9 Key Things You Should Know About Hyaluronic Acid Fillers

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In a beauty editor dream world, hyaluronic acid would spray out from fountains and sidewalk misters to keep our skin plump and dewy—highlighter would be put out of business. But until that day, we’ll take second best: dermal fillers that deliver the same effect. Here's everything you need to know about one of the world's favorite in-office aesthetic treatments.

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Where can hyaluronic acid (HA) fillers be injected? 
“Hyaluronic acid fillers can be used almost anywhere on the face to improve its shape and replenish lost volume, but the most common areas are the midface, the folds around the mouth and the lips/lip lines,” says Nanuet, NY dermatologist Heidi Waldorf, MD. “We also regularly inject them in off-label areas, meaning those outside the FDA-approved indications, such as under the nose, in the tear troughs and on the jawline, nasal bridge, earlobes, forehead, temples and neck lines. There’s also renewed interest in treating the hands since the recent FDA-approval of Restylane Lyft for hand rejuvenation.”

Which brands should I be aware of?
Although there are many more HA fillers available overseas than in the U.S. due to stricter regulations, these are the top products currently on the market stateside, as well as the areas they've been FDA-approved to treat:

Moderate-to-Severe Facial Wrinkles and Folds (Nasolabial Folds): Belotero Balance, Juvéderm Ultra, Juvéderm Ultra Plus, Juvéderm Vollure, Restylane, Restylane Defyne, Restylane Lyft, Restylane Refyne, and Revanesse Versa

Lip Augmentation: Juvéderm Ultra, Juvéderm Volbella, Restylane and Restylane Silk (Silk and Volbella can also treat lines/wrinkles around the lips)

Cheek Augmentation for Age-Related Volume Deficiencies in the Midface: Juvéderm Voluma and Restylane Lyft

The Backs of the Hands: Restylane Lyft

How long do they last?
“They vary wildly—some last four months; others last a year or more,” says West Palm Beach, FL dermatologist Kenneth Beer, MD. “Although several companies advertise that they last even longer, this typically only occurs when large volumes of filler are injected. In areas with little to no facial movement, such as the chin, temples or jawline, I get significantly longer duration from any filler than I get when I put it around the mouth or in the nasolabial folds.”

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Are they painful?
“A numbing agent called lidocaine is infused into almost all Juvéderm fillers and some Restylane fillers to reduce discomfort during the treatment,” says Wexford, PA dermatologist Debra T. Abell, MD. “This can be a positive thing for patients, but those who are allergic to lidocaine will have to opt for fillers that do not contain it, which can limit their options.” Even with lidocaine, some areas of the face may be more painful than others, such as the nasolabial folds, as they have a higher number of nerves.

Can I have them removed if I don't like them?
“An enzyme called hyaluronidase can be injected into the filled area to digest the HA filler if a patient is unhappy with the result or changes their mind,” says Dr. Abell. However, those who have a hypersensitivity to bee stings or bee venom may not be able to use it. One study revealed hyaluronidase was most effective on Restylane injections over other HA fillers, which could be due to the way the HA in that particular product is crosslinked, but the results vary person to person.

Why is it important to see a board-certified expert injector?
“A board-certified expert injector knows the anatomy of the area being injected, as well as how to deliver individual results rather than using a cookie-cutter formula on each person because that’s all they know how to do,” says Dr. Beer. “There is a big difference between someone who takes a weekend course and a doctor who studies anatomy for several years. Properly trained injectors know how to deal with complications such as an infection, and if one does occur, they have the resources to fix it.”

What side effects and problems can occur?
Swelling and bruising are common, but Dr. Beer says they can be minimized with good patient preparation, injection technique and post-treatment care. If the filler is placed too close to the skin’s surface, the skin can take on a bluish appearance when the light hits it, which is known as the Tyndall Effect. It’s often the result of improper injections, but can occur with even the most skilled doctor, and when it does, hyaluronidase can be used to remove the filler. “Although HA fillers are generally very safe, more serious side effects can occur, including an infectious or inflammatory nodule—this is why we ask patients to avoid vaccinations and anything that could allow bacteria to enter the bloodstream, like dental work,” he adds. “In rare cases, filler can block a vital blood vessel, causing skin ulceration or even blindness.”

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What are skin boosters and why aren't they available in the U.S.?
As Dr. Waldorf explains, whereas traditional HA fillers are durable gels of variable firmness and moldability meant for deep skin or subcutaneous injection to sculpt and lift it, skin boosters are softer, often-uncrosslinked HA gels that are injected as a grid of microdroplets into the superficial skin. “It’s usually done with an injection pen or a mesotherapy device, and improves hydration and elasticity for a smoother skin texture," she says. Some beauty editors in Europe get a skin booster treatment once a month, although only one every six months is needed, and have likened it to “applying concealer under the skin for increased radiance.”

“The reason these products aren’t yet available in the U.S. comes down to cost,” says Dr. Waldorf. “Getting them approved in the U.S. would be incredibly expensive, as there isn’t currently a validated rating scale at which to measure them, and creating one comes with a large cost. One crosslinked HA product called Restylane Vital is indicated as a skin booster everywhere but North America, where it’s called Restylane Silk and marketed for volumizing the lips and smoothing the lines around them.” Another crosslinked HA skin booster making its way stateside is Juvéderm Volite—it’s said to enhance skin texture and elasticity for up to six months—which was approved in Europe in 2017, but isn’t expected here until sometime next year.

Are there any new HA fillers on the horizon?
Already available in Europe but awaiting launch in the U.S.—the date is still to be determined—a collection of three new HA fillers under the name Teosyal have received FDA-approval for treating moderate-to-severe dynamic facial wrinkles and folds, such as nasolabial folds. “My colleagues outside the U.S. who use these fillers say they like their flexibility,” says Dr. Waldorf, “but we already have Restylane Refyne and Defyne in the states, which are marketed as being flexible and moving with the skin, so it will be interesting to see how these new versions will be marketed.”


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