The Last Word: Beyond Dermal Filler

By Dr Ali Juma / 26 Mar 2021

Mr Ali Juma debates whether the term ‘dermal filler’ is still fit for purpose

The definition of dermal in the Oxford Dictionary is ‘relating to the skin or dermis’, while filler means ‘a substance used for filling cracks or holes in a surface, especially before painting it’.1

The simplicity of the wording choice, ‘dermal filler’, perhaps was relevant at its inception when the filler was injected within the dermal layers. However, I believe that the nomenclature ‘dermal filler’ is not reflective of the complexity, sophistication and the five decades of research, which have gone into developing and refining these products.

Today, the name doesn’t take into consideration the advances made with dermal fillers, which reflects the limitations in our understanding – and perhaps complacency – in thinking up a new name for the products. Our inquisitive and curious nature favours that we delve more into the advancement of science to achieve higher levels of excellence.

The advances of dermal fillers

Patients’ and clinicians’ demands have been the main driver behind advances in dermal fillers. These demands include longer-lasting, biocompatible and affordable products, which achieve natural outcomes. The principles of beautification and golden ratio facial proportioning with the least adversity, risks and complications must also be kept in mind.2 What started its journey injected within the dermal layers has now moved further into the subcutaneous and supraperiosteal anatomical realm.

Now we have at our disposal dermal fillers that allow us the ability to be more innovative in treating patients, thus pushing the boundaries in achieving clinical excellence and higher satisfaction.

The question which stems to mind: is dermal filler just a filler? Or is it a sophisticated system utilised by skilled clinicians to rejuvenate, and appropriately proportion patients’ faces?

At the start of one’s journey injecting facial dermal fillers, the traditional teaching was to treat anatomical areas like the nasolabial fold in isolation. However, the last few decades have led to advances in the knowledge of facial anatomy, the ageing process of the face, the layers affected, bony resorption of the facial skeleton, in addition to volume loss in the deep facial fat compartments.

Advances in dermal fillers including diversity in their rheology, cohesiveness, biodegradability and mouldability mirrored this. The manufacture of these products has become so advanced that a tailor-made product can be used to achieve a highly refined outcome, especially when injected by an experienced and skilled clinician. Incorporating local anaesthetic into the product syringe means it can now be injected less painfully, therefore more product can be injected in one treatment, thus facilitating better patient tolerance and compliance. Add to this the ability to use these products in different anatomical areas at different depths in the face, thus achieving beyond what earlier fillers could have achieved. Volumisation, contouring, myomodulation and hydration, in addition to neocollagen formation, are changes that dermal fillers can conjure.

Volumisation of the deep facial fat compartments can be achieved by replacing volume lost. One such example is lifting and rejuvenating the mid-face. A deep injection of HA with a concentration of around 20mg/ml above the maxilla periosteum can replace lost volume whilst giving lift. Injecting of HA with approximately 17.5mg/ml following this may volumise the deep fat pads to add further lift secondary to inflating them.

Myomodulation is a newer concept popularised by Brazilian plastic surgeon Dr Mauricio de Maio. It improves facial symmetry through balancing of volume distribution, in addition to harmonising the action of muscles groups working in synergy, thus creating a happy and rejuvenated face.3-5 In my opinion, this concept will shift the dynamics of facial rejuvenation, beautification and proportioning to new dimensions beyond the cosmetic realm; however, the paradigm will shift into the restoration of function and appearance, in parallel. In doing so, balanced facial movements and positive emotional attributes are achieved.

I believe facial contouring relies on two factors: volumisation and myomodulation. Both influence facial contour by lost volume replacement in a convex surface, which has flattened and sagged with ageing. Added to this, it also tensions muscles that have altered in length as a result of facial tissue laxity and displacement, altering their lever arm.

Hydration can also be achieved. A HA dermal filler with a low HA concentration of approximately 12mg/ml is an example of a product used to hydrate the skin and adjacent tissues. It will be more hydrophilic, absorbing water in multiples of its weight. By absorbing so much water, the filler helps to hydrate the skin and the adjacent tissues. This adds vibrancy and volume, which enhances the rejuvenated look of the treated visage. In so doing, further softening of facial lines results.6

Neocollagen formation with dermal filler leads to the formation of a matrix of collagen. In the first instance type III collagen is formed, which is converted to type I in time. A second benefit is the formation of elastin. All this leads to increased dermal thickness and angiogenesis. This helps soften the ageing rhytids and adds to the effectiveness of the treatment.7

We are now beyond ‘dermal fillers’

It is obvious from the dermal fillers’ capabilities noted that a new name should be considered as a starting point in looking at these products with a different eye. They act as more of a rejuvenating system and less so as a ‘filler’. It is also important to consider the most crucial variable in the treatment algorithm; namely, the human factor.

The skilled clinician is the most important variable who will see the future of HA and similar fillers as rejuvenating systems, rather than substances used for ‘filling holes or cracks in a surface’ and in so doing, aspiring to achieve continued excellence.

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