Based on longevity: Temporary, Semipermanent, Permanent, Based on site of placement  Dermal Subdermal Supraperiosteal Based on origin of filler material  Heterografts: (a) Bovine collagen-(1) zyderm 1 and 2 (2)zyplast (3)restoplast (4)artecoll (b) Hyaluronic acid derivative implant-(1) restylane (2) perlane (3) hylaform (4)dermalive (5)reviderm intra (c) Porcine collagen- (1) permacol (2) fibrel Allografts : human derived collagen (a) dermalogen (b) alloderm (c) cosmoderm Autograft: (a) autologous fat (b) autologous collagen Synthetic material: (a) polytetrafluoroethylene (b) silicone (c) biopolymer 3 (d) bioplastique

1. Moderator
Dr Amit Malhotra

2. INTRODUCTION
 Dermal fillers are substances used in soft tissue
augmentation to enhance or replace volume that is lost
in any part of the skin or subcutaneous fat.
 Fillers form an effective tool in rejuvenation, either as
a stand-alone treatment or in combination with other
procedures such as Laser resurfacing or botulinum
toxin.

3. CLASSIFICATION
 Fillers can be classified based on different criteria:
1) Based on longevity:
Temporary-Temporary fillers are also referred to as
nonpermanent fillers.
 Their stay in the tissue is for less than 12 months and
hence, they have the advantage of spontaneously
disappearing if the patient is not satisfied with the
results.
 Similarly, an adverse event with such fillers is also a
temporary one, as seen in the majority of the cases.

4. Some of the common temporary fillers available in India are
described here:
Bovine collagen-based products
 Zyderm 1
 Zyderm 2
 Zyplast
Human tissue-derived collagen
 Cosmoderm
 Cosmoplast
Synthetic fillers: Hyaluronic acid-based fillers
 A wide range of hyaluronic acid products is available with
varying hyaluronic acid concentrations and cross-linking
structure .

5.  Semipermanent- these fillers undergo slow
degradation with time over a period of 1–2 years. Side
effects with semipermanent fillers are more common
and longer lasting than temporary fillers.
 Permanent – these are the fillers that remain for
longer than two years in the tissue. Side effects with
permanent fillers tend to be more permanent, and
complication is the main issue with any permanent
filler.

7. 2) Based on site of placement
 Dermal
 Subdermal
 Supraperiosteal

9. 3) Based on origin of filler material
 Heterografts:
(a) Bovine collagen-(1) zyderm 1 and 2
(2)zyplast
(3)restoplast
(4)artecoll
(b) Hyaluronic acid derivative implant-(1) restylane
(2) perlane
(3) hylaform
(4)dermalive
(5)reviderm intra
(c) Porcine collagen- (1) permacol
(2) fibrel

10.  Allografts : human derived collagen
(a) dermalogen
(b) alloderm
(c) cosmoderm
 Autograft: (a) autologous fat
(b) autologous collagen
 Synthetic material: (a) polytetrafluoroethylene
(b) silicone
(c) biopolymer 3
(d) bioplastique

12. IDEAL DERMAL FILLER

13. INDICATIONS





Facial lines (wrinkles, folds)
Lip enhancement
Facial deformities
Depressed scars(a)post surgical
(b)traumatic
(c) resulting from acne and other diseases
 Breast, buttock augmentation
 Periocular melanoses, sunken eyes
 Dermatological diseases-angular cheilitis, scleroderma,
AIDS lipoatrophy

15. CONTRAINDICATIONS
1.
2.
3.
4.
5.
6.
Positive skin testing
Patient with autoimmune diseases
History of serious anaphylactic reaction in past
Active local disease like acne
Keloidal tendency
Unrealistic expectations

16. CONDITIONS REQUIRING
CAUTIONS
History of facial herpes simplex.
2. History of atopy.
3. History of bleeding disorder or use of anticoagulants.
4. Current or long term use of immunosuppressive
therapy.
1.

17. Preoperative Preparation
 History taking should include history of medications





used, history of allergies, e.g ., the chances of bruising
might increase in a patient on anticoagulant therapy.
Clinical examination, particularly of the area being
injected.
Skin test should be done if heterograft implants are
used.
Counseling .
Preoperative photograpy is preferable.
Informed consent should be taken.

18. SKIN TEST
 It is done in two steps 6 and 2 week prior to treatment.
 Bovine collagen 0.1ml and porcine collagen .05 ml
(diluted in normal saline) is injected intradermally on
the flexor aspect of forearm.
 A positive skin test develops as early as 6 to 48 hrs or 4
wk after the test dose .
 There is erythema , puritis or prolonged induration
that is for more than 4 days.

19.  Inspite of negative skin test ,there is a 1.2 to 6.3 %
chance of hypersensitive ,hence a second skin test after
4 wks is advised .
 If there is no sign of positivity after 2 wk of second test,
bovine /porcine collagen implants can be given with
minimal risk of allergy.

20. INTRAOPERATIVE PROCEDURE
Surgical preparation of the part.
Topical anaesthetics like EMLA or prilox can be used 1-2
hr before injection.
3. Local anaesthesia required in upper lip and in
uncooperative patient.
4. Patient is to be treated under proper lighting in semi
reclining or upright position for the gravity to maximize
wrinkles.
5. All dermal fillers come with prefilled syringes and desired
gauge needle (26-32G) depending on the particle size. the
needle should be screwed carefully on to the syringe to
avoid waste of material.
1.
2.

21. 6. The syringe should be levered over thumb of non
operating hand for proper angle and depth of
injection.
7. 15 degree angle for superficial and 45 degree for
deeper dermal implants are maintained.
8. Needle is inserted with bevelled surface facing
upwards.
9. Blanching should be avoided.
10. The requisite depth of injection depends upon the
nature of material used.
.

22. 11. The material is injected in serial puncture ,linear
threading ,fan or cross hatching technique.
12. The defect fills up immediately.
13. Over correction is recommended only for lip
augmentation.
14. Stop injection prior to withdrawal of needle to
avoid unnecessary spillage.
15. Treated area is massaged lightly to mould the
material appropriately and avoid lump formation.

23. 16. Maximum of 2 ml of filter per treatment session is
indicated.
17. Care should be taken to avoid injecting into a blood
vessel.
18. If needle gets blocked the pressure on the piston
should not be increased rather injection should be
stopped and needle replaced.
19. Repeat injection for correction should only be
administered after 2-4 wk when inflammation
subsides totally.

24. INJECTION TECHNIQUES
(1) LINEAR THREADING TECHNIQUES-
Full length of the needle is inserted into the defect
and the implant is injected while pulling the needle
slowly backwards so that the material is placed
lengthwise in the wrinkle.

26. (2) SERIAL PUNTURE TECHNIQUEMultiple injections are placed serially along the length
of the treated area so that it merges into a continuous
line which lifts the wrinkle.

28. (3) FAN TECHNIQUEAfter injecting one line of implant by the linear
threading technique the direction of the needle is
changed and injected as before along a new line.

30. (4) CROSS HATCHING TECHNIQUE
linear threading technique is used at the periphery of
the defect .then the needle is withdrawn from the skin
and inserted 5-10mm adjacent to the first site of
injection and procedure is repeated.
This method is then carried out at right angles to the
original line.

32. POST PROCEDURE INSTRUCTIONS
 Avoid exposure to extreme cold or heat
 Avoid massaging treated areas for six hours
 Avoid strenuous physical activity for six hours
 Sleep with the head elevated for one night
 Pain medication can be taken if needed
 Resume skin care products such as retinoids, alpha
hydroxy acids the day after the procedure.

33.  Chemical peels ,laser treatment should be spaced out
at least 2wks to avoid inflammation of injection site.
 Repeat injections are spaced after 3-6 months or longer
depending upon the longevity of the material ,site of
injection and the technique used.

38. Combination technique
 Combining two fillers of different particle size or other
materials for enhanced cosmesis.
1. Sandwich method: is a layered technique using zyplast
in deeper dermis and zyderm above it in mid or upper
dermis.
2. Botox and fillers: botulinum toxin injected 1 wk prior to
dermal fillers gives a synergestic effect. Botox reduces
the amount of implant for augmentation and also helps
to increase the duration of the fillers in the treated area
by reducing supposed muscle atrophy and prevent
immediate microextrusion from injection sites by
repetitive muscular action.

39. Complications
Immediate complications
 Pain
 Bruising
 Erythema
 Asymmetry, bumpiness, lumpiness
 Anaphylaxis
 Edema
 Acneiform eruptions
 Infections – reactivation of herpes simplex

40. Late complication










Inflammatory nodule
Tyndall effect
Allergic reactions
Vascular occlusion
Granulomas
Implant migration
Telangiectasia
Lipoatrophy
Hypertrophic scarring
Sterile abscess

41. Advantages of dermal fillers
1.
2.
3.
4.
5.
Instant results .no down time.
Easy technique compared to other procedures for
scar or wrinkle correction i.e punch excision ,punch
graft replacement etc.
Does not require special surgical expertise.
Simple , OPD procedure.
Large area /multiple lesions covered at one sitting.

42. Disadvantages of dermal fillers
It is short lasting hence has to be repeated once in a
year.
2. Costly treatment.
3. Not manufactured in india.
4. Chances of adverse reactions.
1.

43. CONCLUSION
 In a short span of time, fillers have come to play an
important role in the nonsurgical management of
ageing skin.
 The technique is a safe, simple and effective modality,
when used by a properly trained physician.
 Proper knowledge of the anatomy of the area of
injection, aesthetic sense and proper patient selection
are essential.

44.  Fillers can also be combined with other aesthetic
treatments such as Botox, microdermabrasion, peels,
thread-lifts, and Laser resurfacing.
 As in all aesthetic techniques, proper patient
counseling with respect to achievable results is
important.

45. THANKS