Permanent fillers—What is their role

Abstract

Background: With the growing cosmetic industry, there have been numerous advancements in nonsurgical interventions including the use of permanent dermal filler injections. Permanent fillers are relatively novel in clinical use when compared to temporary and semi-permanent fillers. The only FDA-approved, non-biodegradable permanent filler uses polymethylmethacrylate (PMMA) microspheres. PMMA is suspended in bovine collagen and lidocaine solution for injection, absorbed by the body, and replaced overtime by collagen. ArteFill® was the first FDA approved permanent filler in 2005 for correction of nasolabial folds, with studies demonstrating rejuvenation for up to five years, trumping its predecessors in longevity. A decade later with rebranding, Bellafill® was indicated for correction of nasolabial fold and atrophic acne scars. Aims: To review the development of permanent fillers, mechanism, and safety. Materials & Methods: A qualitative systematic review was conducted on PMMA microspheres indications, contraindications, and off-label use on benefits, risks, and adverse events.Results: The durability of permanent fillers has a strong appeal for both patients and practitioners, however, usage for certain patient populations demonstrates increased risk for both early and late complications compared to temporary and semi-permanent fillers. A skin test composed of purified 3.5% bovine collagen gel administered in the volar forearm is recommended one month prior to injection, to identify any patients who may have a positive response. Bovine collagen demonstrates low immunogenicity with the incidence of preexisting hypersensitivity reported to be between 2-4%. Bovine collagen in dermatologic formulations use pepsin-solubilized formulations in which telopeptides are cleaved to further help reduce aberrant immunogenic responses.Discussion: Early and late complications may outweigh the benefits in use of permanent fillers, however these complications are patient dependent. Conclusion:Permanent fillers may be useful in volume replacement for nasolabial folds and atrophic acne scars, however a provider must use good clinical judgement in deciding which patients are ideal candidates.