The Last Word: Permanent Fillers

By Dr Maryam Zamani / 29 Dec 2017

Dr Maryam Zamani debates the use of permanent fillers in aesthetics

With limited to no recovery time and lower costs compared to surgical procedures, dermal fillers have revolutionised non-surgical aesthetic enhancements. However, all dermal fillers have the potential to cause complications and as the number of procedures performed increases, the number of complications will inevitably follow. While most complications are related to the technique of the practitioner, some are associated with the material itself.1

Broadly speaking, there are two types of fillers: temporary biodegradable and permanent non-biodegradable dermal fillers. For optimal outcomes, all injectors should have a detailed anatomical understanding, excellent injection techniques and a detailed knowledge of the characteristics of fillers available.

In this article, I will argue why I do not ever consider the use of permanent non-biodegradable dermal fillers due to the increased difficulty in managing complications, which can impact patient safety.

Biodegradable vs non-biodegradable

It’s hard to determine exactly how many dermal fillers are on the market, but just from researching different markets online, I estimate that there are more than 200 dermal fillers available worldwide.1 Biodegradable fillers are absorbed by the body, and therefore their effects are relatively short-lived. The most common form of biodegradable filler used is hyaluronic acid (HA), which lasts six to 18 months.1 

There are biodegradable fillers that have a longer duration effect of up to two years; calcium hydroxylapatite is the most common.1 Permanent non-biodegradable fillers are most commonly made of polymethylmethacrylate (PMMA).2,3

Obviously, biodegradable fillers biodegrade, which can lead to repeated injections over time. This could be perceived as costlier than a permanent filler, deterring some patients. However, although the option may seem appealing, permanent substances do not adjust to the natural skin and bone changes that occur over time from the ageing process. This can therefore disturb the balance of a patient’s face in the long-term.

Filler complications

All fillers are associated with potential short and long-term complications, and the treatment of these depends on what type of product has been used. Most adverse reactions result from technical faults such as wrong indication, placement site and infection, and are not specific to a particular filler.4 

However, non-biodegradable fillers can have clinically prevalent complications that are more pronounced and persist for longer.5

After any dermal filler treatment, the following complications are possible: swelling, erythema, ecchymosis, lumps, nodules, filler clumping, filler dislocation,6,7 overcorrection, neovascularisation, hyperpigmentation, dyspigmentation, infection, biofilms, abscesses, granulomas, malar oedema and vascular compromise.8 

Vascular compromise can cause other complications such as visual loss or tissue necrosis.8 Antibody mediated oedema (angioedema) is a complication where patients may develop a hypersensitivity to the type of dermal filler used because of a Type I hypersensitivity reaction. Chronic or delayed oedema can be characterised by erythema, oedema, and unresponsive to antihistamines, which can occur days or weeks after initial treatment.1

Treating complications

The main issue associated with using non-biodegradable dermal fillers is that if one of the above complications occur, then they are often far more difficult to treat.4 To address many of the above complications for HA fillers, immediate dissolution with hyaluronidase can be achieved. 

Patients may require further treatment using steroids, antibiotics or lasers, depending on the complication.9 Homogenous fillers, like HA, rarely induce granulomas,4 but if such adverse events happen with HA, they can potentially be resolved with hyaluronidase treatment with or without other adjunct treatments such as steroids or antibiotics.

Malar oedema, caused by dermal fillers injected into the periorbital area, can be long-lasting and difficult to treat for all types of fillers due to lymphatic compromise coupled with thin overlying tissue. 

Vascular compromise, following dermal filler injection, is an immediate, major complication that necessitates swift and aggressive treatment to minimise potential serious irreversible complications.8 With non-biodegradable dermal fillers, such complications are more difficult to treat as they cannot be dissolved using hyaluronidase. 

Instead, they often require extrusion, excision or surgical drainage, which may all result in permanent suboptimal, unsatisfactory aesthetic outcomes. In especially high-risk areas like the periorbital region, the use of non-biodegradable fillers means complications are even more difficult to treat.

Summary

The key to successful treatment is to know the facial anatomy, filler characteristics, proper technique and have a conservative approach to avoid pitfalls and complications. However, complications will still happen. 

Although there is the argument that permanent fillers can have a reduced long-term cost and it may be more convenient for the patient, I personally do not believe that there is a role for permanent non-biodegradable fillers in my practice. 

As removal of permanent non-biodegradable dermal fillers must be achieved surgically, I also believe that those without surgical training must be especially wary of this type of filler placement. Any adverse reaction can be catastrophic for the patient, as well as the treating practitioner, and complications can be long standing. 

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