Botox or Fillers?


One of the most frequent questions asked is, “Which product should I use and when should I use it?”

One generalization from the past was that Botox should only be used for upper facial areas and dermal fillers for lower facial areas.  With all of the scientific advancements in filler chemistry, there are now multiple dermal fillers on the market that can address virtually any facial area. 

Not that long ago, bovine-derived Collagen was the wrinkle filler of choice.  Allergy testing was necessary, and Collagen didn’t last in human tissues for very long.  With the popularity of liposuction, fat grafts also saw some use in some situations, and fat grafts are still used today.  However, fat grafting is a surgical procedure, and requires at least local anesthesia and a period of healing. In addition, fat grafts are not as good for fine lines or wrinkles as much as for contour depressions, such as hollow cheeks. More than one session may be needed for optimum results, but living grafts are permanent, and don’t require repeat visits after the surgical goals are reached.

In today’s fast-paced world, patients frequently want less down time when it comes to facial rejuvenation procedures.  They also want improvements that can bridge the gap between youthful and vital appearance and “needing a facelift,” or between cosmetics and cosmetic surgery! Today’s new products can make that happen.  Two of the newest types of physician-prescribed fillers include  hyaluronic acids (HA fillers--Restylane™, Juvederm™, Perlane™, or Juvederm Ultra Plus™) or calcium hydroxyapatite products (Radiesse™), all of which are substances that are fully bio-compatible with human tissues, and do not require allergy testing.  These fillers can be used in combination with Botox for an even better result.  This new world of products has opened up many exciting avenues for the rejuvenation process, and this combination of fillers and muscle paralytics has been termed the “Liquid Facelift.”  Of course, just as with surgical facelift procedures, the skill and experience of the injector can make the difference between a great result and a rather expensive bad one!

Radiesse™ is a filler that has been FDA-approved for severe wrinkles and deeper facial creases.  This product provides excellent results in the nasolabial folds.  It works splendidly for contouring cheekbones and refining jaw lines (in the fold between the jowls and chin).  This product is not recommended for lip enlargement; better temporary and permanent options exist that can give natural fullness without firmness or lumps.  Radiesse™ works great at restoring volume and helps reduce the signs of aging by smoothing out deeper contours.  Its use can stimulate localized collagen production in patients, allowing Radiesse™ results that have lasted up to a year or more.

Hyaluronic acids such as Juvederm™ or Restylane™ are products commonly known as HA fillers.  HA fillers are used to smooth out more superficial fine lines and wrinkles, like those around the lips and mouth.  These fillers replicate naturally-occurring substances in our tissues, and can also be used to layer on top of a deeper dermal filler (like Radiesse™).  Juvederm™ works great to smooth out fine lines and wrinkles, while Juvederm Ultra Plus™ can improve more severe wrinkles and helps to plump up the lips and smooth out areas of concern for a longer period of time.  Juvederm™ improvements can last 6-9 months or longer; the manufacturer utilizes proprietary Hylacross technology to produce a smooth gel filler with structural characteristics (molecular cross-linking) that helps Juvederm Ultra Plus™ remain stable in tissues for up to an entire year.

Botox is a pure specialized protein (Botulinum-A toxin) that inactivates muscle contraction by blocking the neuromuscular signals used by the body to stimulate muscle contraction.  It has been used for decades for treatment of eye muscle imbalance, facial tics (such as uncontrollable twitching), or in certain types of muscle spasm.  When used in the face for one of these medical reasons, it was noted that the wrinkles or expression lines were diminished or eliminated; this stimulated research and recent FDA-approval for cosmetic treatment of frown lines. 

Botox Cosmetic™ is produced in a laboratory under strict standards set by the FDA.  Botox is FDA-approved for treatment of frown lines or wrinkles in the area between your eyes, sometimes referred to as the 1’s, 11’s or 111’s, which describes how the wrinkles sometimes appear.  Effectiveness requires not only freshly reconstituted Botox that has been stored and prepared properly, but accurate injection into the target muscles that cause the unwanted wrinkles.  Technique and experience are critical to obtain the best results, not just the “cheapest” cost per unit. Botox (and fillers) may be administered only by a physician or physician-supervised Registered Nurse.

Generally, Botox will take 3-5 days from treatment to start working in an area.  It can take up to two weeks before you see the final degree of muscle relaxation and maximum improvement.  The benefits of Botox can last 3-6 months, though most patients do best with repeat treatment at 4 months.  The cost of Botox is dependent upon the amount used, measured in units.  A typical patient will find the cost of Botox for the glabella (frown area between the brows) is comparable to having a mocha or latte per day. 

Botox can be used in conjunction with dermal fillers.  When frown lines are particularly deep or persist even when the muscular contraction that caused them has been eliminated with Botox, dermal fillers can plump up the residual furrow and smooth this area beautifully.  Use of filler alone is not recommended, as continued muscular contraction can push the filler out of its beneficial position in the dermis, shortening its effective duration.  Use of Botox along with filler in these cases gives a better and longer-lasting effect than with either used alone. 

It is very common to have the Botox Cosmetic™, Juvederm™, and Radiesse™ products applied on the same day.  An even better result may be achieved by waiting for a week or two until the Botox has effectively paralyzed the target muscles; then any filler placed is not moved out of position by continued contraction of the frown or wrinkle muscle. Of course, an occasional patient may have some bruising and/or swelling after any injection; this generally is minimal, and may be covered with cosmetics.  Most patients return to their job or everyday activities the same day as their injections. 

Overall, patients have been very satisfied with the results they receive from their Botox and filler treatments as part of their Facial Rejuvenation Process.  We have found that patients are aware of what to expect because of the knowledge we help them obtain, resulting in optimal choices and a happier patient experience.  Patients feel more confident in making decisions once they have all the facts and information that our experienced staff can provide. This includes pre-injection evaluation and analysis that will let each prospective patient know whether the “Liquid Facelift” is for them, or if consultation for possible facelift surgery is more appropriate.

In most cases, we can work out a tailor-made, cost-effective plan for each patient, with their individual goals in mind.

Article by
Minneapolis Plastic Surgeon