Hyaluronic Acid Fillers May Cause Bone Resorption

Thank you for discussing hyaluronic acid fillers and potential bone resorption. Important information in itself and relevant for women also receiving Prolia Injections for post-breast cancer treatment and/or for osteporosis. More information and studies to further explore.

Hyaluronic Acid Fillers and Potential Bone Resorption

Hyaluronic acid (HA) is a compound that is naturally occurring in the body but is most abundantly present in the skin. HA functions as a reservoir for moisture which maintains tissue structure, and aids in tissue repair by activating immune cells and mediating anti- inflammatory reactions. As we age, our skin loses moisture, thus causing our skin to show signs of aging like fine lines and wrinkles. Maintaining adequate skin moisture is key to maintaining youthful skin, of which hyaluronic acid is a key component (Papakonstantinou E).

                  Injectable hyaluronic acid (HA) is a dermal filler that is used to reduce the appearance of fine lines and wrinkles and create structure in the face. It is a popular cosmetic injection product for aesthetic improvements. There are various forms of HA fillers that vary in composition as well as suitable location to be used for injection. Popular brand names include Restylane, Juvederm, and Hylaform. HA fillers differ in concentration. Higher concentrations have greater tissue displacement and exert their effects for longer periods of time (Gold MH). Side effects associated with HA fillers include swelling, bruising, lumps and bumps, bleeding, and redness at the injection sites. Uncommon side effects include numbness, allergic reactions, blistering, and filler migration (ASDS).

There is anecdotal evidence that has prompted studies of the incidence of bone resorption after receiving HA fillers. A preliminary retrospective cohort study in China found that bone resorption can occur when fillers are injected into dermal layers located in areas close to facial bones, such as the chin or the cheekbones. Additionally, certain fillers have a higher propensity to form hard capsules, or granulomas, which can also cause bone resorption due to the pressure created from capsule formation (Lee W).

Based on available literature, there is no true causative relationship between HA fillers and bone resorption, and therefore this is not a true reaction that patients and providers should worry about when it comes to using HA fillers. If patients are worried about the safety of HA fillers, they should speak to a licensed and knowledgeable provider and if willing to receive the injections, to get them from a licensed and trained individual that uses proper technique and products that are suitable for patient- specific concerns.

Citations:

ASDS. Injectable Hyaluronic Acid , American Society for Dermatologic Surgery, 2024, www.asds.net/skin-experts/skin-treatments/injectables/injectable-hyaluronic-acid. 

Gold MH. Use of hyaluronic acid fillers for the treatment of the aging face. Clin Interv Aging. 2007;2(3):369-376. doi:10.2147/cia.s1244

Lee W, Yang, E. Unexpected Bone Resorption in Mentum Induced by the Soft-Tissue Filler Hyaluronic Acid: A Preliminary Retrospective Cohort Study of Asian Patients. Plastic and Reconstructive Surgery 147(6):p 1063e-1064e, June 2021. | DOI: 10.1097/PRS.0000000000007926

Papakonstantinou E, Roth M, Karakiulakis G. Hyaluronic acid: A key molecule in skin aging. Dermatoendocrinol. 2012;4(3):253-258. doi:10.4161/derm.21923

There are several different types of dermal fillers and it is important to note the most common types of fillers. These examples include polylactic acid (brand name includes Sculptra), polyalkylimide (brand name includes Aquamid), calcium hydroxylapatite (brand name includes Radiesse), and hyaluronic acid (brand names include Captique, Elevess, Juvederm, and Restylane). Hyaluronic acid is a natural substance which is already readily found in our bodies, predominantly in the soft connective tissues and in the fluid surrounding a person’s eyes. It is administered as an injectable filler through extraction followed subsequently by reformulation. Albeit hyaluronic acid injections can be utilized as dermal fillers to improve one’s appearance, they can also be used as injections for treating the painful aching joints in the target areas for arthritis patients. Hyaluronic acid is typically deemed as a harder filler (versus a softer filler which is predominantly used in the lips) which is predominantly used to enhance a person’s cheekbones which are directly near the mandibular area.

It is important to note that injectable hyaluronic acid (HA) is a temporary dermal filler. As we inevitably age, the bone, fat, muscles, and skin in our face start to thin. This leads to our faces having a sagging or even a sunken appearance of the face, wrinkles, thin lips, and folds. The loss of volume in our faces can be treated with injectable HA to reduce the appearance of both these fine lines and wrinkles. The effects are seen immediately. If this sounds too good to be true, it is because injectable HA can have side effects and one must ask themself if the pros outweigh the cons for receiving these types of fillers. Most side effects are either immediate or short-term, categorized as occurring within the first one to two weeks after the original intervention. The majority of these side effects are inflammatory responses to tissue damage combined with the introduction of the foreign material of HA and include swelling, pain, tenderness and bruising. These reactions are very common. However, some, albeit rare, long-term effects are much more serious and need to be factored in consultations.

Hyaluronic acid fillers may cause bone resorption, specifically when these fillers are done in conjunction with jawline augmentation which is a common procedure. Bone resorption is, simply put, the breaking down and reabsorbing bones back into the body. Complications of bone resorption would include facial changes such as both the lips and cheeks sinking and/or shifting gradually over time and making it increasingly more difficult to get dentures and/or dental implants. In the article “Bone Resorption in Mentum Induced by Unexpected Soft-Tissue Filler”, a study demonstrated that there was evident bone resorption in the mentum following mandibular injection of 1 ml or more of hyaluronic acid (HA) filler. The authors of this study analyzed the impact of HA on bone resorption in the mentum as well as several other factors which included injection volume, injection interval, the number of injections, product and complications as well.

The study evaluated 80 patients and 160 cases from January 2014 to June 2019 and compared the computed tomographic scans of patients with or without mentum augmentation using HA. Patients who were injected with 1 ml or more per service of HA were more susceptible to bone erosion in comparison to the control group. The authors concluded that HA injection could induce bone resorption in the mentum, but the aesthetics were not impaired, and recommended that large-volume injection of HA should be performed with caution and patients should be informed about this potential complication preoperatively.

References-

What types of dermal fillers are available? American Society of Plastic Surgeons. https://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers/types

Injectable Hyaluronic Acid. American Society for Dermatologic Surgery. https://www.asds.net/skin-experts/skin-treatments/injectables/injectable-hyaluronic-acid

Edwards, P, Fantasia, J. Clinical Interventions in Aging. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686337/

What is Bone Resorption? Alaska Center for Oral + Facial Surgery. https://www.alaskaoralfacialsurgery.com/blog/what-is-bone-resorption/

Guo, X, Song, G, et al. Bone Resorption in Mentum Induced by Unexpected Soft-Tissue Filler. Aesthetic Surgery Journal. https://academic.oup.com/asj/article/38/10/NP147/5062983