What are HA fillers?

“Most people are ideal candidates for HA fillers,” says Dr. Patrick Blake, MD, and Medical Director at Portrait. However, before seeking this treatment option, Dr. Blake advises that patients have clear expectations regarding treatment and outcomes. This includes the costs involved, maintenance, possible adverse reactions, and information on after-care treatment.

The loss of supporting bone mass and loss of collagen in the face are the main culprits of aging. This contributes to the hollowing and loss of volume seen with the normal aging process. There are many treatment options for people wanting to achieve a more youthful appearance.

For every adult, signs of aging such as sunken skin, especially around the eyes, are normal. For people who want to rejuvenate the skin for a smoother and much younger-looking appearance, certain options are available. “The mantra here should be to go light in the beginning,” says Dr. Blake, “you can always go back for more.”

Using injectables to enhance and rejuvenate appearance has become increasingly popular in the United States. Hyaluronic acid (HA)‐based dermal fillers are the most broadly utilized for facial volume restoration. First approved by the FDA in 2003, HA fillers have revolutionized the aesthetic industry. HA fillers are used to augment soft tissues primarily in the face to treat visible signs of aging.

Since the advent of cosmetic injectable neurotoxins known as botulinum toxic type A (BoNT-A), or Botox®, HA fillers have gained extensive popularity. The most widely used product in its category, HA filler represents approximately 48% of all dermal fillers used for facial volume restoration and enhancement.

HA fillers are a type of temporary dermal filler used to increase and restore soft-tissue volume in the face, which has visibly lost volume and elasticity through aging.

What do they do?

Much like the neurotoxins BoNT-A, HA fillers like Juvéderm® are used in significantly reducing the look of visible signs of sunken or sagging skin, particularly around the face to lift cheeks, smooth parentheses lines, or plump the lips. “You do have to be careful to prevent adverse outcomes, like around the mouth for example”, Dr. Blake added.

Hyaluronic acid is a naturally occurring substance called a biopolymer, which exists in soft tissues in the body, particularly the face. HA is highly hydrophilic, meaning it attracts water. The chemical composition of HA filler makes it highly effective in increasing the volume of soft tissues to achieve looking youthful skin.

During a procedure, when the filler is injected under the skin, the hyaluronic acid works by attracting water to it, forming a swelling pressure that allows the HA to withstand compression. That water causes the skin to plump, pushing out fine lines, wrinkles, and folds, creating a firmer look.

“If it is a new patient, it is advisable to counsel them on some possible adverse effects”, adds Dr. Blake.

What are the different lines of HA fillers?

A variety of fillers are approved for use in the United States. Dr. Blake explains that some of the main differentiators for HA fillers are based on their elasticity and support, in terms of the source of HA, the concentration of HA in each syringe, and even the particulate size of the HA. “The filler with a larger particle size and a higher degree of crosslinking will typically give more support,” he explained. Dense fillers are utilized in the cheeks, jawline, and chin. On the other hand, “because of the larger particle size, if laced superficially, it may end up not looking natural”.

Additionally, “the fillers with the most HA concentrations have the most swelling but also pull in the most water to add volume to the skin”, explains Dr. Blake.

The following are different lines of HA fillers available to the US market.

• Restylane®: This line of fillers was FDA approved for use in December 2003 and is manufactured by Galderma Aesthetics. The most common areas include the lips for lip augmentation, cheeks, and glabellar creases to reduce wrinkles. This creates a more youthful appearance, lasting between 6 to 12 months.
• Juvéderm®: A variety of formulations of Juvéderm® are available in the US. They were FDA approved for use in June 2006. Results, like with Restylane®, last between 6 to 12 months.
• Versa®: Revanesse® Versa, or “Versa” for short, is a dermal filler, FDA approved, and most commonly injected in the lips, nasolabial folds, and cheeks. It is similar in composition and uses to Restylane® and Juvederm® fillers.
• RHA®: The RHA® is considered a newer version of the other fillers such as Juvéderm® and Restylane®. The RHA composition most resembles the natural production in the body and produces a smooth, natural result.

What are they used for?

The most popular use for HA fillers is for cosmetic procedures. They are used to boost volume and create shape for a more youthful appearance. HA fillers are known to improve signs of wrinkles and increase the elasticity of the skin, which has been the focus of this article.

HA fillers have also been used for a variety of other purposes throughout the years. They have been historically used to treat and improve pain and function among patients, especially in patients with osteoarthritis (OA) in their knees. HA fillers have been used to restore and improve pain, activity levels, and function in those areas. Before that, HA fillers had also been used in ophthalmology during cataract surgery.  

What is a treatment like?

HA fillers are delivered using a syringe. Before the procedure, patients are normally advised on foods and practices to avoid such as excessive alcohol, taking certain medications like blood thinners, or having any other facial procedures close to the treatment time.

The whole procedure is relatively short, between 15 to 30 minutes. Following treatment, most people go directly back to their usual daily activities.

Potential side effects and risks:

The fact that HA exhibits no tissue or species specificity is crucially important to minimize any problematic effects. Side effects for patients that are typical of fillers may include swelling and redness, mild reactions around the injection site, and mild pain during injection.

High-risk zones:

Adding to the side effects, Dr. Blake explains that there are potentially high risk zones practitioners may have to pay attention to. “Anytime you’re injecting into an area that is considered high risk,” says Dr. Blake, “it is advisable to use different strategies to be sure you’re minimizing risks across the nose, temples, or mouth.”

Cost:

The cost of treatment is dependent on where the treatment is available and the specific patient needs that are recognized. For people looking to use HA fillers, Dr. Blake says, “the costs are a pretty broad range.” Depending on the specific need and availability, the cost of treatment starts around $700. However, “the costs can go lower or higher depending on other factors such as age, type of filler, particulate size of the filler, etc.,” he added.

Who can administer them:

It is advisable to seek treatment from an experienced aesthetic injector with years of experience and continued education. Though eligibility to administer HA fillers varies state by state, they can typically only be administered by a board-certified registered nurse, nurse practitioner, physician assistant, or physician.

Who should get them: “Most people are ideal candidates for neurotoxins like HA fillers,” says Dr. Blake.

Who should not get them: Like other fillers and neurotoxins, women who are breastfeeding or pregnant are not ideal candidates for HA fillers. Patients with allergic reactions to neurotoxins may also not be ideal candidates. Regardless, Dr. Blake advises anyone seeking this specific treatment to consult with their physician or care provider prior to the procedure.

The self-injecting HA fillers:

While these may be available on the market, researchers and medical professionals warn against the practice. From researchers Rauso et al, this is not advisable, stating in their study, “please don’t try to inject yourself with facial fillers - it is extremely dangerous! […] Without knowing the anatomy of facial muscles, nerves, and blood vessels you could cause irreversible facial paralysis, blindness, and tissue necrosis”. These are risks Dr. Blake echoes, adding that the nose, mouth, and temple areas can be problematic without the proper training in anatomy.

For people who are looking to use HA fillers, the word is to consult with a practitioner, making sure you know the risks, costs, and treatment options in detail. The effects can be altered to meet specific needs of the patient, another reason Dr. Blake advises practitioners and patients to start slow and adjust as needed.

These HA filler procedures, although not permanent, can give a lasting aesthetic impression and boost confidence while reducing the visible looks of wrinkles.

Sources:

1. Aggarwal A, Sempowski IP. Hyaluronic acid injections for knee osteoarthritis. Systematic review of the literature. Canadian Family Physician. 2004 Feb 1;50(2):249-56.
2. Ahmet Tezel & Glenn H. Fredrickson (2008) The science of hyaluronic acid dermal fillers, Journal of Cosmetic and Laser Therapy, 10:1, 35-42, DOI: 10.1080/14764170701774901
3. Gold MH. Use of hyaluronic acid fillers for the treatment of the aging face. Clinical interventions in aging. 2007 Sep;2(3):369.
4. Lee W. Hyaluronic Acid Filler Property and Hyaluronidase. InSafe Filler Injection Techniques 2022 (pp. 11-17). Springer, Singapore.
5. Rauso R, Nicoletti GF, Zerbinati N, Lo Giudice G, Fragola R, Tartaro G. Complications Following Self-Administration of Hyaluronic Acid Fillers: Literature Review. Clin Cosmet Investig Dermatol. 2020 Oct 14;13:767-771. doi: 10.2147/CCID.S276959. PMID: 33116740; PMCID: PMC7569170.
6. Sundaram H, Shamban A, Schlessinger J, Kaufman-Janette J, Joseph JH, Lupin M, Draelos Z, Carey W, Smith S, Eaton L. Efficacy and Safety of a New Resilient Hyaluronic Acid Filler in the Correction of Moderate-to-Severe Dynamic Perioral Rhytides: A 52-Week Prospective, Multicenter, Controlled, Randomized, Evaluator-Blinded Study. Dermatol Surg. 2022 Jan 1;48(1):87-93. doi: 10.1097/DSS.0000000000003238. PMID: 34608092; PMCID: PMC8667798.

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