Which Wrinkle Filler?

Injectable wrinkle fillers have exploded in popularity in recent years to fill the wrinkles in the middle and lower part of the face adjacent to the nose (nasolabial folds) and the lower corners of the mouth (marionette lines).

Nasolabial Pre/Post

Marionette Pre/Post

These are areas untreatable by Botox and Dysport because--for the most part--Botox and Dysport only work by relaxing the glabella muscles between the eyes, the frontalis muscles to raise your forehead, and the orbicularis oculi smile muscles just outside eyes, known as the Crow’s Feet.

Glabella Pre/Post

Occipital-Frontalis Pre/Post

Crow’s Feet Pre/Post

It is the flexion of these over time which creates these enlarged muscles which result in these wrinkles. Almost miraculously, Botox and Dysport can relax these muscles temporarily, usually for about 3 months.

However, the typical wrinkles in the middle and lower part of your face are not from overused and enlarged muscles, hence just relaxing them will simply not work. All that Botox and Dysport injections will do to the midface and lower face is to paralyze your facial expressions--such as smiling—which is primary to bringing your personality to life. In the mid-face and lower face, the wrinkles are mostly from skin laxity due to the loss of tissue--primarily subcutaneous fat (with some bone and muscle loss)--which we all selectively lose more in certain areas resulting in the sagging skin characteristic of our midface and lower face wrinkles. Consequently, the solution is to replace the lost fat volume with fat transplanted from liposuction or with a cosmetic injectable filler, like Juvederm or Restylane. Replacing fat with fat has the advantage of lasting longer but the primary disadvantage is that a third (or more) of the fat injected can be lost in the transplantation process resulting in unsightly patches of irregular growth (see below).

Improvements have been made in fat transplantation survival using PRP and other substances; however the results to date are still unpredictable and of course, one must have liposuction to harvest the fat to begin with.

Hence Allergan (Botox) created Juvederm and Galderma (Dysport) created Restylane as cosmetic injectable HA fillers made from the sugar which is already present in your body—hyaluronic acid gel. Juvederm and Restylane generally last up to a year in most injected areas, with the huge advantage of being injectable without uneven implantation patches and being made of a sugar which is already natural to your body--and which your body simply metabolizes as it dissipates. Moreover, it has the tremendous advantage of having an enzyme which can immediately dissolve it if a bit more is placed than wanted, making it the consummate injectable product for facial wrinkle sculpting. Today, Juvederm, by the manufacturer of Botox, is the dominant HA cosmetic injectable wrinkle filler in the USA for which I have the honor of being the physician instructor for the State of Nevada being ranked in the top 1.0% of all Allergan clinical practices in the USA.

Restylane is also an excellent product, but my personal experience has been that Juvederm Voluma to be longer lasting, so we no longer teach physicians for Galderma.

Other cosmetic injectable fillers include Sculptra Aesthetic, which is made with a biocompatible, biodegradable, synthetic material called poly-L-lactic acid, which is gradually and naturally absorbed by the body and helps to rebuild lost collagen through a series of treatments. Our experience has been that it can cause nodules (see nodule below) and usually takes about 3 treatments to get a good result because Sculptra Aesthetic is more of a stimulator for your body to create collagen.

Consequently, we prefer Juvederm because the results are immediate and do not depend upon your individual ability to create collagen.

Finally, Artefill® is a dermal filler that offers longer lasting results of up to 5 years in comparison to other cosmetic filler injections. Artefill® is made of polymethylmethacrylate (PMMA) microspheres (miniature beads) that are suspended in bovine collagen and has been used previously in some medical implants. Our experience has been that Artefill can look great when placed perfectly and lasts much longer than Juvederm, however we have seen appalling results even from prominent local physicians where Aretfill has been misplaced and the distorted results could not be corrected.

Consequently, our first choice for any cosmetic injectable wrinkle filler…is Juvederm, by Allergan.