1. Fat grafts.
   The new science of Structural fat Grafting of small parcels through multiple injections of fat harvested with little trauma and cleaned of blood and oils has contributed to better survival of the fat. About 60% of the fat is absorbed at 4-6 months. Costs range from $750 to $4,500 for the face. Low incidence of infection and lumps. Avoid lower lids and crowsfeet.
2. Fascia grafts soft tissue coverage.
   May resorb. Used in the nose as coverage of thinned areas. No allergy. Rare infection and thickening. One's own tissue and not rejected.
3. Dermal fat grafts.
   The dermis and fat of skin used for bulk. Requires donor scar for harvest and may be bulky. If placed carefully and fixed with internal sutures, it may serve as nice contouring agent and remain long term.

1. Collagen (Bovine)
   Cattle Protein, is the gold standard. Should be injected superficially as the lighter Zyderm II and deeper as the more enduring Zyplast, for lips, smile and frown lines.  Takes about 20-60 minutes. Fees are $300 to $4000. May last 3- 6 months done this way with both agents in one session. Some patients indicate it lasts only 1- 3 months if for example small amounts of Zyderm II are used alone, and by chance if Zyderm I ( the skin test collagen and the weakest of the three strengths) is used without combining it with the stronger formd). Skin testing required ( Zyderm I). 2-4% allergic reaction rate. Always absorbed 100% over time. Bumps can occur if injected too superficially and near the lids. Should not be injected deep into lips and facial fat. Can cause lumps around crowsfeet especially if Zyplast is used in larger doses. Cost about $300 / cc of syringe stock. Can use up to 6 cc around the mouth and lips in some cases. FDA Approval for small areas not lip substance injection for considerable bulk; late breakthrough allergic reactions reported.
2. Restoplast (same as Zyderm)
   Available only in Europe Lasts 3-6 months.
3. Fibrel (Human Plasma Collagen)
   Derived from blood taken from the patient and processed to form injectable collagen. Lasts 2-4 months. Costs $300 to $5000 for major bulk injections. No allergies. No skin testing required.   US YES.
4. Plasma Gel ( Human Plasma Collagen Mixed with Vitamin C)
   Derived from blood taken from the patient, and processed and mixed with a Vitamin C preparation. Lasts 2-4 months. 7-10% is said to be permanent. Costs $250-$500 for limited areas. No allergies. No skin testing required. US YES.
5. Dermalogen
   Human modified collagen matrix in phospate buffer at a neutral pH. No allergic reactions nor skin testing. Usuually 2-3 injections over a 3 months period. Does last longer than collagen and Fibril 3 - 6 months. $400 and up per injection. US YES.
6. Dermicol (collagen from unknown source)
   Colbar R&D Europe.  Lasts 4-6 months.
7. Isolagen
   A biopsy of your own tissue is processed by the company and expanded to increase the volumeof injectable material. Eight weeks after the processing it is ready to inject. You then have several injections scheduled. Does resorb moderately. Expensive. US YES.
8. Fascian
   Cadaver human tissue in particulate form. High absorption rate. Larger volumes like 3cc increments can be used deep in dermis as compared with collagen, but lasts about the same as for collagen. No allergy testing. Fees are $300 per syringe. Usually two are used for the lips. US YES.
9. Cymetra (Alloderm in Particle Form)
   Human particulate cadaver tissue processed to last longer than collagen. Injectable form of the sheets of tissue in Alloderm. No allergies and must be supplemented. More expensive than alloderm, and fascian $500-$1000 per syringe. US YES.
10. Alloderm (Life Cell Corporation Palo Alto, CA)
    Cadaver fascia that comes in sheets for soft tissue coverage and fill. Absorbs in lips and face at one year. May be stiff and bulky in lips. May last 1-3 years. Costs $1200 to $2500 for both lips. US YES.

1. Silicone Gel or Oil (MDX 4-4011) (Silikon 1000)
   Microdroplets are injected with medical grade material. Highly regulated. Only off-label use by selected few centers. Serious complications over time with larger volumes, including lumps, infection, extrusion, and thickening of the skin and underlying tissues. Costs vary. Difficult to correct lumps except by direct excision which leavings scarring.
2. Teflon Paste
   Glycerin plus polytetraflouroethylene. Severe chronic infections have occurred. It must be removed in several months. May transport to liver.
3. Bioplastique
   Initially encouraging in the early 1990s, a suspension of polymerized silicone particles ( 70u-140u), purported not to migrate around, dispersed in polyvinylpolypyrrolidone. Withdrawn from US markets due to chronic inflammation and rejection problems. Still available elsewhere. Surgical removal necessary leaving scars. Used in urethra for urinary incontinence. Feels the consistency of cartilage where injected.

Microspheres of Polymethylmethacrylate (20u-40u, 40u-60u)
Discovered in Germany pre-1936

1. Artecoll (32u-40u)
   Gelatin suspension of collagen or hyaluronate mixed with the above and with a local anesthetic 0.3% lidocaine. Gaining popularity worldwide. Selected centers in US. May receive FDA approval for on label use in 2003. 1% allergy and reactivity rate leaving bumps and redness. Stays firm! Used for 10 years with over 100,000 injections experience. Is steep learning curve
   to inject as small cylindrical parcels in deep dermis. The collagen component resorbs in 3 months and mixes with your own collagen. Liability already shown in US for its use. Requires an allergy test due to the protein. Use in the nose for irregularities, acne scars, and all folds and wrinkles of the face. Controlled absorption may last one year. Costs $600- $4000. Potential
   toxicity at more than 7 cc per year.
2. Metrex
   Canada. Initial results not encouraging.
3. Metacril makers of Metacylathe (40u-80u)
   Similar to Artecoll distributed in Brazil. Discovered in Germany. Polymethylmethacrylate micro beads. Spreads out below dermis in fat. Is permanent and hard to remove if nodules form Cost $400 per injection site. Allergy testing not known. Will not ever be approved in US.
4. Arteplast (20u-42u)
   Microspheres of polymethylmethacrylate suspended in bovine (cattle) collagen like plexiglass and is the same material as Artecoll. Particles felt to be too small compared with Artecoll and thus use discontinued and withdrawn.
   

Polyethylene Micro Beads

1. Profill or Profil
   Suspended polyethylene ( same as components in Porex who makes Medpor facial integrating implants) suspended in saline combined with collagen as a carrier. Reported as permanent. Allergy testing ? Really similar to Artecoll.beads but is polyethylene though.

Gortex ( Expanded Polytetraflouroethylene)
Strands or strings for the lips and folds $1200 to $2000 per lip.

1. Softform Implant
   Hollow tubes like cocktail straw size implanted into nasolabial folds and lip margins. Stiff and can coil and kink and extrude. Particles in the implant are 10u-100u. Severe late and chronic infection may lead to its removal. May be detected in the liver.

Synthetic Biocompatible Biodegradable Polymer ( Aliphatic Polyesters)

1. Polylactic Acid (New Fill) or PLA
   Safety by toxicology studies. Usually 4-5 sessions and repeat at one year. Selected Centers in the US. Costs $800- $6500.
2. Evolution
   Differing views on what this really is
   positively charged non-animal substance from a medical suture model. Attracts negatively charged pro-collagen particles. Injected volume decreases by 30 % and then thickens forming a mesh with collagen. No allergy test required and causes little swelling. $300 per syringe.
3. Restylane ( Q Med Labs in Sweden)
   Synthetic hyaluronic acid (used in knee joints to cushion for arthritis) A natural occurring substance in all living organisms. May integrate with bodies own hyaluronic acid. May last longer than collagen. Last 3-4 months in lips and 4-6 months in nasolabial folds. No skin testing required. Costs $300- $600 for limited areas. US Clinical Trials.
4. Perlane ( Q Med Labs in Sweden)
   Thicker version of Restylane for deeper folds and grooves near the mouth. Said to last 3-9 months. Costs not known. A few centers using in US in clinical trials.
5. Macrolane. (Q Med Labs in Sweden)
   Even thicker than Perlane and longer to absorb. May last up to 2 years. Being studied for Breast Augmentation as well. No skin testing but some are considering skin testing since it has such a lengthy resorption time. Costs not known. Only used in Sweden.
6. Rofilan Hylan Gel
   Hyaluronic acid mixed with acid agent to stabilize it. Larger particle size than hyaluronic gels of other topical fillers and suppose to last longer. Similar longevity as collagen and other hyaluronic acid fillers. No allergy testing. Cost $250 - $300. Not available in US.
7. Hylaform
   Similar to restylane but made from rooster combs which have hylaluronic acid No Allergy Testing but rare allergic reactions. Lasts 3- 12 months, usually the former. US Clinical Trials.
8. Juv'ederm (L.E.A. Derm)
   Hyaluronic Acid No allergy test. Lasts 3-6 months two forms for fine lines and bulk filling. Paris Not in US.
9. MacDermol
   (France mainly) No skin test known. Clear gel like restylane.
10. AcHyal (Europe, UK )
    Non animal based hyaluronic acid. Lasts 3-9 months.

Polyacrylamide Gels

1. Aquamid
   2.5% polyacrylamide gel in 97.5% water. No microparticles. Very elastic and no firmness. Purported to be longlasting. 243 cases in Europe in 2001 without serious side effects. Very expensive in the $900-$5000 range.
2. Bio-Alcamid
3. Formacryl
   Injectable polyacrylamide gel with 0.4% unpolymerized polyacrylamide. Termed an acrylic hydrogel suspended in 95% water. When water is absorbed stays plump like own tissue and does not harden. It retains fluid to create its plumpness. No allergy test. May be removed by aspirating out and said to be permanent. Late bacterial infection reported at 3-5 years and more inflammatory. Our EPA regulates acrylamide in drinking water and raises concerns. The levels in this preparation are very small. Not in US.
4. Argiform
   Europe and Russia production. Same as formacryl. Is antibacterial in this new form. The company Bioform in Russia says safer since presence of silver ions in preparation which repel bacteria. Permanent but can be removed by needle aspiration.
5. Bioformacryl
   Same as formacryl. Italian produced. Late problems like Formacryl.
6. Dermalive
   Acrylic hydrogel implant suspended in hyaluronic acid. Hardening and infection can occur. Removal difficult. Not designed for superficial lines in lips. Best for deep nasolabial folds.
7. DermaDeep
   Like Dermalive for even deep layers including below the dermis.
8. Amazing Gel
   Injectable hydrophilic polyacrylamide gel with unknown % of residual unpolymerized acrylamide. No skin testing is necessary. Same as Formacryl and clones.
9. Evolution
   Polyvinyl spheres in polyacrylamide gel Decreases then builds with time ? Permanent no allergy testing and minimal swelling. Not in US.
10. Outline
    Hydrophilic polyacrylamide hydrogel. No allergy test and minimal swelling Similar to Evolution ? Permanent ? Touchups