Dermal Fillers Guide

Dermal fillers have revolutionized the cosmetic industry. In the past, patients seeking a more youthful appearance would have to go under the knife for a facelift to achieve noticeable results, but today, dermal fillers make it possible for patients to get rid of wrinkles and add volume to the face with a minimally invasive procedure that takes only minutes to perform. According to the American Society for Aesthetic Plastic Surgery, the use of dermal fillers is the second most popular cosmetic procedure in the United States today.

Patients do not need to take time out of their busy schedule to recover from a painful procedure but instead can merely make an appointment over their lunch hour to temporarily smooth out wrinkles, plump the lips and cheeks, and fill facial folds. Dermal fillers are safe and affordable and provide patients with age-defying options that have never before been available.

What are dermal fillers?

Dermal fillers are products that were created to help add volume to the cheeks, lips, eyes, or ears or to smooth out or fill in fine lines and wrinkles. There are a variety of different dermal filler products available including brand names such as Restylane, Juvederm, Sculptra, and Perlane. Botox has a similar impact on the skin but works as a neurotoxin to paralyze underlying muscles instead of filling in wrinkles like dermal fillers. Botox is often grouped together with dermal fillers because the results of Botox treatments can be similar.

Dermal fillers are administered as an injection. They help the skin retain a youthful appearance, keeping it hydrated and adding volume while encouraging the production of new collagen and skin cells. Often dermal fillers can turn back the clock by ten years or more, with very little pain and no recovery period required.

Dermal fillers are affordable and accessible, allowing patients who are not willing to go under the knife for a facelift to still improve their appearance and maintain their youth. The low-cost and low risk associated with dermal fillers has made them remarkably popular among both men and women as an alternative to major surgical procedures.

What are Fillers and Injectables?

There are a variety of different injectable products on the market today to smooth lines and remove wrinkles. The product that your doctor chooses for you will depend on several factors and your own unique situation.


There are two basic categories of collagen: human and animal. Collagen exists naturally in the body in abundant supply, but it can also be used as a dermal filler. Collagen is a temporary biocompatible treatment that can remedy volume deficiencies in soft tissues.

Collagen cells from animals such as cows and pigs have been used as dermal fillers with success since the 1980s. The first product approved by the FDA for use on soft tissues was Zyderm, the first non-autologous agent that could be used on soft tissues in humans. Its effects lasted between 3 to 6 months. It became quite popular in the 1990s, but other dermal fillers have risen in popularity to take the place of collagen today.

Hyaluronic Acid-Based Fillers

Hyaluronic acid is an important component of the dermal layer of the skin as well as the subcutaneous and connective tissues. This natural polysaccharide of glycosaminoglycan functions to bind water, increasing the moisture content and volume of the skin. Chemically, the sugars that compose hyaluronic acids are Cross-linked which helps make them more stable and long-lasting by preventing rapid degradation.

In all living things, hyaluronic acid is chemically the same, however, the extent to which the acids from different sources are cross-linked may differ somewhat. The source of hyaluronic acid can play a role in the type of cross-linking associated with the product. Additionally, the concentration and the size of the particles,  and the concentration of hyaluronic acid. As a result of the fact that hyaluronic acids are all chemically identical, doctors do not need to test patients for allergy sensitivity. Only about 1 out of 2000 patients show signs of an allergic reaction. The substance is highly bio-compatible which is what makes it such a good choice as a dermal filler.

What’s even more compelling is the fact that hyaluronic acid is a component of the skin that diminishes as a person ages. The skin begins to wrinkle more as dermal moisture is lessened. Hyaluronic acid fillers are able to return moisture and volume to the skin and essentially replace exactly what’s been lost.

Many patients choose hyaluronic fillers over collagen replacement. The product is in higher demand than collagen because it lasts 3 to 6 months longer and is less likely to cause problems due to allergies.

Some of the most popular cosmetic dermal fillers with a hyaluronic acid base include:

  • Perlane
  • Prevelle
  • Captique
  • Restylane
  • Juvederm
  • Hylaform

Calcium Hydroxyapatite

The use of nonimmunogenic calcium hydroxyapatite has provided some patients with slightly longer-term effects. The product is superior as a dermal filler for particularly deep wrinkles or folds that require a large volume of the material.

Radiesse is a calcium hydroxyapatite product that utilizes microscopic particles suspended in a carboxymethyl-cellulose gel. The gel slowly degrades, but as it does, new tissue moves in and surrounds the hydroxyapatite particles perpetuating its volumizing effects.

Poly-L-Lactic Acid

Poly-L-Lactic acid is a compound that has been in use for many years as an absorbable suturing material. It is biocompatible and biodegradable that functions as a non-toxic, and non-immunogenic material that can be injected as a dermal filler.

Sculptra is a product that makes use of microscopic crystalline particles of poly-L-lactic acid. It is packaged as a sterile powder that can be reconstituted with water and lidocaine for injection.

Clostridium Botulinum (Botox)

Botox is a popular treatment method for wrinkles today. The product can be used to treat different areas of the face including the lower eyelids, the oral commissures, dimpling of the chin, glabellar frown lines, forehead wrinkles, crow’s feet, and issues with the brows. Though Botox has had limited success at treating wrinkles and aging issues in the lower part of the face, its track record at treating the upper areas of the face are well known.

Botox inhibits wrinkles by paralyzing the muscles that cause them. Some doctors recommend the use of Botox in conjunction with dermal fillers for best results.

What is a cross-linked filler?

Fillers that are not cross-linked are in a liquid state while those that have been cross-linked are in a gel state. Cross-linking chemically alters that arrangement of molecules to create a sort of “mesh” at the molecular level. This “mesh” gives the filler more volume and also increases the time it takes for it to deteriorate. The more heavily cross-linked a dermal filler is, the longer it will probably last and the better it will be at filling areas that are lacking in volume.

Heavily cross-linked fillers have to be injected into deeper layers of the skin because they are thicker and have the tendency to leave nodules or bumps under the skin if injected too superficially. Fillers like hyaluronic acid that are created with less cross-linking are easily broken down by the body, but provide the some of the best treatments for fine lines or wrinkles because the thin fluid won’t create a noticeable bump under the skin. This thinner, less cross-linked version of hyaluronic acid is not a good choice for adding volume to the face.

Skin Rejuvenation with Dermal Fillers

Patients have long demanded less invasive means of maintaining a youthful appearance and adding volume to the face. New technological innovations have led to the development of various dermal filler options that provide a subtle, natural-looking change to the face without requiring patients to endure a prolonged recovery. Because of their low-cost, low-risk profile along with their notoriety for producing noticeable yet natural-looking results, dermal fillers have become the second most popular cosmetic procedure in the U.S. today.

There are three layers of the skin: the epidermis (top layer), dermis (middle layer), and the subcutaneous (bottom layer). Dermal fillers are administered in the mid-dermis region of the skin. This makes it possible for the filler to actually add volume where you can see it without blanching the skin, which can happen if the fillers are injected at a superficial level.

The dermal filler that you choose to have administered will depend on different factors. The different types of dermal fillers vary in terms of their composition, how long they last, ease with which they can be administered, risks associated with them, and their palpability. Hyaluronic acid products are currently considered to be the most versatile dermal fillers. Hyaluronic acid is a glycosaminoglycan that occurs naturally in the dermis, providing nutrients and support to the skin. Its presence slowly diminishes with age and exposure to the sun. Hyaluronic acid attracts moisture and thus adds volume and fullness to the skin.

different levels of dermal injection
Dermal fillers are injected at different levels in the skin, depending on the wrinkle and area treated.

By administering hyaluronic acid using injections facial wrinkles and lost volume can be corrected. However, it’s important that patients choose a skilled practitioner to administer the treatment because obtaining desirable results from dermal fillers is more difficult than getting an aesthetically pleasing appearance from Botox. Practitioners administering dermal fillers need to be highly skilled with an artistic eye to be able to achieve pleasing, symmetrical results.

Typically hyaluronic acid yields the most predictable results on the lower two-thirds of the face. The three most commonly treated areas include the nasolabial folds, oral commissures, and lip augmentation.  These three areas can be successfully treated using dermal fillers with the most predictable and desirable results.


Practitioners who are going to be administering dermal filler treatments will begin by preparing the patient, their tools, and their workspace. Patients are positions supine at about a 65-degree angle. The syringe is then prepared for the procedure.


When the procedure is ready to begin, the practitioner will place the needle at the bottom of the fold or wrinkle and insert it into the skin at about a 30-degree angle until it reaches the mid-dermis. The person administering the injection will be able to see the volumizing effects of the injection and feel resistance against the syringe plunger as it goes into the mid-dermal layers of the skin.

After the first injection, the practitioner will make a second injection about a centimeter above the last injection. The dermal filler is slowly injected into the fold or wrinkles as the needle is being withdrawn. Another injection is then applied and so on and so forth, slowly moving upward from the original injection whenever appropriate. The practitioner will probably complete one area of the face before moving on to other areas.

Dermal Injection of the Naso Labial Fold : Step 1Dermal Injection of the Naso Labial Fold : Step 2Dermal Injection of the Naso Labial Fold : Step 3aDermal Injection of the Naso Labial Fold : Step 3b

Injection Techniques

A couple of different injection techniques exist including linear threading and serial puncture. In linear threading, a continuous line of filler is injected while the syringe is slowly moved forward or backward under the skin from the injection site. Serial puncture, in contrast, is the injection of beads of filler under the skin along a wrinkle or a fold.

Your doctor will choose an injection technique that best suits your situation. Often, both injection techniques are used during treatment. Linear threading is often used for the overall treatment while serial puncture is used to touch up areas of the skin that still need more volume.

Dermal Filler: Linear threading technique
Linear threading technique


Dermal Filler: Serial puncture technique
Serial puncture technique


Dermal Filler: Cross hatching technique
Cross hatching technique (the filler is placed following perperdicular ‘linear threading’ lines)


Dermal Filler: Radial fanning technique
Radial fanning technique (the needle is redirected and the filler is placed following a radial pattern)



There are four main anesthesia techniques that are used during dermal filler treatments to remove any pain associated with the procedure without causing distortion to the target areas. Anesthesia helps to improve the overall results of treatment with dermal fillers as well as providing the patient with a better experience of the procedure.

The four anesthetic techniques used for dermal fillers include:

  • Regional nerve blocking-this type of anesthesia is most effective when used for lip treatments.
  • Local anesthesia with lidocaine-this type of anesthesia is used for nasolabial and oral commissure treatments.
  • Topical anesthesia-this type of anesthesia is also used for nasolabial and oral commissure treatments.
  • Ice-this type of anesthesia is effective when used by itself directly on the injection site or in tandem with other types of anesthesia.

Follow-up Treatment

Immediately after a dermal filler treatment, patients will be able to see a difference in the way they look. However, swelling may persist for 3 to 5 days after the initial treatment. Once the swelling subsides the treated area will have slightly less volume.

Different dermal filler injections produce effects that last for differing amounts of time. For example, Restylane and Juvederm Ultra Plus can last from 6 months to 1 year depending on the patient’s metabolism and the amount of movement that happens in the area that was treated. Most patients go in for a follow-up maintenance treatment at about 6 months or when the filler seems to be diminishing. Most patients require less dermal filler on the subsequent treatment than what was required at first.

Treated Areas

The areas of the face most commonly treated with dermal fillers are the nasolabial folds, perioral lines, and the lips. Other areas of the face, however, may also be treated effectively with fillers. For example, glabellar lines, scarring, and cheek enhancement are all possible using dermal fillers. Patients can have their jaws or chins contoured or treat marionette lines as well. There are so many different ways in which dermal fillers can be used to accomplish aesthetic goals that it’s impossible to include a complete list here. Instead, we’ll discuss the goals of the most popular treatment areas.

Target areas: Facial Dermal Fillers
Target areas of the face to be treated with dermal fillers and other rejuvenation injections

Lip Augmentation

Lip augmentation is done to provide patients with a fuller appearance to the lips. Usually, the bottom lip is injected to make it larger than the lower lip by a ratio of about 1:2. Anesthetic is required for this procedure. Doctors typically administer several nerve block injections to fully anesthetize the lip region during the procedure.

Lip augmentationVermillon fold

After a lip augmentation, the borders of your lip will be enhanced and perhaps the body of the lips may also be augmented, depending on the shape and original volume present. The vermillion border will probably be slightly everted as well.

Lower Face Folds (Oral Comissures and Marionette Lines)

The oral commissures are located at the corners of the mouth where the upper and lower lips meet. As people age, a loss of volume can cause this part of the mouth to take on a “downturned” appearance.
Marionette lines are related to the oral commissures in that they are skin folds in the lower face region that go down from the oral commissure toward the jaw. Oral commissures and marionette lines should be treated contemporaneously for best results.

Oral commissures

Dermal fillers can add lost volume to the lower face, thereby diminishing wrinkles that contribute to an aging look. Oral commissures and marionette lines are particularly noticeable as signs of aging and the use of dermal fillers can easily turn back the clock by 10 to 15 years.

Naso-labial Folds

Also known as “parentheses”, the nasolabial folds extend from the nose to the corners of the mouth. They are telltale signs of again. These folds can be quite noticeable and deep, but these deeper folds can, however, be softened substantially with dermal fillers. The doctor injects the dermal filler directly along the fold line to add volume and reduce the appearance of these wrinkles, creating a look of youth and radiance.

Naso labial fold