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This interview appeared in New You magazine:

Q: What are the different kinds of fillers available?
Ans: There are almost 25 types of fillers available in the market, some approved in UAE some not approved. These can basically be classified into 3 types: temporary, semi-permanent [long lasting temporary] and permanent. The temporary ones either are digested by the body and absorbed or broken down by the body and removed via urine. The permanent ones stay in the body.

Temporary: this is the commonest class of fillers in clinical use. Chief among them is Hyaluronic Acid otherwise called HA. This is naturally present in the body tissues and acts as a cement between cells. It is part of what is called intercellular matrix. HA is now synthetically manufactured by biotechnology and used to make filler gels. Rarely it is also extracted from cock’s comb [the red tuft on a rooster's head]. The biotech HA is called NASHA [short for non-animal stabilized HA].

Normally HA is degraded quickly by the body so it does not long. Manufacturers of gels overcome this problem but the HA in filler gels by ‘cross-linking’ of the molecule. This slows down the digestion and allows the gel to stay longer in the tissues after injection.

Semi-permanent: In this category there are fillers like Remake and Aquamid. These are broken down slowly in the body and excreted in urine. They tend to stay for 2-3 years or longer. They are completely synthetic and therefore foreign to the body but are well tolerated.

Permanent: In this group we have Dermadep, Dermlive, Polyacrilamide, Silicone and so on. This group is tricky. If all goes well and remains well then they are good. But if problems happen then they are a misery. Solving complications is very difficult and can lead to disfigurement. They have a place in treatment but in highly selected cases.

Q: What do fillers do essentially?
Ans: Body and especially facial tissues lose volume over time due to ageing/excessive sun damage, bad lifestyle including smoking. The skin appears wrinkled and sags. By restoring volume the overlying skin can be made to appear tighter and less wrinkled. Filler gels provide volume and filling effect. Hyaluronic acid gels also act as an internal moisture banks thus improving tissue hydration. The skin thus becomes thicker and more vitalized.

Fillers need to be injected precisely in specific planes under the skin. Each filler is designed to be injected in a specific layer. Knowledge of anatomy is essential to inject the gels correctly. For example some HA gels need to be within the mid or deep layers of skin while some other gels should not be injected into the skin layer, rather they should be deep to skin. So matching the correct indication and the right gel to the correct level of injection is essential to success.

Fillers and Botulinum toxin injections [BT] are often confused by public. Fillers fill and BT paralyses muscles, so the two are entirely different. As a rule of thumb BT is not used much in lower face while fillers are extensively used in cheeks/lips. Another fact worth remembering is that if wrinkles are seen only on movements or expression [dynamic wrinkles], then BT injection can soften these lines by weakening the muscle pull. But if the lines are deep enough to be present at all times [static lines] then it needs fillers to fill out the “cracks” in the skin. In summary, the fillers can give increased volume and also fill out deep crease lines.

Q: Are they safe and what are they made from?
Ans:HA fillers are the safest of the lot. The other fillers are made of different synthetic chemicals that are not present in human body. Generally these are inert and the body accepts them. However on this point there is a lot of individual variation both with different fillers and with different clients. For example some individuals may have a bad reaction and form lumps while others may tolerate the same filler without any lumps or reaction. This is not like allergy that can be checked by test injection so there is no fool-proof way of knowing if there will be a granuloma reaction in these fillers. Among the non-HA fillers here are some which seem to have better acceptance than others i.e the chances of having a reaction are very rare. These are now also being used more often. Others that had a high incidence of reaction are going out of the market. This is especially true of permanent gels which most doctors have stopped using. Polyethileneglycol [PEG]based gels seem to be safe going by my personal observations and going by remarks from other users.

Q: How are they put into the body/face?
Ans:They are put in by injections using syringe and needles. Usually they come pre-packaged with syringe and needle. Usual volume is 1cc per syringe. If larger volumes are needed, then multiple syringes are used and the cost goes up. Some fillers used in the body for buttock filling come in small bottles in larger volumes.

Q: Tell us the technique in detail including any aesthetic, duration, risks, down time, how long it takes to see results and how long the material stays in the body.
Good precautions and correct technique are very important to get safe results from fillers. It is not uncommon to see injections done by untrained persons [even non-medical persons] ending in infective complications for the client. Fillers are foreign materials to the body and so due care must be taken with sterile precautions. I usually use local anesthetic nerve blocks or cream but there are others who do it without using any anesthesia. If done with aneshtetic, the procedure can be painless [except the initial injection of anesthetic drug]. The procedure may take from 15 minutes to an hour depending on the extent of work. The result is seen immediately but after 3 days it looks even better.

The client can go back to work an hour after the procedure. Most do not bruise after the procedure but some persons develop a bruise or redness, this may last 3 days. Cooling the area with cold packs before and after filling helps to reduce bruise. Mild pain or burning sensation or numbness may be experienced for a few days. In the absence of bruise there is no downtime but if bruise occurs there may be 3-5 days social down time;so it is best not to have social engagements for that period. If there are minor areas of irregularity or unevenness or asymmetry, a firm massage will help to improve the gel distribution to make it more uniform. This is best done by the medical practitioner who did it.

The length of time a filler lasts is different for different classes of compounds, the manufacturers usually give that information. For example HA products last 6 to 12 months. Even the same gel lasts differently in deferent parts of the face;it lasts longer in less mobile areas like forehead and for shorter time in mobile areas like the lip. There is difference between individuals, some have strong enzymes that break down the HA in a shorter time. PEG based gels last 2 years. Bio-”alkamid has been approved for lipoatrophy especially in HIV positive patients and it may last 3 years. Aquamid lasts 3-5 years. Permanet fillers last several years.

Q: What is the difference between semi-permanent and non-permanent fillers?
Ans: Answered above. Permanent fillers use materias that the body cannot break down so it lasts a long time. If there are any aesthetic problems or reactions, unfortunately they tend to be permanent headaches.

Q:How do they get absorbed?
Ans: Either by enzymatic digestion or by non-enzymatic breakdown of the molecule into smaller molecules which are then excreted by the body usually in urine.

Q: Can a person get cancer from fillers?
Ans: Among the approved fillers there is no cancer risk. However, client s should be careful what is being put into their face since there are unfortunately many quacks who are injecting dubious products. These may have a host of issues and have not gone through stringent process of control.

Q: How often do they need to be repeated?
Ans: Temporary fillers may need a top-up or fine tuning after a month to get optimum cosmetic results, most persons do not return for this as they are happy with the amount injected first time. After a variable period,depending on the life of the gel, the procedure needs to be repeated. Over a period of time some residual benefit remains due to the body forming more collagen to fill the areas.

Q: Which is the gold standard filler in the market and why?
Ans: Asgiven above, HA based fillers are the commonest used products in spite of their short life. Under this we have several competitors such as Restylene, Teosyal, Visagel, Juvederm etc. PEG based gel likeRemakeis gaining popularity. Others in use includeBio-alkamid, Bio-in-blueand Argiform. Silicone oil is not indicated for use but it is still being used illegally. Some others like Polyacrilamide gelare also popular with some doctors especially for body applications. Very recently a gel based on HA has been introduced for small breast enhancements but this cannot yet compete with breast implants which remain the gold standard. Yet this gel [called Macrolane] offers an alternative to women who want only small enhancements. The effect is however temporary.

On a completely different front there is an exciting new silicone lip implant called Permalip available;this is not a silicone oil or gel but a lip implant made of solid soft silicone elastomer. This is implanted into the lip through a mini-cut to give permanent enhancement and volume to the lips. If for any reason the woman wishes to get it removed, removal is easy.

Q: Are there any alternatives to filler injections for enhancing volume in lips/face/hand?
Ans:Fat is the best filler. Fat grafts are a superior alternative to inert fillers. The advantage is unlimited volume and the fact that it is a living permanent filler. The disadvantage is the inconvenience and cost of doing a procedure that takes about 5 days of recovery time.