Keywords | Summary | Correspondence | References
calcium hydroxyapatite, dermal fillers, Hyaluronic acid, poly-L-lactic acid, skin rejuvenation
The improvement of skin appearance, by restoring lost contours and volumes and treating muscular relaxation, has long been the principal goal of facial aesthetic medicine. The use of injectable materials within soft tissues has greatly increased in recent years. Hyaluronic acid fillers represent a classic example. These fillers vary widely in physical and chemical characteristics and in their correct positioning in the dermis, influencing the desired aesthetic result. In several of these compounds has also been added, within the pre-filled syringe, some anesthetic (lidocaine) to reduce the discomfort connected to the injection technique. Other fillers commonly used are made of calciumhydroxyapatite and poly-L-lactic acid. They have a long lasting effect and are highly biocompatible. In general, the ideal filler should be biocompatible, should not cause any inflammation or granuloma formation and should be durable over time. Nowadays there is no filler that encompasses all of these features, in fact all the compounds above mentioned may be responsible for the onset of adverse events. Therefore, the knowledge of the physico-chemical characteristics of the products can help the dermatologist, along with his / her personal experience, choosing the most suitable filler to be injected in order to achieve the result desired by the patient, reducing downtime and related morbidity.
Address of Correspondence
Ilaria Ghersetich, MD
Division of Clinical, Preventive and Oncologic Dermatology
Dept. of Critical Care Medicine and Surgery
University of Florence
Ospedale P. Palagi
Viale Michelangelo 41
Conflict of Interests
1. Tezel A, Fredrickson GH (2008). The science of hyaluronic acid dermal
fillers. J Cosmet Laser Ther 10: 35-42.
2. American Society of Plastic Surgeons (2006) Injectable fillers: Improving
skin texture. Arlington Heights, IL: American Society of Plastic Surgeons;
2006. Accessed June 22, 2006. URL: http://www.plasticsurgery.org/public_
3. Donofrio L, Weinkle S (2006) The third dimension in facial rejuvenation:
A review. J Cosmet Dermatol 5: 277-283.
4. Carruthers J, Cohen SR, Joseph JH, et al. (2009) The science and art of
dermal fillers for soft-tissue augmentation. J Drugs Dermatol 8: 335-350.
5. Wollina U, Goldman A (2011) Hyaluronic acid dermal fillers: Safety and
efficacy for the treatment of wrinkles, aging skin, body sculpturing and
medical conditions. Clin Med Rev Ther 3: 107-121.
6. Goldman A, Wollina U (2010) Facial rejuvenation for middle-aged
women: A combined approach with minimally invasive procedures. Clin
Interv Aging 5: 293-299.
7. Wollina U, Goldman A (2013) Dermal fillers: Facts and controversies.
Clinic Dermatol 31: 731–736.
8. Rivkin A (2009) New fillers under consideration: what is the future of
injectable aesthetics? Facial Plast Surg 25: 120-123.
9. Pickett A (2011) Serious issues relating to counterfeit dermal fillers
available from Internet sources. J Am Acad Dermatol 65: 642-643.
10. Glaich AS, Cohen JL, Goldberg LH (2006) Injection necrosis of the
glabella: Protocol for prevention and treatment after use of dermal fillers.
Dermatol Surg 32: 276-281.
11. Rohrich RJ, Pessa JE (2007) The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:
12. Carruthers J, Glogau R, Blitzer A (2008) Facial Aesthetics Consensus
Group Faculty. Advances in facial rejuvenation: botulinum toxin type A,
hyaluronic acid dermal fillers, and combination therapies: consensus
recommendations. Plast Reconstr Surg 121: 5–30.
13. Berbos ZJ, Lipham WJ (2010) Update on botulinum toxin and dermal
fillers. Curr Opin Ophthalmol 21: 387-395.
14. Greco TM, Antunes MB, Yellin SA. (2012) Injectable fillers for volume
replacement in the aging face. Facial Plast Surg 28: 8-20.
15. Prendergast PM (2012) Anatomy of the Face and Neck. Cosmetic
Surgery, Springer-Verlag Berlin Heidelberg 29-45.
16. Mendelson B, Hartley W, Scott M et al. (2007) Age-related changes of
the orbit and midcheek and the implications for facial rejuvenation.
Aesthetic Plast Surg 31: 419–423.
17. Greco TM, Elenitsas R (2010) Localization and histological characterization
of injected hyaluronic acid in excised nasolabial fold tissue. J Drugs
Dermatol 9: 399–404.
18. Klein AW (2006) Techniques for soft tissue augmentation: an ‘a to z’.
Am J Clin Dermatol 7: 107–120.
19. Park KY, Kim HK, Kim BJ (2013) Comparative study of hyaluronic acid
fillers by in vitro and in vivo testing. J Eur Acad Dermatol Venereol. In press.
20. Hilinski JM, Cohen SR (2009) Soft tissue augmentation with ArteFill.
Facial Plast Surg 25: 114–119.
21. Nast A, Reytan N, Hartmann V et al. (2011) Efficacy and durability of two
hyaluronic acid-based fillers in the correction of nasolabial folds: results of
a prospective, randomized, double-blind, actively controlled clinical pilot
study. Dermatol Surg 37: 768-775.
22. Arlette JP, Trotter MJ (2008) .Anatomic location of hyaluronic acid
filler material injected into nasolabial fold: a histologic study. Dermatol
Surg 1: 56-62.
23. Weiss R, Bank D, Brandt F (2010) Randomized, Double-Blind, Split-Face
Study of Small-Gel-Particle Hyaluronic Acid with and without Lidocaine
During Correction of Nasolabial Folds. Dermatol Surg 36: 750–759.
24. Levy PM, De Boulle K, Raspaldo H (2009) Comparison of injection
comfort of a new category of cohesive hyaluronic acid filler with
preincorporated lidocaine and a hyaluronic acid filler alone. Dermatol
Surg 1: 332-336.
25. Callan P, Goodman GJ, Carlisle I et al. (2013) Efficacy and safety of a
hyaluronic acid filler in subjects treated for correction of midface volume
deficiency: a 24 month study. Clin Cosmet Investig Dermatol 6: 81-89.
26. Raspaldo H. (2008) Volumizing effect of a new hyaluronic acid subdermal
facial filler: a retrospective analysis based on 102 cases. J Cosmet
Laser Ther 10: 134-142.
27. Eccleston D, Murphy DK (2012) Juvéderm(®) Volbella™ in the perioral
area: a 12-month prospective, multicenter, open-label study. Clin Cosmet
Investig Dermatol 5: 167-172.
28. Hedén P, Sellman G, von Wachenfeldt M et al. (2009) Body shaping
and volume restoration: the role of hyaluronic acid. Aesthetic Plast Surg 33:
29. Sadick NS, Anderson D, Werschler WP (2008) Addressing volume loss in
hand rejuvenation: a report of clinical experience. J Cosmet Laser Ther 10:
30. Cohen JL. (2008) Understanding, avoiding, and managing dermal filler
complications. Dermatol Surg 4: 92–99.
31. Park TH, Seo SW, Kim JK et al. (2011) Clinical experience with hyaluronic
acid-filler complications. J Plast Reconstr Aesthet Surg 64: 892-896.
32. Kim DW, Yoon ES, Ji YH et al. (2011) Vascular complications of hyaluronic
acid fillers and the role of hyaluronidase in management. J Plast Reconstr
Aesthet Surg 64: 1590-1595.
33. Yocum RC, Kennard D, Heiner LS (2007) Assessment and implication of
the allergic sensitivity to a single dose of recombinant human hyaluronidase
injection: a double-blind, placebo-controlled clinical trial. J Infus Nurs
34. Busso M, Applebaum D (2007) Hand augmentation with Radiesse
(Calcium hydroxylapatite). Dermatol Ther 20: 385-387.
35. Marmur ES, Al Quran H, De Sa Earp AP et al. (2009) A five-patient
satisfaction pilot study of calcium hydroxylapatite injection for treatment of
aging hands. Dermatol Surg 35: 1978-1984.
36. Fabi SG, Goldman MP. (2012) Hand rejuvenation: a review and our
experience. Dermatol Surg 38: 1112-1127.
37. Van Dam D, Van Der Lei B, Cromheecke M (2009) Statements on the
safety of permanent soft tissue fillers in Europe. Aesthetic Plast Surg 33:
38. Borelli C, Kunte C,Weisenseel P et al. (2005) Deep subcutaneous application
of poly-L-lactic acid as a filler for facial lipoatrophy inHIV-infected
patients. Skin Pharmacol Physiol 18: 273–278.
39. Rohrich RJ, Sullivan D (2011) So you want to be like Leonardo da Vinci
or Michelangelo? Which one are you? Plast Reconstr Surg 128: 1309-1311.
40. Narins RS, Donofrio L (2010) Updates on fillers. Dermatol Surg 36: 729.