Dermal fillers have evolved over the last few years from a simple wrinkle and line chasing technique to a 3 dimensional volume enhancing modality, which can effect both wrinkle reductions and tissue lifting. This is an exciting new frontier in aesthetic medicine, where state of the art products, technical skill, aesthetic judgment and detailed anatomical knowledge combine to create the result.

I perform the latest techniques and procedures with Juvederm (Allergan) Hyaluronic acid fillers (HA) exclusively. I believe that each product requires experience in selection and placement techniques and as I train others and have myself been extensively trained with these particular products, I can offer natural and predictable results with this exclusivity. A simple “backgrounder” PDF on understanding HA is downloadable here.

I do not personally use or recommend the use of semi-permanent or non-permanent filler (other than fat grafting). There have been too many cases of disastrous complications (which will of course be permanent) for me to recommend this to my patients.

Hyaluronic Acid Filler FAQ

What is hyaluronic acid (HA)?

Hyaluronic acid (HA) is a member of the glycosaminoglycan (GAG) family, which are a form of carbohydrate molecules. These molecules form the extracellular “ground substance” of human soft tissues, in which all cells and fibres (such as collagen) “float”. The purpose of these molecules is to bind water in the extra-cellular space, essentially making us bags of jelly, rather than bags of water. This relatively simple organic sugar molecule is found in abundance in all mammalian soft tissues and is absolutely identical across all species of mammals.

Where does HA come from?

The first commercially available HA products were isolated from rooster combs. Modern HA products are all synthesized in the laboratory by bacterial fermentation. The raw HA molecules are then polymerized into chains of various lengths. If these HA polymer chains were injected into human tissue, their half-life would be less than 24 hours, due to human tissue degradation. In addition, the product would be very fluid. This would make them unappealing for aesthetic use!

To make fillers long-lasting as well as more viscous, the HA chains undergo a process of cross-linking using a small organic chemical known as BDDE (1,4-Butanediol Diglycidyl Ether). The exact process of stabilization and cross-linking are proprietary to each manufacturer. The most important production step is the washing of the cross-linked gel to remove the unreacted BDDE to a very low level (less than 2ppm is required). This is a critical quality step and is the most time consuming and costly production step. The washed product is then sterilized and pre-packed into syringes for injection.

Is there anything specific you look for when considering a filler?

There are over 180 different HA fillers on the market, as well as numerous other filler materials. Because dermal fillers are registered as medical devices and not scheduled medications, less rigorous regulatory requirements need to be fulfilled before these products may be marketed. This means that a wide range of quality is presently available. Juvederm, manufactured by Allergan is of exceptional quality and has a large body of scientific and safety data to support it. For patients and practitioners alike, it is essential to choose a product that has proven clinical benefits, has undergone rigorous testing and has an extensively studied safety profile. One of the best ways to do this, is to choose a product from a leading global brand, with an outstanding clinical heritage. Such brands also voluntarily partner with leading doctors to develop best-practice and elevate the standard of care in aesthetic fillers. Choosing products from such a brand is both safe and responsible. This was one of my motivating factors when considering my exclusivity.

It is also important to appreciate that fillers are only sterile in the unopened original packaging. It is considered poor practice to “share” syringes between patients due to various infective risks. Most practitioners will show the patient the unopened package before treating them.

How long can you expect the results of a Filler treatment to last?

Fillers, as a group, are very diverse and there are some permanent fillers. Hyaluronic acid (HA) fillers are completely degraded by the human body. The time to degradation varies with numerous factors, related to the filler itself, the technique used and the patient. Factors related to the product include the amount of HA, the cross-linking efficacy and the homogeneity of the product. Factors related to the placement include the injection technique used, the volume of product injected and location of the product. Patients are also diverse and have varying metabolic degradation rates. These are difficult to compare directly but HA fillers have been documented to last between 9 and 24 months. Generally, once a desired result is achieved, an annual “top-up” procedure is recommended.

Why does an HA product “go hard”?

This is a very uncommon and vexing problem. It has been documented to occur in about 0.1 to 0.3% of cases. All brands of HA filler have been implicated, and it appears that the short chain HA degradation products themselves may be the problem. Many theories have been put forward and the most current understanding is that the problem occurs at the intersection of a very specific set of circumstances :  genetically susceptible patient, an “inducing” event and a suitable amount of free HA. Although successful treatment of this problem is available, it remains an exceptionally rare problem.