The Basics of Dermal Filler
Let’s talk about dermal fillers!
What pops into your head? Sculpted jawlines? High, full cheekbones? Luscious, juicy lips?
These treatments are getting more and more popular as celebrities and others in the public eye are being more honest about getting the stunning little tweaks. But while we might be more and more aware of the fact that fillers exist, there’s a lot more under the surface that we should know.
Yes, we should know the basics of what fillers are made of, what they can do, and how most appointments play out - but the number one thing that we need to know about when it comes to fillers is safety. See our fun round-up of the Top Five Rules for Filler Safety.
What are fillers made of?
Dermal fillers are composed of soft, clear gel made from a substance found naturally in your skin called hyaluronic acid (HA). HA is a type of sugar that can bind 1000x its own weight in water, and helps skin look plump and hydrated. It is also naturally degraded by our body’s own enzymes, which means that these fillers are not permanent and are also much safer to inject as they can be dissolved in case of an emergency.
You should be aware of other materials and types of filler - but in general I would recommend hyaluronic acid fillers as the gold standard in clinical practice if you are new to fillers. There are older types of fillers that used to be injected like collagen, and we touched on the history of injectables and their complications.
For your information I’ve listed the most popular non-HA fillers here. Stimulatory fillers induce a foreign body reaction and stimulate collagen production. These fillers are immunologically inert, and are metabolised to CO2 and water by the body. They do not cause the immediate volume enhancement that many are used to with hyaluronic acid fillers, but rather the results build up over time. They also have to be injected over several sessions 4-6 weeks apart.
Non-HA Fillers
What about safety?
If you read nothing else, please read this!
There is a massive issue in the UK with the lack of regulation. I’ve written about this in my article about medical aesthetics, and touched on this in my piece on ethics in cosmetic medicine.
Fillers are classified as a medical device here in the UK, and legitimate pharmacies as well as the actual manufacturers of these products will only sell to licensed medical professionals (see Juvederm’s excellent post on this).
However there are so many ways to get your hands on filler (dodgy Instagram and internet “pharmacies” being a common culprit), and there are many random fillers out there without the long-term data or safety profile to back them (General rule of thumb: the cheaper the filler is, the less likely it is that it’s legitimate or safe).
So to keep you safe, this is what you need to know about what is being injected into your face.
Number 1: Medical professionals only
This should go without saying, and we will discuss this further when we cover complications below.
At the risk of repeating myself too often I will summarise by saying the following: diagnosing, prescribing, and complication management are skills that only medically-trained professionals are competent in, and that is a basic cornerstone of the aesthetic consultation. The medical model, treatments plans, and patient care exist in this realm.
I’ve heard the bizarre argument that facial anatomy is not taught at medical school, and that beauticians take the same aesthetic courses that medics do. I don’t know what medical schools they attended, but I absolutely covered facial anatomy as a medical student. And no, of course I did not train specifically in aesthetics as a specialty the same way I didn’t train specifically in cardiology or orthopaedics as a student. Medical school gives you the foundation that you expand upon when you then go on to do two grueling years of initial training as a doctor before branching out further and gaining specialist knowledge in a certain area (on the background of 6-8 years of higher training).
And no one medically unqualified did the same training courses that I did. I trained at Harley Academy and Acquisition Aesthetics, taught by nurses, doctors, and surgeons on courses that do not accept those without a healthcare degree and a registration/PIN number by a regulatory body. It is a baffling argument to say our qualifications and training are in any way comparable.
Most importantly, at the end of the day, no one has the right to take your money and put their hands on you in a way that risks serious medical complications that can only be remedied by a medical professional.
Number 2: Always ask what filler your injector is using
Always ask, and they should always be able to tell you.
Brands used by medical professionals
There are a few brands that have excellent clinical data behind them, and for this reason they are preferred by most medical professionals. This is not an exhaustive list and this is in no particular order, but it is good to have some familiarity with the highest quality brands out there.
What about other fillers you find floating around? Now this is not an exhaustive list as I said, and if you go to a medical professional they will have no problem explaining their filler choice and discussing the safety aspects around it.
But if you go to anyone else and you’ve never ever heard of the filler? Honestly, I would be highly skeptical.
Most HA fillers available in the UK and Europe do not have robust clinical trials behind them, even thought they pretend they do. Often the reason these brands are chosen is because they are cheap and because the person injecting does not have access to the legitimate brands because they are not a medical professional.
Cheap or unknown filler brands have also been reported as much more difficult to dissolve (or even impossible if they are not composed of hyaluronic acid), which is a potential disaster in the event of a vascular occlusion.
Basic Safety Checks
FDA-approval
The Food and Drug Administration in the States has strict standards to approve fillers for use, including review of data from controlled clinical studies for both safety and efficacy. In the States it is completely illegal (criminal) for non-medical professionals to inject filler.
CE marks
Dermal fillers are medical devices by law in the UK. They are regulated by the Medicines and Healthcare Products Regulatory Agency (MHRA) and pre-Brexit were under European Regulations EU 2017/745 and required a CE mark. A CE mark ensures that the proper guidelines of safety have been adhered to in the manufacturing process. It is not a guarantee of the efficacy or quality of the product.
UKCA marks
Post-Brexit, all dermal fillers must have a UKCA mark from Jan 1, 2021.
Number 3: No sharing syringes
This is an absolute no-no for any ethical practitioner. Your health and safety should never be compromised for the sake of a good “bargain.”
Anyone who offers to let you share a syringe with a friend or another patient is putting you at risk. It doesn’t matter if they change the needle (there’s still cross contamination) - that syringe of filler is a sterile product and is for use of one person only. There is risk of blood-borne virus transmission, not to mention basic hygiene. Infection control principles are vitally important in medical procedures.
Just think about whether you would be happy to have your blood drawn with a dirty, used needle you’d just seen put in someone else’s arm. No?
Then don’t let anyone convince you to share a syringe of filler!
Different characteristics of fillers
While this technical aspect is more important for medical injectors to understand, it is worth knowing a little bit about the science behind the properties of fillers to understand why we use certain types of fillers in different areas. There is an excellent summary in the Aesthetics Journal that you can read here.
G-prime is one of the main characteristics used to describe filler, a rheological property that basically describes how elastic the filler is and how well it keeps its shape. Higher G-primes are generally “harder” are will be used in areas that need more sculpting like the cheeks or chin, whereas lower G-primes are “softer” or more liquid and might be used in areas like the tear troughs.
G-double prime is another important characteristic of fillers, and basically describes how viscous the filler is and how easily it flows. This can be an important consideration in injecting techniques as well as aspiration, as the higher the G-double prime the most difficult the filler can be to inject.
Understanding these different forces guide the type of filler that should be used in different areas.
Where can you use fillers?
Everyone knows about lip fillers, but fillers can be used in many other places as well! This includes tear troughs, cheek fillers, marionette lines, nasolabial folds, and enhancements to your jawline, chin, and temples. You can also have dermal filler injected in your nose as a non-surgical rhinoplasty, however this is a very advanced procedure that should only ever be done by a medically-qualified and very experienced practitioner due to the riskiness of the area. Use of fillers to rejuvenate your features in multiple areas is known as a "liquid facelift."
Are there any side effects from fillers?
Most of the time there are no major side effects associated with fillers.
Minor, common side effects include things like bruising, swelling, and some bleeding - but these usually subside after a few days. Less commonly, local reactions or infections can occur, which may require input from your practitioner to resolve.
What is the biggest risk and most important thing to know about fillers?
Vascular occlusion
The biggest risk associated with fillers is injection into a blood vessel. You have a lot of veins and arteries in the face, which is why your aesthetic practitioner should be medically qualified with a clear knowledge of anatomy.
If filler does enter a vessel, known as a "vascular occlusion," your practitioner will have to dissolve the filler right away.
The medication used to dissolve this filler is known as hyaluronidase (or hyalase) and is prescription-only. It is only legal for prescribers to hold stock, so unless they are doing so illegally, non-medical practitioners cannot hold emergency hyalase in stock for you.
That means that if you need filler dissolved in a medical emergency, which a vascular occlusion is by definition, and you are not seeing someone medically qualified for your fillers, they will not be able to do anything about it.
Often you will be covered with a short course of antibiotics and steroids, which again are prescription medications that need to be given by a medical professional. You might need referral for hyperbaric oxygen. Again, these are protocols that can only legally be carried out and prescribed by a medical professional.
What should I do before and after my filler appointment?
Before your treatment, avoid any medications that could increase your risk of bleeding and bruising (such as aspirin or ibuprofen), unless you are taking them as prescribed by your doctor. It's usually recommended that you avoid alcohol on the day before and after your treatment.
After your treatment, you should also avoid any strenuous exercise or heat. For the rest of the day avoid touching the area of putting any makeup on your skin. For the next two weeks do not have any other cosmetic treatments, chemical peels, or use a tanning bed.
Final thoughts
Fillers are an extremely versatile medical device that can be used in multiple different areas of the face to restore or enhance, and in an experienced clinician’s hand can give wonderful results.
However, given the unregulated nature of medical aesthetics in the UK, for me the most important thing when it comes to fillers is understanding basic safety. Your injector needs to be medically qualified, you need to be consented properly with all the risks and side effects explained, and never go for bargain-basement deals or share syringes.
For the longest time Botox has dominated the aesthetics market when it comes to botulinum toxin - so much so that its name is ubiquitous and basically synonymous with the treatment. But there are other brands out there, and for the longest time there have been three main ones competing.
However, the past year has seen a plethora of new brands. The different brand names and characteristics become confusing to both patients and clinicians, so we are going to set things straight. Most importantly, for safety reasons it is vital to know which products are licensed for use here in the UK, and how to recognise you are getting illegal or counterfeit products injected.