What is the best Dermal Filler?

I have wanted to write this blog for a long time , about botox’s slightly less famous but equally brilliant brother.

Dermal fillers complement botox so well in the wonderful world of non-surgical rejuvenation. They remove wrinkles and folds, they contour and shape the aging face,they correct facial assymetries,  they help to create  the non-surgical facelift and they fight side by side with botox in the eternal battle against the aging process. Call them Butch Cassidy and the Sundance kid, Torville and Dean or even Morcambe and Wise , they are a truly magnificent partnership.

Dermal fillers are a brilliant tool in the aesthetic doctor’s tool box, and in the right hands of the right doctor dermal filler procedures create  the most wonderful and natural rejuvenating results. The popularity of dermal filler treatments has been rising exponentially over the last decade and hyaluronic acid fillers are now in the top 3 most popular treatments in the aesthetic medicine world along with botox and laser hair removal.

But what are the best dermal fillers? Which give the best and most natural results? Which last the longest? Which one should you choose? These are just some of the questions I get asked by patients, colleagues and pupils every day. Well here is a comprehensive and user firendly guide  to what I think makes the best dermal filler, spelling out the strengths and weaknesses of some of the most popular and most effective fillers.   A nice compare and contrast list,  just like those you may have seen when searching for a new TV or a new mobile phone. The scores are out of 10 for each category and out of a total of 100. I have chosen the 5 leading dermal fillers to compare. And which is the king of fillers? The answer is at the bottom of the blog..

RESTYLANE

RESULTS–9/10– Q-MED’s Restylane and Perlane give the perfect  natural rejuvenating results when used to correct lines, wrinkles and folds. In my opinion, these hyaluronic acid fillers are the best fillers on the market for facial contouring and shaping such as cheek enhancement.

DURABILITY–8/10—In my experience, the results can last from 9 to 18 months, even though literature will tell you that the durability is a lot shorter. With repeat treatments, which induce the body’s own collagen production, the results can last a lot longer. These Q-med fillers are made of particles, and in my opinion it is this along with the stabilisation technology that makes them last so long.

CLINICAL EVIDENCE–10/10–This is definitely the “trump card” for restylane fillers, with well over a decade of copious and second to none clinical research testing the efficacy and safety of these fillers.

SIDE-EFFECTS–8/10–Side-effects,  more serious than swelling, redness and slight bruising are rare with only a 1 in 15,000 chance of side-effects such as  prolonged lumpiness or infection. Allergic reactions are also very rare as hyaluronic acid fillers are non-animal. And the best thing, just like other hyaluronic acid fillers, if the patient does not like the result, for example the lips being too large, there is a special enzyme which can be injected to melt the product away safely.

PAIN–7/10–When emla cream is applied or local anaesthetic block is injected,  this is a relatively painless procedure, although slightly more painful than botox.

SYRINGE DESIGN/EASY TO USE?–9/10—Again this almost another “trump” for Restylane. The design of the restylane syringe is second to none, and other companies are trying to copy it. Why is this important? The better the design of the syringe, the easier it is to use and  for the doctor to achieve the best possible results.The reason it doesn’t get a perfect 10 is that sometimes, and I see this on courses I teach on, beginners do find it just slightly harder to use compared to some other fillers as it is a slightly thicker product .This however is reassuring as the thickness of the product does give better results and you should only be seeing experienced aestheticians anyway!

VALUE FOR MONEY–7/10–Taking into account the great durability, the quality of the results and the actual reasonable price, these fillers do represent pretty good value for your “credit crunched” pound!

POPULARITY–10/10–These Q-med fillers are still  the market leaders in the UK by a long mile. As the TV advert says: (I saw it I am embarassed to admit during Desparate Housewives!) “Ask for Restylane by name!”

RANGE–9/10–With Restylane, Perlane, Restylane Lipp, Restylane Touch, Restylane Vital, Restylane Sub-Q, and now the big brother Macrolane, Q-med have the most varied and most relevant range.This range is also the only one which has half size syringes, for those subtle procedures and small touch ups. No frills here, just fillers designed to address various signs of aging , various volume deficiencies and with the great Restylane Vital, even skin rejuvenation is covered.

VERSATILITY–10/10– Restylane does not really have any limits unlike many other fillers which can’t treat various areas as you can see further down the list. We used to stay away from the under eye area, but with the new Perlane treatments for the “tear trough” area, there are now no stones left unturned for the Q-med family of fillers.

TOTAL 87/100

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JUVEDERM ULTRA

RESULTS–5/10–Juvederm ultra is the newest member of the Hydrafill/Juvederm family produced by Allergan, the makers of botox. In my experience the results are good and reliable, and some clinicians rave about these fillers due to the smooth homogenous make-up of this stabilised hyaluronic acid gel giving a smooth and natural result. However, exactly because of this smoother gel, I find it is less accurate, and while injecting it it often does not stay where I place it and I sometimes see it shoot off at right angles, unlike Restylane which stays put. It is also not as good at facial contouring, again because it is just too soft!

DURABILITY–7/10–The results of the Juvederm family should last up to 12 months, but in my experience these fillers do not last as long as their biggest rivals, the restylane family. It is difficult to know exactly, but I feel that the two main reasons for this are that: 1.Because these fillers are not particulate in make up, they do not induce further collagen production by the skin. 2.Juvederm Ultra comes with lignocaine pre-added in the syringe  to help with the procedure related pain, but there is a lot of conjecture in the aesthetic industry that lignocaine de-stabilises the dermal filler, making it’s durability much poorer.

CLINICAL EVIDENCE–7/10—Corneal and now Allergan have published many papers and clinical research is ongoing, but the weight and volume of evidence is not as great as some of it’s rivals.

SIDE-EFFECTS–7/10–Due to it’s homogenous  smooth nature, the side-effects are  very rare just like with other Hyaluronic acid fillers. Due to it’s user friendly nature, side-effects such as lumpiness are probably even less common than with other fillers, and some practitioners report that they get less bruising. However, due to it’s slightly unpredictable and inaccurate nature, the side-effect of the filler residing in the wrong place at the end of the procedure is more likely.

PAIN–8/10–The pain is minimal, and with the addition of a small amount of lignocaine to the Juvederm ultra syringes, this is a bit of a “trump” feature for the juvederm/hydrafill range. I did a cheek augmentation procedure with juvederm ultra recently and was rather pleasantly surprised by the lack of pain experienced by the patient.

SYRINGE DESIGN/EASY TO USE?–4/10– The only thing that saves the day here is the beginner friendly smooth gel nature of these fillers. The actual syringe though is absolutely awfull. It comes in two parts and to say that it is cumbersome is an understatement. Allergan have to pull their finger out quickly with this below power syringe design.

VALUE FOR MONEY–7/10–On the surface, this juvederm family of fillers is better value for money than the restylane fillers as they are actually cheaper to buy for the doctor who can then of course pass that on to the patient. However, taking into account that Juvederm fillers come in 0.8ml syringes, and restylane in bigger 1ml syringes, it works out to be very similar. The results of juvederm also do not last as long..

POPULARITY–7/10–Allergan have recently run a very expensive advertising campaign promoting juvederm ultra, and their adverts could be seen all around the US open tennis courts this year. The popularity of these fillers is increasing.

RANGE–6/10–The addition of Juvederm ultra 2,3 & 4  versions to cover thin wrinkles all the way up to thick folds, the range is much improved, and there is of course the unique feature of the added local anaesthetic. My big bug bear here however is that in the same family of allergan fillers we also have Hydrafill 1, 2 and 3, and also Hydrafill Softline and Softline Max, oh yes and Juvederm 18, 24 & 30. So why is such a wide range a bad thing? Well all of the fillers I have listed are all variations on pretty much the same filler! There are no specific lip fillers here or rejuvenating fillers. Confused? I certainly am!

VERSATILITY–8/10–Despite some of my misgivings  about this range, juvederm ultra is a good versatile filler which can treat most signs of aging and can treat patients of all ages and both sexes efficiently, although it may not be as good as some other fillers for volumising procedures.

TOTAL 66/100

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SCULPTRA

RESULTS–7/10–Sculptra is not strictly a filler, but is a sculpting and volumising agent. Unlike Restylane and Juvederm it is not a hyaluronic acid filler,  but is made up of Poly L Lactic acid, which is a sugar molecule said to be a collagen stimulator. In the right hands, and used for carefully indentified facial corrections, sculptra results in second to none results, earning in it’s media nickname of “the liquid facelift”. For filling large depressions and for facial contouring this is arguably the best of the lot, but when used to  remove wrinkles it does fall slightly short. It is a very “technique sensitive” product and in inexperienced hands the results can still be less than perfect. And another thing, if you are the kind of person who wants to see immediate results, you will be very disappointed as the full results with Sculptra can take as long as 6-18 weeks! On the flip side this means you achieve rejuvenating results gradually and naturally!

CLINICAL EVIDENCE–8/10–There has been some very good and very valid clinical evidence backing up the efiicacy and safety of this product.

SIDE-EFFECTS–6/10–In it’s previous guise of Newfill, Sculptra had many problems, small hard long lasting lumps being a common one. To their credit the manufacturers of sculptra went back to the drawing board, and with strict new guidance on the injection technique, these side-effects have become very much more rare. However, these problems do still arise as this is still quite a technique sensitive procedure.  Due to Sculptra’s longevity, unlike it’s hyaluronic counterparts, if the results are not satisfactory there is nothing else you can do but wait for 3 years or more..

PAIN–9/10–This is a relatively pain free procedure, as lignocaine local anaesthetic is mixed in with Sculptra.

SYRINGE DESIGN/EASY TO USE?–6/10– Sculptra does not come in pre-filled syringes, and the syringes usually used are very easy to use. However, the relatively low score in this category is partly because the injector will often experience a lot of blocking of the syringe during the Sculptra procedures which are due to the particle filled fluid being injected, and this can be very frustrating indeed.

VALUE FOR MONEY–8/10–Scupltra possibly provides the best value for money. Even though the patient may need an initial 2-3 treatments at a cost of £1000-£1500, Sculptra can cover a lot more areas of the face at that price, definitely more than the hyaluronic acid fillers, and don’t forget 3 years!!

POPULARITY–7/10–Popularity of sculptra is ever increasing, not least due to the sterling work put in by the Sanofi Aventis team, who have been providing excellent training courses, and expert lectures for all the practitioners. The general public is slowly waking up to the fact that the “Liquid Face lift” really could be the real deal!

RANGE–6/10–This category is slightly unfair on Sculptra as it does not have a pre-packaged range for different treatments, but actually the experienced doctor can fashion their own range by varying the dilution of Sculptra for different treatments and different facial areas.

VERSATILITY–6/10–Despite my enthusiasm for Sculptra, it’s versatility is not great. It is brilliant for treating hollow cheeks, for filling big depressions and for the non-surgical face lift, but it is poor for the treatment of fine lines and wrinkles. It also can’t be used on areas of the face such as lips. It is also an age specific product, great for over 50s, but definitely not as effective for the younger patients.

TOTAL 73/100

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RADIESSE

RESULTS–8/10–Radiesse is made up of synthetic Calcium Hydroxylapatite microspheres, and it is both a filler like restylane, and a collagen stimulator like Sculptra. It is the new kid on the block, having been launched as recently as 2004, and the results do seem to be quite impressive so far.

DURABILITY–8/10–Being a collagen stimulator, this product will last as long as 18 months. One draw back however is that when some patients, especially the older ones,  are not great at producing collagen  the durability could be greatly affected.

CLINICAL EVIDENCE–7/10–Even though there is over 8 years of clinical research behind this filler, the direct rivals have been around for longer and can show a longer safety and efficacy record. At a recent conference, I saw a few studies on radiesse presented, and I did identify a few flaws in the research!

SIDE-EFFECTS–6/10–Radiesse is made up of calcium crystals, and basically it’s make up is the same as that of bone or teeth. It is partly because of this make up that the use of radiesse is a lot more technique sensitive, and in unexperienced hands side effects such as hard nodules are more likely than in fillers such as restylane. It is also a more viscous filler which makes it more durable, but it is this viscocity which means that more severe side effects such as artery compression more likely. Also there is no antidote for these fillers, unlike the hyaluronic acid fillers, so if you don’t like the results or you have some undesirable side effects, tough they are there to stay, and for as long as 18 months. Having said all of this, all these side effects are relatively rare in the hands of an experienced doctor.

PAIN–6/10–Many patients comment on an “after pain” when Radiesse is injected which they say is stronger than when they were previously injected with restylane or juvederm. They describe it is a delayed pain, which is slightly burning in nature and comes a few seconds after the injection.

SYRINGE DESIGN/EASY TO USE?–8/10– A very good syringe design, easy to use. The material is viscous so quite hard to inject, and in inexperienced hands this is not the easiest filler to get side-effect free results.

VALUE FOR MONEY–7/10–Taking into account the longer durability and the larger 1.3ml syringe , radiesse does provide good value for money.In addition, due to it’s very viscous nature, 1 syringe of radiesse will go a long way! On the flip side, Radiesse will cost you as much as on average £400-£500 per syringe, as opposed to an average of £300-£350 for many hyaluronic acid fillers. Also Radiesse treatment often require a 3 month top up, incurring an extra cost.

POPULARITY–6/10–There is no doubt, Radiesse’s popularity is increasing, and allegedly this was the filler of choice at this year’s Oscars ceremony. However, Radiesse is still 3rd or 4th choice for many patients and doctors alike.

RANGE–4/10–No range, just Radiesse!

VERSATILITY–7/10–There is no doubt, this is a great filler , and definitely one that any good cosmetic doctor should have as part of their armoury. It’s versatility however does not compare to some of it’s filler rivals. It is not recommended for use in lips or tear troughs, for fear of nodule formation. It is also contraindicated for use in the frown area, due to risk of skin necrosis.

TOTAL 67/100

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TEOSYAL

RESULTS–6/10–Just like other hyaluronic acid fillers, good dependable results, just not quite as good as it’s nearest rivals.

DURABILITY–5/10–In my experience and that of many my colleagues, this filler last much shorter than all the other fillers on this list.

CLINICAL EVIDENCE–6/10–Only launched in 2005 in the UK, so has a long way to go to prove it’s long term safety and efficacy through more studies.

SIDE-EFFECTS–8/10–Like other hyaluronic acid fillers, the side-effects are usually minimal.

PAIN–7/10–Pain levels are minimal, just like the other hyaluronic acid fillers.

SYRINGE DESIGN/EASY TO USE?–7/10– Teoxane, the makers of the Teosyal range, have replaced the terrible old syringe  with a very good restylane like compact syringe. However, they have almost gone too much the other way in the ease of injection, with great pressure needed to squeeze the product out.

VALUE FOR MONEY–5/10–Despite slightly cheaper prices for Teosyal syringes  which can be found at many UK clinics, the poorer durability and results which are just not effective, in my opinion teosyal fillers do not provide great value for money.

POPULARITY–5/10–The popularity of teosyal has increased slightly, but in the long term it is very unlikely that these fillers can fight the bigger and better brands of coca cola and pepsi! No sorry I mean to say restylane and juvederm!

RANGE–8/10–This is the only other filler in this review apart from restylane , which provides a good varied range of fillers for all occasions!

VERSATILITY–7/10– This is a versatile filler, just not the best!

TOTAL 64/100

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So the winners list:

1. RESTYLANE 87/100    The gold standard! The longest track record, the best results. The king filler!

2.SCULPTRA  73/100      Silver medal. The come back kid, 3 year longevity, the liquid face-lift!

3.RADIESSE  67/100       Bronze!. The new kid on the block. Tougher, longer lasting!

4.JUVEDERM  66/100      Just missed out! Lots of potential, big allergan budget!

5.TEOSYAL   64/100      Wooden spoon!  A decent filler, tough competition! Room to improve…�

For the updated version of this survey blog, please click on: https://www.miloclinic.com/blog/?p=182