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Restylane, Juvederm, Perlane, Voluma

With so many facial fillers, how do you figure out which one to use?

Back in the dark ages (1995) when I started practicing plastic surgery, we only had one facial filler: collagen.  Collagen injections were clumsy, fairly ineffective, and only lasted a couple months—and you had to have a skin test beforehand just to make sure you weren’t allergic to it.

Fast forward to 2014; we have a proliferation of facial fillers with more seemingly on the way every day.  How do you figure out which filler to use where?  Which ones are safe?  Which ones are effective?

Despite the variety of fillers on the market, the dominant facial injectibles today are all just different versions of the same underlying chemical: hyaluronic acid.  Hyaluronic acid (HA) is a naturally-occurring polysaccharide or complex sugar that is present in our connective tissues, skin, joints, and even our eyes.  It binds to water in the areas outside our cells (extracellular matrix). Depending upon the length and chemical cross-linking of the sugar chains, HA products can be made thinner or thicker, resulting in varied effects.

Now let’s discuss the individual HA filler products, which are currently produced by two leading companies, Allergan (based in the U.S.) and Galderma (based in Sweden):

Allergan Galderma
Thin Juvederm Ultra Restylane Fine Lines
Medium Juvederm Ultra Plus Restylane
Thick Juvederm Voluma Perlane

Juvederm Ultra is my “thin filler” choice for injecting for poorly defined wrinkles and adding volume superficially.

Think of Juvederm Ultra like a magic marker.  It spreads outside the boundaries of the injection, making it effective for smoothing irregular surfaces, filling the tear troughs (hollow beneath the eyes), or adding volume to the lips.  It’s a bit like coloring outside the lines—to avoid a line of demarcation along the edge of treatment.

I have never used Restylane Fine Lines (the other candidate in the “thin” filler category) because it is not approved for use in the United States.

Restylane is my “medium thickness” filler choice for injecting distinct lines, such as well-defined nasolabial folds (the folds between the nose and the corners of the mouth), deep vertical lip wrinkles, and deep vertical glabellar (between the eyes) wrinkles.

Think of Restylane like a pen.  It stays exactly where you put it and spreads very little, making it effective for filling very specific spots.  Juvederm is less effective for distinct wrinkles, since it spreads out from the injection site.

I have tried Juvederm Ultra Plus on several occasions, and I simply don’t think that it works as well as Restylane. It still diffuses outside the site of injection, though somewhat less than Juvederm.

Perlane has been my traditional choice for “thick filler” and is useful for deeper areas of injection, such as very deep nasolabial folds and volumizing along the cheeks and jaw line.  It is a poor choice for superficial areas, such as the lips, as it will be lumpy and firm.

Voluma is the new kid on the block among thicker fillers.  Launched by Allergan just a few months ago (March 2014), Voluma competes with Perlane and Sculptra (another thick filler) for adding volume to the cheeks.  In fact, the FDA approval is limited to adding volume to the cheeks.   Its advantage over Perlane is longevity (up to two years duration, rather than one).  Its disadvantage is price; the extra longevity isn’t free.

Here’s a summary of hyaluronic acid fillers used in my practice:

Use Typical Duration Cost (2017)
Juvederm Superficial volume, poorly defined folds, Lip enlargement, tear troughs 6-12 months $540 first syringe

$490 each additional

Restylane Distinct lines, well-defined, nasolabial folds, Lip lines, vertical lines between the eyes 6-12 months $540 first syringe

$490 each additional

Perlane Deep volume, deep folds, cheeks, jaw line 6-12 months $540 first syringe

$490 each additional

Voluma Deep volume, cheeks 12-24 months $795 first syringe

$745

Frequently I mix and match fillers for different areas, placing Juvederm to enlarge the lips while placing Restylane in the nasolabial folds and lip lines.  And yes, I personally perform every facial filler injection (and Botox and Dysport injection) in my practice.  We use a very effective, potent anesthetic cream and have laughing gas available at no additional charge.

Before

After

This 54-year-old patient from Corinth presented to Dr. Friedman dissatisfied with the appearance of her face. Over a 2 year period, she underwent both Restylane and Juvederm injections to her nasolabial folds, marionette lines, corners of her mouth, and vermillion border, resulting in a more youthful face.

Before

After

This 56-year-old patient from Fort Worth presented to Dr. Friedman dissatisfied with the appearance of the lines around her mouth. Dr. Friedman performed Restylane injections to her nasolabial folds and upper lip, resulting in a more youthful appearance.

Before

After 3 years

After 5 years

This 59-year-old patient from Frisco presented from to Dr. Friedman dissatisfied with the appearance with her face. Over the past 5 years she has undergone routine Restylane and Juvederm injection to her jaw line, prejowl sulci, vermillion border of upper lip, marionette lines, and hollows of the cheeks, resulting in a younger appearance.

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