Fillers – Juvederm, Restylane, Botox, Radiesse
The advantage of fillers over fat grafting is that these products are available in a syringe ready for injection and are fairly reliable in their effectiveness. They are used in many areas of the face, even though they are usually FDA approved for the folds between the corner of the mouth and the sides of the nostrils, which we call the nasolabial folds. So please understand that using them in all the other areas of the face is considered an off-label use.
Restylane® and Juvéderm®
The fillers I like to use are Restylane®, Juvéderm® Ultra Plus and Radiesse®. There are other fillers on the market, but they are usually similar in characteristics to the above products. Restylane and Juvéderm are both hyaluronic acids, a substance that occurs naturally in the body. There are various degrees in cross linking that makes one substance last longer. There are also other characteristics that make one stay in the precise place where you put it (Restylane) and the other to diffuse a little (Juvéderm). Experience is required to use the appropriate product for each area to get good results and avoid complications.
Radiesse is a hydroxyapatite, suspended in a gel that will absorb. As the gel absorbs, the particles of hydroxyapatite will stimulate collagen formation and create volume. This product is good for use where volume is needed.
In general, the longevity is dependent on the product, but is also dependent on where it is used. The less mobile an area is, the longer the product lasts. For example, Restylane could last for two years or more in the tear trough, but only six months in the lips, where there is a lot of motion. It also depends on the patient. In some patients, I have used Restylane for lip augmentation and I didn’t have to redo it for more than two years. In others, it lasts less than six months. Patients break down these products at different rates, and the only way to find out is to try.
Neuromodulators (Botox®, Dysport®)
These are both Botulinum Toxin type A. The muscles that cause frowning are stimulated by nerve endings. This happens at the neuromuscular junction where acetylcholine, one of the neurotransmitters, is released. Acetylcholine stimulates the muscle and causes contraction. Botulinum toxins block the release of acetylcholine and prevent muscle contraction. This happens only within a half an inch area where the injection is done with Botox, and a slightly larger area with Dysport. Only a specific area of a muscle is relaxed.
This effect has been used for many years to prevent abnormal muscle contractions, like in torticollis. The cosmetic benefit, however, is what has made Botox a blockbuster drug. Patients always tell me that they are worried about injecting a toxin in the body. My answer is that all drugs and even some foods are toxins. For example, one can die of an overdose of Tylenol, an over-the-counter drug. It’s all a question of dosage. In minimal doses, toxins can be perfectly safe and produce desirable effects. The doses of Botox used for cosmetic effects are indeed very safe.
These products are FDA-approved for the frown areas, but they are routinely used off label to reduce crow’s feet, forehead lines, platysma bands under the chin and other muscles like the ones that depress the corner of the mouth (depressor anguli oris). With knowledge of the anatomy of the facial musculature, one can produce a brow lift by weakening the depressors of the brows and allow the forehead (frontalis) muscle tone to pull the brow up. This effect can be used to shape the brow as well.
Recently, the FDA approved the use of Botox to relieve migraine headaches. I was instructed by Dr. Bahman Guyuron, who first discovered this effect. I have been using it ever since with success in patients with migraines. The theory is that the constant frown muscle contractions cause nerve irritation and trigger the migraine.
