Dermal Fillers

Dermal Fillers

Dermal fillers are different from Botox. Botox relaxes muscles to minimize wrinkles, while the fillers replenish volume loss under the skin. Dermal fillers are considered sculpting agents that dramatically change one’s appearance. Fillers have multiple uses, either by filling pre-existing facial defects (cheeks) or augmenting existing facial structures (lips).

A confusing array of non-permanent, semi-permanent and permanent substances exist to sculpt the face. The focus here will be to discuss the most common dermal fillers used today. To minimize confusion, this page will concentrate on hyaluronic acid fillers, which are considered non-permanent. The semi-permanent fillers, Radiesse and Sculptra, will be discussed separately.

Hyaluronic Acid


Restylane, Juvederm, Boletero

Hyaluronic Acid (HA) is ubiquitous in human tissue and is widely distributed in all connective, neural  and soft tissues.  It plays a very important role in wound healing and joint health. It binds enormous amounts of water to its core molecule, giving it a hydrating property when found in the skin. With age, the amount of hyaluronic acid decreases in the skin and soft tissue, resulting in reduced dermal hydration and volume loss.

Because of its hydrating and biocompatible properties HA has been used medically since the 1960’s. In its natural form unmodified HA lasts only 1-2 days in human tissue, making it a poor candidate for soft tissue augmentation. In the 1980’s the mechanism of cross-linking was established to address these concerns. By chemically linking molecules of HA together, a more stable macro-molecule was formed that had an even higher affinity for water than the native molecule. This new molecule was more stable, more hydrating and still biocompatible with nascent tissue, thus creating the perfect triad for the new dermal filler.

Restylane, Juvéderm, and Belotero are the three most common HAs used in the United States. All three perform similarly in addressing volume loss and they all have several product lines. Each product line features different bonding and concentrations of hyaluronic acid, and each product is tailored to target a specific problem.


The first hyaluronic acid filler introduced to the market was Restylane, made by Galderma, in 2003.  From 2003-2004 the market experienced a 700% increase in use, as it quickly replaced bovine collagen for lip augmentation.  Before Restylane was introduced to the market, hyaluronic acid gels were of animal origin and often associated with allergic reactions. Restylane was the first hyaluronic acid produced by bacterial fermentation.


Juvéderm, produced by Allergan, quickly followed suit and was approved by the FDA in 2006. There are several products in the Juvéderm family to address volume loss. Allergan seems to focus more on long term sustainability of their HA filler, reporting results lasting from 12 to 24 months.


Belotero, made by Merz, was last on the scene and approved in 2011 by the FDA. It also has a line of products to address specific issues, but differs in its cross-linking process from Restylane and Juvéderm. Although all three products deliver good results, Belotero will not cause the Tyndall effect due to its unique cross-linking.

The Tyndall effect is a phenomenon in physics in which light rays scatter when they pass through suspended particles, such as hyaluronic acid. As light rays scatter, they emit a light blue color. Most HA fillers consist of a gel of suspended particles which can result in a bluish tinge when skin comes in contact with light. However, the HA of Belotero is a cohesive matrix and not a suspension.  Therefore, the Tyndall effect does not occur.

Which Is The Right One?

Each manufacturer has a vast portfolio of hyaluronic acids to be utilized for specific situations, but don’t get overwhelmed trying to distinguish all these different products. Although some will be better for volume loss, others better for fine lines, at the end of the day they are all hyaluronic acid. Nuances in different products present more of a marketing tactic, as you could use many of them interchangeably. Think of Colgate toothpaste— 53 varieties of toothpaste but they basically do the same thing— that is, clean your teeth.