Filler or filler-folly? A guaranteed addiction

What are fillers?

Fillers are special substances that can be injected directly into the facial skin, using a specifically designed fine needle. They are designed to fill the depressions that wrinkles, scars, and nasolabial folds cause and that become more noticeable with aging. Aesthetic medicine uses fillers to plump the lips, chin, or cheekbones.

The use of fillers dates back to the late 1960s when silicone oil began to be used to correct facial imperfections such as folds or wrinkles. However, silicone oil could often disperse in microdroplets to other parts of the tissue or body, triggering an inflammatory foreign body reaction at the injection site. Due to further reports of microemboli (obstruction of blood vessels) and skin reactions, silicone oil was banned in the 1980s.
Subsequently, collagen-based fillers were introduced from the mid-1970s and have since become the standard norm. At this time, collagen was primarily derived from cows that were raised in environments free from mad cow disease. However, regardless, it was soon realized that bovine collagen is a biological material foreign to humans and can, therefore, trigger an immune response. Reactivity to bovine collagen can cause prolonged inflammatory reactions at the graft site and potentially trigger autoimmune responses against human collagen. For these reasons, bovine collagen is essentially no longer used.
Then came nonabsorbable filler material including granules of calcium hydroxyapatite (CaHA). However, this filler often caused granulomatous reactions due to foreign body response in some particularly sensitive individuals, and is also now out of use.
To learn more about fillers read this article.

Hyaluronic Acid Fillers

Today, the field of fillers is dominated by hyaluronic acid fillers.

Hyaluronic Acid

From a chemical perspective, hyaluronic acid is composed of a linear polysaccharide chain, produced by the concatenation of thousands of disaccharide units, linked by β-(1→4) bonds and consisting of residues of glucuronic acid and N-acetylglucosamine, in turn linked by β-(→3) bonds. [Source: https://www.my-personaltrainer.it/integratori/acido-ialuronico.html]
Hyaluronic acid is a large molecule (polymer) present in abundance in the dermis, where it contributes to the viscoelastic properties of the tissue by binding water molecules. Hyaluronic acid supports immune defense by forming a dense network that helps trap bacteria and viruses. It is produced by dermal fibroblasts which allow cells to rebuild damaged tissue, especially in the case of wounds. Hyaluronic acid is also present in the joints, where it acts as a cushioning lubricant between the articular surfaces and is also in the vitreous humor of the eye. While abundant in children’s skin, levels of hyaluronic acid decrease proportionally with age.

Hyaluronic acid: an increasingly fashionable molecule

Certain biological terms become extremely popular every now and then. Terms such as DNA, vitamins and free radicals have all trended and, recently, hyaluronic acid has been added to the list. What’s often not considered, but is important to bear in mind is that each of these terms encompasses considerable scientific complexity, which makes it difficult for most to truly understand their true biological significance.
In the media, hyaluronic acid is touted as beneficial with natural properties whether ingested, applied to the skin or injected, however this is not entirely true.
When applied to the skin as a cream, gel or serum, hyaluronic acid does not exhibit any particular activity as a polymer and is not absorbed by the skin. It does not, therefore, not provide any of the benefits attributed to it in product descriptions.
If ingested, hyaluronic acid is immediately broken down into its individual sugar components and then metabolized to produce energy. Neither of these actions firm the skin or fill in wrinkles.

Hyaluronic acid as an injection

Hyaluronic acid as an injection
Hyaluronic acid is widely considered by doctors and patients to be a natural, safe, and effective filler. Let’s take a look at this claim, step by step.
If hyaluronic acid was injected as a filler, it would be immediately broken down by the hyaluronidases enzymes present in the skin, rendering it useless. To overcome this, the cross-linking technique was introduced. This makes hyaluronic acid heavier and prevents degradation by hyaluronidases enzymes, meaning the acid is more stable and lasts longer. [Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590699/] In reality, therefore, when hyaluronic acid fillers are discussed, these do not actually contain the natural molecule but a derivative that doesn’t plasticize, but only fills.

How is hyaluronic acid obtained?

The most common technique is molecular engineering, whereby hyaluronic acid is produced by bacterial strains in culture. This method has relatively low production costs, but guarantees a high purity of the final product. However, there is a drawback: during purification, bacterial-derived molecules may remain in the compound, which can have a sensitizing effect on the host’s immune system.

How much hyaluronic acid is present in a filler?

In currently registered fillers, 2% hyaluronic acid derivative is present on average in the injection (approximately 20mg per 1000). Despite commonly being referred to as hyaluronic acid filler, it’s more accurate to say the injection is a filler with traces of the compound.

A medical mystery: the composition of fillers

Actually, one could trace the composition if one could access the registration documents, which is far from simple and even more complicated because the first registration is made in various states other than Italy. The inference is that doctors who inject a filler do not know 98% of the composition of the product they inject and consequently the patient is not aware of what has been infiltrated.

Breach of the casket

Regardless of the considerations set out above, from a medical and biological point of view, it is never a good idea to insert a foreign substance into the dermis, thus bringing it into direct contact with immunocompetent cells, violating the epidermal barrier that is deputed to our defence. This is all the more negative when it comes to injections that are repeated over time and can therefore trigger a sensitisation reaction.

Full pocket, Empty pocket

Another well-known reflection on fillers is that of the so-called ‘full pocket empty pocket’. When a certain volume of filler is injected into the dermis it makes space between the collagen fibres by dislodging them to create a pocket where it can be contained. When the filler is reabsorbed the empty pocket is no longer filled by the collagen fibres, or at least not in older subjects, so that the empty pocket collapses to form a depression that is often noticeable even on the surface. This is one of the reasons why the subject requires a new filler injection.

Filler, a guaranteed addiction

Fillers are considered addictive agents for the majority of those who undergo this treatment. Like all addictions it induces anxiety, depression, lowered self-esteem and, not least, financial ruin. Only recently have some celebrities of the star system confessed publicly so that this form of addiction has become known even if the real contours of the problem still elude us. https://www.celebsnow.co.uk/celebrity-news/stars-addicted-fillers-482052

The trout pout

These are the lips of those who have undergone several consecutive treatments for which scarring often irreversible fibrosis has eventually set in. In fact, the lips, like the eyelids, are areas where there is no dermis and hypodermis under the skin, so that the fillers end up being deposited in the underlying muscle, a muscle that is even less suitable than the dermis to accept the filler and that is more likely to undergo inflammation and consequent fibrosis. Lips and eyelids should therefore be considered as unsuitable sites for fillers.

Filler-folly

In conclusion, the use of fillers should give pause for thought, especially to doctors who should try to better inform those who request these treatments, with an informed consent on the physical and psychological risks they may face. At the same time, they should adopt de-addiction techniques for those who have fallen into filler addiction.