People have long dreamt of finding the elixir of life. Indeed, the notion that, no matter how old you are, you can still look young is a tremendously lucrative driver of many marketing and brand campaigns.
What changes appear on the face over time? Aging loosens the skin's elasticity and reduces the number of fat cells, which results in loose skin and visible troughs. These are many in number and type, including 'tear troughs' that run diagonally from the internal side of an eye, 'nasolabial folds' that got deeper by the sagging cheeks, 'marionette lines' around the bottom lip, 'glabella lines or frown lines' on the glabella when frowning, and 'forehead wrinkles', created by using the forehead muscles to lift sagging upper eyelids.

There are two options that are commonly used to tighten up loose or sagging skin. And, indeed, the same methods are applied to restoring aging skin. The first option is cosmetic surgery to recover the skin's elasticity, which can be likened to tightening up the neck of the sack in order that the remaining matter inside the sack can fully fill the sack up. The second option is to fill up the sack by putting more materials into it which, in aesthetic facial recontouring, means filling the skin with materials by autologous fat injection or injectable cosmetic fillers. Autologous fat grafting is safe because it uses self-donated fat tissues. However, cosmetic fillers are more in use these days because autologous fat grafting has a high absorption rate that may require repetitive injections. Moreover, while the transferred fat tissue can survive in the shorter term, given the pain and effort that were input, its result is difficult to predict.

The Korean cosmetic filler market is estimated to be worth hundreds of billions of KRW. In other words, there are a great number of Koreans and overseas patients who choose to opt for a filler procedure. Fillers need a strict medical examination because they are injected into the body. The paraffin or silicon illegally used at beauty parlors in the past were very hazardous and should never have been used.

Hyaluronic acid fillers are currently the most popular type of fillers in the world. CLEVIEL by AMOREPACIFIC Group's AESTURA is a Korean brand selling hyaluronic acid filler. Hyaluronic acid attracts water which has formed in large concentrations and safely maintain the volume. It can also be easily melted by injecting 'hyalase' if a patient does not like the result of the procedure. These features have contributed to its surging popularity. However, it lasts only 9 to 12 months, which has helped to spur the demand for permanent fillers. PMMA is one such permanent filler. This bone cement filler is injected in a powder form of 30-42 μ of polymethylmetacrylate (PMMA), with collagen made from calf skins used as the solvent. The injected PMMA microsphere forms a layer of collagen around it through the immunomechanism, which prevents it from being attacked by macrophages.

PMMA fillers have evolved since their launch. Artecoll was the only PMMA filler in Korea until AESTURA imported Artefill back in 2013. Several side effect cases (Granuloma, inflammatory nodules) were reported during the early period of Artecoll, but the manufacturer fixed the problems with repetitive washing technology. No more cases of such side effects have since been reported. Another type of side effect of PMMA fillers in the past was the large amount of PMMA in a filler product, which made it difficult to inject and sometimes caused the needle to become separated during the injection. There was one case in which the rough and uneven surface of the PMMA microsphere caused a foreign body reaction to the immunocytes and resulted in forming the uneven layers of collagen. This type of case was reported in academic papers in the 90s and is still cited as one of main risks of permanent fillers.

Fillers are now used not only to fill up facial wrinkles and troughs, but also to raise the height of the nasal bridge, to correct a weak chin, as well as dents in the forehead or the temporal region. However, it is fair to say that fillers can be as dangerous as autologous fat transfer. If the filler agent is accidently injected into a blood vessel, for example, it could flow into the blood vessels of the brain or the eyes. This can lead to partial skin necrosis, vision loss, and cerebral infarction. Vision loss is particularly common in Korea, which makes it critically important to get a specialist's help.

After all, even a well-made car can have an accident or not function well because of an incorrect driving style. The same goes for the permanent fillers that have been developed over the last 25 years. The technique of the doctor who performs the filler procedure can make all the difference. I was surprised by the lasting effect of permanent filler when my patients, who had received Artecoll for nasolabial folds 15-16 years ago, came back to see me to have an Artecoll procedure on other parts of their face. (Artecoll was the only permanent filler available in the Korean market until AESTURA imported and supplied Artefill in 2013). From my many years of experience in fillers, I can say that Artefill is a very soft and smoothly injected filler which can be used for various parts.