Acid Fillers
The main differentiators for HA fillers are: source of HA; concentration of HA in each syringe being utilized; the particulate size of the HA; whether the HA is cross-linked; the type of cross-linking agent used in the HA; whether the HA is monophasic or biphasic; and whether there is an anesthetic in the HA syringe. The HA source for the available fillers are either avian, that found primarily in rooster combs, or from bacteria-sourced HA, mainly from the synthetic fermentation of the Staphylococcus equine bacterium. This latter source has become more popular recently because of potential allergy to the avian source owing to a high avian protein content, and because the bacterial-derived HA products are more pure, more viscous, and not derived from an animal source. The concentration of HA fillers is also important. Those HA fillers with higher HA concentrations displace more tissue and are felt to equate to longer duration of effect. Those HA fillers with concentrations of 20 mg/g or more of HA are now considered ideal. All HA fillers utilize a single ether cross-link bond to stabilize the product. The newer non-particulate HA fillers are either double cross-linked, multi crossed-linked, or monophasic gels. They are cross-linked with a single ether bond and have their long chains of HA bound to 1,4-butandiol diglycidylether (BDDA) as well as having the shorter HA chains bound to the network, also with BDDA. The resulting homogeneous mass becomes potentially less resistant to degradation, making for a longer-lasting HA filler. As a result of these processes, and because these newer gels are non-particulate in formation, they require a higher HA concentration for the duration of effect. The cross-linking of HA is required to prevent biodegradation from free radicals and enzymes and to increase the HA filler duration. A newer agent, 1, 2, 7, 8-diepoxyoctane, may further enhance duration. Larger HA particles tend to last longer and are usually used for deeper dermal injections and defects. Monophasic HA fillers are cohesive gels rather than just HA particles. Biphasic HA fillers are made into particle form. Each form has proponents – monophasic HA fillers may last longer and may not migrate after injection.

Volume and Wrinkle Treatment with Hyaluronic Acid Fillers
The aging process in the face is particularly evident in the loss of volume on the cheeks, wrinkling of the nasolabial fold, sunken rings under the eyes or thin lips. The fresh, radiant and plump appearance decreases due to the reduction of the skin's natural hyaluronan depots. Fortunately, nature can be helped a little here. Due to its high water-binding capacity, the hyaluronic acid filler is perfectly suited to counteract skin aging. It works wonders, not only padding the skin by binding water, but also supporting collagen and elastic fibres and stimulating their reproduction. We use only high quality hyaluronic acid fillers. These have an effective duration of up to one year or even longer, depending on the region treated. The anti-aging effect is maintained if the treatments are repeated at regular intervals. Before treatment with hyaluronic acid fillers, your doctor should inform you in detail about the filler. Blood-thinning medication should be discontinued if possible to minimize the risk of bruising. The injection sites must be thoroughly disinfected before treatment. The filler is then injected with a blunt cannula or fine needle. If you are sensitive to pain, an anaesthetic cream can be applied beforehand. This can be collected from our practice at any time to shorten the waiting time. Furthermore, the injection sites can be pre-cooled with a cold pack. The effect is immediately visible, but the skin is still a little swollen at the beginning. After about 2 weeks the final result is achieved.

Precautions for Hyaluronic Acid Fillers
Injectable hyaluronic acid (HA) is a type of temporary dermal filler. Hyaluronic acid is found naturally through out the body, with the highest concentrations in the joints, eyes, and skin. In the skin hyaluronic acid attracts water, which allows the skin to become more hydrated. As we age, the fat, muscles, bone, and skin in our face begins to thin. This loss of volume leads to either a sunken or sagging appearance of the face, fine lines, wrinkles, folds, and thin lips. Injectable HA is used to reduce the appearance of fine lines and wrinkles, facial folds, and to create structure, framework, and volume to the face and lips. The effects of injectable hyaluronic acid are seen immediately. Outcomes and longevity vary from patient to patient and are influenced by the location of the injection, the individual properties of the hyaluronic acid filler, the age of the patient, and the individual characteristics of the patient's skin. For example, results in the lips may last 6 months, but those in the nasolabial folds may last 9-12 months or longer. After that time, additional injections are required to maintain the desired effect. Your doctor will evaluate the areas of your face and/or lips needing improvement in lines, structure, and/or volume. Topical or injection numbing medication may be used for added comfort prior to your procedure. Areas to be treated should be kept clean. If there is a skin infection, then treatment needs to be postponed until it resolves. Patients who take blood thinners (such as aspirin, ibuprofen, certain herbal medications) should stop them two weeks prior to injection with the approval of their prescribing doctor.