The dichotomy of dermal fillers: when does the biostimulatory response become one of regeneration versus one of replacement?
Many dermal fillers are classified as biostimulatory, meaning they stimulate the dermis to create new collagen, elastin, and other components of the extracellular matrix. Normal wound healing is also a biostimulatory process. It can be one of tissue replacement with scar formation, or one of true regenerative healing with functional restoration of the tissue. Dermal fillers can stimulate both types of healing, but to different degrees. This paper reviews this mechanism, exploring why some fillers seem to favour replacement, and some true regeneration. The patient's and the filler's propensity for late inflammatory reactions and their relationship to the biostimulatory characteristics of the product are examined as well.
Since the advent of injectable dermal fillers, the quest for the perfect filler has been a lofty goal. The perfect filler would integrate smoothly into tissue, cause minimal oedema and inflammation, be easily reversible, be devoid of any type of foreign body response, be non-allergenic, be stable and predictable, breaking down into to nonimmunogenic particles and be naturally absorbed or dissolved without incident. Unfortunately, such a filler does not exist. Since the Food and Drug Administration's (FDA) approval of injectable bovine collagen in the early 1980s, dozens of injectable filling agents have been developed; but history has taught us that new technologies must be used with care because complications can occur, sometimes many years after treatment (Kontis and Rivkin, 2009). Dermal fillers are no exception. While the vast majority of patients have good outcomes, late onset adverse reactions have been reported with all the available products on the market.
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