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Which Injectable is Right for You?

Injectable treatments like Botox and dermal fillers are relatively new in the world of aesthetic medicine.  In fact, Botox received its first cosmetic indication for facial wrinkles in 2002, and the hyaluronic acid filler Restylane launched in Europe in 1996, receiving FDA approval in the United States a few years later.  In just a couple of decades, both Botox and dermal fillers have grown in popularity and treatment indications, expanding the nonsurgical aspect of aesthetic medicine at a rapid pace. The number of injectable treatments has seen a 40% increase in the past five years, and this trend has been apparent in our practice as well.  But which injectable treatments are right for you?  Dr. Fishman, our facial plastic surgeon, describes the different indications and characteristics of these medications.


What is Botox?

Botox is a muscle-relaxing medication, which is also called a neuromodulator or neurotoxin, says Dr. Fishman.  The generic name of Botox is botulinum toxin type A. There are 4 medications approved for the treatment of facial expression lines (also called dynamtic rhytids in the medical aesthetic space) as of 2022, and they are Botox, Dysport, Xeomin and Jeuveau.  Much like the brands Xerox and Kleenex, people often refer to the different muscle-relaxing medications by the Botox name.  These neuromodulators diminish the appearance of your wrinkles by temporarily relaxing the muscles underneath the skin; by treating directly the muscles responsible for frowning, for example, the overlying frown lines in the skin relax and often disappear.

While the term “neurotoxin” and “toxin” may sound scary, Botox and the other neuromodulators are some of the most studied and safe medications around.  These medications may be harmful in very large doses, but the amount you get during your aesthetic treatment is miniscule and rarely produces any harm outside of minor bruising and swelling.

While the FDA-approved indications for Botox and the related neuromodulators are frown, forehead, and crows feet or smile lines, these medications are very commonly used in an “off-label” manner to treat many other aesthetic concerns, including bunny lines (the crinkly lines that can form with smiling at the root of the nose), downturned corners of mouth, masseter hypertrophy (or too-bulky chewing muscles at the back of the jaw, which can contribute to tooth grinding), overly dimply chins, and platysmal banding (or vertical bands of muscle tissue which can appear in the neck).  Botox is used for a procedure called a lip flip, where small parts of the muscle around the mouth is relaxed and leads to a fuller, more pouty lip.  Outside of these cosmetic uses, Botox and the other neuromodulators are used to treat excess sweating of the scalp, face, neck, armpits, and hands; migraines; vocal cord problems; and muscle spasticity in a number of neurologic disorders.

Unlike dermal fillers, Botox and the other neuromodulator medications do not volumize tissues.  These can be used to improve the facial contours by making too-bulky muscles smaller and flatter, which is helpful in treating the too-masculine and square jaw in female patients with masseter hypertrophy; or make the lips appear fuller with a lip flip, for example.


What are Dermal Fillers?

Dermal fillers are volumizing medications, with the most popular fillers being made of a sugar substance called hyaluronic acid. Hyaluronic acid is a polysaccharide that is naturally formed by our body, and serves as plumping and cushioning in the skin and joints. Hyaluronic acid is highly hydrophilic meaning it attracts water. When injected as a gel-like substance, the filler will stay put while also attracting water molecules to plump up the area even more. Most hyaluronic acid fillers are made by bacteria, and look like clear, colorless gels; medications like Restylane, Juvederm, Voluma, and RHA are hyaloric acid dermal fillers.  Other popular types of dermal fillers are made of calcium crystals (eg Radiesse) or collagen-stimulating PLLA molecules (eg Sculptra).

While dermal fillers are mostly FDA approved for treatment of smile lines, volume-depleted cheeks, and lip augmentation, they have a myriad of “off-label” uses, says Dr. Fishman.  She commonly uses dermal fillers to perform facial balancing, and to add volume and improve the contour of too-thin temples; highlight and contour jawlines and chins; reshape noses; smooth crepey skin of the neck and decolletage; and improve the appearance of the backs of too-thin and veiny hands.  Dermal fillers are commonly used to treat certain types of undereye circles, by smoothing deep tear troughs under the eyes.  Dr. Fishman also frequently uses dermal fillers to fill in depressed acne scars.  Outside the face, dermal fillers enjoy popularity in smooth the neck and chest, improving the appearance of hands, buttocks, cellulite, and depressed body scars.


What are the differences between Botox and Dermal Fillers?

To start, these two products are composed of different ingredients. The muscle-relaxing neuromodulator in Botox targets expression or dynamic wrinkles, while the hyaluronic acid in dermal fillers helps volumize and recontour the face and other features.  Botox also takes up to 2 weeks to show its full effect, while dermal fillers show their effect immediately and can instantly recontour and rejuvenate the facial features. The effect of dermal fillers lasts for months to years, while Botox lasts 3-5 months for most patients.  While some patients benefit from one over the other, Dr. Fishman often uses both Botox and filler to optimize patients’ facial appearance, taking advantage of the different capabilities of these medications.


Botox or Fillers?

There are many differences between Botox and fillers–so which should you receive? The answer depends on your aesthetic concerns, treatment goals, and expectations.  If you are bothered by frown lines, crows feet, or wrinkles in the forehead, and these lines appear with muscle activity only, or are very very lightly etched in the skin, muscle-relaxing Botox may be a suitable option for you. If you are looking to contour your face or add more volume to your lips or chin, injectable dermal fillers would be a much better treatment option than Botox. Another factor to consider is that Botox can take up to two weeks for its full effect to show. On the other hand, you see instant effects with dermal filler injections.  Dr. Fishman recommends seeing a seasoned facial aesthetics expert to discuss your concerns and develop a thorough and customized treatment plan to optimize your appearance.

Ready to put your best face forward?  Schedule a consultation with our expert facial plastic surgeon today!

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