Permanent Facial Fillers

By Dr. Stephen Cosentino

Data collected by the American Society of Plastic Surgeons reveals that temporary facial fillers are second only to botulinum toxin A formulations (chiefly Botox®) in terms of popularity with consumers seeking minimally invasive alternatives to cosmetic surgery. Medical providers completed about 2.6 million soft tissue filler procedures in 2018, mostly with shorter-acting hyaluronic acid fillers (Juvederm® and Restylane®). Many users prefer temporary fillers because their effects fade, allowing the patient to choose whether to continue treatment. On the other hand, returning to the provider’s office for follow-up injections and consultations can be tiresome, and the cumulative cost of temporary filler treatments is not insignificant. For this reason, among others, some patients choose another option: permanent fillers. Permanent facial fillers deliver results over a very long term, measured in many years or decades, and often require minimal follow-up after the initial post-treatment period. Permanent facial fillers come in several different forms, including synthetic “biocompatible” PMMA formulations, silicone, and autologous grafts (skin or fat taken from the same patient’s body). Some patients and providers prefer them to treat notable cosmetic defects that do not respond well to other fillers, such as deep acne scars. And despite their permanence, they are still regarded as a lower-risk alternative to invasive plastic surgery. This guide to permanent facial fillers (dermal fillers) covers the most commonly used types and procedures in North America, the general differences between permanent and temporary dermal fillers, and the possible risks of treatment.

Types of Permanent Facial Fillers

“Permanent facial filler” may describe any type of dermal filler with effectively permanent results. That is, any filler that remains more or less stable in the body unless and until it is removed or deactivated by a qualified medical professional.

Synthetic Facial Fillers

Permanent facial fillers may be synthetic or autologous. The two most widely used synthetic fillers are:

Polymethylmethacrylate (PMMA). PMMA is a synthetic biocompatible that remains stable under the skin indefinitely. It’s housed within tiny “microspheres” suspended in a gel. PMMA formulations may also contain collagen, a volume-enhancing substance naturally produced by the body. Although PMMA fillers do not degrade and should not lose their shape as time passes, they are easily removed in a clinical setting. The principal PMMA formulation available to U.S. patients is Suneva Medical’s Bellafill®, formerly known as ArteFill. Bellafill is used to treat severe acne scars and deep nasolabial folds.
Polyalkylimide. Polyalkylimide is a synthetic biocompatible that stimulates collagen production at the injection site. Unlike PMMA, it is a homogeneous formulation that does not contain microspheres. Most commonly offered in the U.S. under the brand name Aquamid®, polyalkylimide is most often used to reduce the appearance of deep nasolabial folds, marionette lines, and depressed scars, and to plump lips, increase cheek volume, and add depth to the chin. Like PMMA, polyalkylimide treatment can be reversed if desired.

A third type of filler, poly-l-lactic acid, produces results over long periods of time but is not considered “permanent” as periodic touch-ups may be required to maintain results. Long used in dissolvable stitches, poly-l-lactic acid is a biocompatible synthetic that durably stimulates collagen production. It’s most often used to plump thin lips, soften laugh lines, and reduce nasolabial folds.

Autologous Facial Fillers

Autologous facial fillers, sometimes known as implants, use fat or skin from elsewhere on the patient’s body to achieve the desired results at the treatment site, usually the face or lips:

Fat Grafting: This technique implants small amounts of fatty tissue from other parts of the patient’s body, often the thigh or abdomen, into treatment areas on the face. Because the material is the patient’s own, there is little risk of allergic reaction or rejection, though other side effects can certainly occur.
Skin Grafting: This technique is similar to fat grafting, except with skin tissue instead of fatty tissue. Both procedures can be performed in an outpatient setting.

Permanent Dermal Fillers vs. Temporary Dermal Fillers

Permanent dermal fillers differ from temporary dermal fillers in some important ways:

Composition and Formulation. The most common temporary dermal filler is hyaluronic acid, a naturally occurring substance (found in the skin) that temporarily hydrates and plumpens the treated area. The next most widely used is calcium hydroxylapatite, another naturally occurring substance (found in bones) that stimulates collagen production.

Duration of Results. Whereas permanent dermal fillers’ optimal results can last for years between touch-ups, temporary fillers’ results may last only for a matter of months. For example, hyaluronic acid treatment can dissipate after as little as 6 months, though some formulations may persist for 18 months. Calcium hydroxylapatite fillers do not last much longer.

Treatment Areas. Temporary facial fillers have a wider range of indications covering most areas of the face. That said, both temporary and permanent facial fillers may be used “off-label” (for procedures not approved by the FDA) by qualified practitioners.

Delivery Method. All temporary fillers are injectable fillers delivered by syringe to the treatment area. PMMA and polyalkylimide are also injectable, but autologous grafts are not.

Possible Risks and Side Effects of Permanent Facial Fillers

Like their temporary counterparts, permanent facial fillers present notable risks for patients. While the most severe complications, including adverse clotting events and stroke, are much less likely when injection is done by providers with proper dermal filler training, no patient’s risk is zero. Providers must fully apprise treatment candidates of all possible side effects and complications. They should also conduct a thorough pre-treatment evaluation (including a thorough patient medical history and a skin test for allergic reaction potential) before approving a treatment plan. These relatively common dermal filler side effects tend to be mild and resolve in a matter of days to a few weeks:

Itching at the injection site
Redness or bruising at the injection site
Mild swelling or tenderness at the injection site

Though less common, these side effects have the potential to be more serious and may require medical evaluation:

Injection site infection
Skin discoloration (“bluing”) around the injection site
Necrosis (skin death characterized by blackened skin)
Prolonged bleeding following injection
Skin lumps or bumps (granules) around the injection site

Though even rarer, these side effects and complications have the potential to cause death or disability and may require immediate medical attention:

Allergic reaction characterized by severe swelling or difficulty breathing
Suspected stroke, which may result from improper injection technique (injection into a blood vessel)
Vision changes, including blindness (another possible sign of vascular complications)
Signs of abnormal blood clotting

Before proceeding with treatment, providers can help treatment candidates make informed decisions about permanent facial filler procedures by informing them of the alternatives, including temporary fillers like hyaluronic acid. Due to concerns about possible complications and the long duration of results, many patients choose to begin with temporary fillers and move to permanent fillers only if they grow dissatisfied with the results.