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A review of dermal fillers in facial plastic surgery

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Purpose of review: Over the last decade, injectable soft tissue fillers have become an integral part of facial plastic surgery practice. The vast choice of new products being brought to the market, improved safety profile, lower costs in the current economic climate and high street availability mean that demand for nonsurgical rejuvenation treatments are increasing at an exponential rate and are no longer the preserve of the affluent. Recent findings: Recent published work has focused on the addition of local anaesthetic into fillers, widening their indications, reporting longer term results, avoidance of complications, regulation and future directions. Summary implications: The refinement of techniques to restore facial volume with dermal fillers, and widely available botulinum (BTX) injections to treat dynamic facial rhytids, fuelled by widespread mainstream advertising, has led to a surge in demand for nonsurgical rejuvenation procedures. An increasingly well informed and discerning patient population now seek better value procedures that require minimal downtime and have instant results. A thorough knowledge of the dermal fillers available for soft tissue facial augmentation is therefore essential to any clinician involved in facial plastic surgery.
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A review of dermal fillers in facial plastic surgery
Dominic Bray, Claire Hopkins and David N. Roberts
Introduction
Nonsurgical rejuvenation procedures such as botulinum
toxin (BTX) and dermal filler injections are now the most
common aesthetic treatments performed worldwide. In
2008, the American Society of Aesthetic Plastic Surgeons
(ASAPS) published projected nationwide statistics of US
dermal filler practice [1]. Hyaluronic acid-based fillers
(Restylane, Juvederm, Hylaform) were the most com-
monly performed with over 1.26 million treatments.
Calcium hydroxylapatite (Radiesse) accounted for just
under 123 000 filler injections, collagen 58 000, and poly-
L-lactic acid (Sculptra) nearly 32 000 [standard error (SE)
3.21% at 95% confidence level (CI)]. These figures are
likely to be a conservative estimate as they are based on a
members’ survey that was projected to include only
board-certified plastic surgeons, otolaryngologists and
dermatologists. This article reviews the dermal fillers
available today in the USA and Europe, the injection
techniques, indications, avoidance of complications and
regulation of dermal fillers in facial plastic surgery.
Techniques
Most injectable dermal fillers are supplied with a dis-
posable plastic syringe and Luer-Lok fitting, co-packaged
with a sterilized needle gauge appropriate for the filler
viscosity. Depth of the defect determines the depth of
injection, and generally speaking the deeper the defect,
the more viscous the filler. Superficial lines require
shallow correction in the upper dermis and cause blanch-
ing on delivery; deeper furrows and folds require place-
ment in the mid, deep or subdermis. Four techniques for
injection are reported: serial puncture, linear threading,
fanning and cross-hatching [2] (Fig. 1).
Serial puncture
The skin is pulled taught to stabilize the defect and
multiple boluses of filler are delivered along the defect
line. The injection sites should be close enough to form a
continuous smooth bead; however, small gaps can be
moulded with massage. This technique is useful for acne
scarring, shallow forehead rhytids, the glabella, philtrum
enhancement and nonsurgical rhinoplasty.
Linear threading
The full length of the needle is advanced along the
wrinkle or fold to create a tunnel for filler placement.
Injection can be anterograde ‘the push-ahead technique’
as the needle is advanced or retrograde as it is withdrawn.
Anterograde delivery may displace small blood vessels,
but retrograde delivery allows more uniform placement,
Department of Otolaryngology, Guy’s Hospital, London,
UK
Correspondence to Mr Dominic Bray,
FRCS(ORL-HNS), Department of Otolaryngology,
Guy’s Hospital, Great Maze Pond, London SE1 9RT,
UK
Tel: +44 207 188 2215; e-mail: dbray@doctors.org.uk
Current Opinion in Otolaryngology & Head and
Neck Surgery 2010, 18:295– 302
Purpose of review
Over the last decade, injectable soft tissue fillers have become an integral part of facial
plastic surgery practice. The vast choice of new products being brought to the market,
improved safety profile, lower costs in the current economic climate and high street
availability mean that demand for nonsurgical rejuvenation treatments are increasing at
an exponential rate and are no longer the preserve of the affluent.
Recent findings
Recent published work has focused on the addition of local anaesthetic into fillers,
widening their indications, reporting longer term results, avoidance of complications,
regulation and future directions.
Summary implications
The refinement of techniques to restore facial volume with dermal fillers, and widely
available botulinum (BTX) injections to treat dynamic facial rhytids, fuelled by
widespread mainstream advertising, has led to a surge in demand for nonsurgical
rejuvenation procedures. An increasingly well informed and discerning patient
population now seek better value procedures that require minimal downtime and have
instant results. A thorough knowledge of the dermal fillers available for soft tissue facial
augmentation is therefore essential to any clinician involved in facial plastic surgery.
Keywords
dermal fillers, dermal implants, facial fillers, facial rejuvenation, soft tissue augmentation
Curr Opin Otolaryngol Head Neck Surg 18:295 –302
ß2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1068-9508
1068-9508 ß2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MOO.0b013e32833b5162
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the preference being largely operator-dependent. Linear
threading is best for the nasolabial folds and vermillion
contour. Serial threading uses elements of both tech-
niques and is useful in wider folds.
Cross-hatching/fanning
The fanning and cross-hatching techniques are variations
of linear threading that allow filling of larger defects or
facial contouring. In the fanning technique a single
needle puncture allows ‘fan-like’ placement of successive
linear threads by radially changing the needle direction.
Cross-hatching delivers linear threads in a predetermined
grid by multiple punctures. Both techniques are useful in
the malar region and oral commissures.
Indications
Dermal fillers are licensed for injection into the mid to
deep dermis for the correction of moderate to severe
wrinkles and folds (such as the nasolabial lines). Some
have limited indication for correction of facial lipoatrophy
in HIV and acne scarring [3]. Dermal fillers are also used
‘off-label’ to treat facial rhytids, folds and depressions;
restore age-related facial soft tissue volume loss; augment
existing facial structures and improve nasal function. The
off-label use of medical devices was legalized by the US
Food and drug Administration (FDA) Modernization Act
of 1997. For ease of review indications are separated into
horizontal facial thirds [4

].
Upper face
The most commonly treated areas in the upper face are
the fine forehead lines created by the action of frontalis,
the vertical glabella furrows created by the depressor
corrugator complex and the crow’s feet formed by action
of orbicularis oculi. Whilst these dynamic lines are best
treated initially with BTX, in recalcitrant cases con-
comitant intradermal injection of hyaluronic acid filler
by serial puncture (e.g. Restylane Touch, Juvederm 18)
works well. Deeper furrows are best filled using Perlane
or Juvederm 24/30 by subdermal linear threading. Acne
scars can be elevated by needle subcision followed by
filler injection. Age-related temporal volume loss can be
replaced by subcutaneous injection of Restylane Sub-Q
(FDA approval pending) or Sculptra by cross-hatching.
Mid-face
Sinking or effacement of the malar eminence and hollow-
ing of the cheeks can be corrected with dermal fillers.
Restylane Sub-Q (the largest particle size in the hyaluro-
nic acid facial filler range at 1000 particles/ml) is an
effective alternative to fat transfer for mid-facial augmen-
tation and contouring [5]. Sculptra, whilst not a true
‘dermal filler’, stimulates collagen neogenesis. ‘Tear
296 Facial plastic surgery
Figure 1 Injection techniques
(a) Serial puncture; (b) linear threading; (c) fanning; (d) cross-hatching (from Rohrich et al. [2]).
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troughs’ formed by the naso-jugal fold can be corrected
with filler but achieving good results in this area is
challenging [6]. Accurate facial analysis, product choice,
injection technique and preparation are key to a good
outcome. The area should be anaesthetized with topical
cream to avoid distortion of the soft tissues and ice should
be used for vasoconstriction to reduce ecchymosis. The
patient should be seated upright to prevent gravitational
movement of the orbital fat pads and to best delineate the
area of correction. Preseptal injection of filler by linear
threading along the orbital rim avoids exacerbation of the
pseudoherniation of orbital fat that creates the original
deformity. Product choice depends upon degree of cor-
rection required but, in our experience, Restylane or
Juvederm give an excellent result. The area should be
gently massaged after injection to ensure even distri-
bution. If bruising becomes evident prompt pressure
and ice should be applied and injection postponed until
review at least 4 weeks later to allow time for dissociation
of water from the hyaluronic acid and oedema to settle.
Too superficial placement leads to bluish discoloration by
the Tyndall effect, which may improve with observation
but can be treated with hyaluronidase injection [7] or
Nd:YaG laser [8]. A good correction can last up to 2 years
owing to the relative immobility of the area.
A recent use of dermal filler is in nonsurgical ‘injection’
rhinoplasty [9]. Discreet volumetric changes in the
fronto-nasal angle, nasal dorsum and nasolabial angle
lead to significant differences in our perception of the
nasal aesthetic. These areas can be injected with dermal
filler to rejuvenate the nasal profile and correct asymme-
tries. In our experience the correction can last up to
2 years with Restylane [10], and 3 years with Radiesse,
probably because of the relative immobility of the mid-
face.
Injection augmentation of a deep radix will soften the
fronto-nasal angle (Fig. 2c,d) and may disguise a promi-
nent rhinon and dorsal cartilaginous hump. Medial linear
subcutaneous threading of the bony and cartilaginous
dorsum will narrow a broad nose, and lengthen a shor-
tened nose. Saddle nose deformity and/or upper lateral
collapse may be disguised with injection superficial to
perichondrium. An underprojected tip may be built up by
supratip injection followed by moulding to the desired
aesthetic result. Nasal tip ptosis is addressed with single
puncture injection into the collumellar base to open the
nasolabial angle. This angle may be opened further with
injection of 2 units of Botox (Allergan Inc.) into the
depressor septi muscle.
Functional internal valve collapse may be addressed with
an endonasal ‘spreader’ injection of calcium hydroxyl-
apatite (Radiesse) into the apex of the internal nasal valve
[11] (Fig. 2a,b).
Lower face
The most commonly treated area is the lower face. Aging,
volume loss and gravity cause descent of facial soft tissue,
leading to down-turned oral commissures and develop-
ment of marionette lines exacerbated by the action of
depressor anguli oris. Descent of the malar fat pad leads
to deepened nasolabial folds and a prejowl sulcus and loss
of jawline definition is exacerbated by mandibular resorp-
tion. Selective correction with site appropriate filler can
restore volume and ‘lift’ the lower face nonsurgically
(Fig. 3a,b).
Deeper nasolabial folds can be softened with retrograde
subdermal linear threading of hyaluronic acid, Radiesse
or collagen derivatives, but finer nasolabial lines are best
effaced by intradermal injection of hyaluronic acid.
Superficial injection during needle withdrawal risks
nodularity and should be avoided.
The lip is a common ‘off-label’ area for injection.
Orbicularis oris action causes development of perioral
rhytids, and age-related atrophy leads to volume loss,
A review of dermal fillers in facial plastic surgery Bray et al. 297
Figure 2 Nonsurgical ‘injection’ rhinoplasty
Right upper lateral cartilage collapse causing right internal nasal valve
dysfunction (a); at 18 months corrected with endonasal Restylane
injection (b). Saddle nose deformity (c); at 18 months following sub-
dermal radix Restylane injection (d).
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flattening of the cupid’s bow, loss of vermillion contour
and convexity of the pout on profile view. These features
can be restored and our preference is to use Restylane
lidocaine as the gel is firm enough to provide support, can
be moulded into position, and rapidly softens. Treatment
in this area is painful and a local infraorbital and mental
block with 2% lidocaine and 1 : 100 000 epinephrine is
advised. Starting at the commissure, the needle is
advanced along the vermillion line. Retrograde linear
threading in the subdermis enables filler hydrodissection
and augmentation of the vermillio-cutaneous border. The
cupid’s bow can be sculpted and the commissures
upturned by selective filling of the upper and lower
lateral commissure vermillion. Perioral rhytids are filled
with mid-dermis serial puncture [2]. Lip volume is
enhanced by injection of filler at the junction of the
wet/dry mucosa in the middle third (Fig. 3c,d).
Fillers
There are over 150 injectable fillers on the global market,
but at the time of writing only a dozen or so have FDA
approval. These include modifications (larger particle
size, addition of lidocaine) of existing fillers and fillers
no longer available [12]. Fillers can be permanent or
temporary and classified into three categories: collagens,
hyaluronic acids and biosynthetic polymers. Commonly
used FDA-approved/Conformite
´Europe
´enne (CE)-
marked fillers available at the time of writing are sum-
marized in Table 1 [13].
Collagens
Collagen is the major structural component of skin. Inject-
able forms consist of varying concentrations of bovine
(Zyderm 1&2, Zyplast), human bio-engineered or more
recently porcine (Evolence) collagen. Human collagens
are derived from cadaveric skin (Alloderm, Cymetra) or
laboratory culture of human fibroblasts (Cosmoderm 1&2,
Cosmoplast). They have a significantly reduced allergic
risk compared with their bovine counterparts. Autologous
collagen from punch skin sampling (Isolagen) was recently
in vogue but, owing to its cost, complexity and processing
time, did not realize the initial interest and is no longer
available. Despite FDAapproval in 2008, Evolence, which
is derived from porcine collagen, stopped distribution in
November 2009. Allergan, following their 2006 acquisition
of INAMED (manufacturers of Zyderm, Zyplast, Cosmo-
derm and Cosmoplast), have not actively marketed their
collagen dermal fillers – a reflection of the global move
towards hyaluronic acid injectables.
Hyaluronic acids
Since its 1934 discovery in the vitreous of cow’s eyes [14],
hyaluronic acid has become the most commonly used
298 Facial plastic surgery
Figure 3 Restylane– lidocaine for lower facial rejuvenation
Lower facial third volume loss characteristic of ageing (a); 3-month review following Restylane injection to the nasolabial folds, marionette lines, perioral
rhytids, commissures and vermillion contour (b). Ageing lips with decreased volume, loss of cupid’s bow and down-turned commissures (c); 3-month
review following injection augmentation (d).
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A review of dermal fillers in facial plastic surgery Bray et al. 299
Table 1 Summary of FDA-approved dermal fillers on the market
Filler type Subtype Name (manufacturer) Distributor Indication (off-label use) Durability Market status
Collagens Bovine Zyderm 1 Allergan Correction of dermal contour deficiencies
(superficial defects and rhytids, acne scars)
2– 4 months FDA-approved
(1981)/CE-marked
Zyderm 2 Allergan Correction of dermal contour
deficiencies (moderate defects,
deep acne scars, lip volume)
2– 6 months FDA-approved
(1981)/CE-marked
Zyplast Allergan Correction of dermal contour
deficiencies (deep defects,
lip volume)
2– 6 months FDA-approved
(1981)/CE-marked
Cell-cultured Cosmoderm Allergan Superficial dermis for soft tissue contour
deficiencies, rhytids and acne scars
3– 4 months FDA-approved
(2003)/CE-marked
Cosmoplast Allergan Mild to deep dermis for soft tissue
contour deficiencies, rhytids and
acne scars
3– 4 months FDA-approved
(2003)/CE-marked
Cadaveric Alloderm Lifecell Corp.
Woodlands, TX
Deep rhytids, scars, lip volume 6– 12 months CE-marked
Cymetra micronized
injectable Alloderm
Lifecell Corp.
Woodlands, TX
Deep rhytids, scars, lip volume 3– 6 months CE-marked
Hyaluronic acids Avian derived Hylaform (Genzyme) Allergan, CA Mild to deep dermis for mod-
severe folds (superficial
rhytids, glabella, nose and lips)
3– 4 months FDA-approved
(2004)/CE-marked
Prevelle Silk (Genzyme) Mentor, Irving, TX Moderate to deep dermis for
mod-severe folds, for example
nasolabial folds (superficial
rhytids, glabella, nose and lips)
3– 4 months FDA-approved
(2008)/CE-marked
Bacterial-cultured Perlane (Qmed) Qmed Deep dermis to superficial subcutis
for mod-severe folds, for example
nasolabial folds
6– 12 months FDA-approved
(2003)/CE-marked
Perlane lidocaine (Qmed) Qmed 6– 12 months FDA-approved
(2010)/CE-marked
Restylane/Restylane
touch (Qmed)
Qmed Mild to deep dermis for mod-severe
folds, for example nasolabial
(superficial rhytids, glabella,
nose and lips)
6– 12 months FDA-approved
(2003)/CE-marked
Restylane lidocaine (Qmed) Qmed 6– 12 months FDA-approved
(2010)/CE-marked
Elevess (Annika Therapeutics) Annika Therapeutics
Woburn, MA
Mild to deep dermis for mod-severe
folds, for example nasolabial
(superficial rhytids, glabella,
nose and lips)
6– 12 months FDA-approved
(2006)/CE-marked
Captique (Genzyme) Allergan, CA Mild to deep dermis for mod-severe
folds (superficial rhytids, glabella,
nose and lips)
3– 6 months FDA-approved
(2004)/CE-marked
Juvederm (Corneal, Paris) Allergan, CA Mild to deep dermis for mod-severe
folds, for example nasolabial
(superficial rhytids, glabella,
nose and lips)
6– 12 months FDA-approved
(2006)/CE-marked
Juvederm lidocaine
(Corneal, Paris)
Allergan, CA 6– 12 months FDA-approved
(2010)/CE-marked
Synthetic polymers Poly-L-lactic acid Sculptra Sanofi Aventis Facial lipoartophy in HIV (facial
contouring and volumetric
augmentation)
1– 2 years FDA-approved
(2004)/CE-marked
Calcium hydroxylapatite Radiesse Bioform medical Moderate to severe folds, for example
nasolabial, facial lipoatrophy in
HIV (nose)
1– 2 years FDA-approved
(2006)/CE-marked
4% Polyalkylimide Bio-alcamid Ascente Medical Deep defects Permanent CE-marked
Polyacrylamide hydrogel Aquamid Contura International Deep defects Permanent CE-marked
Adapted and updated from Buck et al. [13].
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dermal filler worldwide. It has been identified as the main
polysaccharide in the extracellular matrix of human con-
nective tissue. Hyaluronic acid stabilizes intercellular
structures, and produces a viscoelastic framework for
collagen and elastin to bind; it potently binds water
and when injected, volumizes, softens and hydrates
the skin. As the skin ages, hyaluronic acid content
decreases leading to decreased cell hydration, elasticity
and movement. The half-life of hyaluronic acid in the
dermis is 1 day as it degraded by hyaluronidase. The
hyaluronic acid molecule can be stabilized by bio-
chemical reticulation (cross-linking) with butanediol
diglycidyl ether (BDDE Restylane, Juvederm), or
divinyl sulfone (DVS Prevelle Silk, Captique, Hyla-
form) conferring resistance to degradation by heat or
enzymatic action [15
]. Hyaluronic acid implants can
be divided depending upon their reticulation character-
istics into biphasic (reticulated chains in fluid suspension
that is resorbed after implantation) and monophasic (con-
tinuous polysaccharide reticulated chain) implants. The
former enables even distribution of hyaluronic acid HA
macromolecules, the latter is more homogeneous with
theoretically easier delivery [16]. The cross-linking pro-
cess can be further engineered to produce particulate or
nonparticulate forms. The jury is currently out as to
which form delivers a better outcome the particulates
depend on particle size to increase volumetric lift and
longevity, the nonparticulates (of which Juvederm is the
only FDA-approved product) depend on greater cross-
linking to produce volume. The ideal degree of cross-
linking is unknown, as significant cross-linking may
reduce the hydrophilic properties of hyaluronic acid
and therefore reduce lift or could affect biocompatibility
and cause rejection or encapsulation [17].
Restylane was the first hyaluronic acid to gain FDA
approval in December 2003 and remains the market
leader today. A recent advance is the addition of 0.3%
lidocaine to the filler (Restylane-L, Juvederm XC). In a
multicentre, double-blind, randomized clinical trial, 72
patients received Juvederm XC and Juvederm in separate
nasolabial folds. Ninety-three per cent of patients
reported less procedural pain when treated with the
lidocaine-containing dermal filler compared with the
original version. The safety profile and outcomes were
similar [18]. Another multicentre study of 3566 patients
in 16 European countries reported greater than 95%
patient and injector satisfaction with the lidocaine-con-
taining filler [19]. Within a week of writing, Restylane-L
and Juvederm XC have gained FDA approval and await
US market release.
Biosynthetic polymers
Synthetic facial fillers are composed of a biosynthetic
polymer (poly-L-lactic acid, calcium hydroxylapatite,
polymethylmethacrylate) combined with differing inject-
able carriers including hydrogels, beads and liquids [13].
Concerns remain about the long-term effects of the
permanent synthetic compounds Bio-Alcamid and
Aquamid [2024] and, in our opinion, cannot be justified
when other fillers with more predictable outcomes and
safety profiles exist.
Radiesse
Calcium hydroxylapatite (Radiesse) consists of a 30%
concentration of 25 –45 mm spherical particles suspended
in sodium carboxymethylcellulose gel. It is FDA-approved
for facial soft tissue augmentation,specifically correction of
moderate to severe facial lines and folds and correction of
soft tissue loss from HIV lipoatrophy, vocal cord augmen-
tation and as a radiological tissue marker. In addition, the
off-label use of Radiesse has been reported for the infra-
orbital rim [25], nose [26], internal nasal valve [11] and
malar/submalar augmentation [27]. Following injection,
the gel is phagocytized and the calcium hydroxylapatite
microspheres displace surrounding soft tissue. Collagen
proliferation and slow degradation of the microspheres
lead to a prolonged duration of effect up to 2 years.
Sculptra
Poly-L-lactic acid (PLA) is not designed as a filling
agent per se. It is indicated for HIV-associated lipoa-
trophy but is widely used off-label for cosmetic facial
volumization. It is given by subdermal injection and
activates collagen neogenesis by granulomatous inflam-
mation [28]. This process takes at least 6 weeks but
the ‘filling’ effect is noticeable for up to 2 years. Serial
treatments are often necessary. Sculptra, like Radiesse,
contains sodium carboxymethylcellulose gel to aid
particle displacement.
Complications
Adverse events from dermal fillers are classified into
immediate (pain, hypersensitivity, anaphylaxis), early
(swelling, erythema, infection, overcorrection, necrosis),
late (activation of HSV, nodules, granuloma formation)
and permanent (scarring) [29
].
Patients’ expectations should be addressed prior to treat-
ment and they should be informed of the risks, altern-
atives, and aftercare instructions. Fillers have FDA
approval for soft tissue augmentation in the nasolabial
fold; all other sites are off-label and the patient should be
informed of this. Injectors should be aware of facial
danger zones, specifically embolization of the supra-
trochlear (glabella), facial (alar facial angle) and dorsal
nasal (nasal dorsum) arteries [30,31].
International regulations vary with regard to who can
inject fillers. In the USA, fillers must be FDA-approved
and prescribed as medicine. However, in the UK and
300 Facial plastic surgery
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Europe they require only CE marking (pertaining to
production standards not efficacy) and are classed as non-
prescription medical devices [32]. Over 140 injectable
fillers are therefore available to the UK/European market
compared with only six in the USA. The massive growthof
the industry, fuelled by exponential demand, demedica-
lization through advertising, and lack of regulation, has led
to dentists, nurses and beauticians offering filler injections
on the high street. There is currently no requirement for
certified training or background in facial plastic surgery.
An international report in 2008 by the FDA of adverse
events highlighted the potential for serious complications
resulting from filler injection, especially from inexperi-
enced practitioners [2]. Of the 823 adverse events
reported, 638 (78%) responded to medication (from
topical steroid cream to systemic steroids, antibiotics,
anti-inflammatories and antihistamines), 94 (11%)
required surgical intervention (abscess drainage and/or
nodule excision) and 19 (2%) required emergency admis-
sion for hypersensitivity reaction.
Despite widespread variation in injector experience, per-
manent complications are fortunately rare. In the UK,
these most commonly arise with permanent fillers (e.g.
Bio-Alcamid/Aquamid) and no permanent filler is cur-
rently FDA-approved after Artes Medical, manufacturers
of Artefill, went into administration in late 2008 [29
].
A quarter of British Association of Aesthetic Plastic
Surgeons (BAAPS) members have reported surgery for
complications following their use and 96% of BAAPS
members want regulation and UK adoption of FDA
approval for dermal fillers [33].
Conclusion
Dermal fillers are now an essential part of any facial
plastic and aesthetic surgical practice. The field is moving
so quickly, with new fillers being manufactured at an
ever-increasing rate, that published reviews less than a
year old at the time of writing include products no longer
available [4

,13]. The FDA is responding to this by
streamlining the approval process and improving safety
testing, event reporting and product labelling.
We echo the call by the BAAPS for tighter regulation in
the UK [33]. The increased choice of products available
in the UK and Europe has not conferred better outcomes
as the literature is full of adverse events from fillers now
withdrawn from the market [34]. The FDA approval
process has in some way protected American patients
from these products.
Lastly, despite perceived demedicalization of fillers,
it is essential that the injector remains their patients’
advocate. They should understand the differences,
indications and safety profiles of available products to
achieve a mutually desired outcome.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 346).
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www.surgery.org/sites/default/files/2008stats.pdf (accessed 19th February
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2Rohrich R, Ghavami A, Crosby M. The role of hyaluronic acid fillers (Restylane)
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4
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8Cho SB, Lee SJ, Kang JM, et al. Effective treatment of a injected hyaluronic
acid-induced Tyndall effect with a 1064-nm Q-switched Nd:YAG laser. Clin
Exp Dermatol 2009; 34:637–638.
9De Lacerda DA, Zancanaro MD. Filler rhinoplasty. Dermatol Surg 2007;
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10 Bray D, Hopkins C, Roberts DN. Injection rhinoplasty: nonsurgical nasal
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302 Facial plastic surgery
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