Botox & Injectable Facial Fillers

There is no doubt that aging causes visible changes to a person’s face. These changes are a natural process that tends to progress slowly. There is nothing that can truly reverse the aging process, and many people discover that the face looking back at them in the mirror appears older than they truly feel. Fortunately, there are excellent minimally invasive treatments available to help reverse some of the signs of aging and restore a more youthful but natural look. Injectable facial treatments are extremely popular in the U.S. and across the globe with two of the most popular treatments falling into the class of botulinum injections such as Botox® and dermal fillers.

Botox and injectable facial fillers work in very different ways so they are often used together in a complimentary fashion to provide optimal results. Facial fillers restore volume to tissue under the skin’s surface while Botox® reduces wrinkles that are caused by muscle activity. Through careful combination of these two treatment types along with regular skin care, a much more youthful look can often be restored without the need for surgery. 

Botox®

Botox® is a minimally invasive non-surgical treatment that reduces the appearance of facial wrinkles that are caused by repeated action of the underlying muscle. The repeated natural movements of the muscles in the face cause creases to form in the overlying skin. With time these creases can deepen and remain visible even when the muscle is at rest. Examples of this include horizontal lines in the forehead, vertical lines between the eyebrows, and radiating creases around the eyes and mouth. Botox® reduces the appearance of wrinkles by partially weakening the underlying muscle so there is less motion that causes the wrinkles. The goal is not to cause total immobility or a frozen appearance, but to maintain a natural look with some preserved movement.

How does Botox® work?

Botox® is made from purified botulinum toxin that is naturally produced by a certain type of bacteria and then suspended in a sterile solution for injection. Botox® is only one form of available botulinum toxin; other forms include Dysport®, Xeomin®, and Myobloc®. Botox® is FDA approved for the treatment of lines of the glabella between the eyebrows and crow’s feet around the eyes. Botox® has been used safely for years in many other regions of the face listed below. Botox® works by temporarily blocking transmission from the nerve to muscles which causes weakness; reducing the signs of aging related to repeated muscle use.

What areas can be treated?

• Vertical lines between brows “worry lines”
• Horizontal lines on forehead
• Lines radiating from the eye over the cheek bone “crow’s feet”
• Diagonal lines on either side of the nose “bunny lines”
• Lines radiating from mouth “lipstick lines”
• Banding in the neck
• Corner of mouth (lift)
• Outer aspect of eyebrow (lift)

How quickly does Botox® work and how long does it last?

Botox® begins to take effect after 24 to 48 hours and the full benefits of the injection will be apparent in one to two weeks. The effects of Botox® injections typically last around three to four months.

How is the injection performed?

Botox® injections are performed in the office with the injection placed into the desired area using a very fine needle. Several injection sites are used to spread the medication throughout the target muscle. There is mild discomfort associated with the needle injections, but this can be lessened by pre-treating with ice or topical numbing agents. Certain locations, such as the lips, may be more sensitive than others and nerve blocks can be performed if desired to minimize pain with the injection. The actual amount of medication given at each location is very small. Following the injection there may be a temporary area of raised skin that goes away quickly. There is a slight risk for developing a bruise at the injection site, but this can be limited by injection technique and icing the area after injection. Most people elect to return to work or other daily activities the same day as the injection.

What are the risks and side effects?

The primary risks of Botox® injection are pain or bruising at the injection site. Local allergic reactions are possible, but are quite rare. The goal of treatment is to specifically target injection into the desired muscle, but there is a possibility of the medication spreading to surrounding muscles. For injections around the eye this can potentially lead to temporary drooping of the upper eyelid or weakness of the muscles the move the eye leading to temporary double vision. Injections in the neck may rarely spread to muscles involved in swallowing and speaking.

Who should not get Botox®?

You should not get Botox® if you are pregnant, planning on getting pregnant, breastfeeding, have an infection in the area to be injected, taking certain antibiotics, have a history of neuromuscular disease or weakness, or are allergic to any of the ingredients in the Botox® or other botulinum toxin medications.

What are other uses of Botox®?
In addition to treating facial wrinkles, Botox® can be used in a variety of ways. Botox® can be effective for some patients in treating migraine headaches or tension type headaches. Treatment of facial spasm, blepharospasm, or synkinesis resulting after facial paralysis or Bell’s palsy also shows improvement with Botox® treatment. Additionally, Botox® works to decrease secretions from certain glands such as the lacrimal glands that produce tears and the salivary glands (parotid and submandibular) that produce saliva.

Injectable Facial Fillers

Youthful faces tend to have more round and full features, while older faces develop areas of shadow that appear “sunken in”. Additionally, some facial structures descend with age and may accentuate a naturally occurring depression to form a deep furrow. Shadows can develop on the face under the eyes, around the mouth, and in the cheeks that can contribute to a somewhat tired or deflated look. Facial fillers work to counteract these changes by adding volume to specific areas under the skin. This can help restore volume that may have been lost due to aging, or augment an area that is deficient in volume such as the lips.

How do facial fillers work?

Two of the most popular classes of facial fillers are made of hyaluronic acid (HA) and calcium hydroxylapatite. HA is a naturally occurring molecule found in the skin, and loss of this molecule with aging contributes to some of the volume loss that occurs. There are multiple formulations of HA fillers made by several companies with examples including: Juvederm®, Juvaderm-Voluma®, Restylane®, Restylane Silk®, and Belotero®. Each product contains an HA gel with slight variations in particle size and viscosity that is formulated for different treatment areas. Thinner gels with smaller particles are better for treating fine lines in thin skin regions, while thicker gels with larger particles are used for deeper creases or overall volume restoration in areas with thicker skin. The HA works by directly restoring volume at the site of injection and by attracting water to the area for added volume and moisture. Over time the HA is slowly broken down by the body through a natural process, but the injection can also be reversed by an injectable enzyme that can breakdown the HA more rapidly if needed.

Calcium hydroxylapatite (Radiesse®) is made of calcium based microspheres suspended in a carrier gel. This filler works in a slightly different way than HA fillers. At the time of injection the improvement in volume seen is directly related to the product injected. With time, the filler helps stimulate the body’s natural production of collagen and as the filler is broken down only the natural collagen remains. This filler is firmer than most HA fillers and is injected in a deeper location under the skin to help minimize deep creases like nasolabial folds or add volume and provide lift to larger facial structures like the cheek and jaw line. There is no reversal agent for Radiesse® filler, but the product will be naturally broken down over time.

What areas can be treated?

Multiple areas of the face can be treated with filler injections and the ultimate locations chosen depend on the specific anatomy and desires of every person. Some of the most common treatment areas include:

• Temple
• Lower eyelid shadows “tear trough”
• Midface – cheek bones
• Nasolabial fold “parenthesis lines”
• Lip lines
• Lips
• Marionette lines

How quickly do facial fillers work and how long do they last?

Unlike Botox® treatment that takes some time to become effective, filler injections are typically effective immediately. There may be some mild associated swelling following the injection that contributes to slight excess volume for the first few days, but once this swelling resolves the full effect of the filler can be seen. There is a wide range for duration of filler depending on the location of injection and specific filler used. HA fillers can last between six months to more than two years. The shortest time frames tend to be seen for injections in the lips which are more mobile than other facial structures and have quicker filler breakdown. The longer lasting fillers such as Juvaderm-Voluma® can last up to two years and the calcium hydroxylapatite filler Radiesse® lasts up to one year.

Many patients who return for a repeat filler injection find that they do not need as much volume to achieve the same result with repeated injections.

How is the injection performed?

Facial filler injections are easily performed in the office during a regular clinic visit. The filler is supplied in a sterile syringe and is injected under the skin with a specialized needle or cannula. Often the area to be injected is pre-treated with a topical anesthetic, and for particularly sensitive areas like the lips a nerve block can be performed if desired. Many of the fillers contain a local anesthetic as well, so treatment area is numbed during the injection. Following the injection the area may be treated with ice to decrease the chance for swelling or bruising to develop. Most patients choose to return to their regular daily schedule following their treatment.

What are the risks and side effects?

The most common risks of injectable fillers are minor and include pain or bruising at the injection side. There is also a risk of swelling or localized infection. Occasionally there may be some nodularity felt underneath the skin or localized inflammation at the site. This may require treatment with steroid injections or partial reversal of the filler in the case of HA fillers. Serious side effects are possible, but fortunately are very rare. These side effects are related to injection of the filler into a small blood vessel under the skin and can cause interruption of blood flow to the skin with resulting necrosis or infection of the skin. Blindness has been reported from filler injections around the eyes causing disruption of the blood flow to the eye, but this is also extremely rare.

Who should not get facial fillers?

Facial fillers used today are not derived from animal sources like the collagen fillers in the past, so there is no standard need for allergy tests to facial fillers before injections. Patients who have a known allergy to the filler or a product contained in the filler should not have injections. Injections should not be done at the site of a current infection. Caution should be taken when patients are on blood thinning medications as this may increase the risk of bruising or even hematoma with injection.

What are other uses for facial fillers?

Besides their widespread use for restoring facial volume due to aging, fillers have many other uses in reconstructive purposes. Facial defects related to trauma or surgery that cause volume depletion can be treated effectively with facial fillers. HIV-associated lipoatrophy can cause generalized loss of facial volume and responds very well to fillers. Fillers can also be used to augment intact facial structures that do not function well for another reason, such as injections into the lips of people with facial paralysis that causes trouble with drinking or speaking.