View from America

Dermal fillers
Blackwell Publishing, Ltd.

Leslie Baumann
Department of Dermatology, University of Miami, USA

Summary The new bioengineered human collagen products and the various hyaluronic acid (HA)
fillers are all safe and effective agents for soft tissue augmentation. There is no one best
filler for all purposes and optimal results are achieved by using these products in various
combinations. In my opinion, HA-containing products provide volume while collagen
products are better suited to provide structural support. Less downtime is associated with
the collagen products, due to the platelet-aggregating effects of collagen and the eosinophil-
stabilizing effects of lidocaine. Using collagen in combination with HA, during the same
office visit, may help reduce some of the bruising and swelling seen with HA alone.
Keywords: collagen, dermal filler, hyaluronic acid

Introduction
The goal of soft tissue augmentation is to safely achieve
a younger but natural appearance in facial skin. This
can be done by replacing some of the naturally occurring
building blocks of the dermal layer of the skin, particularly
collagen and glycosaminoglycans (GAGs), which are lost
through ageing. (Elastin, another important structural
component of the dermis, is not yet available as a filler
substance.) For nearly two decades, bovine collagen was
the dermal filler of choice in the United States. In the last
two years, human bioengineered collagen became popular.
With the recent approval in the US of two new hyaluronic
acid-containing fillers, more choices are available and
the techniques used are changing in response to the
abundance of options. These new substances do not
require skin testing and have a very low risk of allergic
reactions. Each of these fillers has specific properties that
should be considered when choosing which filler to use in
which anatomical location.
This paper outlines the author’s preferred approach to
using the newest dermal filling agents.
Correspondence: Leslie Baumann, 1295 North-west 14 Street, Suite K,
Miami, Florida 33125–1600, USA, E-mail: lsb@derm.net
Accepted for publication 26 November 2004
Collagen
Cosmoderm and Cosmoplast (Inamed Corporation, Santa
Barbara, CA) were approved by the FDA (Food and Drug
Administration) in March 2003. These agents contain
type I/type III human collagen, which are known to be
lost in aged skin.1,2 The collagen is derived from human
bioengineered dermis. Cosmoderm contains 35 mg/cc of
collagen dispersed in phosphate buffered saline solution
and 0.3% lidocaine. Cosmoplast is composed of these
ingredients, but is also cross-linked with gluteraldehyde
that extends the duration of the cosmetic correction.
Cosmoderm is better suited for superficial wrinkles, while
Cosmoplast is indicated for the treatment of deeper
wrinkles, scars and for enhancing the vermilion border
of the lips. When used in combination, Cosmoderm can
be layered over Cosmoplast to treat deeper furrows.
These collagen products have several distinct advan-
tages. Because collagen forms the natural scaffolding of
the skin, giving it support, Cosmoplast is the ideal filler
when trying to make an area stand up or trying to ‘give
it altitude’. For example, if it is desired to enhance the
vermillion border of the lip, Cosmoplast is ideal for getting
vermillion to stand proud. The same is true for the
corners of the mouth. In my opinion, there is no better
filler (with the exception of Zyplast which is similar), that
works as well to prop up the corners of the mouth. In

© 2004 Blackwell Publishing Ltd • Journal of Cosmetic Dermatology, 3, 249–250 249

Dermal fillers • Leslie Baumann
addition, the collagen contained in these fillers has platelet-
aggregating effects that are thought to help decrease
bruising.3,4 Both Cosmoderm and Cosmoplast contain
lidocaine, which are believed to be responsible for reduc-
ing the incidence of swelling and bruising by inhibiting
the activation of eosinophils.5 It is for these reasons, that
I often treat a particular patient first with Cosmoplast in
the mid dermis and then, in the same treatment visit, with
a hyaluronic acid filler at the same level in the mid dermis.
Hyaluronic acid
These agents contain naturally occurring chains of
hyaluronic acid (HA) that are cross-linked in order to
increase the amount of time that the HA remains in
the skin. The differences in the characteristics of these
products are due to the varying cross linking processes
used and the chain lengths of the HA. HA products do
not contain lidocaine. A downside to these is that HA
is structurally similar to heparin, thus leading to an
increased incidence of bruising. Restylane (Q-med,
Uppsala, Sweden; in the U.S. Medicis, Scottsdale, Arizona,
USA), was approved by the FDA in December 2003 and
Hylaform (Inamed Corporation, Santa Barbara, California,
USA) was approved in April 2004. Since these new
fillers have been added to the American market, many
new filling techniques are being adopted. For example,
Hylaform has a soft consistency that makes it ideal for use
in the body of the lips, cheek bone area, and jaw lines.
Restylane has a stiffer consistency that may make it more
useful in scars. Although the HA fillers lack the capacity
to provide the structural support conferred by the
collagen dermal fillers, they strongly bind water and
so provide greater volume than either Cosmoderm or
Cosmoplast. For this reason, it may be helpful to us HA
and bioengineered human collagen agents in combination.
The Cosmoplast is placed first in the mid dermis to
achieve about a 50% correction. Hylaform or Restylane is
then placed at the same mid dermal level. The cosmetic
250 © 2004 Blackwell Publishing Ltd • Journal of Cosmetic Dermatology, 3, 249– 250
results of these procedures are immediate and the corrections
with Restylane.6,7 Hylaform8 and Cosmoplast typically last
4–6 months.
Conclusion
Using a collagen-containing dermal filler immediately
prior to a hyaluronic acid product may improve the
cosmetic outcome and decrease the adverse events associated
with dermal filler use.
Acknowledgements
Financial disclosure: Leslie Baumann is a clinical
investigator for Inamed and Dermik.
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6 FDA Panel Proceedings November 21, 2003.
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8 FDA Panel Proceedings November 21, 2003.