Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

PMID: 18688100

Standard guidelines for the use of dermal fillers

Maya Vedamurthy
 Member, IADVL Dermatosurgery Task Force* and Consultant Dermatologist, Apollo Hospitals, Chennai, India

Correspondence Address:
Maya Vedamurthy
Consultant Dermatologist, Apollo Hospitals, Chennai
How to cite this article:
Vedamurthy M. Standard guidelines for the use of dermal fillers. Indian J Dermatol Venereol Leprol 2008;74:23-27
Copyright: (C)2008 Indian Journal of Dermatology, Venereology, and Leprology


Currently used fillers vary greatly in their sources, efficacy duration and site of deposition; detailed knowledge of these properties is essential for administering them. Indications for fillers include facial lines (wrinkles, folds), lip enhancement, facial deformities, depressed scars, periocular melanoses, sunken eyes, dermatological diseases-angular cheilitis, scleroderma, AIDS lipoatrophy, earlobe plumping, earring ptosis, hand, neck, dιcolletι rejuvenation. Physicians' qualifications : Any qualified dermatologist may use fillers after receiving adequate training in the field. This may be obtained either during postgraduation or at any workshop dedicated to the subject of fillers. The physicians should have a thorough knowledge of the anatomy of the area designated to receive an injection of fillers and the aesthetic principles involved. They should also have a thorough knowledge of the chemical nature of the material of the filler, its longevity, injection techniques, and any possible side effects. Facility: Fillers can be administered in the dermatologist's minor procedure room. Preoperative counseling and informed consent: Detailed counseling with respect to the treatment, desired effects, and longevity of the filler should be discussed with the patient. Patients should be given brochures to study and adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. A consent form should include the type of filler, longevity expected and possible postoperative complications. Preoperative photography should be carried out. Choice of the filler depends on the site, type of defect, results needed, and the physician's experience. Injection technique and volume depend on the filler and the physician's preference, as outlined in these guidelines.
Keywords: Wrinkles, Static wrinkles, Aging, Scars, Fillers

Introduction [1],[2]

Dermal fillers are substances used in soft tissue augmentation to enhance or replace volume that is lost in any part of the skin or subcutaneous fat. Fillers form an effective tool in rejuvenation, either as a stand-alone treatment or in combination with other procedures such as Laser resurfacing or botulinum toxin. [1] The use of dermal fillers in soft tissue augmentation is undergoing a renaissance period with many new filler materials appearing in the market. The practice of soft tissue augmentation was started by Neuber in 1893, who took fat from the arms and transplanted it into facial defects. In 1899, paraffin was used and was later given up due to foreign body granulomasor paraffinomas. In the 1940s and 1950s, silicone was used extensively until the commissioner of the US-Food and Drug Administration (US-FDA) declared the use of injectable silicone to be illegal. The field of softtissue augmentation underwent a revolutionary change in the early 1970s when researchersat Stanford University worked on the use of animal and human collagen as implant materials. The search for an ideal, permanent dermal filler is still ongoing and no single,currently available filler meets all expectations of the physician.

Rationale and Scope

With an increasing number of filler materials flooding the market place, any physician practicing soft tissue augmentation should possess a thorough knowledge of the filler material, including the mode of action of every material, its technique of injection, its limitations, advantages and disadvantages. These guidelines provide a minimal framework for reference to the practicing dermatologist. The field of fillers is a rapidly evolving one, with new fillers being introduced every year but no controlled, long-term data for long-term efficacy and longevity. These guidelines are therefore based on available data and experience of the task force members.

Dermal Fillers-Materials, Characters, Types and Classification

Dermal filler products possess a number of attributes: substances, substance source, compounds, performance, duration and mechanism of action, consistency, approved indication(s), and substantiation. Preferences of patients and providers may differ. With temporary fillers, per injection costs are less and complications are minor and rare. However, long-term maintenance costs are higher due to the necessity of repeated injections. With longer-duration fillers, the time-and-cost horizon is shortened but any complication can potentially be more significant. A balance is achieved when all factors are taken into consideration and tempered by the provider′s expertise and the patient′s expectations and acceptance of potential outcomes. While the perfect filler is yet to be available, characteristics of optimal filler are listed in [Table - 1].

Types of Fillers [3],[4],[5]

Fillers can be classified based on different criteria:

1) Based on longevity: Fillers are classified as temporary, semipermanent, and permanent depending on the longevity of action, as shown in [Table - 2].

2) Based on site of placement

  • Dermal
  • Subdermal
  • Supraperiosteal

3) Based on origin of filler material

  • Heterograft
  • Allograft
  • Autograft
  • Synthetic material

[Table - 3] summarizes different fillers, site of placement, injection technique and their approval status from FDA.

Various brands are available in different parts of the world and it is therefore not possible to list every brand of filler available in the market. Annexure 1 shows different brands that are available. New fillers are introduced every year and it is therefore recommended that the physician seek full information from the manufacturer /distributor before using a filler.

Task Force Recommendations: Level D

  1. As mentioned above, it is generally recognized that permanent and semipermanent fillers have potentially more adverse effects than temporary fillers. It would therefore, be more prudent on the part of the treating physician to use a temporary filler, at least initially, as a first injection. However, if a patient chooses to opt for a semipermanent or permanent filler for cost considerations or for longevity of results, these may be administered after duly explaining all aspects about their potential adverse affects, and recording the facts in the informed consent form.
  2. In general, it is not advisable to inject different fillers in the same site in the same individual.
  3. Controlled data for the longevity of the filler materials published by the manufacturing company may not always be available. Both this and the fact that individual results may vary should be explained to the patient.
  4. Fillers from different countries are available in India and many of these may not have received approval from the drug authorities. It is therefore, not always possible to use only FDA-approved fillers in our country. In view of these facts, full information about the filler and its approval status should be sought from the distributor to learn about the filler substance. Moreover, every country has its own approval system and this should be taken into consideration.

Indications: Level C[3]

  1. Facial lines (wrinkles, folds)
  2. Lip enhancement
  3. Facial deformities
  4. Depressed scars
  5. Breast, buttock augmentation
  6. Periocular melanoses, sunken eyes
  7. Dermatological diseases-angular cheilitis, scleroderma, AIDS lipoatrophy
  8. Earlobe plumping, earring ptosis
  9. Hand, neck, dιcolletι rejuvenation

Of these, the most common indications of fillers are wrinkles, scars, lips, and lipoatrophy.

Informed consent should be taken after proper counseling of the patient. The consent form should include full details about the filler (chemical nature and source) to be administered, indication for which the filler is being used, expected longevity of results, its approval status, possible side effects and the cost.

Preoperative Preparation: Level C[6]

  1. History taking should include history of medications used, history of allergies, e.g ., the chances of bruising might increase in a patient on anticoagulant therapy.
  2. Clinical examination, particularly of the area being injected.
  3. Counseling as mentioned above.
  4. Preoperative photograpy is preferable.
  5. Informed consent should be taken as mentioned above.

Intraoperative Procedure: Level C[6]

  1. Clean the area to be injected and the surrounding skin with antiseptic.
  2. Anesthesia (Patient comfort technique) may be needed in certain situations and in sensitive patients. Dental block (infraorbital) is preferred for lips and nasolabial folds.
  3. Injection: Different techniques such as layering, tunneling, serial puncture and cross-hatching have been described. The choice of the technique depends on the physician. Volumes of injection at different sites are shown in [Table - 4]; however, this would vary depending on the depth of the fold / line / defect.

Postprocedural Precautions and Advice

  • Avoid exposure to extreme cold or heat
  • Avoid massaging treated areas for six hours
  • Avoid strenuous physical activity for six hours
  • Sleep with the head elevated for one night
  • Pain medication can be taken if needed
  • Resume skin care products such as retinoids, alphahydroxy acids the day after the procedure.

Complications: Level C [7],[8],[9],[10]

Complications are infrequentand usually minor; usually, permanent and long-term fillers have greater risk for complications. These include:

Immediate complications

  1. Pain
  2. Bruising
  3. Erythema
  4. Asymmetry, bumpiness, lumpiness
  5. Anaphylaxis
  6. Edema
  7. Acneiform eruptions

Late complications

  1. Inflammatory nodule
  2. Tyndall effect
  3. Allergic reactions
  4. Vascular occlusion
  5. Granulomas


In a short span of time, fillers have come to play an important role in the nonsurgical management of ageing skin. The technique is a safe, simple and effective modality, when used by a properly trained physician. Proper knowledge of the anatomy of the area of injection, aesthetic sense and proper patient selection are essential. Fillers can also be combined with other aesthetictreatments such as Botox, microdermabrasion, peels, thread-lifts, and Laser resurfacing. As in all aesthetic techniques, proper patient counseling with respect to achievable results is important.


The author is are indebted to Dr Apratim Goel for her inputs while preparing these guidelines

Naoum C, Dasiou - Plakida D. Dermalfiller materials and botulin toxin: Review. Int J Dermatol 2001;40:609-21. Level B
[Google Scholar]
Roenigk HH Jr. Treatment of the aging faces. In: Roenigk and Roenigk's Dermatologic surgery - Principles and practice - 2nd ed. New York: Marcel Dekker; 1996. p. 1057-76. Level B
[Google Scholar]
Baumann L. Soft tissue augmentation in cosmetic dermatology, principles and practice. New York; Tata McGraw Hill: 2003. p. 155-72. Level B
[Google Scholar]
Hanke WC. Filler materials. Year book of Dermatology and Dermatologic Surgery Mosby In: Thiers BH, Lang PG Jr, editors. Level B. 2004. p. 1-15.
[Google Scholar]
Cheng JT, Perkin SW, Hamilton MM. Collagen and injectable fillers. Otolaryngol Clin North Am 2002;35:73-85. Level C
[Google Scholar]
Klein AW. Temporary fillers. Techniques in dermatologic surgery editors. Keyvan Nouri Susana Leal Khouri Edinburgh, Mosby: 2003. p. 281-92. Level B
[Google Scholar]
Lupton JR, Alsters TS. Cutaneous hypersensitivity reaction to injectable hyaluronic acid gel. Dermatol Surg 2000;26:135-7. Level C
[Google Scholar]
Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial embolisation caused by injection of hyaluronic acid (Restylane). Br J Dermatol 2002;146:928. Level C
[Google Scholar]
Piacquadio D, Jarcho M, Goltz R. Clinical and laboratory studies - evaluation of hyalan B gel as a soft tissue augmentation implant material. J Am Acad Dermatol 1997;36:544-9. Level C
[Google Scholar]
Michaels P. Human anti hyaluronic acid antibodies: Is it possible? Dermatol Surg 2001;27:185-91. Level C
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections