How can you recognize safe hyaluron fillers?

Aesthetic medicine would be unthinkable without them – hyaluron fillers are now considered the gold standard for combating wrinkles, fine lines, dry skin and volume deficits. That is why they can be found in practically every practice that offers medical-aesthetic treatments.

Although there are already more than 150 different hyaluron fillers on the European market, the stream of new products is not (yet) stopping. And hyaluron fillers are not only available in medical practices, but also on the Internet for free sale to end consumers. At the same time, prices are getting lower and lower and instructions on YouTube for self-treatment are becoming more and more numerous. What is the result of hyaluron fillers in the test? Regardless of this unfortunate development, is everything really of the same quality and safety just because the same ingredient is used? This question must be asked both as a patient and as a practitioner, as the number of side effects after hyaluron treatments continues to rise, albeit at an overall low level. There has even been a court ruling on filler treatments that have been unsuccessful.

Quality criteria for hyaluron fillers

Although the currently marketed hyaluron fillers have a lot in common at first glance, the differences lie, as so often, in the details. In recent years, extensive clinical studies have revealed more and more criteria that have brought to light major differences in tolerability, durability, treatment comfort and many other aspects in the supposedly uniform mass. However, before delving into the biophysical properties of filler products, it is also worth taking a look at the legal side.

New: CE Certification for Hyaluron Filler

Hyaluron fillers are gel implants and as such remain in the tissue for many months. Some manufacturers had taken advantage of a legal loophole that existed until then and marketed their fillers as cosmetic products. From May 2021, this will no longer be possible for new products. All tissue fillers will then be considered medical devices of the highest risk class and as such will require CE certification. This represents an important quality criterion. This is because, according to the new specifications, such implants must have many safety checks and clinical data on tolerability as well as on possible short- or long-term risks in order to receive such a certificate.

Even after product launch, annual safety updates must be provided in the form of further clinical data. In this way, a continuous risk-benefit review of the fillers takes place. This means increased safety for patients in the medium and long term. At the same time, a market shakeout will take place. Smaller producers, who under the current legal requirements of the German Medical Devices Act have so far hardly had to submit any data for their CE certificate, will no longer be able to meet the increased legal requirements, if only for cost reasons, and will have to leave the market.

Filler starting material animal or synthetic?

Today, modern hyaluronic fillers are generally produced from synthetically obtained hyaluronic acid. They are based on special strains of bacteria that secrete hyaluronic acid as part of their metabolic processes. This is then purified from the residual bacterial components in several passes and then further processed according to the recipe of the respective manufacturer. If the number and intensity of the cleansing processes are skimped on, tissue reactions can occur as a result of residues. In earlier years, there were products made from animal starting materials. Cock combs in particular, which are rich in hyaluron, were used for this purpose. The risk of intolerance was much higher then than today. A certain amount of protein is also found in synthetically produced fillers. However, incompatibilities are extremely rare in quality fillers due to the small quantities involved.

Face Contouring, Hyaluronic Filler, Filler, Wrinkle Injection, Juvéderm, Klinik am Rhein, Dr. Manassa, Allergan, Marina JagemannCross-linked for lasting effect

Natural hyaluronic acid has a retention time of 24-48 hours in the tissue. Therefore, to achieve a long-lasting filling effect, chemical additives called crosslinkers must help. The most common is an ester compound called BDDE (1,4-butanediol diglycidyl ether). Its use leads to a linking of the hyaluronic acid chains and thus to a prolonged retention time in the tissue. BDDE in itself is considered non-toxic by scientists. However, the art of manufacturing a filler is to find the right proportion of crosslinking to achieve optimal durability of the gel in the skin. On the other hand, the proportion of crosslinker must not be too high, otherwise there is a risk that an excessively modified hyaluron molecule will be recognized as a foreign body and cause corresponding undesirable reactions in the skin.

Hyaluron concentration important for volume build-up

In simplified terms, the hyaluron concentration in filler products allows a statement to be made about how much water a product is likely to be able to bind in the tissue and, consequently, what volume increase can be expected after injection. Basically, it can be said that one drop of hyaluronic acid can bind about 300 drops of water. Fillers generally consist of a proportion of low-molecular hyaluron (short hyaluron chains) and a proportion of long-chain hyaluron. The low-molecular-weight portion gives the product a certain fluidity and thus ensures that it can be squeezed out of the syringe and applied to the skin. Both portions bind water and thus provide volume build-up and moisture in the skin. The more precisely they are applied, the more individual the result.

How safe are fillers for injecting the skin? The opinion of renowned experts on results

Although the distinction into mono- or biphasic products lacks a certain scientificity, it has become established as a criterion for differentiating filler products. Ultimately, this approach attempts to describe different properties of hyaluronic gels. Monophasic gels have a very homogeneous gel structure. With them, it is often easier to achieve smooth transitions and more even results, as in face contouring with fillers. Biphasic products are characterized by more identifiable gel particles. They are therefore said to have a somewhat superior lifting and volumizing capacity, especially in thicker tissue, for example also for chin lifting.


High quality of filler products is essential for safe treatment of volume deficits and wrinkles, including the questions filler or facelift or even laser or filler? Patients should therefore inquire accordingly, especially before the first application, and not be satisfied with generalities. All too often, they do not know which products have been injected. This can be problematic for follow-up treatments, as it is not yet conclusively clear whether and which filler products from different manufacturers are compatible with each other. Even in the event of an adverse reaction, it is crucial for the attending physician to know the product that was administered. Only then can the appropriate measures be initiated. A filler guide can also help. Just as important for a side-effect-free and aesthetically pleasing result, however, is the training and experience of the practitioner. He or she is responsible not only for selecting the right product for the treatment area, but also for applying the right techniques in the right skin layers, because fillers are now also used for the body, for example for firmer arms. The patient should therefore also pay attention to this.

Text: Astrid Tomczak/mabelle