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Back in the old days (before 2003), only collagen and fat were used to fill wrinkles. Other than Botox, the hyaluronic acid wrinkle fillers have had the biggest impact on facial rejuvenation.

We have so many new fillers - it's hard for you to keep up. But I do the homework for you. I use a variety of fillers - Restylane Refyne and Defyne, Juvederm Volbella and Voluma, and others.

Hyaluronic acid wrinkles fillers are available in a variety of viscosities. Like maple syrup, they can be thin and watery or thick and gooey. Hyaluronic acid is a chemical that is already part of normal skin, but decreases as you age. This decrease is one of the reasons your skin loses moisture as it ages.

My technique for injection is very different than most other doctors. I teach my technique to the plastic surgery trainees at Columbia and Cornell Universities and have written a paper for the plastic surgery journal that will soon be published. Here's what I do:

First, I numb you up like a dentist does. I use lidocaine and numb up the four nerves in your mouth. You'll supplement this with EMLA anesthetic cream. Then I clean your skin with antiseptic and I use sterile gloves and a surgical mask. I treat this like a real procedure to minimize the chance of infection.

And then I go to town. I use what I call the "microdroplet technique", injecting teeny tiny drops of filler into each and every wrinkle. I inject the wrinkles that cause lipstick bleed, I buttress the edges of your lips, recreating your Cupid's Bow and that all-important philtrum. That's the spot in the center of your upper lip that women crushed flowers to disguise their breath a few hundred years ago. I typically inject 300-500 micro droplets. Don't faint - you shouldn't feel anything because I've numbed you up. To keep the procedure as safe as possible and minimize the chance of injecting into blood vessels, I use blunt tipped microcannulae. Everyone should.

I use thicker fillers, like Restylane Defyne, to plump out the deeper folds, such as the nasolabial folds, the marionette lines, and to smooth out the borders of the jowls.

I use even thicker fillers, like Juvederm Voluma, to enhance the cheek bones or fill out hollows in the cheeks. I can even use this to make your chin larger.

The new generation of wrinkle fillers last longer than the old ones. They begin to go away at about 9 months and are gone by a year and a half. Voluma lasts even longer.

I use filler mostly in the face, but I also use it to hide the veins and tendons on the back of your hands. If I've rejuvenated your 60 year old face, we don't want your hands to give away your real age! The best filler for the hands is called Radiesse. I've been using this for over a decade but I don't use it in the face anymore. It can cause lumps. But in the hands, it's the best material because it's thick and opaque. It does a great job at rejuvenating the hands and it lasts over a year.

Fat is the only material that has a chance of permanence. Most people are only too happy to give up a little fat, which is usually taken from the belly or hip area under local anesthesia. A space is then made for the fat, and the fat is placed under the skin. Fat is used to fill areas such as the nasolabial folds, the marionette lines, the lips, and other areas that are depressed. Since fat is harvested in a true surgical procedure, there are more risks to its use than with the commercially available fillers. Despite the popularity of fat grafting (and I've been doing it since 1987!), I try to dissuade people from having it. Why turn a simple office procedure into a surgical operation, with all the risks of surgery and an extended recover period? Interestingly, I've had people who I fat grafted and it's still there two decades later...and then I've seen people who I can't tell if it's there 6 months after the procedure. It's that variability that bothers me.

How about those permanent fillers like Bellafill or silicone? Sounds great, doesn’t it? But if there is a problem then the problem is also permanent. Or if an infection occurs, it can be a disaster. The only solution might be to cut out the area of skin! I strongly advise against permanent fillers.

Ok, here's the bad news about fillers:  there are risks, but other than bruising, they are rare. Infections can occur, but they are also rare. Nodules may occur, some even many months after the procedure, but they are very rare with the hyaluronic acid fillers. There is even a drug that can remove the filler (hyaluronidase) if too much is placed. If filler is inadvertantly injected into a blood vessel, a blister can occur or a whole patch of skin can die and be replaced with scar. And yes, there have been cases of blindness and strokes with fillers. These are one in a million risks...and the risk of driving to your appointment is actually much higher. But it's my legal and ethical obligation to tell you these things....