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Plump Up the Volume

Plump Up the Volume

These days, there seem to be endless options for anyone seeking a more youthful appearance. With the abundance of non-surgical procedures, anyone can turn back the clock with just one office visit. And while anti-aging injectablesand fillers are based on science, the results can seem more like magic. “Injectables and fillers are a great way to treat, smooth, or ‘fill in’ wrinkles, lines, creases, depressions or scars,” says Dr. Alan Gardner, board-certified dermatologist with over 20 years of experience and owner of Gardner Dermatology and Med Spa. “Many patients call injectable fillers the ‘liquid face lift’ and love the instant results they receive without the downtime associated with surgical cosmetic procedures.”

Going Under the Needle
These products, which are injected with a fine needle, work in two basic ways. Neurotoxins can be injected into specific muscles of the face reducing muscle contractions so they cannot pull the underlying skin, helping to stop the source of wrinkles. “Fillers literally fill areas that have lost volume due to aging,” says Jessica Crawford, a physician assistant with Atlanta Dermatology & Laser Surgery.

When considering injectables and fillers keep in mind there is not one best product or procedure for everyone. There are various treatments available, and it is important to find a doctor who is skilled in the range of injectables so he or she can help you decide which one will best treat your area of concern.

The Starting Point
The category of injectables most people are familiar with is neurotoxins, and many patients will find the best results come from combining a neurotoxin and a filler. While Botox® has become the household name for this botulinum toxin, in recent years, additional products like Myobloc®, Dysport® and Xeomin® have come on the scene. “These are all FDA-approved products that reduce or eliminate wrinkles primarily on the upper half of the face by weakening or paralyzing the target muscle,” says Dr. Katia Castillo with WOW Aesthetics. Patients usually get neurotoxin injections for the forehead, glabella (area between eyebrows) and crow’s feet area around the eyes.

While injectables like Botox® soften lines, fillers are used to restore fullness mostly in the lower half of the face. The most well-known fillers are hyaluronic acids (Juvederm® and Restylane®, or Perlane®), calcium hydroxylapatide (Radiesse®), man-made biodegradable polymers (Sculptura) and microscopic beads and bovine collagen (Artefill). These fillers are most commonly injected into nasolabial folds (creases from the sides of the nose to the corner of the mouth), marionette lines, cheeks, fine lines above the mouth, hands and upper or lower lip. They are also sometimes used to treat scars, hollow areas under the eyes and earlobes.

It is important to note that the various fillers differ in their thickness and should be matched to the patient’s needs. “To reduce fine, thin lines, a very thick filler may not be the best choice because it could result in unnatural looking lumps. However, to add volume to deeper lines, wrinkles or shallow contours, a heavier, thicker filler may be better to use,” Dr. Gardner says. Radiesse®, for example, works to boost the body’s own natural collagen production. It is a mineral component of bone and is thicker than many other fillers.

Restylane®, on the other hand, is a gel made of small molecules and is used for correcting thin superficial lines around the mouth, forehead and smile lines, according to Dr. Matteo Taerri of Advanced Anti-Aging and Aesthetic Medicine. Fillers can also be used to replenish volume under the eyes. “There are several FDA-approved fillers as well as one’s own fat that can be safely injected into the hollowness under the eyes,” says Dr. Seth Yellin of Marietta Facial Plastic Surgery.

Options, Options, Options
New products are developed regularly, which means treatments are increasingly specific to patients’ needs. “The industry is always coming up with new products, and coming on the horizon are new injectables like Volumna and Belotero®, stem cell injections, a topical Botox® called RevanceTM and new wrinkle repair agents like PurTox. All of these promise to be better options,” Dr. Castillo explains.

Belotero Balance® is a new cross-linked hyaluronic acid injectable filler that satisfies a niche in the injectable product market by being less viscous and less stiff. According to Dr. Yellin, it is best suited for the treatment of fine lines around the mouth and is superior to any other available injectable for that purpose. Advancements also work to combat known reactions like allergies. For example, Xeomin® is the newest botulinum product. “It works just like Botox® but has the advantage of being pure botulinum without any additional carrier proteins that can create an allergic reaction in a small number of patients,” he explains.

Another anti-aging treatment called Platelet Rich Plasma (PRP) uses the patient’s own blood that has been transformed into platelet rich plasma to stimulate the stem cells of the dermis. “The PRP is injected into areas to rejuvenate or volumize them by supercharging the body’s capacity for healing and tissue repair,” Dr. Taerri explains. This method can be used to repair crinkling skin around the eyes, on cheeks, smile lines and even the neck. And according to Dr. Jerry L. Cooper, owner of Atlanta Dermatology & Laser Surgery, “everything old is new again.” He uses silicon (brand name Silikon 1000®), which he calls “a very safe and pure, FDA-approved compound” to create a permanent correction for wrinkles and folds.

Sharpen Your Plan
With so many options, the most challenging aspect of injectables and fillers could be fashioning the best and most cost-effective treatment plan. Being armed with information and the right questions will help ensure good results that won’t break the bank. Dr. Cooper suggests finding out what to expect from the treatment, how long the results should last and whether there are any unwanted side effects. You will also want to know exactly who will perform the injections and how long the doctor has worked with cosmetic injectables and fillers. Is the injector board-certified by the American Academy of Dermatology, American Society of Plastic Surgery or American Society of Aesthetic Plastic Surgery? If not, what are their credentials and how long have they been administering injections?

Next, find out where the practice obtains injectable products. The best response to this question is that the product is shipped directly from the manufacturer to the doctor. In fact, Dr. Gardner says you should be able to see the box to know it is legitimate, make sure that the product is not expired and that it was shipped properly from the company in the United States.

Finally, develop a treatment plan that is based on your actual needs and considers the long term. Keep your budget in sight by remembering that “more is more and not necessarily better,” Dr. Castillo says.

While there is typically no real downtime with these procedures other than some temporary bruising and swelling that can be easily covered with makeup, the length of results vary considerably. Over time the body breaks down and rejects the fillers, which means that repetition of the procedures is necessary. Injections like Botox® typically last three to six months. Fillers usually last longer, from about eight months to up to two years, and silicone injections are more permanent.

The Price Point
Comparing prices on procedures can be another challenge. Most people have seen billboards that advertise Botox® for as little as $10, but in that case, the fee refers to the unit of product, not to the entire treatment cost. Each area of the face will typically require several units. Many doctors charge by the area treated rather than by the unit, and it gets even more complicated than that. “Pricing can vary based on anything from location to amount of product used to injector experience,” says Dr. Robert Colgrove of Vinings Surgery Center and Blue Divine Aesthetics.

Beware of very low prices, which could indicate that the products were not purchased in the United States. This may allow the injector to offer a cheaper price, “but could be dangerous to patients,” Dr. Castillo cautions. In fact, it is very easy to “cheat” when injecting a neurotoxin because the product comes dehydrated and must be reconstituted with saline. There is no standard dilution, and therefore no way for a patient to know how many units she receives per area, according to Dr. Yellin.

The average price per unit for Botox®, when injected by a board-certified dermatologist or plastic surgeon, is about $12 to $15 per unit. If a patient needs 25 units for full correction of forehead wrinkles, and the doctor charges $12 per unit, it would cost the patient $300. If that patient went to another doctor for a second opinion, he may recommend injecting only 15 units, resulting in a partial correction, but the patient would pay a lot less. “The results, of course, will depend upon the placement, skill and ability of the injector,” Dr. Gardner says.

Although legally, many professionals are permitted to inject these products, choosing the right injector is as important as selecting the right product. “When entrusting your face to a health care professional, the provider you choose can mean the difference between looking fabulous or freaky,” Dr. Yellin says. “From the initial analysis of your face, to the products and techniques selected to correct sagging skin, textural changes and volume loss, the rejuvenation of your face is an artistic endeavor honed by years of experience.”

Physicians, nurse practitioners, physicians’ assistants and registered nurses who have been trained in injectables can inject, but experience and training of the injector are always most important. “Referrals from other patients are a great way to find good injectors,” Dr. Colgrove says.

So if you are considering injectables, discuss the many options available with your dermatologist or plastic surgeon to develop a treatment plan that is ideal for your face. When done correctly, these small, non-surgical procedures can take years off your appearance.


New Cannula Injecting Technique Decreases Bruising
The most common concern regarding fillers is bruising or swelling. Any time a sharp needle is used for a treatment, it can lead to discoloration or inflation; however, using a blunt cannula, (a tube that can be inserted into the body), as part of the injecting technique has many benefits including:

  • It can significantly reduce swelling from injectable fillers.
  • They are especially helpful for decreasing bruising and swelling with lip augmentation and nonsurgical rhinoplasties (nose jobs).
  • The cannulas are not a guarantee that you won’t bruise, but it definitely decreases the likelihood by 90 percent.

— Courtesy of  Mike Majmundar, MD, Northside Facial Cosmetic Surgery


Editorial Resources

Katia Castillo, MD – WOW Aesthetics

Robert Colgrove, MD – Blue Divine Aesthetics and Vinings Surgery Center 

Jerry L. Cooper, MD – Atlanta Dermatology & Laser Surgery

Alan Gardner, MD – Gardner Dematology & Med Spa

Mike Majmundar, MD – Northside Facial Cosmetic Surgery

Matteo Taerri, MD – Advanced Anti-Aging

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