If you ever look at a young person you will see how soft their skin is, how plump and how it recovers from each move and every gesture. How unblemished and how perfect the features. Clean, bouncy and as inviting as a hotel bed with new duvet and beautifully ironed sheets. Plump is the right word – all the tissues supporting the skin are plump and healthy; the fatty layer, the blood vessels, the supporting collagen fibres and the "ground substance", the hydrating gel.

Youth is wasted on the young, or so they say. Slowly and imperceptibly this supporting layer starts to lose its fullness. Like an apple drying in the fruit bowl, the skin starts to sag, to line and to pucker, eventually overhanging its bony margins at the jaw line and in the cheeks. In the absence of severe weight loss or other accelerating elements (smoking and sun abuse), volume loss precedes loss of elasticity by about seven years.

Many lines on the face are caused by volume loss much deeper down. Up till recently we filled the lines themselves, but now this new understanding has allowed us to replace the underlying volume disturbance and achieve better, more natural and longer lasting results.

Many lines in the skin still need filling – cheek lines, nose to mouth lines, lips for example. For these areas subject to movement and micro-trauma to the skin/filler junction, the latest generation of fillers are very flexible. These quickly become incorporated into the skin and move as it moves, ensuring a smooth and long-lived result. Esthelis and Esthelis Soft (marketed as Belotero in the UK) are the flexible fillers that we use for lines on the skin. Cheek lines, crow's feet, forehead lines, lipstick lines and lines on the chest/décolleté area all respond well to fillers.

Cheeks are a sign of both youth and beauty. The cheeks highlight the eye area by catching the light. Together with the eyebrows they frame the eye, drawing the viewer's eyes to the target.  Regardless of bone structure the cheek area will disappear with age, leaving tell-tale signs – crows feet, nose to mouth folds, loss of facial balance and the "banana" – the fold above the nose to mouth area.

Young people have voluminous cheeks, as do "pretty" people, and loss of cheek volume can be quickly and easily restored with a filler. Longer-lasting products such as Restylane's Sub Q and Corneal's Voluma are used to build up the cheek area and lift the face. Both Sub Q and Voluma are designed to give instant results and last about one year. Voluma can also be used in the nose to mouth area.

Lying close to the bones of the face is yet another layer of fatty tissue. This, too, disappears with age, weight loss, stress, smoking and severe sun damage and can lead to a very craggy-looking face with chiselled features. This type of volume loss responds very well to Restylane Sub Q administered through the gum above the third tooth. It may sound horrible, but this is a remarkably non-invasive, safe technique with no pain and no injection sites, so no bruising. Because the volume close to the bone is replaced, the face fills out immediately and the chiselled features soften instantly. This is a technique increasingly preferred by our European colleagues in view of the safety aspects.
Another area of the face that shrinks with age is the chin. Even with good dentition this area slowly becomes smaller, pulling the mouth corners down and contributing to the marionette lines. This, too, responds well to Restylane Sub Q or to Voluma.

Lips, like the cheeks, are a sign of youth and fertility. The fleshy red aspect is due to circulating oestrogen, the female sex hormone. Young women have rich, fleshy red lips, and this is a sign of their oestrogen levels (=fertility). When red lipstick was first created it was banned by the Pope on the grounds that it incited and excited men. That may have been the case, but in fact we enhance our lips for ourselves, not for the men.

Lips require special treatment and there are two fillers created to withstand the constant movement of the lips and the physical trauma of heat and cold in food. Restylane Lipp and Surgiderms' Surgilips are designed for use in the lips. By carefully injecting either of these around the lip border and just under the thin skin of the lips they can be made full, fleshy and stunningly attractive once more. No longer do we inject large volumes into the lips, or in big lumps. By replacing the volume exactly where it is deficient we can achieve a natural and realistic result.

Up till now the fillers that we have described are based on the natural hydrating substance of our skin, hyaluronic acid (HA). HA has been used as a filler substance for over 15 years and technology has allowed the product to be made so that it is virtually pure and totally compatible with the human body. HA is a large sugar molecule that attracts water; it is a hydrating and lubricating agent and is identical across the mammalian and bird species. The first HA fillers were derived from the comb of the cockerel, but nowadays all HA comes from bacterial fermentation (the standard process for all biological substances). It has other even more exciting properties which will be explored in the Restylane Vital section.