What is the best dermal filler? September 2009 UPDATE

Dear Readers

A golden rule of blogging, especially for blogs such as this survey blog which I wrote about 1 year ago, is that you have to update them from time to time. This couldn’t be more true for this specific blog, especially because my opinions on what indeed is the best dermal filler have changed somewhat! What a difference a year makes! And I have to tell you many things have changed in our lives in the last year, not least the birth of my son almost exactly a year ago, but then there was a blog about that too!

I feel like an ageing footballer updating his autobiography..

What has changed? Well read on and see if you can spot the differences.. (the older version of this blog post is on https://www.miloclinic.com/blog/?p=22 if you want to compare and contrast). As a preview, my top five are definitely not the same as 1 year ago, and there has been one significant move up the charts….Can you guess?  All that I will say is that in my opinion, hyaluronic acid fillers are still the best , and restylane and juvederm ultra are the coca cola and pepsi cola of the dermal filler world. Very similar and both very good. Here’s the new UPDATED blog:

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–8/10In 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–9/10 In the last few months Q-med have come up with Restylane Lidocaine and Perlane Lidocaine, which have local anaesthetic already pre added making this an almost painless procedure.. Procedures such as tear trough have suddenly become so much more comfortable for the patient. For procedures such as lip enhancement, dental block may still be necessary, but these new fillers are revolutionary.

SYRINGE DESIGN/EASY TO USE?–9/10Again 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,Reatylane Lidocaine, Perlane Lidocaine, Restylane Lipp, Restylane Touch, Restylane Vital light, Restylane Sub-Q, and now the big brother Macrolane, Q-med have the most varied and most relevant range.This range is also one of  the only ones 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 light, 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 89/100

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JUVEDERM ULTRA

RESULTS–7/10–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 many 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 slightly less accurate,  and while injecting it,  it sometimes does not stay where we place it, unlike Restylane which stays put. I also used to think that it was not as good as the Q-med fillers for volume replacement and contouring, but with the relatively recent advent of Voluma, these Allergan fillers are hot on the heels of their Q-med counterparts.

DURABILITY–7/10–The results of the Juvederm family should last up to 12 months, but in my experience these fillers do not last quite as long as their biggest rivals, the restylane family.

CLINICAL EVIDENCE–7/10Corneal 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–8/10–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.

PAIN–9/10–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 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?–8/10– For those of you who read my original blog on dermal fillers, this is one of the biggest differences you will notice. (I think the old mark was 4/10!). The juvederm ultra syringes are now almost as good as the restylane ones, and are very easy to use. Restylane still has the edge, but it’s a close one!

VALUE FOR MONEY–6/10–This is the only section where I am giving juvederm a lower mark comapred to last time. The allergan fillers used to be much cheaper than their restylane counterparts, but having spent so much money on reserach and marketing, these fillers can now be even more expensive than their rivals.

POPULARITY–8/10–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, and even during X-factor advert breaks. The popularity of these fillers is increasing.

RANGE–7/10–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. The addition of Voluma for facial contouring has made this range even better. My big bug bear here used to be that in the same family of allergan fillers we have also had Hydrafill 1, 2 and 3, and also Hydrafill Softline and Softline Max, oh yes and Juvederm 18, 24 & 30. And why would such a wide range be a bad thing? Well all of the fillers I have listed are all variations on pretty much the same filler, so really quite confusing!  Having said that, most of the aforementioned fillers apart from the juvederm ultra range, are fast becoming obsolete, therefore clearing up the confusion from the past. However,there are still no specific lip fillers , rejuvenating fillers or indeed any product for breast enlargement such as macrolane.

VERSATILITY–8/10–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.

TOTAL 75/100

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SCULPTRA

RESULTS–5/10–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 are very good indeed, earning in it’s media nickname of “the liquid facelift”. For filling large depressions and for facial contouring this is arguably one of the best, 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! My big problem with Sculptra is , that you are somehwat in the “lap of the Gods”, in that you are not seeing instant results, but are relying on the body’s own ability to produce collagen in order to get good and accurate results. With hyaluronic acids, you are a lot more specific and accurate with you treatment.

DURABILITY–9/10–According to reserach and and from our experience,  results can last as long as 3 years. Having said that, is that a good thing? If you don’t like the results, you have to wait for much longer for them to go away..

CLINICAL EVIDENCE–6/10–There has been some very good and very valid clinical evidence backing up the efiicacy and safety of this product. However, a lot more is needed.

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?–5/10– 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–6/10–Popularity of sculptra has been increasing, although I have noticed a slight levelling off recently.

RANGE–7/10–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. The perfect patient is one over 40 or 50, with a lot of lines , wrinkles, folds and loose hanging skin, who may need far too much botox and dermal fillers, and sculptra can achieve some good results, but a lot more cheaply.

TOTAL 67/100

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RADIESSE

RESULTS–6/10–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 there have been some good reports on results achieved. For me however, the jury is still out!

 DURABILITY–7/10–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–6/10–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?–7/10– 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–6/10–Taking into account the relatively good 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 potentially good filler , and definitely one that any good cosmetic doctor should consider. 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. I am prudently going to keep an eye out for this potentially good “tool in the box”, but for now not my cup of tea..

TOTAL 61/100

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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–5/10–Pain levels are minimal, just like the other hyaluronic acid fillers, but unlike it’s hyaluronic filler counterparts, still no pre-added lidocaine, hence the mark down since the last blog on this.

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 62/100

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So the winners list:

1. RESTYLANE 89/100    Still the gold standard! The longest track record, the best results. The king filler! Coca Cola!

2.JUVEDERM  75/100      The biggest chart climber! I like it more and more! The queen filler! Pepsi Cola!

3.SCULPTRA  67/100      Dropped down to bronze! Still brilliant at times, 3 year longevity, the liquid face-lift!

4.TEOSYAL   62/100      Off the bottom!  A decent filler, tough competition! Room to improve…

5.RADIESSE  61/100       The new kid on the block. Tougher, longer lasting! Still has to prove itself!

20, September, 2009Dr Milo Blogs