Update on Injectables: What To Consider

No one really wants to look old. We talk about aging gracefully and accepting the process, which is great on paper, but looking old doesn’t mean you’re aging gracefully, and having a few lines and wrinkles doesn’t mean you look old. Since the first Hyaluronic Acid (HA) soft tissue filler was FDA approved in the US in 2004 we have had 10 new products approved in the US and literally hundreds available around the world to help you look soft, smooth and contoured. It’s been a game changer for those who want to enter the rejuvenation market without undergoing surgery, but there’s a lot to know before you get started.

It is very important to understand that non-surgical is not synonymous with safe, and having treatments without proper guidance and technique can have serious consequences. FDA approved fillers are considered safe when used properly but it is vital that the person with their hand on the syringe understand aesthetics, anatomy and safety. There are too many women (and now men too) out there who’ve had so much filler put in their face they have no lines or wrinkles at all. It’s hard to know if they’re 30 or 60, they have a look of “sameness” that’s become epidemic, where the filler is put in the same place in the same way in so many with the look of big round apple cheeks, big full lips and overfilled lower eyelids. It creates an amorphous look that looks the “same” in everyone, and often makes a younger person look older and an older person look “done,” rather than optimizing and enhancing your own special features and celebrating your unique beauty.


The first and one of the most important parts of your visit with your aesthetic dermatologist is the assessment. This is when your doctor will look at you, talk with you, take photos and discuss what they see and what they think you need. For me, the assessment often starts right from when I walk in the room. I note the patients’ demeanor, their body and facial posture. We discuss any previous treatments and their goals for our work together. I offer them a hand held mirror and we look together so I can see what concerns them and they can see how I would address it. It is important that we have the same vision for the end result, that I understand their goals and they understand my strategy for helping them reach it. It seems simple, see a line and fill it but true beauty and proper restoration for balance is almost never that simple and chasing lines and wrinkles often leads to results that may erase lines and wrinkles but doesn’t make you look younger.

I investigate every line and wrinkle and every asymmetry or hollow to understand the source so I can address it in the most natural way. This means that I sometimes need to be indirect in my approach and use more than one product. For example, lines on the sides of the mouth, extending beyond the marionette lines often are a sign of teeth grinding and the fix involves using both a neuromodulator to the specific muscles causing the grinding as well as filler in specific discrete locations. If I just chased and filled the line, the line would be gone but the  would look like a “chipmunk” with a heavy lower face, I’ve seen it, it doesn’t look better or younger. In this case I often need a neuromodulator like Botox, Dysport or Xeomin to soften the muscles along the jawline and then add the fillers towards the back of the jawline near the ear to help lift the face and smooth the lines. The result is beautiful and very natural.

It may take several different fillers in different parts of the face, sometimes layered, to create the optimal results but it takes less product to maintain the results over time. The final steps before treatment are taking photos and reviewing the consent form.

In considering filler options there are three basic categories: Temporary, semi-permanent and permanent. We’ll go through each one:


These are hyaluronic acid fillers. Hyaluronic acid (HA) is a protein that is natural to your body and 60% of your body’s HA is found in the skin. Its job is to hold water, and in doing that your skin feels resilient and looks young. You can apply HA to the skin as a moisturizer which is great since it will also hold and pull water into your skin but the molecules are typically too big to penetrate so if you want a lasting effect you need to have it injected.

If you were to inject pure HA into the skin it would last about 24 hours. Not acceptable for the effort and cost. Companies have found ways to stabilize it by creating cross links and combinations of particle size which is essentially what separates one product from another. The science of fillers is complicated and takes up much of our discussions at scientific meetings but in general, the smaller the particle size and the less cross linking the more temporary the filler and also the more superficially it can be injected. This makes it good for finer lines, for lips and for layering over products used deeper under the skin. Products in this category include Restylane Silk and Restylane, Belotero, and Juvederm Ultra and UltraPlus. Your dermatologist will explain the best one for the area of concern and sometimes even combine different ones for the best effect.

Concerned with signs of aging around her eye, mouth and lower face, this patient received a series of chemical peels and injectable fillers to achieve a natural and rejuvenated look.
Injectables for The Beginner
Exposed veins and lost volume can make hands look older. The use of the injectable Radiesse helps restore a youthful appearance.


These are fillers that are generally used deeper under the skin for a lifting effect. They often last longer and have had a great impact on our ability to create balance and a naturally rejuvenated look for our patients. They need to be discreetly placed for the best effect and I often recommend a small amount done over several sessions.  Personally, I often start in the mid face as I find that lifting the cheeks corrects so much of the deflation and volume loss we experience as we age. Not only does it create a re-draping and lifting effect, the end-result means less filler is needed in other areas especially the nasolabial folds (those pesky lines that run from the corner of the nose to the corner of the mouth). In this category we have two HA fillers Restylane Lyft and Juvederm Voluma and one non-HA filler Radiesse. Radiesse is made of calcium hydroxyapatite and while not natural to the skin, it is natural to the body.

Finally, there is also one more product in this category, called Sculptra that is more of a bio stimulator than a filler. It is an outstanding product for the right candidate and helps restore volume and also improves skin quality. The effects last up to 2 years according to the studies but I’ve seen it last longer than that in my patients.


I consider Belafill to be a permanent filler but it may also be considered by some to be semi permanent since the data goes through 5 years.  Bellafill is FDA approved for the correction of nasolabial folds and acne scars on the cheek.  It is made from cow tissue (bovine collagen) and non-absorbable polymethylmethacrylate beads (PMMA microspheres). It also contains a very small amount of a local anesthetic (lidocaine). Skin testing is needed to ensure you’re not allergic to the collagen used in the product. The other truly permanent filler is silicone and is considered an off label use. It should only be done by a doctor highly trained in its use. It is not a product I use or generally recommend.


Non surgical options for rejuvenation have improved to the point where they may be able to help you avoid the need for a facelift. Fillers are one of the best minimally invasive tools your aesthetic physician has to help you age gracefully and to look your most beautiful best in the most natural way. It is important to have a proper assessment and combine treatments as needed and always make sure you’re in the hands of a trained aesthetic physician for the best results. And remember, it’s not about chasing lines and wrinkles, true beauty is about balance and harmony.