Ellen C. Gendler, M.D. is a widely respected New York City dermatologist, who, in addition to her busy practice, has served as a consultant to leading cosmetic and pharmaceutical companies, lectures regularly at national and international medical conferences, has been a principal investigator in clinical trials and has published extensively in prestigious medical journals and textbooks. She is also our “Dr. G,” straight talking, no nonsense, brilliant interpreter of how best to take care of our skin. We asked her to break down the basics of injectable filler and , at last, it is all making sense.
ITG: Can you describe the different kinds of filler?
Dr. G: The majority of fillers are made of hyaluronic acid, which is a naturally occurring material that is the same in all species, so skin testing before injecting is not required. There are other fillers which are permanent or semi-permanent (silicone, Radiesse, Bellafil) but they are much less commonly used. And then there are injectables like Sculptra, which are not really fillers but allow volume to be added gradually after a series of injection sessions.
ITG: Which fillers are best for which areas?
Dr. G: I don’t like to use the expression “best for this area” because it really depends on the injector and his or her preference. But in general, the deeper fillers (like Voluma and Restylane Defyne) are used to replace volume in cheeks and hollow areas, and the more superficial fillers are used elsewhere. But there is a complicated explanation for what each filler is made of in terms of cross-linking of proteins, etc. and each behaves differently depending on the area in which it’s injected. I like Juvederm Ultra Plus and Belotero for the lips and perioral lines, but others use Volbella (hate it) or Restylane Silk or Restylane, or Juvederm Ultra……hence my response that it’s more the preference of the injector. However, there is never a reason to use thick fillers like Voluma or Defyne in the fine lines between the eyebrows.
ITG: Which fillers last longest?
Dr. G: Obviously the permanent fillers last longest! But of the HA fillers, Voluma and Defyne last the longest, for the most part.
ITG: Are any fillers more naturally derived?
Dr. G: The HA fillers are as natural as you can get.
ITG: Do some fillers cause more bruising?
Dr. G: Nope. No filler causes more bruising than another, but surely one injector can cause way more bruising than another! It’s technique. I have a light hand and I use an expensive tool called the Accu-Vein to try to avoid blood vessels and minimize bruising, but most injectors don’t do this.
ITG: Is using filler a slippery slope? Once filler dissolves is the need to refill more apparent?
Dr. G: No, not a slippery slope. But if you do injectables and like the way you look, and then they dissipate, you will likely want to repeat the injections. Kind of like when you get your hair cut and it looks great, and then over months it grows out, you tell yourself that you could use a haircut.
ITG: Are some fillers more painful than others?
Dr. G: No—but some injectors make the injections more painful than others.
ITG: Are some places more difficult to fill?
Dr. G: Not sure what you mean by difficult. But tear troughs (under the eyes) are pretty tricky to do well, and lips can be a disaster if the injector does not understand proportions and have an artistic eye.
ITG: Can a doctor approximate how much $$ filler a patient will need before the procedure?
Dr. G: Sometimes we can estimate how much filler a patient will need beforehand, but often once you start injecting, it becomes clearer, as some areas require more material (or less) than initially thought.
ITG:Will preventative use of Botox have an effect on the need for filler?
Dr. G: Not really, but preventive Botox can help keep eyebrows up in place and obviate or delay the new eyelid surgery.
ITG: Do some wrinkles require both Botox and filler?
Dr. G: Yes, typically the lines between the eyebrows (glabellar lines) are softened with Botox, but often there are etched-in lines that remain there, and filler helps these. Sometimes fine lines are left over the eyebrows after Botox, and filler works well because it won’t contribute to dropping of eyebrow height.
ITG : Should they be done at the same time?
DR.G: They are often done at the same time, but I wouldn’t say they necessarily SHOULD BE.
ITG: Are there any side effects to filler injections?
Dr G: Of course. Bruising is possible, asymmetry possible, and less commonly, small bumps at the injection sites, or even delayed nodules, which are not fully understood.
ITG: How important is regular maintenance? Is there an economical way to keep it all together. (i.e. alternate upper and lower face?)
Dr. G: The best way to do it is to start early with sun protection and skin care. Regular maintenance is important if you want to maintain nice results. Filler does not help prevent further lines from developing, like Botox and the other toxins do. But giving your face the appearance of restored volume is the most important goal in creating a youthful look. I never say I fill wrinkles. I restore volume and try to replicate the contours that a patient had in his or her youth.