A woman’s right to choose is a beautiful thing—unless, of course, it means choosing between beautiful things. Laser or IPL? Kybella or lipo? Radiesse or Restylane? Welcome to This/That, where each month, we’ll compare two common solutions to popular aesthetic concerns, delivering all the pros, cons, and caveats you need to make safe, smart decisions.
Early last year, when I walked into my first injectables appointment at a swanky dermatologist’s office on New York City’s Upper East Side, I really had only one thing in mind: bigger lips. Not big in an unnatural sort of way, just slightly more voluminous—especially regarding my then nonexistent upper lip. What I didn’t foresee at the time were the many questions I’d be confronted with. Did I want a hyaluronic acid–based filler? Did I have a preference between Restylane Silk or Juvéderm Volbella? Was I aware of just how much swelling could potentially ensue? (No, I was not—and so I subsequently canceled all plans for the next three days.)
Fortunately, I was in the hands of a very knowledgeable dermatologist who took the time to walk me through my options and then chose for me when I still came up unsure, carefully explaining why he picked what he did. Since then, a handful of board-certified dermatologists have augmented my lips, each partial to a different filler and injection technique.
My point is this: even as someone who writes about skin for a living, I was still befuddled by the many nuances of filler. This is why it pays to seek out a board-certified physician who can guide you, of course—but, as I learned, it’s also wise to familiarize yourself with the products’ unique personalities before booking your appointment. Here, experts break down the two main categories of filler—hyaluronic acid (HA) and biostimulatory—along with all the pros and cons.
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What distinguishes HA fillers from biostimulatory fillers?
All fillers work to achieve similar goals—imparting substance and shape—however, the mechanism of action and ingredients used to do so differ. The primary ingredient in HA fillers, like Juvéderm and Restylane, is, as the name implies, hyaluronic acid.
“Hyaluronic acid is a sugar, [and] the body naturally makes hyaluronic acid as one of the building blocks of collagen,” explains Dr. Jason Chouake, a board-certified dermatologist in Cliffside Park, New Jersey. The “hyaluronic acid used in fillers is synthesized in a laboratory so that it is free of bacteria and other contaminants.” Among each brand, you’ll find multiple variations, each boasting specific traits: in the Juvéderm class is Ultra, Ultra Plus, Voluma, Vollure, and Volbella, and among the many iterations of Restylane are Silk, Lyft, Defyne, Refyne, and the original formula, classic Restylane.
“HA fillers differ in their various properties, including viscosity, cross-linking [the way the HA molecules are strung together], and their ability to provide lift or volume,” says board-certified New York City dermatologist Dr. Marisa Garshick. “The degree of cross-linking, for instance, can determine the firmness or flexibility of the product and guide the location that it’s best suited for.”
Firm, robust fillers with a higher HA concentration (like Restylane Lyft) are often used to define bony areas such as the chin and jawline; to buoy cheeks and temples; and to add fullness to the backs of the hands. Thinner formulas with a lower concentration, such as Restylane Silk, offer a softer, more subtle boost to delicate lips and nasolabial folds.
When injected into the body, the jellylike substance that is HA not only expands the tissue with its mere physical presence but absorbs water—up to 1,000 times its weight—which “causes swelling, to give volume and support to the surrounding structures,” explains Dr. Sarika Snell, a board-certified dermatologist in Washington, D.C. “As we age, we [naturally] lose hyaluronic acid, which can clinically result in volume loss, wrinkles, and sagging.”
Injecting HA leads to immediately plumper skin, since the molecules begin to draw in water right off the bat—and the effect will last anywhere from a few months to a couple of years, depending on the filler’s unique characteristics and how quickly your body breaks it down. Injectable HA has also been shown to boost the body’s natural collagen production.
Unlike their biostimulatory counterparts (coming up next), HAs can be reversed with a shot of hyaluronidase—something experts view as a gift, both aesthetically speaking (should you not love your new look) and from a safety POV (melting filler can prevent serious complications).
The dissolvant doesn’t work on biostimulators, such as Radiesse, Sculptra and Bellafill, which include ingredients that gradually spark collagen growth, explains Dr. Juliya Fisher, a board-certified dermatologist in New York City.
Sculptra is made of poly-L-lactic acid (PLLA), which “triggers an inflammatory reaction that both degrades the PLLA particles and stimulates collagen production,” Dr. Snell explains. Radiesse is composed of calcium hydroxyapatite—a material “identical to one of the components found in bone,” Dr. Fisher notes. Bellafill is a mix of polymethylmethacrylate beads and cow collagen.
While these three products share cell-activating abilities and are commonly discussed as a single entity—”biostimulators”—they really don’t have much else in common. Sculptra, for instance, is a liquidy suspension famous for inflating sunken areas, like cheeks and temples, in a very soft, diffuse way. Radiesse, on the other hand, is a dense paste that doctors use as a replacement for weak or time-eroded bone in areas like the chin and jawline. Bellafill, with its cow component, requires allergy testing before use, but some doctors like it for elevating depressed acne scars.
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Thanks to the uptick in collagen they yield, “biostimulatory fillers can provide a long-lasting result, without the need to repeat the treatment as frequently as with HA fillers,” Dr. Garshick says. However, “because they’re considered semipermanent, any issues that arise as a result of the treatment—lumps and bumps, for example—can be more challenging to reverse.” Sometimes lumps respond to massaging of the area; in other cases, injections of cortisone or saline can help resolve them. More stubborn nodules may require oral steroids or antibiotics. When all else fails, surgical removal is a last resort.
Generally speaking, potential side effects for both types of fillers are similar, with bruising, swelling, redness being the most common, and infections and arterial occlusions (or blockages) being severe but rare. Allergic and foreign-body reactions, which present as lumps, are more commonly associated with biostimulatory fillers (due to the nature of their ingredients) and can form at any time after injection—even years later.
Which type of filler is right for you?
This depends on a myriad of factors, but primarily: what part of the face or body you’re looking to treat and your degree of volume loss. “Biostimulatory and HA filler can be used together or separately, depending on the goals of a particular patient,” explains board-certified dermatologist Dr. Cather McKay in Daphne, Alabama. “Biostimulatory fillers are ideal for patients with more extreme or extensive volume loss, as well as for those who need revolumization throughout the face and body.”
Sculptra is frequently used to treat gaunt cheeks, hollow temples, and crepey skin on the body. A number of doctors also love the understated swell it gives to hips and butts.
Radiesse adds definition to bony areas of the face; restores skeletal hands; and can camouflage cellulite dimples on butts and thighs. “Although certain HAs, particularly Juvéderm Voluma and Restylane Lyft, are also designed to provide structural support and lift when injected on the bone,” says Dr. Garshick, on the whole, HAs tend to possess properties—lifting ability, water retention, a way of integrating into the skin—that make them better suited for delicate areas like the lips and tear troughs.
Another factor to consider when choosing a filler is cost—though this will also largely depend on the size of the treatment area. In general, fillers tend to range from $600 to $1,000 per syringe or vial, Dr. Snell says. According to RealSelf members, the average cost for Juvéderm and Restylane HA filler is $750. On the biostimulatory side, RealSelf members say the average cost is $1,050 for Radiesse; $1,900 for Sculptra; and $2,675 for Bellafill.
The bottom line
HA fillers are short-term in all regards: Their effects are instantaneous but wear off in a matter of months. For lip shaping, fine line filling, and under-eye circles, in particular, HAs rule because they offer a more targeted, predictable approach and can be reversed. More gradual and long-lasting, biostimulatory shots can help restore natural-looking structure and padding to larger, more significantly sunken areas. Since they can be more temperamental and are not easily undone, they require more know-how and skill on the part of the injector.
