17 January 2020
Botox (Botulinum toxin) and dermal filler injections are two of the most common anti-aging treatments worldwide. Even though Botox (botulinum toxin) and dermal fillers have been used in dermatology for decades, there is still a lot of confusion among patients about these two treatments.
In a nutshell, Botox/ botulinum toxin injections are for relaxing muscles that cause wrinkles (e.g. crows feet and forehead wrinkles) or make the face look broad (jaw muscles). Dermal fillers replace volume in the face to restore facial balance (e.g. flat cheeks, laugh lines).
This review will address the differences, uses and effects of Botox vs Fillers and share about the latest updates for Botox and dermal filler treatments.
Botox is the trade name of Botulinum toxin, a toxin that has been purified from a bacteria called Clostridium Botulinum. The four main brands of Botulinum toxin that are US FDA approved and used commercially for treating wrinkles are: Botox, Dysport, Xeomin and Jeuveau. The first brand of Botulinum toxin that was made available for commercial use is Botox and this is why Botulinum toxin is synonymous with Botox.
Even though botulinum toxin is a deadly toxin, commercially available Botox for dermatological and anti-aging treatments is very safe. Botox has undergone stringent and rigorous extraction and purification to ensure the safety of Botox injections. Botox injections should also only be administered by experienced doctors to reduce the risk of side effects.
To learn more about the safety issues and side effects of Botox, Is Botox Deadly? 5 Things You Need to Know About Botox Safety will discuss these concerns in greater detail.
Botox/ botulinum toxin functions a neuromodulator to relax or reduce the activity of muscles. This allows Botox to reduce wrinkles or prevent wrinkles; reduce muscles in bruxism/ teeth grinding; and correct asymmetry or hypertrophic muscles (e.g. jaw slimming). The other common uses for Botox/ Botulinum toxin are to shrink enlarged face pores, tighten skin and treat excessive sweating (hyperhidrosis).
Let’s first understand processes that lead to wrinkles and hypertrophic muscles.
Botox/ botulinum toxin blocks nerve signals to muscles that tell the muscles to contract. In doing so, the muscle becomes relaxed. So if botox/ botulinum toxin is injected in the outer corners of the eye; the orbicularis oculi muscle relaxes and the crows’ feet wrinkles are removed.
Results of my crows feet wrinkles before and after botox. I use baby doses of botox to remove the wrinkles while preserving my facial expressions. When expertly done, the results of botox injections can be very natural looking while serving their anti-wrinkle functions.
Likewise, when botox or botulinum toxin is injected into the jaw muscles (also called the masseter muscles), the jaw/ masseter muscles relax. This is why jaw botox is used to treat teeth clenching or bruxism. As the jaw/ masseter muscles relax, they also become slim down for a slimmer and sharper face shape.
Unlike dermal fillers, the results of Botox/ botulinum toxin injections are not immediate. It can take approximately 1 week for wrinkles to be removed and 4-6 weeks for jaw botox to relax the muscles and slim down the jaw.
It stands to reason that if you have any of the conditions listed above: wrinkles; bruxism/ teeth grinding; broad face due to hypertrophic jaw muscles; excessive sweating and oily skin; large pores…etc; botox/ botulinum toxin injections are suitable for you.
The more important question is whether botox/ botulinum are safe for you. Botox/ botulinum toxin injections are contraindicated if you are or have the following conditions:
● Neurological conditions e.g. myaesthenia gravis
● Allergy to botulinum toxin or proteins used
● Infection or inflammation at the sites of injection
If you have the above mentioned conditions, botox/ botulinum toxin injections are not suitable. You will have to consider alternatives.
Botox/ botulinum toxin injections in dermatology and anti-aging treatments are very safe because only small doses of botox/ botulinum toxin are used. Of course, it helps to choose an experienced doctor with good anatomical knowledge to reduce risks of side effects. Some of the side effects of Botox/ botulinum toxin are related to injections in general; such as discomfort, swelling, bruising.
The other uncommon side effects from Botox/ botulinum toxin injections are related to the specific sites of injections. For example, Botox/ botulinum toxin injections for forehead wrinkles may cause a mild headache that is temporary. More about the specifics of these risks can be discussed with your doctor.
In a nutshell, Botox/ botulinum toxin treats conditions of the muscles like wrinkles and large pores, bruxism and broad faces. Dermal fillers are very different from Botox/ botulinum toxin injections. Dermal fillers are used to fill in lines, folds and areas of volume loss.
Dermal fillers are soft gels that are injected into the face to fill lines (e.g. laugh lines/ nasolabial folds) and static wrinkles; sculpt the face (e.g. nose and chin fillers); and treat sagging and volume loss (e.g. cheek fillers).
The most commonly used dermal fillers in Singapore are hyaluronic acid fillers. You may have heard of brands of dermal fillers like Juvederm, Restylane and Boletero which contain hyaluronic acid. There are other types of dermal fillers that are less commonly used such as Polycaprolactone (Ellanse), Poly-L-Lactic Acid (aka Sculptra) and Calcium hydroxylapatite (Radiesse). These non-hyaluronic acid fillers are also called collagen biostimulators.
In recent years, dermal fillers have progressed to be used as Skinboosters for skin hydration. By replenishing depleted hyaluronic acid levels in the skin; skin hydration and firmness are improved; and treat enlarged pores become smaller and acne scars become shallower.
Dermal fillers are used to fill in lines such as the nasolabial folds and static wrinkles. Dermal fillers also add volume so they can replace areas of volume loss in the face that have occured due to aging (e.g. temples and cheeks) and can gently lift the face to correct sagging.
When injected under the skin, hyaluronic acid dermal fillers plump up the face. Hyaluronic acid a water loving molecule, so it also attracts water molecules to hydrate the skin. Hyaluronic acid dermal fillers last approximately for one year. They are also reversible; and can be dissolved with an antidote called hyalase.
The other 3 types of fillers are also classified as collagen biostimulators. Polycaprolactone (Ellanse), Poly-L-Lactic Acid (aka Sculptra) and Calcium hydroxylapatite (Radiesse) stimulate new collagen formation (hello anti-aging!) and so their results last for at least 2 years; longer than hyaluronic acid fillers. However the drawback with collagen stimulator fillers is that results are not as obvious immediately as opposed hyaluronic acid fillers, so less instant gratification there.
Collagen biostimulator fillers also require a few rounds of injections in the same year and are not reversible. The implication is that if any of the complications of dermal filler injections occur like necrosis and blindness, the outcomes will be very worrying for the patient who has received the injections.
With hyaluronic acid dermal fillers, the results are immediately apparent. The collagen stimulator fillers- Polycaprolactone (Ellanse), Poly-L-Lactic Acid (aka Sculptra) and Calcium hydroxylapatite (Radiesse)- can take months for more obvious results.
● Allergy to ingredients in the dermal filler
● Infection or inflammation at the site of injection
Yes, Botox and dermal fillers can be combined in the same patient in different areas of the face. Botox and dermal fillers achieve different results and they are not mutually exclusive. For example, if you are looking for a slimmer and sharper face, Botox to the jaw (masseter muscles) can slim down the sides of the face and dermal fillers to the chin to add definition or lengthen the chin (if the chin is proportionally shorter).
Combination treatment with Botox and dermal fillers is also the new rejuvenation paradigm to address aging. In an anti-aging treatment called the Liquid Facelift, Botox is given over the sides and upper parts of the face to reduce wrinkles and tighten the skin and dermal fillers are injected into the middle and lower parts of the face to restore the profile of the face and replace areas of the face that look flat or sunken.
With Botox and dermal fillers are combined, the outcomes are much nicer and softer. If you prefer natural looking results for your treatments, combining Botox and dermal fillers allows me to use less of Botox and dermal fillers alone; so the likelihood of looking expressionless (‘frozen face’) or overfilled with dermal fillers (pillow face) is much, much lower.
Conventionally, Botox/ botulinum toxin has been used to treat muscles that cause wrinkles. Dermal fillers add volume, so they are not used as a treatment for muscle movement. In 2018, a new paradigm shift emerged with the finding of myomodulation; the concept that dermal fillers could affect and rebalance muscle activity.
Myomodulation is the hypothesis that muscle activity changes when dermal fillers are injected next to the muscle. Interest in myomodulation started to take off in 2018 after world renowned Brazilian plastic surgeon, Dr Mauricio de Maio published a study on the concept of myomodulation based on his expert opinion and observations.
Our faces comprise of muscles that balance the activity of each other for us to look normal. For example, the forehead muscles comprise of those that elevate the eyebrows and muscles that depress the eyebrows. The activity of these muscles are balanced by each other so that we do not look like we have our eyebrows arched or have droopy eyebrows.
Aging affects our faces in several ways. First, the skin becomes thinner and more lax (due to loss of elastic and collagen). Secondly, fat and bone are also lost with aging. These changes cause sagging of the skin.
It is suggested that sagging and loss of fat and bone mass in the face that distorts muscle action and the balance of activity between muscles in the face. The muscles of the face become stretched when the overlying skin sags and this results in a reduction or an increase in muscle activity depending on the location of the face.
One example of myomodulation is the use of chin fillers to reduce chin dimpling/ wrinkles. Have you noticed someone who has wrinkling or dimpling of their chin when they speak or pout? This is due to overactivity of the chin muscles (called the mentalis musle) which causes wrinkles in the chin. Conventionally, chin wrinkles can be treated with a baby dose of Botox/ botulinum toxin to erase these wrinkles. In a demonstration of his theory of myomodulation, Dr Mauricio de Maio showed that chin wrinkles could be reduced with chin fillers. This would reduce the amount of Botulinum toxin if the patient still required botox to the chin.
In practice, myomodulation is not a new concept. For years, doctors like myself have already been using dermal fillers to reestablish and reconstruct natural structural anatomy that has been lost due to aging.
Another example of myomodulation using dermal fillers is the the correction of downturned angle of the mouth. The downward pointing mouth corners give a sad and haggard look and this can be easily treated. I usually give a small amount of filler to lift up the depressor anguli oris muscle (to reconstruct the muscle’s anchor point). The depressor anguli oris muscle’s action is to pull down the corners of the mouth. Aging to the chin caues the depressor anguli oris (DAO) muscle to give this downturned smile look. Myomodulation of the depressor anguli oris muscles also allows a smaller amount Botox to be given if it is still needed to correct the downturned smile.
Myomodulation presents a novel way of addressing this theory of imbalance of muscle activity using facial fillers. In myomodulation, dermal fillers are injected adjacent to the muscles to support the movement of muscles or block over activity of the muscles by correcting bone and fat loss in aging. To be clear, dermal fillers are for correcting volume loss and structural deficits that affect muscle activity; they do not directly affect the activity of muscles like botulinum toxin/ botox. Botulinum toxin or Botox still functions as a neuromodulator to directly reduce muscle movement. Myomodulation presents an interesting angle on treating signs of aging using dermal fillers to balance muscle activity. This allows the patient to have less of botulinum toxin/ Botox or dermal fillers injected to avoid overdoing either treatment for an expressionless, frozen face or overfilled pillow look.
In general, Botox/ botulinum toxin acts on muscles and is used to treat wrinkles, reduce teeth grinding/ bruxism and shrink pores. Dermal fillers add volume, fill lines and lift saggy skin. I hope that you found this review on the differences between Botox and dermal fillers useful.