Comprehensive Review of Botox, Injectables / Dermal Fillers and Kybella by Dr. David Shafer
"Injectables" is a broad term that can be broken down into three general categories - neuromodulators (Botox Cosmetic to smooth dynamic lines), fillers (Juvederm to add volume or fill static lines and Voluma to lift the cheeks), and fat modulators (Kybella to melt fat under the chin). Informed consumers love that their doctors now have a range of non-invasive tools to help rejuvenate their entire face while maintaining a natural appearance. Many patients are hesitant to schedule a surgery but would consider doing an injectable treatment, which is minimally invasive. Other patients like the idea of combining a less invasive surgery with injectables to achieve a customized result. And post-surgical patients like maintaining their results with occasional injectable treatments. The currently available injectables are safe and effective and have a broad range of appeal and uses.
Often patients ask about laser or other energy-based technologies in addition to Botox and fillers. I explain that it is best to think of the face in 3 dimensions or layers – the skin is the outer layer, the soft tissue is the middle layer and the underlying facial bones are the inner structural layer. Lasers are excellent treatments for the outer skin texture and color, but do not add volume or affect facial structure or shape. Many fillers are excellent choices to add thickness to the soft tissue layer such as enhancing the cheeks (Voluma, Sculptra), filling creases (Juvederm, Restylane) or enhancing the lips (Juvederm) or smoothing peri-oral lines (Volbella, Belotero, Restylane Silk). Other fillers (Voluma, Radiesse) are great for adding structure to lift the cheeks, define the jawline or camouflage a crooked nasal bone (non-surgical rhinoplasty). In fact, these fillers have largely replaced cheek implants as they can achieve an instant, natural appearing result in one office visit. Treatments such as Ultherapy do not add volume but do help tighten the middle layer to help lift tissues.
The next question patients ask is which injectable or treatment should they have. In most cases, one filler or treatment is not the answer. Often the answer is all the above – but customized to the patient’s anatomy and desired result. During my consultation process, I have patients prioritize what they would like to achieve and then we map out a plan for injectables and laser treatments based on timeline, budget and recovery time. At the same time, we also start a daily skincare regimen for skin maintenance and good nutrition to enhance skin health.
There is no specific age requirement for injectable treatments. The clinical decision depends on the individual patient and the condition being treated. As an example, Botox treats dynamic lines around the eyes and upper face. Dynamic lines are those that are caused by movement of the underlying muscle. With the muscle movement, the overlying skin folds and causes visible wrinkles. With Botox treatment, the muscle contraction is weakened and the overlying dynamic wrinkle is lessoned. Over time, in patients that don’t use Botox, the dynamic wrinkle turns into a static line that is present even at rest. These are lines associated with normal aging and stress. Think of someone who is always squinting or frowning – these people have deep creases around their eyes, between their eyebrows on their forehead. Early and effective treatment with Botox can not only reduce the dynamic lines associated with movement but also soften or eliminate the static lines as well. If a person in their 20s in constantly staring into a computer concentrating they may develop static glabellar lines (between the eyebrows) at a much younger age and seek Botox treatment earlier than someone else. A lifeguard who is constantly squinting in the bright sun may develop crow’s feet lines around their eyes at a much younger age than someone else. This person would be a good candidate for Botox treatment around their crow’s feet at a younger age than someone that does not squint as much. For fillers, a patient may naturally have sunken eyes and look tired even though they get plenty of sleep. A simple filler injection under their eyes can make a remarkable difference smoothing their lid-cheek junction and rejuvenating their appearance regardless of age.
It is best to categorize the injectables based on action. Many patients get confused about what each product does. For instance, you would not want Botox injected in your lips as you would be unable to speak properly or hold food in your mouth. The fine muscle action of your lips and mouth is very important for functioning. Conversely, the softening of muscle action between your eyebrows and to the sides of your eyes when done correctly gives a nice rejuvenating effect while maintaining a natural appearance. The newest of the injectables is Kybella, which was recently approved by the FDA. While Botox smooths wrinkles around the eyes and forehead by softening muscle action, Juvederm and other fillers smooth wrinkles around the mouth and contour the cheeks and lips by adding volume, Kybella is the first and only FDA approved fat melter - specifically for under the chin.
Fillers can be subdivided into hyaluronic acid (Juvederm, Voluma, Restylane, Belotero, Volbella, Restylane Silk), calcium hydroxyapatite (Radiesse), and poly L-lactic acid (Sculptra). Each brand of filler also has sub-categories based on concentration of product (For example, Juvederm Ultra versus Juvederm Ultra Plus) and also whether the product is mixed with anesthetic (For example, Restylane versus Restylane-L). These are all temporary fillers. There are also permanent fillers such as liquid silicone, which I do not recommend anyone have injected because of potential permanent complications. Finally, for patients interested in a more invasive procedure, the patient’s own fat can be harvested in a mini-liposuction technique and that fat can be injected back into the same patient similar to fillers.
Hyaluronic Acid Fillers
When looking broadly at the categories of fillers, hyaluronic acid (HA) fillers are excellent for first time patients and can be injected almost anywhere. Depending on the product, the FDA approval is for nasolabial lines or cheeks or lips, but these fillers are great for eyelids, eyebrows, forehead lines, nose and even the hands – almost anywhere you can think to add volume or shape – when injected by a qualified and experienced injector.
The greatest advantage is that they are the only filler category that is reversible. Meaning that there is an enzyme, hyaluronidase, which can “melt” the filler almost instantly. This has been revolutionary in treating patients with filler. I see many consultations of patients with filler mishaps injected elsewhere who want corrections. If they were treated with HA fillers such as Juvederm, Voluma, Restylane or Belotero, these are easily fixable by melting the filler. Another advantage of HA fillers is that they are made out of a molecule that is naturally found in our skin, so there is minimal tissue reaction and high compatibility with the body.
The brands differ by their concentration of hyaluronic acid and bonding between the molecules. For instance, Juvederm Voluma XC is tightly bound and acts more like a spring when injected onto the cheekbone. It lifts the midface and does not swell like other fillers. It also lasts much longer (up to 2 years) because of the tight bonding. Belotero on the other hand, is very thin and smooth, so it can be injected very superficially with less risk of being seen through the skin or creating the appearance of a bluish tinge (a complication called the tyndall effect), which can occur with other fillers if injected superficially. The newest FDA approved filler, Volbella has positive properties of being soft, smooth and long lasting – making Volbella an excellent filler for fine lines on the upper lip and around the mouth.
The effect from HA fillers is instant. You see the results immediately after injection. The patient can expect some swelling for a day or so and minimal chance of bruising.
Off-label (non-FDA approved) uses of these fillers is common. For example, most of the HA fillers have approval for injection in the nasolabial folds (smile lines), cheeks or lips. However, it is very common for patients to request injections in the tear troughs under their eyes to help with dark circles, camouflage eye bags or fill a hollow area. Another off-label use of fillers is for non-surgical rhinoplasty. Injecting filler along the nasal bridge or tip can help shape the nose or improve symmetry. For many patients this can save them from needing invasive surgery or help correct any asymmetry, lumps or divots after nose surgery.
Cost for HA fillers can vary from city to city and injector to injector. Most commonly doctors charge by syringe. However, some charge by area or procedure. When charging by area for example, injecting the lower eyelids or lips might be more expensive than injecting the cheeks. In general one can expect to pay in the range of $700 -$1500 per syringe. Some products, such as Juvederm Voluma XC are considered premium and have a higher price. However, the longer duration of action actually makes the added cost a value in the long run.
The only product in this category is Radiesse. This is an excellent filler for experienced patients, as it is not reversible like the hyaluronic acid fillers. However, it has excellent lifting capacity when injected deep onto the cheek bone and is also great at adding volume. Additionally, for about the same price, it has 50% more product in the syringe for added value. It must be injected deeper in the skin and cannot be used for fine lines or wrinkles. It also cannot be used in the lips or lower lids – areas with thin skin.
An exciting new development is the FDA approval of Radiesse for rejuvenation of the hand. With aging, subcutaneous fat loss in the hand is telling. Injections of Radiesse into the dorsum of the hand help plump the soft tissue, cover veins and hide tendons. The results are instant and can last up to a year or even more.
One interesting off-label use is for nipple projection. Patients wanting improved nipple projection can have filler injected behind their nipple to help make their nipples more prominent and fuller.
Radiesse comes pre-packaged either with or without lidocaine mixed in the product. The cost is similar to the hyaluronic acid fillers ($700-$1200 per syringe)
Poly L-Lactic Acid
The only product in this category is Sculptra Aesthetic. Sculptra is unique in the filler category as you do not see the results instantly and you need up to three treatments, with 4-6 weeks between treatments for full correction. However, it’s the only filler which is good for generalized filling of larger areas.
The concept with Sculptra is the product stimulates you to grow your own soft tissue. The Poly L-Lactic Acid molecules are injected into the areas of treatment and over the next 4-6 weeks stimulate tissue growth. Patients like this effect as they can achieve a very natural appearance. However, it takes patience, as the effect is not instant. This is a good filler for someone who needs diffuse or generalized filling over their whole face or temples. It is not good for lips, eyelids or for targeted filling. It also takes some effort on the part of the patient, as the areas injected require massage for five minutes five times per day for five days after the injections. The results can be very long lasting – up to two years for more. And, often the subsequent treatments do not require as many injections for maintenance.
Areas to inject besides the face include the back of hands and some report nice results of diluted product injected through the decollete.
Sculptra comes in vials not syringes. Each treatment usually requires 1 to 2 vials per session. Each vial can cost in the range of $800-$1200 per vial.
The “freezers” or neuromodulators are Botox Cosmetic, Dysport and Xeomin. All three products work essentially the same. The action prevents dynamic wrinkles by temporarily weakening the underlying muscle. The most common areas of treatment are between the eyebrows (the frown lines or “11’s”), to the sides of the eyes (the crow’s feet) and the forehead lines. Other areas are the masseter (jaw) muscle to thin the cheeks, the vertical neckbands to lessen lines when you talk or clench your teeth and also used in the armpits or other areas to stop sweating.
Interestingly, there is a difference between what is FDA approved and how the product is used clinically. For example, everyone thinks of Botox being used for forehead wrinkles. However, the FDA approval for Botox is only for the glabella (between the eyebrows) and the crow’s feet (to the sides of the eyes), so the forehead is an “off-label” use though widely practiced. There are similar examples for the injectables as well.
Cost for Neuromodulators can be by Unit or by Area. Botox and Xeomin have similar Unit dosing while Dysport requires about three times as many units to achieve the same effect. However, Dysport costs about three times less per unit, so the price ends up being about the same. Costs can vary widely between city-to-city and injector-to-injector. However, the patient should keep in mind that they are not only paying for the cost of the product, but also the experience of the injector. Costs can range from $500 to $2000 depending on the number of areas being treated and who is injecting you. It cannot be emphasized enough that patients should not seek treatments based on cost alone. There is an ethical component in the preparation of the product and a skill in the injection of the product which can only be found in high quality offices and with highly trained and certified injectors.
After the injection, the effect of Botox can be seen within 3-5 days. In most patients, the average effect lasts for 3-5 months. So most patients have injections three times per year. My advice is to have repeat injections before the wrinkles fully return. There is evidence of a preventive effect of treatment, by relaxing the face and preventing the dynamic wrinkles from turning into permanent deep lines.
There is not one magic filler or injectable to treat all areas. Each injectable has different properties that I use to achieve specific goals. In most patients, I use a combination of different injectables to give that patient the most natural appearance. A typical patient will receive a combination of:
Botox Cosmetic in their glabella, forehead and crow’s feet.
Restylane in their lower lid/cheek junction and lips
Voluma XC in their midface, upper lateral cheeks
Juvederm Ultra Plus XC in their nasolabial folds
Juvederm Ultra XC in their lips
Volbella in their lips, perioral lines and crow's feet
Off-Label uses of filler is very common. Safety, however, is also very important. One advancement is the use of the cannula for injecting around the eye. The cannula is a blunt needle as opposed to a sharp needle that is most commonly used. This allows the injector to get closer to the lower lid and tear trough with less risk of puncturing an artery or vein. The cannula technique is not for every patient, but it is good to ask your injector if it is appropriate for the procedure you are having.
Some of the best off label uses of injectables are:
Botox (Every 4 months)
1. Masseter muscle injections. The masseter muscle is located in your lower jawline. In some people this a bulky muscle and can make the face look wider. Injecting Botox into the masseter can help slim and contour the lower face.
2. DAO muscle injections. The DAO muscle pulls the corners of the mouth down into a frown. In some people this gives them a resting sad look. Injecting Botox into the DAO muscle can help give some people a happier appearance at rest by lifting the corners of the mouth.
3. Neck bands. Those pesky vertical neck bands that appear when you are talking or flexing your neck. A few injections of Botox can help soften those bands and smooth your neck.
4. Bunny Lines. If you tend to scrunch your nose and get lots of wrinkles across the top of your nose, a few drops of Botox can help soften your nose lines.
5. Armpits. This is actually on-label but not often thought about for injections in your plastic surgeon’s office. Botox significantly stops sweat glands. A round of injections at the beginning of the summer can keep your dry through the season or before the important business meeting.
Fillers (Every 8 months)
1. Non-surgical rhinoplasty is a common off-label use of filler. If you have a slight asymmetry or bump on your nose, often filler can be use to shape or smooth your nose. Voluma XC is a good option as it is long lasting. Radiesse is also a nice filler, however it is not reversible if you do not like the results.
2. Temple injections. Sculptra Aesthetic and Voluma XC are the two most common fillers for this area. As we age, the temple area becomes hollow. Filling the temple area can be very rejuvenating.
3. Brow and forehead contouring. Injection with Voluma XC or Restylane Lyft along the supra-orbital ridge under the eyebrow can help lift and shape the eyebrow. Also, many patients are not happy with shape of their forehead and fillers can be used in a thin layer to contour the shape and projection.
4. Lower eyelid. Hollowness under the lower eyelids or a deep lid/cheek junction can be aging or make one look tired. Placing Restylane or Juvederm Ultra along the infra-orbital ridge and tear trough can help fill the hallowing and mask the lower eyelid bags helping to rejuvenate this area.
5. Jawline. Contouring along the jawline and chin can help mask the jowls or strengthen the jaw. The best fillers are Voluma XC, Restylane Lyft or Radiesse. In many ways, this is equivalent to an injectable chin implant. Many patients choose to try this out first before choosing to move forward with a permanent surgical chin implant procedure.
Modern day injectables are safe and effective. With the three categories of injectables - fillers, freezers and fat modulators - the injector is effectively able to sculpt to the face. However, there are limitations and a serious discussion must occur with every patient about their expectations. For instance, when a patient takes their fingers and pushes back their face in the mirror to simulate the result they are hoping to achieve with filler, I emphasize that surgical facelift is the only treatment that can accomplish that much lift of the skin. However, some technologies such as Ultherapy can give a slight lift and tightening for those not ready for surgery. I often ask my patients to trust my judgment. Sometimes patients lose touch with reality or sense of what is “normal” looking. For example, a little filler in the lip can look very nice. Sometimes after injections, the patient goes home, feels good, gets compliments on their results, and then returns in a few weeks wanting more filler in her lip. I have to tell her that more is not necessarily better. I have had some situations when I have said no and the patient has gone elsewhere and another doctor has injected more filler and caused considerable problems. The patient then returns to my office wanting their lips “fixed.” Fortunately, with the HA fillers we can “melt” the filler and start over. However, in most cases it is best to get it right the first time.
I would never suggest having permanent filler such as silicone. There is no turning back once these fillers are injected and they can have some long-term and not-reversible issues.
Another advantage of injectables is quick recovery. Most patients can have the treatments and return right back to work. If they are worried about bruising or swelling then I would suggest having the treatments on a Friday so they have the weekend to recover. Additionally, in our office we offer V Beam Perfecta laser when significantly decreases the appearance and resolution of bruising if needed.
Finally, Injectables offer a bridge to surgical procedures. While in the past patients may have gone right to surgical procedures such as brow lift or lower eyelid surgery, now with fillers, these procedures can be put off for several years if not forever. For other procedures a combination of surgery and injectables can allow for a less invasive or less extensive surgery with quicker recovery.
Injectables are real procedures and involve needles and medicines. There are risks even though they are very low. The most common risks are swelling and bruising. For Botox, the risk of swelling and bruising is very low. Any concern of Botox results are also temporary. Botox is always temporary. So if you do not like your results, there is no permanent effect.
For fillers, there is a slightly higher but still very low risk of swelling and bruising. Areas such and the lower eyelid and lips are more commonly swollen after injections and may require ice after the injection. I always warn patients not to schedule treatments on the same day as an important meeting or special date.
Kybella will have swelling for about a week and possible bruising. Many patients describe soreness similar to a flu shot, which can linger for a few days. Kybella also requires from 2 to 6 treatments to see full results of under chin melting.
A special note on bruising. There is a laser treatment, which we offer in our office called V Beam Perfecta. This laser helps bruising resolve about 80% faster than no treatment. So, even though the risk is low, we always ask patients to return to the office if they do develop a bruise so they can have a laser treatment. We also offer medical grade foundation (Oxygenetix) which helps cover any bruise or skin irritation while helping the underlying skin heal.
Other much less common risks include skin changes, infections and vascular injuries. That is why it is so important to have an experienced doctor performing your injections.
In the last year, Kybella was approved by the FDA. This is the first and only fat modulator / melter. This injectable is injected under the chin and melts the fat. The treatment takes up to 6 sessions separated by 4 weeks each. There is some swelling after each treatment as the fat is melted and absorbed. However, in the last several months since the FDA approval as I have treated many patients, I am seeing amazing results! The limitation is that injections are restricted to the central neck for on-label FDA use. So if you want contouring under your jawline, then you may want to consider neck liposuction instead. Additionally, if you have loose skin, then a neck lift may be more appropriate. Just like the other injectables, it is very important that you are evaluated by an experienced and qualified doctor prior to your treatment. Some interesting off-label uses of Kybella is shrinking the fat that bulges between the breast and armpit area, melting small fat deposits around the knees and even treating post-operative lumps and bumps to achieve a smoother result.
Volbella is the most recent filler approved by the FDA. Volbella builds on the vycross technology seen in Voluma helping the filler produce a smooth texture and maintaining results almost twice as long as other fillers. Volbella is FDA approved for peri-oral lines such as vertical lip lines and other creases around the mouth. I really enjoy injecting Volbella in these lines as I can achieve a nice and natural effect while not making the area appear puffy from too much volume. Another great use of Volbella is injecting the edges of the lips after filling with Juvederm. This extra effect helps smooth the lips and gives them a nice hydrated feel and appearance.
I am excited about new filler technology that is in the pipeline including longer lasting fillers and smoother particles, which will allow an even wider range of application for facial fillers.
An area related to injectables and bridging the gap between non-invasive and surgical procedures is fat grafting and PRP (Platelet Rich Plasma). With Fat Grafting, the patient’s fat is harvested under local anesthesia and the living fat cells are then re-injected similar to an injectable filler. As technology advances, these fat cells can be further isolated into categories including stem cells. While these treatments are more invasive than off-the-shelf fillers, the volumizing and rejuvenating effects of these injections show great results and are potentially longer lasting. With PRP, blood is drawn from the patient’s vein and then the blood is centrifuged and the components separated with the Platelet Rich Plasma isolated. This Platelet Rich Plasma layer has high concentration of growth factors and cytokines that are effective in healing and rejuvenating. The PRP layer is then injected similar to a filler or used topically on the skin to harvest the beneficial effects of the patient’s own growth factors. In combination with microneedling such as Rejuvapen or Aquagold can be injected through micro-channels created in the skin.
Finally, injectables are just one component to your overall appearance and skin health. Injectables help smooth wrinkles, fill lines, add volume and melt fat under the chin. This allows the doctor to no longer address just a wrinkle but the overall face as a whole. However, skin health depends on a healthy diet, good hydration (lots of water), protection from the harmful sun rays and dangerous toxins in the air (Pravage City Smart SPF), avoiding the harmful effects of smoking, maintaining a daily skincare regimen (Sente Dermal Repair, Skin Medica TNS serum) and maintenance with in-office procedures such as chemical peels, laser, Ultherapy and other treatments for fine lines and dyschromkias which are not treated by injectables.
For any patient interested in Botox, dermal fillers, Kybella, lasers and other aesthetic treatments, I recommend scheduling a consultation to review your options. It is important that you are evaluated by a board certified and qualified doctor with experience in the treatment you are seeking.