You ask – we answer: Questions and answers about fillers

Die Faltenunterspritzung mit Filler – Füllmaterialien – gilt als eine der bewährtesten und sichersten Methoden, vorhandene Falten zu glätten und das Gesicht zu verjüngen. Ein bewährter Filler ist die Hyaluronsäure, ein natürliches Molekül, das im Körper zwischen den Zellen als Füllmaterial existiert. In geringen Mengen unter bestehende Gesichtsfalten injiziert können so bereits vorhandene Falten unterpolstert und geglättet werden. Besonders wirksam sind Filleranwendungen im Bereich zwischen Nase und Mundwinkeln, an den Lippen, den Schläfen, den Kieferwinkeln und den Wangen.

Entscheiden Sie sich für eine Faltenunterspritzung mit Filler:

  • endlich wieder jünger aussehen
  • ganzes Erscheinungsbild zum positiven verändern
  • sich in der eigenen Haut wohlzufühlen

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1 Sunken temples 2 A-frame deformity 3 Bridge of nose
4 Eye circles (tear trough) 5 Cheek contour 6 Earlobe wrinkles 7 Wrinkle between nose and mouth (nasolabial fold)
8 Drooping corners of mouth 9 Marionette fold 10 Sunken cheeks (submalar hollow) 11 Jaw contour (Jaw line)
12 Lip enlargement 13 Flying chin 14 Retraction at the lower jaw margin between chin and sagging cheeks (prejowl sulcus)

Below you will find the most frequently asked questions and answers about filler injections.

Filler (Hyaluron)

The injection of wrinkles with tissue fillers (synonym: “filler”) serves to improve the external appearance without surgery. Fillers can be injected without downtime to correct wrinkles and increase volume.

Today’s injectable techniques are based on decades of research and experience. Volume augmentation with the grafting of autologous fat tissue from the upper arm to the face was performed in the 19th century described [1]. Injection with a filler product to build up facial contours was introduced at the beginning of the 20th century undertaken [2].

Only with the production of safe and effective fillers did tissue injection become one of the most common forms of treatment in plastic surgery. Hyaluronic acid as a tissue filler (Zyderm I) was first approved by the American health authority FDA in 1981 (Ozgentaş H.E., et al, 1994, Ann Plast Surg). The number of filler treatments has more than doubled worldwide from 2010 to 2018. In 2018, an estimated 3.8 million treatments were performed worldwide (ISAPS Global Statistics).

When do you experience the effects of hyaluronic acid?

Immediately after an injection with hyaluronic acid, wrinkles are smoothed and facial contours are rejuvenated. In the first five to seven days, the distribution and water binding of the hyaluronic acid change slightly. We therefore offer our patients an appointment two weeks after the injection to achieve the very best result. If necessary, a touch-up can then be carried out at your premises.

The loss of moisture in the skin with age is due to the reduced production of hyaluronic acid. Certain hyaluronic acid preparations are injected to improve skin hydration, elasticity and firmness. These effects appear after four to six weeks.

How long does a hyaluron injection last?

The breakdown of the injected hyaluronic acid depends on the following parameters:

  • the concentration of hyaluronic acid,
  • the size of the hyaluronic acid molecules,
  • the treated body region,
  • the amount of hyaluronic acid injected,
  • the metabolism of the respective person and
  • the degree and type of cross-linking of hyaluronic acid.

The effect of hyaluron treatments only lasts for a limited time depending on the hyaluron preparation used. The range can be from three to twenty-four months for hyaluronic preparations commonly used in the face [3]. The results of hyaluronic acid injections of the cheeks or tear troughs are more long-lasting than treatment of the wrinkle between the nose and mouth (nasolabial fold) [4]. Please feel free to make an appointment for a personal consultation to find out what your individual case will look like for the treatment you require.

Lipofilling with autologous fat: this is how it is done

Lipofilling is an interesting alternative to the use of hyaluronic acid. On the one hand, the use of the body’s own material is a less risky method – there is no danger of nodulation, rejection or allergic reactions. On the other hand, the fat can be taken from places on you where it bothers anyway.

Clear advantages result from the fact that the living fat tissue contains different cell types – for example stem cells, which have a regenerative effect and can thus improve the appearance of the skin beyond pure filling. Since the cells grow in large numbers at the transplant site, the beautifying effect of lipofilling usually lasts much longer; post-injection as with hyaluron is usually not necessary.

What costs me a filler treatment?

You can find out the costs of a hyaluronic acid injection on our costs page. The prices include a syringe of hyaluronic acid at cost price. If a larger amount of hyaluronic acid is needed, the cost will increase by the required out-of-pocket expenses and the additional labor.

Is the wrinkle injection painful?

With every treatment, whether surgical or non-invasive, we take care of your relaxation and well-being in a variety of ways. The following measures contribute to your painless hyaluron injections:

  • So that the insertion of the cannula does not cause no pain, an anesthetic cream is applied before the treatment.
  • If you have there is no allergy, mixing the hyaluronic acid with a local anesthetic prevents the development of pain.
  • Some background music distracts from the pain and promotes relaxation.
  • To reduce the sensation of pain, we apply on you the vibration anesthesia. Using a small handpiece (NüeVibe™), vibrations are applied to the treated Skin region transferred. A vibrating metal rod interrupts the transmission of the pain sensation.
  • The finest cannulas are used for the injection of wrinkles and lip injections. The puncture of these special cannulas is particularly gentle and is usually hardly noticed.

What types of tissue fillers are there?

There are basically 4 categories of tissue fillers:

  • Hyaluronic acid tissue fillers (for example Juvéderm® Volbella, Volift, Voluma; Defyne, Kysse, Skinboosters) consist of naturally occurring glycosaminoglycans. Typically, the results of hyaluronic acid supplements last between six months to two years. A key advantage of hyaluronic acid tissue fillers is that they can be rapidly degraded with an enzyme (Hylase©) if needed.
  • Calcium hydroxyapatite tissue fillers (for example Radiesse®) are degraded by the natural metabolism after about 12 to 18 months. They are characterized by a high viscosity. Radiesse® is suitable for the treatment of deep wrinkles and sagging facial contours.
  • Lactic acid tissue fillers stimulate the production of new collagen, which leads to more volume. It therefore takes about 6 months until the final result is visible.
  • Hyaluronic acid tissue fillers (e.g. Juvéderm® Volbella, Volift, Voluma; Restylane® Volyme, Defyne, Kysse, Skinboosters) consist of naturally occurring glycosaminoglycans.

Are fillers medical devices or pharmaceutical products?

Fillers are classified as medical products, such as dressing materials or visual aids. Hyaluronic acid preparations for injections are not subject to the strict drug law. The CE marking for medical products provides for a compatibility check. The approval as a medicinal product is much stricter. It includes, for example, proof of efficacy and safety in meaningful clinical studies. These studies require considerable financial resources as well as extensive human and material resources. Recognised and established companies find it easier to raise these funds.

Who gets to inject Filler?

In principle, licensed doctors and alternative practitioners are allowed to inject hyaluronic acid. For a good result not only the quality of the hyaluronic acid is important, but also the skills and knowledge of the user. The following information should help you to decide who to trust:

  • As before any medical treatment, a consultation and an examination are required to determine the exact findings. Making a diagnosis in the field of plastic and aesthetic surgery requires appropriate training and professional experience.
  • Often the combination of different procedures leads to the best possible result (for example microneedling, therapy with own blood, muscle relaxant). In some cases, completely different treatment techniques are required (for example, autologous fat injection, tightening operations, silicone implants). Knowledge and experience of these techniques are important in order to be able to advise you correctly.
  • Scientific training and constant updating of knowledge are necessary for a careful consideration of different medical treatment methods.
  • A forward-looking treatment plan is a basic prerequisite for a successful result. To do this, the surgeon must assess the patient’s individual health risks and have the appropriate knowledge of preventive measures.
  • An aesthetic treatment is a medical treatment. Before any medical treatment, it is necessary to be informed about possible risks. Clarification by non-medical personnel violates the German Civil Code Sections 630c Paragraph 2 S. 1, 630e Paragraph 1, Paragraph 2 S. 1 No. 1.
  • The practitioner should be able to control possible complications. Emergency medication such as Hylase® and a medical emergency kit should be available. The type of application and dosage of the emergency medication should be familiar.
  • The treatment requires a precise knowledge of the anatomy, the interaction of the cells, the processes in the tissue and the metabolism. Experience in the implementation and treatment of complications is necessary.
  • Heilpraktiker may call himself any person who has a secondary school leaving certificate and passes an examination at the responsible health office. Training is voluntary. The specialist for plastic and aesthetic surgery has undergone an admission procedure to study medicine. The medical studies comprise 5,500 hours of theoretical and practical instruction and three state examinations. A specialist in plastic and aesthetic surgery has completed practical training of approximately 11,600 hours and passed an oral examination. The European specialist title requires the passing of an additional oral and written examination.

Qualification and experience matter

The popularity of the treatment with wrinkle filling materials should not hide the fact that professional know-how is necessary to achieve an optimal result and to minimize the risks. A secondary school leaving certificate and an examination at the public health department are sufficient for the granting of a licence to practise as a non-medical practitioner. The training to become a non-medical practitioner is voluntary. Surgery is a craft. However, it doesn’t just take training to be a surgeon. A great deal of knowledge and experience is necessary to be able to recognize when a treatment measure is appropriate and when it is not. Managing complications and treatment alternatives also requires extensive training. The terms “cosmetic surgeon”, “cosmetic surgeon” or “aesthetic surgeon” are not protected. This is different for the professional title “plastic and aesthetic surgeon”. These physicians have always completed an appropriate 6-year continuing education program.

What is hyaluronic acid?

When examining the vitreous body of the eye in 1880, a special transparent substance was described and called hyalomucin (“hyalos” ancient Greek for glass) (Beauregard, 1880, J de l’Anat et de la Physiol Norm et Pathol de l’Homme et des Animaux). Later, a building block of this substance was discovered: uronic acid or glucuronic acid (Meyer K., et al. 1934, J Biol Chem). From this the name hyaluronic acid is derived. Hyaluronic acid dissolved in water is called sodium hyaluronate. Hyaluronan is the scientific umbrella term for the dry substance hyaluronic acid and the sodium hyaluronate dissolved in water.

Hyaluronic acid is a natural building material of the human body, which occurs in identical form in all vertebrates. Hyaluronic acid consists of a chain of a sugar compound that is repeated 10,000 to 25,000 times (glucuronic acid and acetylglucosamine). Hyaluronic acid is important for the health and function of all organs. Collagen and hyaluronic acid are essential components of a scaffold that connects the cells in the body tissue. Hyaluronic acid is used in medicine as a “lubricant” and “shock absorber” for worn joints (arthrosis), among other things.

Hyaluronic acid binds more water than almost any other substance in nature. The reasons for this are the water-attracting sugar components and the long chain of sugar compounds of hyaluronic acid. It stores moisture and increases the skin’s resistance. One gram of hyaluronic acid binds about 500 milliliters of water (Ogston AG, et al. 1966, Fed Proc).

Its ability to store water is interesting for aesthetic medicine. It is also pressure stable. Both these properties make hyaluronan ideal for padding slack skin areas and underfilling wrinkles. Irregularities of the skin and sunken skin areas can be balanced with hyaluron. Hyaluron is also used to define facial or body contours more clearly and to make lips fuller.

Where does hyaluronic acid occur?

Hyaluronic acid is widely distributed in nature: It occurs in humans, vertebrates, molluscs, bacteria, algae and certain yeast fungi (De Oliveira J.D., et al., 2016, Microb Cell Fact). In humans, hyaluronic acid is present in the joints, skin, intervertebral discs, lungs, eyes and brain. In the deepest layer of the skin (stratum basale) there is a high concentration of hyaluronic acid. Interestingly, the highest concentration of hyaluronic acid is found in the umbilical cord (4 milligrams per milliliter).

The body of a 70 kilogram person contains about 15 grams of hyaluronic acid (Stern R. 2004. Eur J Cell Biol). The largest amount of hyaluronic acid (7-8 g in adults) is found in the skin (Reed RK, et al. 1988. Acta Physiol Scand).

Hyaluronic acid fills the space between the cells (extracellular matrix). This space can be imagined as a scaffold consisting of hyaluronic acid, collagen and sugar molecules. Enzymes on the surface of specific cells, also called fibroblasts, produce hyaluronic acid. The enzymes assemble the chain of hyaluronic acid inside the cell. The longer chain of hyaluronic acid is released into the intercellular space (extracellular matrix).

What does hyaluronic acid do in the body?

Many studies are intensively concerned with the role of hyaluronic acid. Hyaluronic acid influences many processes in our body. Hyaluronic acid controls among other things:

  • the cohesion of cells,
  • the migration of cells,
  • the multiplication of cells,
  • the healing of wounds and
  • serves as a lubricant in the joint fluid,
  • the shape of the vitreous body of the eye,
  • the conduction of impulses from nerves and
  • the development and maturation of the child in the womb.

Many processes are controlled by the hyaluronic acid triggering a reaction like a key in a lock on a cell surface. One of the most common “locks” for hyaluronic acid is called CD44. This lock is present on almost all cells of the human body.

The control mechanisms are highly complex and are influenced by many parameters. In fact, in the body one key can open different locks and different keys can open one and the same lock. A variety of different signaling molecules (growth factors, cytokines and extracellular matrix proteins such as fibronectin) can open the CD44 lock. The effect of hyaluronic acid also depends on the length of the hyaluronic acid chain and the concentration of hyaluronic acid (Cyphert J.M., et al., 2015, Int J Cell Biol).

How is hyaluronic acid injected?

A hyaluronic acid injection rarely takes longer than 20 minutes. The preparations are for your comfort and safety. Hygienic work and surgical disinfection are a matter of course for us. Before the injection, make-up is removed and the skin is carefully disinfected.

Depending on the region treated, a different technique of injection is used (linear technique, fan technique, criss-cross technique, vertical technique). Special atraumatic cannulas reduce the risk of bruising. The hyaluronic acid is injected gently and specifically into the corresponding tissue layer.

For the treatment of drooping cheeks or the build-up of cheekbones, the filler is inserted into deeper layers. A superficial treatment serves to correct fine skin wrinkles and improves skin moisture and elasticity.

Cooling pads are then applied to prevent swelling and bruising. You can resume your normal daily routine a few minutes after the treatment. Since hyaluronic acid binds a lot of water, the result can still change slightly until the second week.

How is hyaluronic acid broken down?

Approximately one third of the total amount of hyaluronic acid in the human body is broken down and newly formed every day (Volpi N, et al. 2009, Curr Med Chem). Under normal circumstances, hyaluronic acid is broken down after only a few hours. With age, less and less hyaluronic acid is produced. Between the ages of 19 and 47, the skin consists of 0.03 percent by weight of hyaluronic acid. At the age of 60 or 75 years the percentage decreases to 0.015 or 0.007 percent respectively. Furthermore, the chains of hyaluronic acid become shorter with age (Longas MO, et al. 1987 Carbohydr Res). The consequences are dry skin and wrinkles.

Hyaluronic acid is broken down in the human body by enzymes and by chemical reaction with oxygen. The broken down building blocks of hyaluronic acid are broken down in the liver to water and carbon dioxide. Hyaluronic acid is broken down at different points in the body at different rates. For comparison, the time span is given after which half of the hyaluronic acid is broken down (half-life). The half-life of hyaluronic acid in the skin is 24 hours, in cartilage 1-3 weeks and in the vitreous body 70 days (Schiraldi C., et al, 2010, Biopolymers).

How do hyaluron products differ?

The injection of hyaluronic acid was approved in Europe in 1996 and for the first time in the USA in 2003 for the treatment of facial wrinkles. Hyaluronic acid preparations for wrinkle treatment differ, for example, in the following properties:

  • the concentration of hyaluronic acid (milligram per milliliter),
  • the size of the hyaluronic acid molecules,
  • the proportions of high and low molecular weight hyaluronic acid,
  • the degree and type of cross-linking of hyaluronic acid,
  • the ability to bind water (millilitres per gram),
  • the tendency to return to the original shape (modulus of elasticity: G’ in Pascal, the higher the value the firmer the gel),
  • the viscosity of the gel (viscosity module: G” in Pascal, the lower the value, the thinner the gel or more simply the injection with wafer-thin needles and low pressure),
  • Quotient of viscosity and elasticity (Tan Delta value: the lower the value, the firmer the gel),
  • the cohesion of the gel (cohesiveness),
  • the addition of a local anaesthetic.

A dense cross-linking of the molecules, a high concentration and a high molecular weight of hyaluronic acid slow down the body’s normal breakdown. The viscosity of the gel increases with increasing molecule size and concentration. The addition of a local anaesthetic (for example lidocaine) reduces the elasticity and viscosity of a gel. Elasticity and viscosity are measured with a rheometer.

How is hyaluronic acid produced?

Hyaluronic acid is used in medical and medicinal treatments, as a cosmetic product and as a food supplement. Accordingly, the biotechnological production is being researched intensively. The goal of these efforts is the production of pure hyaluronic acid, resource-saving and cost-effective. Therefore, certain bacterial strains are used in the modern production of hyaluronic acid (Tezel A, et al., 2008, J Cosmet Laser Ther). This process is also called NASHA (non-animal stabilized hyaluronic acid). The extraction of hyaluronic acid from animal tissue is time-consuming and labor-intensive and is therefore rarely used. Animal hyaluronic acid has ten to fifteen thousand sugar compounds per chain. Bacterial hyaluronic acid, in contrast, has four to six thousand sugar compounds per chain. The hyaluronic acid produced by bacteria is classified as harmless by the American health authority (FDA: Food and Drug Administration) (Widner et al. 2005).

The degree of cross-linking indicates the percentage of sugar compounds of hyaluronic acid that are linked to another chain of hyaluronic acid. A degree of crosslinking of four percent means that four out of every hundred sugar compounds in a chain are crosslinked. A higher degree of cross-linking is associated with a higher viscosity and a lower ability to bind water. Linked chains of hyaluronic acid are broken down more slowly by enzymes. The effect of hyaluronic acid injections lasts longer.

The most commonly used substance for cross-linking hyaluronic acid is 1,4-butanediol diglycidylether (BDDE). BDDE has been used since 1986 (Weiss C. et al., 1986, Bull Hosp Jt Dis Orthop Inst). The stable compound of BDDE extends the hyaluronic acid effect up to one year. Through a complex purification process, the unbound BDDE is removed up to the detection limit. Traces of BDDE occur in concentrations of 1 to 2.46 micrograms per liter (ppb: parts per billion) (Figaldo F., et al., 2018, Med Devices Auckl). The BDDE is degraded in the liver by a specific enzyme (Cytochrome P450) into glycerol and butanediol. Both substances will in turn be broken down into carbon dioxide. Other substances such as divinyl sulfone are hardly used anymore, as BDDE is more compatible than divinyl sulfone (De Boulle K, et al., 2013, Dermatol Surg).

Which hyaluronic acid is the best?

A high quality product should have the following characteristics:

  • There should be no doubt about the safety of the filler.
  • The product should be well tolerated by the tissue.
  • It should not cause allergies.
  • The filler should be easy to use.
  • The substance should be durable.
  • The result of the injection should look natural.
  • The tissue filler should not spread throughout the body.
  • The filler should be dissolvable if necessary.
  • The product should not be too expensive.

The selection of the optimal tissue filler depends on the individual needs. A filler for treating lips has different properties than a filler for improving sagging cheeks.

Approval by the US Food and Drug Administration (FDA) is subject to more stringent requirements. The data from good scientific studies, experience over many years and the approval of the US Food and Drug Administration (FDA) are quality features of a filler product. Published scientific studies exist almost exclusively on FDA approved products. Nevertheless, there are hardly any independently financed studies of treatment results. Evidence-based objectifiable differences in treatment outcomes with Belotero® Balance, Juvéderm® Voluma and could not be demonstrated [5].

Hyaluronic acid as a food supplement

Hyaluronic acid as a food supplement is absorbed by the body to about ten percent and stored in various organs (Balogh L., et al., 2008, J. Agric. Food Chem. 2008). Several comparative studies show that the intake of 40 to 240 milligrams of hyaluronic acid over four to twelve weeks leads to an improvement of skin hydration (Kawada C., et al., 2014, Nutr. J.). There is also evidence that supplementation with hyaluronic acid relieves knee pain (Oe, M., et al, 2016, Nutr. J.). The number of persons examined and the duration of the examination are not always very meaningful. The independence of the investigators is also questionable in certain studies (Göllner I., et al, 2017, J. Evid. Based Complement. Ageing. Med.). For the improvement of the skin appearance the combination of food supplement, skin care cream and a hyaluronic acid injection seems promising (Kawada C., et al, 2015, J. Photochem. Photobiol. B.).

What should be considered before an injection?

Hyaluron injections are a safe treatment with few side effects. The risks are even lower if you take certain precautions.

Blood-thinning medications such as aspirin or diclofenac affect blood clotting. If you can do without these medications, you will prevent the development of bruising. Certain vitamins (vitamins E and A) and food supplements (ginkgo biloba, green tea, garlic capsules, omega-3 fatty acids, echinacea, St. John’s wort) also inhibit blood clotting. As a rule, it is sufficient to stop these blood-thinning substances ten days before the injection.

Postpone the treatment if you are currently suffering from cold sores. If the cold sore has healed completely, but you are particularly susceptible, preventive treatment may be considered.

Thorough but gentle skin cleansing on the day of treatment reduces the number of germs on the skin. Remember that immediately before the treatment make-up must be removed for hygienic reasons.

What should be considered after a filler treatment?

Gentle cooling after a filler treatment prevents the development of reddened skin. The treated areas should not be massaged. Alcohol consumption, especially red wine, causes dilation of the vessels, which in turn promotes the development of bruising. It is therefore advisable to avoid excessive alcohol consumption after a treatment.

There is no published evidence that the use of make-up after treatment increases the likelihood of inflammation. Nevertheless, we advise caution, as even the smallest puncture in the skin can allow germs to enter the body and cause inflammation.

How long no sport after filler injections?

After the injection of hyaluronic acid, swelling, slight pain, redness or itching may occur at the injection site. After 24 hours, this mild discomfort should pass on its own. After injections of the lips, the swelling may last a little longer. Light physical activity can be continued on the day of the injection. However, endurance sports or weight training should be paused for two days, or longer if swelling persists.

Filler during pregnancy

Hyaluronic acid is produced in the human body and is found in the skin and umbilical cord, among other places. It does not pose a risk to pregnancy. Therefore, if you have had a wrinkle injection without knowing about your pregnancy, you do not need to worry. However, rare unpredictable risks may occur during treatment that require further action. The effects of wrinkle injections and possible follow-up treatments on pregnancy have not yet been studied. For precautionary reasons, we do not recommend hyaluronic acid injections during pregnancy.

Can I have an allergic reaction to hyaluron?

Hyaluronic acid is found in all organs of the body. An allergic reaction to the hyaluronic acid itself is therefore not possible. A skin reaction is estimated to occur in one in five thousand patients. Signs include redness, swelling, pain, itching or temporary bumps. The symptoms appear on average twenty-two days after the treatment and after a few weeks they recede. This is probably triggered by protein-containing residues from bacterial production [6]. Also preservatives or substances used for the cross-linking of the hyaluronic acid are possible triggers. In these rare cases, cortisone treatment is recommended to relieve the signs of inflammation.

Additives such as the local anaesthetic lidocaine, can in very rare cases lead to an allergic reaction. Please be sure to inform us if you have had an intolerance to any anaesthetic in the past.

When should fillers not be injected?

If you have an allergy to bacterial proteins, we test the compatibility of the hyaluronic acid before a filler application. For test purposes, a small amount of hyaluronic acid is injected into the forearm. In the very rare case of an allergic reaction, there is temporary swelling, redness or induration. Hypersensitivity to the tested hyaluron injection is unlikely if the skin shows no abnormalities five days after the treatment.

Many hyaluronic acid products contain a numbing agent. If there is an intolerance to a certain anaesthetic, we apply hyaluronic acid without anaesthetic.

In order to avoid even remotely conceivable risks, we do not inject hyaluronic acid during pregnancy or breastfeeding.

If you have a tendency to bleed or are taking blood-thinning medication, bruising can occur that is slow to disappear. In view of the unfavourable risk-benefit ratio, we do not recommend filler treatment if there is a tendency to bleeding.

Which filler lasts the longest?

Hyaluronic acid is a natural component of the body. Like all of the body’s own building blocks, hyaluronic acid is subject to constant build-up and breakdown. The hyaluronic acid of the wrinkle injections is also broken down naturally. The durability of hyaluronic acid depends on the following factors:

  • The concentration of hyaluronic acid
  • The degree of cross-linking of hyaluronic acid
  • Additives such as the naturally occurring glycerol
  • The length of the hyaluronic acid chains
  • The parts of the body where the hyaluronic acid is injected
  • The individual body metabolism

The properties of the hyaluronic acid are decisive for the individual treatment goal. Short chains, i.e. hyaluronic acids with a small molecular size, are suitable for superficial treatment. Highly concentrated hyaluronic acids have a particularly high ability to bind water and restore volume. A high degree of cross-linking of the hyaluronic acid chains ensures that the fillers are distributed only slightly in the tissue. Fillers for the treatment of small wrinkles therefore have a shorter shelf life than hyaluronic acid gels for volume building.

Most hyaluron preparations for superficial skin treatment (for example Juvéderm®, Belotero® Balance) have a duration of action of six months or more. The effect of fillers to improve facial contours (Juvéderm® Voluma) usually lasts one to two years.

Filler with or without anaesthetic?

Most pre-filled syringes of hyaluronic acid (for example, Juvéderm® and Belotero®) contain the anesthetic lidocaine. Lidocaine has been used worldwide since 1948 and is one of the best tolerated local anesthetics. A relaxed atmosphere and an empathetic team help to alleviate discomfort and anxiety before an injection treatment. Often a temporary feeling of anxiety is mistaken for an intolerance. Actual intolerance of topical anesthetics is confirmed in less than one percent of suspected cases [7]. The addition of lidocaine affects the firmness of certain hyaluronic gels. However, the treatment outcome is not affected by the addition of lidocaine [8]. Hyaluronic acid injections with a local anesthetic have been shown to be less painful than without [9].

11 tips for the correct application of fillers

For a high level of satisfaction with the treatment result, the following conditions should be met:

  1. The doctor should understand exactly what your treatment wishes are. Bring photos from younger years or of role models. This can be helpful in planning treatment.
  2. A thorough knowledge of your health and lifestyle habits is important. We need this information in order to identify any risks in good time and to be able to take better preventive action.
  3. The entire mouth region and facial proportions should be examined. A holistic examination and treatment lead to naturally beautiful results.
  4. The surgeon should have a detailed knowledge of the anatomy. The interaction of nerves, vessels, muscles, skin, subcutaneous fatty tissue and bones is very complex. Injections can affect all anatomical structures. In-depth knowledge is indispensable for avoiding risks and for an optimal result.
  5. Your practitioner must be familiar with the physical properties of hyaluronic acid. Hyaluronic acid fillers have different properties. For reliable results, it is important to be able to assess the manufacturer’s specifications (e.g. modulus of elasticity, modulus of viscosity, cohesiveness).
  6. The doctor must have experience in the use of different hyaluronic acids. The experience in the application of fillers is based on the knowledge of physiology and anatomy. Knowledge cannot replace experience. Conversely, experience alone is not enough to achieve the best possible results and avoid complications.
  7. Choosing the right hyaluronic acid is crucial. Certain products differ despite seemingly comparable manufacturer claims. We therefore select the best filler for each patient and each treatment.
  8. You should be fully advised about different options for treatment. The effects of fillers, a muscle relaxant and minimally invasive surgery complement each other. The all-purpose treatment for everyone and every woman does not exist. Trying to solve every problem with fillers leads to unnatural results and can come with increased risks.
  9. A treatment plan to maintain and restore harmonious facial proportions should be established. Changes in one region of the face affect the entire facial expression. For a natural result, the subtle connections must be taken into account.
  10. The doctor should be proficient in various techniques of injections. The choice of the right technique depends on the facial regions and the filler required for this.
  11. Treatment should be followed by an examination to ensure that the treatment goals have been achieved. In the first few days after the injection, the volume may change slightly. To avoid unnatural results, a touch up is occasionally necessary after two weeks.

Where can fillers be used?

Filler for the chin

The contour of the chin affects the entire facial expression, especially the appearance of the nose and neck. In men, the chin is approximately at the level of the lower lip. In women, the chin is one to two millimeters behind the lower lip. A receding chin can be corrected by injecting hyaluronic acid. Particularly good results can be achieved when the chin protrudes 4 to 10 millimeters. A somewhat firmer hyaluronic acid gel is injected deeply and in a fan shape for this purpose.

Filler against crow’s feet

Before the hyaluronic acid injection, a treatment with a muscle relaxant is indicated. Superficial wrinkles can be corrected by a microneedling treatment. With the right technique and a thin liquid hyaluronic acid, wrinkles can be effectively corrected. As the subcutaneous tissue in this area is richly supplied with blood, a temporary haematoma may occur. The choice of the applied hyaluronic acid and the expert injections prevent the appearance of small irregularities. After the injection, a gentle massage helps to prevent swelling.

Filler for the eyebrows

The fat pad below the eyebrows becomes smaller with age. The brow flattens. By injecting hyaluronic acid and a muscle relaxant, the brows can be brought into shape. Laterally, the eyebrow can be lifted by relaxing the muscles and injecting. 0.3 milliliters of hyaluron can be enough to give a fresh and youthful appearance. When combined with the muscle relaxant, the results last up to 9 months. Deep injections may cause temporary sensitivity of the eyebrows. In order to achieve permanent results, the patient’s own fat can be injected as an alternative.

Filler against forehead wrinkles

Hyaluronic acid creams or hyaluronic acid capsules cannot eliminate forehead wrinkles. Small wrinkles on the forehead are effectively treated with a well-known muscle relaxant. It relaxes the forehead muscle so that mild wrinkles fade. Deep wrinkles are effectively smoothed or eliminated two weeks after the treatment with a muscle-relaxing active ingredient supplemented by a hyaluronic acid injection. During the examination it is determined whether a co-treatment of the eyebrows or the temples is useful for a harmonious result. For a safe treatment and a pleasing result, you should only trust experienced doctors. CenterPlast doctors have a detailed knowledge of anatomy and years of experience. Injection by non-medical personnel carries high risks. If complications are not recognized and treated immediately due to a lack of expertise on the part of the injector, permanent damage can remain. In good hands, fillers are an effective and safe treatment for forehead wrinkles.

Filler for the temples

Sunken temples a great effect on the overall appearance. The soft transition from the forehead to the cheekbone is interrupted by deep temples. This makes the eyebrows look shorter and deeper. Hollow temples make you look pre-aged or in poor health. Injecting sunken temples with the right hyaluronic acid rejuvenates and refreshes the appearance for a long time. Be treated by experienced doctors who are very familiar with the anatomy and the technique. Before the injection, the superficial temporal vessels (vasa temporalia superficialis) are identified to avoid hematoma. The filler is injected about one centimetre up the head along the frontal bone (squama frontalis) and one centimetre to the side. Usually 0.5 to 1 millilitre of hyaluronic acid is injected into the deep tissue layers of the temple per side. The front edge of the temporal fossa can be accentuated with a superficial injection of a low-viscosity hyaluronic acid. After the injection we recommend a gentle massage of the temple to support the even distribution of the filler.

Filler for earlobes

With age, the proportions of the earlobe and the auricle change. Due to age-related tissue loss and reduced skin elasticity, wrinkles appear on the earlobe. In 1973, a pulmonary specialist suspected that an oblique fold on the earlobe was associated with coronary artery disease. The scientific data are contradictory and of insufficient quality to assume a link. Therefore, you need not worry if you suffer from such wrinkles. With a hyaluronic acid injection, wrinkles on the earlobe are quickly and effectively smoothed out.

Our before and after pictures of filler treatments

If you are interested in before and after pictures (photos) of injections with fillers like hyaluronic acid, visit our before and after pictures page.

Our testimonials on treatments with fillers

If you would like to read testimonials or patient testimonials about filler treatments, or see reviews of our practice, take a look at our Testimonials page.

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The author

Unsere Fachärzte für Plastische Chirurgie Saarbrücken
Dr. Adelana Santos Stahl

“Our goal is to provide the best, most discreet and precise treatment based on our extensive expertise in plastic surgery. „

Dr. Adelana Santos Stahl is distinguished by a unique international perspective with a feminine view of plastic surgery. Her personalized and detailed approach is key to the beautiful and natural results she achieves. Having trained in Brazil, one of the largest and most well-known countries for aesthetic and reconstructive plastic surgery, she understands her patients’ desire to look and feel their best. She completed her medical studies and her training as a specialist for plastic and aesthetic surgery in Brazil. In 2009, she also successfully passed the German equivalence examinations for the medical state examination. Two years later, in 2011 she received the German and in 2012 the EU specialist recognition (EBOPRAS) for plastic surgery. From 2009 to 2013, she deepened her knowledge of aesthetic and reconstructive facial surgery with world-renowned representatives of plastic surgery such as Professor Gubisch at the Marienhospital and Madame Firmin in Paris. A VDÄPC Fellowship (continuing fellowship for graduate students) in Switzerland, France and the USA has further enriched her professional experience. Dr. Santos Stahl is active in several prestigious professional societies. Besides the DGPRÄC and DGBT, she is also a member of the Brazilian Society of Plastic Surgery – SBCP. She is also the author of several scientific articles and, together with her husband, is dedicated to research and clinical studies in the field of plastic surgery.


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