Hyaluronic Acid Fillers (Restylane, Juvederm, Hylaform, Captique)

When you look at the face of a young adult, you will see youthful plumpness of the skin without lines or wrinkles around the eyes and mouth. As we age, gravity causes jawlines to sag, and lines to develop. To smooth out wrinkles and add volume to an aging face, cosmetic physicians use multiple fillers (substances injected into the skin to “fill” various skin imperfections). Once in the skin, most fillers are gradually degraded by the body. How long the filler lasts depends on its chemical composition, as well as the speed the body gets rid of it.

Currently hyaluronic acid fillers are the most popular worldwide. They have become the new gold standard, replacing collagen fillers. The popularity of these fillers derives first and foremost from their safety. Hyaluronic acid (HA) is a substance found naturally in the connective tissue of the human body.

The role of this substance is to cushion and lubricate. HA also provides volume and fullness to the face, giving it a healthy, youthful appearance. HA fillers are produced as clear gel substances and are injected directly beneath the skin’s surface. They add natural volume and lift resulting in smoother lines and less prominent folds. HA treatment results are immediately visible and typically last from 4 to 12 months.

HA maintains its shape using the body’s own moisture. It naturally binds to water molecules. As HA gradually degrades, each molecule binds to more water and over time, the same volume can be maintained with less HA. This ability of HA to bind to water is what helps provide long-lasting results. Over time, HA dissolves without any residue.

No testing for allergy is required for any of HA fillers. They can be used whenever a patient is ready.
Side effects of HA fillers are usually mild and transient. Swelling and bruising around the injection sites are sometimes seen, but usually disappear within several days. HA fillers are biodegradable. Even if too much filler is injected into the skin, within a short time the body breaks down the excess amount. This is a real plus as compared to permanent fillers. If an area is “overfilled” with a permanent filler (such as Artecoll or Silicone), it is very difficult to get rid of the excess amount that has been injected.

HA fillers available on the market do not contain an anesthetic. Some degree of discomfort is usually present during injections. Yet in most cases (excluding lip correction), the injections may be given without anesthesia.

Hylaform and Hylaform Plus are HA fillers derived from rooster combs. They are very soft and malleable. Hylaform is composed of medium-sized HA particles. It is indicated for medium-depth wrinkles. Hylaform Plus is composed of larger particles. It is indicated for deep wrinkles and enhancing lip volume. Both fillers do not last long (only about 3-4 months). Their softness makes them useful for filling lips and areas around the eyes.

Captique is derived from bacteria, rather than roosters. It is slightly stiffer than Hylaform, but otherwise very similar. Captique lasts about 4 months.

Restylane is the most popular and well-kown HA filler. It is derived from bacteria and contains medium-size particles of HA. Perlane is produced by the same company as Restylane, but contains larger particles. Both of these products are rather stiff, which makes them suitable for correction of deep wrinkles. The cosmetic effects of Restylane and Perlane are thought to last from 6 to 9 months. Longer duration of action (up to 1 year) has also been observed.

Juvederm line of products approved in the United States consists of Juvederm Ultra and Juvederm Ultra Plus. They contain the same amount of HA, but have slightly different chemical composition. Their differences make Ultra Plus product more suitable for deeper facial folds. Both of these products derive from bacteria. The manufacturer claims duration of effects of up to 1 year. Since Juvederm has not been on the U.S. market for a long time, it is not clear whether these claims will be substantiated.

HA filling agents are now widely available for the treatment of aging face. They have a good safety record, and provide excellent results. The choice of fillers depends on individual facial imperfections that need to be corrected.

L. Baumann. Dermal filling agents: making the right choice for your patient. Skin and aging, March 2007: 38-40.

Alexander Doctoroff, D.O., F.A.O.C.D.
Assistant Chief of Dermatology, Veterans Administration Medical Center
East Orange, New Jersey
Assistant Clinical Professor of Medicine,
University of Medicine and Dentistry of New Jersey.

Stephen M. Purcell, D.O., F.A.O.C.D.

Professor and Chairman of the Department of Dermatology
Philadelphia College of Osteopathic Medicine
Philadelphia, Pennsylvannia