Most fillers used today are hyaluronic acid; this material is injected under the skin and gives volume precisely at the location it is injected. Most of the time, these materials come in 1 ml syringes, so that a patient will receive one, two, or more syringes. To be fair, 1 ml is a small amount of material—a teaspoon is 5 ml—and so the treatment is precise and addresses a very specific area.

Fillers are best used to treat depressed wrinkles, such as the nasolabial folds, or areas that need more fullness, such as the cheekbones or lips. Sometimes it is injected into the tear trough or the prejowl sulcus. In these areas, the material increases the fullness and brings the skin out. It is important to remember that while sometimes an area needs more than one syringe, we also want to put as little as necessary to not overcorrect. A common strategy is to start with one syringe and then add more as needed. I also think it is very helpful to limit treatment to a single area (such as the left and right nasolabial folds), rather than to take a syringe and inject multiple areas in one session. Injecting multiple areas in one session, especially with one syringe, tends to result in multiple areas with minimal improvement which can be frustrating. Finally, I think it is important to remember that the goal is to make the face look holistically better, and that we are not dealing with a series of imperfections that need to all be addressed. The reality is that by making a few changes, the face can look considerably better. One strategy is to select one area that is of higher concern, or perhaps one area that is of concern and is particularly amenable to treatment and address that one area first. Often by improving one or two areas, the face looks good, and it is unnecessary to treat every single area that might have been identified for treatment. Ultimately the goal is to make as little intervention as needed to give a pleasing, natural appearing result.

Following treatment, it is helpful to apply ice for ten to fifteen minutes. The tissue swells and usually takes a few weeks for that to improve. In the lip, swelling can last up to one month, and this is important because the effect of the filler is usually visible in three to four weeks. Sometimes patients see the lips swollen at first and like the results, only to find it fades after a few weeks or month. It is not the filler that is fading, but the swelling, and the result at one month out is effect of filler alone without swelling. Fillers usually last for approximately one year, although some fillers last longer in certain locations on the face. Bruising sometimes occurs, but that usually is minimized with ice. Most patients who get fillers will repeat on an annual basis; in patients who want more volume, sometimes a syringe is placed every six months to keep the volume at a plumper level.

Fillers: Restylane, Lyft, Juvederm, Voluma

Injectables have revolutionized cosmetic treatments over the past two decades and have given us opportunities to help patients with a diverse array of needs and desires. Injectibles refer to those medications that are injected directly, and can be divided into two broad categories, the neuromodulators (such as Botox and Dysport), and fillers (Restylane, Juvederm, Voluma, and so forth).

Neuromodulators: Botox and Dysport

The neuromodulators work by relaxing muscle, and usually we are treating the upper 1/3 of the face—the glabella (the area between the eyebrows), forehead, and crow’s feet (the wrinkles on the outside of the eyes). There are many other areas on the face and throughout the body that are treated, but I usually try to limit treatment to these three areas which tend to work in a highly effective, reproducible manner.

There are several interesting features about these medications. First, they do not work immediately; they can take from three to seven days to have their effect. The implication is that I do not see the effect while treating, and so there is always some uncertainty about the treatment. I usually inject the same amount of medication on both sides, but if the muscles are slightly stronger on one side, asymmetry can result. Second, these agents are temporary. They last four to six months, and most begin to wear off after about five months, which is why most patients are scheduled for treatment every four to five months. Third, they do not have any known permanent effects, so that if you treat and then stop treating, you simply return to your state you would have been without medication. Finally, the results tend to improve over time. Assuming treatment occurs on a regular basis (every four to five months), each subsequent treatment tends to look better than the past, mainly because the muscles have a slight atrophy that smoothens the tissues. If a patient then stops treatment and the muscles become strong again, and then resumes treatment, the results resort back to that of an initial treatment.

Neuromodulators work by weakening the muscles, so that you will not be able to move the muscles as much. The result is that the skin does not wrinkle as deeply, and the glabella, forehead, and crow’s feet tend to soften. In my experience, the degree of relaxation is between 50-70%, and with time can increase above 90% with subsequent treatments given before the muscles have a chance to regain strength. Many patients have continued treatment for years, and we have not seen any long-term adverse effects, nor any resistance of which I am aware.

The position of the eyebrows can be a source of frustration for many patients, particularly following the first few treatments. The reality is that the forehead muscles raise the eyebrows, and as there is increased laxity with age, these muscles pull harder and create frowns and wrinkles in the forehead—these are the wrinkles that patients are often coming to treat. The neuromodulators work by making the muscles work less powerfully, and this has two effects: (1) the wrinkles will be reduced because the muscles cannot pull as hard, and (2) the eyebrows will drop because the muscles cannot pull as hard. The first effect is loved by patients; the second effect, not so much. The reality is that these two effects are linked by the same mechanism. We would love to have an agent that relaxes the wrinkles but lifts the eyebrows, but it doesn’t exist. There are two strategies to help patients with this dilemma. First, the amount of medication placed in the forehead can be moderated, so that we achieve a mild to moderate improvement in forehead wrinkles, without significantly dropping the eyebrows; by repeating treatment on a regular basis (every four to five months), the muscles will slowly atrophy and smoothen, and wrinkle reduction can be achieved without dropping the eyebrows. Second, in females, less medication can be placed over the outside of the eyebrows. This strategy allows the forehead to continue to pull the sides of the eyebrows up, offsetting any drop in the middle part of the eyebrow. Of course, the degree to which the lateral eyebrow elevates tends to vary based on how strong the forehead muscles are on the sides; some patients have very strong muscles here, and some patients’ muscles are mild on the sides. Of note, there are other strategies to raise the eyebrows (such as injecting antagonist muscles under or on the eyebrows), but I have found these maneuvers to be inconsistent in their results and can be associated with problematic side effects such as eyelid drooping; I find the risks do not warrant the use of these other strategies.

After treatment, there are often small bumps and sometimes bruising that usually resolve promptly. I ask that ice be applied for the first ten minutes on the treatment sites, and at that point no further intervention is needed. There is no need to limit your activity afterwards—no need to limit head position, exercise, or any dietary changes.

Injectables: Botox, Dysport, and Fillers