Collagen and Fillers

Introduction

Soft tissue filler procedures are minimally invasive cosmetic treatments used to correct signs of facial aging and facial volume deficiency/volume loss. There are many different classes of soft tissue fillers, but they share the common characteristic of being injected under the skin at varying depths (depending on the application). Older and younger patients alike use fillers for their cosmetic enhancements.¹

With patients that show signs of aging, injectable facial fillers can treat the following changes:

• Deepening of facial folds and lines (smile lines, frown lines, etc.)
• Loss of youthful fullness in the face (cheeks, lips, eyelids, temples, etc.) and hands
• Mild tissue sagging
• Early jowls and changes along the jawline

With younger patients that do not have significant signs of aging, injectable fillers can enhance facial volume for the purpose of:

• Improving fullness and pout in the lips
• Enhancing the cheekbones
• Enhancing the chin or jawline
• A “non-surgical Rhinoplasty”
• Correcting mild asymmetries of the face

Many of our patients in the Toronto area achieve successful facial rejuvenation using dermal fillers, to the extent that they are able to postpone or even forego a more invasive procedure such as a Facelift. Dr. Lawrence Tong is highly experienced with the application of a range of dermal fillers, and can help our patients achieve results that look natural.

Benefits of Soft Tissue Fillers

Soft tissue filler procedures have the advantage of:

• Being minimally invasive
• Having little to no downtime after the procedure
• Having little to no downtime during recovery
• Not requiring sedation or systemic anesthesia
• Immediate results
• Lower cost than surgery

There are many facial areas that can be cosmetically enhanced through this minimally invasive procedure. Please visit our page on the most popular treatment sites to learn more about common areas for soft tissue filler injections.

Types of Dermal and Soft Tissue Fillers

There are many types of fillers on the market; they are categorized by their “active” component.²

The following fillers are the most popular:

• Collagen
• Hyaluronic Acid-Based Fillers
• Calcium Hydroxylapatite Fillers
• Platelet Rich Fibrin Matrix Fillers
• Poly-L-Lactic Acid

Collagen

Collagen was one of the first available FDA-approved soft tissue fillers. Initially, the collagen was derived from an animal source. Later on, human-derived collagen became available on the market. The main disadvantages of collagen were its cost and relatively short duration of results. These days, collagen is seldom used, having been eclipsed by many newer products with better aesthetic properties, less expense, and longer-lasting results.

Hyaluronic Acid-Based Fillers

Hyaluronic acid, or HA, is an especially popular injectable filler ingredient. Hyaluronic acid occurs naturally in the connective tissue of the skin, where it attracts water molecules to increase plumpness. Injections of hyaluronic acid fillers also stimulate the production of collagen, further promoting a more youthful appearance. Our patients have the option to choose from a variety of HA fillers, so treatment can be customized to suit their unique goals.

Some fillers, such as JUVÉDERM® Ultra Plus, JUVÉDERM VOLUMA™, and Restylane Lift®, are designed to significantly enhance volume and are used for:

• Lip augmentation
• Cheek augmentation
• Plumping nasolabial folds and “marionette lines”

Other HA fillers, such as Restylane® Fine Line and JUVÉDERM VOLBELLA™ are ideal for:

• Reducing the appearance of under-eye bags
• Mild to moderate lip augmentation
• Diminishing the appearance of fine lines around the mouth (“smoker’s lines”)

JUVÉDERM®

JUVÉDERM® is a hyaluronic based injectable filler from Allergan. It comes in different preparations that reflect varying degrees of volume enhancement. The HA concentration and cross-linking affects its volume enhancing properties. JUVÉDERM Ultra provides moderate volume enhancement, while JUVÉDERM® Ultra Plus provides maximum volume enhancement. It is most commonly used in the nasolabial folds, lips, “marionette lines,” and cheeks.

JUVÉDERM VOLUMA™

Developed by Allergan, JUVÉDERM VOLUMA™ is the first, and currently the only, hyaluronic acid based filler to be FDA-approved for midfacial volume enhancement in patients 21 and older. This injectable treatment is most commonly used to augment the cheeks and regions of the midface to achieve a fuller, more youthful contour. Additionally, it can also help smooth and fill out lines and wrinkles in the targeted treatment area. The volumizing effects of JUVÉDERM VOLUMA™ have been clinically-proven to last up to two years in several instances.

JUVÉDERM VOLBELLA™

JUVÉDERM VOLBELLA™ is a newer generation of HA filler from Allergan. It has the unique property of looking very “smooth” and is suitable for injection very close to the skin’s surface. The result is that even very superficial fine lines can be treated with a low risk of looking bumpy or creating contour irregularities. The properties of VOLBELLA™ generally make it an excellent HA filler for natural augmentation of the lips, lip lines, and lower lid tear trough region.

JUVÉDERM VOLIFT™

JUVÉDERM VOLIFT™ is also a newer HA filler from Allergan. Similar to Volbella, it has the unique property of looking very “smooth” and is suitable for injection close to the skin’s surface. It is positioned “in between” JUVÉDERM VOLUMA™ and VOLBELLA™, and is commonly used for correction of “laugh lines” (nasolabial folds) and “marionette lines,” pre-jowl sulcus, and submalar cheek hollowing, among other areas.

Restylane®

Restylane® is a hyaluronic acid (HA) based injectable filler. Restylane® provides a moderate degree of volume enhancement. It is most commonly used for enhancement of the lips, nasolabial folds, and “marionette lines.” Restylane® Fine Lines is a filler that provides less volume enhancement than regular Restylane®. Its properties are more suited for delicate areas, such as camouflaging bags in the lower lids and “smoker’s lines.” For long-term enhancement in the upper or lower eyelids, Dr. Tong also offers eyelid surgery for individuals seeking more enduring results than can be provided with soft tissue fillers.

Restylane Lift (Perlane)®

Restylane Lift® can be thought of as the maximum volumizing version of Restylane®. Its chemical composition is formulated for improving fullness and correcting volume deficiency. It is most commonly used by Dr. Tong in the nasolabial folds, “marionette lines,” and cheeks.

Calcium Hydroxylapatite Fillers

Calcium hydroxylapatite (CaHA) is a mineral substance found in teeth and bones. When used in tissue fillers, it is synthesized as smooth microspheres and is suspended in a gel carrier. As the gel dissolves, the CaHA remains and induces collagen production, which is thought to be the mechanism of its volume enhancement. The CaHA is eventually broken down by the body. It is thus a filler and stimulatory agent. RADIESSE® is the only available CaHA based filler on the market.

RADIESSE®

RADIESSE® is calcium hydroxylapatite based filler. RADIESSE® has the advertised advantage of longer-lasting results over HA based fillers. The average duration of results varies between 9-12 months. RADIESSE® is best used for increasing volume in the cheeks and filling the nasolabial folds or “marionette lines.” The filler should not be used in the lips or the lower eyelid area. RADIESSE® tends to be slightly firmer in feel during the early recovery period when compared to other fillers. Dr. Tong uses RADIESSE® primarily for cheek augmentation, chin augmentation, nasal bridge augmentation, nasolabial fold correction, “marionette line” correction and general volume enhancement.

Platelet Rich Fibrin Matrix Fillers (“Vampire” Facelift)

Platelet rich fibrin matrix fillers are soft tissue fillers that use a patient’s own blood as the principal active ingredient. Its mechanism of action is thought to be due to the release of the abundant growth factors found within platelet cells. Selphyl® is the only commercially available soft tissue filler that utilizes this technology.

Selphyl® (The “Vampire Facelift”)

Selphyl® is a product that allows a patient to use a small amount of their own blood to create a filler used for treating wrinkles and folds in the face. Thus, it has been termed the “Vampire Facelift.” Despite its name, the treatment is not a facelift procedure, but one that helps improve fine lines and skin quality. The appeal is that the filler is completely natural, using growth factors found naturally in the platelets (the clotting cells in your blood).

The procedure involves drawing blood from the patient, and preparing it immediately to form the filler for injection by Dr. Tong. These growth factors stimulate improvement in the injected areas. The enhancement tends to be more of a qualitative improvement of skin quality and fine lines, rather than strict volume enhancement.

Poly-L-Lactic Acid

Poly-L-Lactic acid is a material used to make dissolvable stitches. In a different form, it can be utilized as a soft tissue filler. Unlike HA and CaHa fillers, the result is not immediately apparent. The Poly-L-Lactic acid works by stimulating collagen synthesis under the skin. Over a period of weeks, the result gradually emerges, and the treatment is repeated two to three times until the desired end-result is achieved. The brand name for this filler is Sculptra®.

Sculptra®

Sculptra® is a filler made from Poly-L-lactic acid, the material used in dissolvable stitches. Sculptra® is injected as a liquid solution underneath the skin. Results are not immediate, and generally require an average of three injection sessions over a period of months to achieve optimal correction. Following each injection, there is gradual collagen deposition that results in increased facial volume and decreased facial lines, folds, and areas of depression. Sculptra® is a very gradual treatment, but the duration of results can last up to two years.

Common Areas for Soft Tissue Fillers

Soft tissue fillers can be administered to a number of facial areas for exceptional results in facial rejuvenation. Depending on your cosmetic goals, these minimally invasive treatments are typically utilized to improve the appearance of fine lines and facial folds, or for natural-looking volume enhancement.

• Dermal Fillers can be used to correct Fine Lines, Wrinkles, and Folds in the Face:
  • Nasolabial Folds
  • Marionette Lines
  • Lips (for Smoker’s Lines)
  • Frown Lines (Glabella)
• Dermal Fillers can be used for Volume Enhancement in the Face:
  • Lips (for Increasing Volume)
  • Cheeks
  • Under the Eyes
  • Jowls
  • Acne Scarring
  • Liquid Nose Job
  • Liquid Facelift
• Dermal Fillers can be used for Hand Rejuvenation

Dermal Fillers for Fine Lines, Wrinkles, and Folds

Nasolabial Folds

The nasolabial folds (smile lines) are the most common areas for soft tissue fillers. Usually one to three syringes of product are required to obtain the best correction. Dr. Tong typically utilizes volumizing HA fillers (hyaluronic acid), or CaHA (calcium hydroxyapatite) fillers for this area. Selphyl® or micro fat grafting is an alternative for patients that seek a purely natural filler source.

Marionette Lines

The “marionette lines” occur at the corners of the mouth. They are associated with downward drooping mouth corners. Fillers can lift the corners of the mouth and soften these lines. Volumizing HA fillers (e.g. JUVÉDERM®, Restylane Lift®) or CaHa fillers (e.g. RADIESSE®) are used most often here.

Lips (for Smoker’s Lines)

Lines around the mouth make a person look aged. Women are commonly concerned with lipstick bleeding into these lines. These lines may be caused by smoking, aging, weight loss, or sun exposure. Dr. Tong recommends the use of an HA filler for delicate areas (e.g. Restylane® Kysse or JUVÉDERM VOLBELLA®) to help correct the appearance of the lines. Other options for “smoker’s line” correction include dermabrasion (for deeper lines), and BOTOX® Cosmetic to reduce muscle contraction (for more shallow lines) .

Frown Lines (Glabella)

The frown lines between the eyebrows are best treated with BOTOX® Cosmetic. This is very effective when the lines are mild to moderately deep. If the lines are very deep or the lines have been present for a long time, they may be “etched” into the skin. In these cases, using a soft tissue filler may be beneficial as an additional treatment to fill in the depressed folds. A volumizing hyaluronic acid (e.g. JUVÉDERM®, Perlane®) is recommended by Dr. Tong in these cases. Other surgical options for frown line treatment include fat transfer or Corrugator removal.

Dermal Fillers For Volume Enhancement

Lips (for Increasing Volume)

You may have thin lips due to age or genetics. Soft tissue fillers placed in your lips can enhance fullness, creating a youthful pout and shape. Dr. Tong generally recommends either a volumizing HA filler (e.g. JUVÉDERM® Ultra, Restylane®) or a softer HA filler (Juvederm Volbella®, or Restylane Kysse) used for delicate areas. When using a volumizing filler for lip augmentation, there is more enhancement and longer duration of effect as compared to the softer fillers. The tradeoff is that there is a slightly higher risk that the lips may feel firm, and a slightly higher chance of bumps or asymmetry. A thorough discussion about choices for lip filler occurs for all patients seeking lip enhancement with Dr. Tong.

Cheeks

Sunken or flat cheekbones may be due to aging, weight loss, or something you are born with. Enhancing the volume of the cheeks is a simple procedure using soft tissue fillers. Dr. Tong generally recommends a volumizing HA filler (e.g. JUVÉDERM ULTRA®, JUVÉDERM VOLUMA™, Restylane Lift®) or CaHa filler (RADIESSE®). Sculptra® is recommended when there is a significant amount of volume restoration needed in multiple areas (i.e. gaunt-looking faces). Selphyl® often works well for patients looking for a more moderate and gradual degree of enhancement, coupled with improvement to the quality of skin. Another option for a more permanent improvement is fat transfer to the cheeks.

Under the Eyes

A noticeable trough or line can form at the junction between the lower eyelid and cheek. Patients with either hollowness in the lower lids, or fat bags in the lower lids, can have this condition. Lower lid blepharoplasty is often the best way to correct this problem, but fillers can camouflage this by filling in the area so that there is a smooth transition from the lid-to-cheek region. Dr. Tong uses a HA filler specifically designed for filling delicate areas, such as Juvederm Volbella®.

Jowls

If you have mild jowling, the appearance of the jowls can be camouflaged by placing soft tissue fillers along the jawline, directly in front of the jowls. This area is called the pre-jowl sulcus. A volumizing HA filler (e.g. Perlane®, JUVÉDERM®) or CaHa filler (e.g. RADIESSE®) is typically used with good results. Patients with moderate or severe degrees of jowling will likely require a facelift or extended neck lift in order to obtain optimal results in jowl correction.

Acne Scarring

Acne scars can be treated with soft tissue fillers. Dr. Tong uses a special technique called subcision to first release the scarred tissues, followed by injection of a volumizing HA filler (e.g. Perlane®, JUVÉDERM®), CaHa filler (e.g. RADIESSE®), or PRFM filler (e.g. Selphyl®).

Liquid Nose Job

Small imperfections of the nose can be improved by using fillers. The most common applications are in Asian patients who want to elevate the height of the bridge, or (typically) a non-Asian patient who wants to hide a bump on the bridge. Sometimes, patients use fillers to hide small imperfections after rhinoplasty as an alternative to doing a revision procedure. This is especially suitable when the imperfection may be too minor to warrant another surgical procedure. One notable feature about fillers in the nose is that the duration of the effects tend to be much longer than fillers in other areas. Lasting improvement in the nose for 12 months is not uncommon. The nasal tip is not as well-suited for filler injection, as it tends to give a rounded, fatter appearance rather than providing a sharper, thinner look as some patients mistakenly assume.

The Liquid Facelift

Liquid facelift is the term used for facial rejuvenation done with a combination of minimally invasive techniques, without undergoing a traditional surgical procedure. In the right candidate, a significant degree of facial rejuvenation can be accomplished using only soft tissue fillers and BOTOX® Cosmetic.

This is an attractive option for patients who:

• Do not want to have surgery, or are not ready for surgery
• Cannot undergo surgery for medical reasons
• Do not have the time/resources to commit to surgery/recovery
• Do not have advanced signs of aging (i.e. significant skin laxity)
• Want a “quick fix”

An example of what a typical liquid facelift would utilize:

• BOTOX® Cosmetic in multiple areas of the face (e.g. glabellar frown lines, “crows feet,” forehead lines)
• Soft tissue fillers in multiple areas of the face (e.g. the nasolabial folds, cheeks, “marionette lines,” under the eyes, wrinkles around the lips, etc.)

A liquid facelift does not produce the same improvement as a traditional surgical facelift. This holds true with respect to the degree of correction and the duration of the results. Despite this, patients are generally very satisfied with the improvement obtained. The key to success is having an educated patient with the correct expectations for the procedure.

Hand Rejuvenation with Soft Tissue Fillers

As we age, the hands can also appear aged. Soft tissue fillers can be used to camouflage veins, tendons, boniness, and general loss of soft tissue volume. Dr. Tong prefers to use volumizing hyaluronic acid fillers on the back of the hand to smooth out contours, which become more apparent as you get older. A more lasting alternative to using a tissue filler is using your own fat with a fat transfer procedure.

Choosing the Right Filler For You

With so many fillers on the market, consumers can be confused with all of the choices (and marketing) put out by the different manufacturers. In reality, differences between products within the same class (e.g. hyaluronic acid-based fillers) are not as significant as they are marketed to be. Even differences between products of different classes may not be very dramatic when comparing aesthetic outcomes.

Although the mechanisms of action and principal components may be quite different, the end results tend to be comparable, assuming the products are designed for similar applications. For any one area to be treated, there is usually more than one soft tissue filler that could be used very appropriately.

Dr. Tong can make a recommendation regarding which soft tissue filler would be best suited to your needs. Some factors taken into account are location, depth of lines, required degree of augmentation, skin quality, and skin thickness.

The Dermal Filler Procedure

The selection of filler must be well-suited to the patient’s needs. Dr. Tong will make his recommendations when he sees you during a consultation.

Anesthetic

Injections are usually supplemented with some form of local anesthetic. The local anesthetic helps to relieve discomfort that may occur during the injection procedure. Dr. Tong can administer the anesthetic prior to the start of the procedure. More commonly these days, the local anesthetic comes pre-mixed with the product and is administered simultaneously with the product.

Injection

The areas to be treated are marked on your face by Dr. Tong in conjunction with your input. The areas are cleansed with alcohol or antibacterial soap to remove dirt, oils, and bacteria. If local anesthetic is to be utilized before the procedure, it is administered at this point. The product is injected through a series of linear threads or puncture sites. There is no single method of soft tissue filler injection. Dr. Tong has specific configurations of injection for each specific area of the face.

Dr. Tong’s underlying principles regarding filler injections:

• Distribute the filler evenly and at the correct depth
• Assure symmetry
• Do not fill beyond accepted limits (to maintain a natural-looking outcome)

Each area generally takes 15-20 minutes and Dr. Tong shows you the progressive result from time to time during the procedure.

Recovery from Soft Tissue Filler Injections

After the procedure, we will give you an ice pack, and recommend you ice the area for 20 minutes each hour as you are able for the rest of the day. This helps to decrease any swelling or bruising that may occur with the injection. You may return to work or daily activities, so long as they are not overly strenuous. You may begin exercising 24 hours after the procedure, unless advised otherwise by Dr. Tong. Bruising is unusual, but if it occurs, it can be covered with makeup and generally lasts a few days.

There may be some swelling of the area, which tends to subside over the first 48 hours. Sometimes, the product feels firm in the treated areas. This tends to be more common in some products than others. Patients may occasionally see some minor contour irregularities that are caused by the product as well. These issues are temporary and any firmness or visible contour irregularities should smooth out over the first few days as the product has some time to distribute itself.

Your Dermal Fillers Consultation

If you are concerned by signs of aging to your face such as fine lines, wrinkles, or loss of volume, dermal fillers are a minimally invasive treatment that may help you achieve a more youthful and refreshed appearance. During your consultation with Dr. Tong, you will have the opportunity to discuss your concerns and your goals, and Dr. Tong will recommend the most appropriate treatment for you.

For more information on dermal fillers or to schedule your personal consultation at Yorkville Institute of Plastic Surgery near Toronto, please contact us today.

¹American Society of Plastic Surgeons. Dermal Fillers. Available: https://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers. Accessed July 13, 2020.
²American Society of Plastic Surgeons. Types of Dermal Fillers. Available: https://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers/types. Accessed July 13, 2020.