What is the difference between Fillers and Botox and when is one recommended over the other?

They are completely different products. The Filler is used to rebuild the volume in your face that has shrunk due to weight loss, sickness or to the ageing process (simply getting old) or when used in the lips to plump them up. They are made from different ingredients. The most common ingredient is Hyaluronic Acid (HA) which is compatible with human tissues. Natural HA is found in many parts of the human body. I like HA Fillers because they are reversible. So if the results are not to your liking you can have it dissolved and start again. There are many brands and within each brand there are many different grades and so you will need to discuss with your practitioner which brand and which grade is most ideal for the area you wish to fill.

Botox is a Trade Name. In Australia we have two other brands viz Dysport & Xeomin that are approved by the TGA for use by practitioners. The main ingredient in all three brands is Botulinum Toxin A. This is a Muscle Relaxant meaning that when injected into the muscle of choice it causes the muscle to relax but if too much is injected it can result in paralysis of the muscle which then has no movement (Not a good result and not intended) It has a Cosmetic use as in relaxing the lines in the face and it has a Medical use as in the treatment of Migraine, Muscle spasms as in Cerebral Palsy cases, Hyperhidrosis (Excessive sweating) in the Arm Pits etc.

Fillers and Muscle Relaxants can be used together at the same time or each on its own. Your practitioner is the best person to advise you on this.

What is the price comparison between Fillers and Botox?

Fillers are generally more expensive because they require more skill to inject and the procedure takes a longer time to do. Most of them come in pre-packed syringes containing 1ml of the product. So you are charged for the 1ml whether you use it up or not. You cannot share that one syringe with another person as there is the higher risk of cross contamination. However, you can use up the whole syringe by placing it in different parts of the face if your practitioner is skilled enough to do it. The exact cost of each Filler or Muscle Relaxant (Botox, Dysport or Xeomin) will vary from clinic to clinic. But be sure to compare apples with apples ie the price of Botox vs Botox, Dysport vs Dysport and Xeomin vs Xeomin.

Generally, Fillers are sold by syringes of 1ml. Depending on the brand and the grade it can vary from $350 to $800 per syringe. Muscle Relaxants are sold by the unit. Depending on the brand it could be $5 – $15 per unit.

What is the difference between Botox and Dysport? Is one better than the other?

They are produced by different companies and though each contains the same major ingredient ie Botulinum Toxin A, they have different properties. They behave differently when injected into the muscles due to the different methods in their production. There is a difference in the time of onset and in the longevity for instance. The differences can also be due to the skill of the injectors, the amount given and to the patient. Some patients require more for an area of her face compared to others for a similar area of the face. We know that all brands do not last as long in a very active person who works out in the gym everyday. (Related to a faster metabolism) So the answer is not as simple as saying that one brand is better than another. All of us are different in the way our bodies process any medication given to us.

Are there different types of Fillers and is one better or safer than the other?

There are many brands and many types of Fillers. Each brand has subdivided their products into different grades of density from the very light ones which are very soft to the heavy ones which are very thick. Soft ones are useful when you do not want to volumise the area too much and thicker ones are useful when you need to volumise or build up the area a lot as in the Mid Face. In the main these products are divided into two streams – the HA Fillers and the Non-HA Fillers. All the HA Fillers whatever the brand are reversible using an enzyme called Hylase meaning you can have it dissolved if you are not happy with the result. The Non-HA Fillers cannot be dissolved but can be aspirated or removed surgically. Generally the Non-HA Fillers tend to last a little longer and some have the capacity to build up the collagen in the skin thus resulting in better tightening and texture of the skin.

The safety of Fillers used in Australia is checked by an authority like the TGA before approval is granted for use in the public. So all Fillers approved for use on patients in Australia are safe. Complications arise more commonly when the practitioner doing the injecting is not properly trained or not experienced in the use of the injectable products. It is important to remember that there is an element of risk that something can go wrong when you have a procedure done. So it is important to find the practitioner who has the skill to perform the procedure you are after and who has the knowledge and skill to reverse any unwanted side effects.

How long do the results from Fillers and Botox last? What are your tips for increasing the longevity of both?

Results vary from one brand of Filler to the next and from one person to the next. The same applies to the Muscle Relaxants (Botox, Dysport & Xeomin). Longevity also vary depending on the areas treated. In the case of the Fillers, longevity varies depending on whether the gel is a soft one or a thick one. Soft ones tend to last a shorter time , say, 6 months and the thicker ones can last 12 months or longer. There are exceptions because I have cases where the soft ones have lasted 12 months or more and the thicker ones have lasted 2 -3 years.

Generally, the HA Fillers last longer if you continue to be well hydrated, so drink lots of water everyday, at least 1 litre or more. Make sure you are not dehydrated especially when you are into heavy exercises. There are no special tips for making Muscle Relaxants last longer. They usually last 3 – 4 months, sometimes 6 months. However, if you are regular with your return visits be it 4 or 6 months you will find that after a few years there is a tendency towards longer intervals between treatments.

What are the most common side effects of both Botox and Fillers? And are there any known long term side effects?

The most common side effects of Fillers and Muscle Relaxants are those related to bad injecting.

In regards to the Fillers:

  1. Too much in the lips so they look bloated, pouty and fishy.
  2. Lumpiness due to injecting too shallow when it should be deeper

Or due to wrong choice of products using the thicker grades too close to the skin or placing too much in one single spot.

  1. Uneveness or lack of balance when too much is placed in one side against the other side
  2. Blue tinge under the skin due to injecting too superficially but may also be due to the wrong choice of product.

In the case of Muscle Relaxants:

  1. Droopy brows when too much is given in the forehead or the injection points are too close to the eyebrows.
  2. Raised brows (The surprise look referred to as The Spock Look ) due to insufficient amount given above the mid point of the brows.
  3. The fixed stiff motionless unnatural look due to too much injected all round. It is better to have less because you can add more but when you have had too much you can’t take it out and will have to allow the effects to wear off.

There are no Long Term Side Effects with Muscle Relaxants that we know of today. Most of these side effects are short lived from a week to a few months.

More side effects are seen in the case of Fillers. However, in the case of the HA Fillers the side effects of lumpiness can be reversed by injecting the enzyme Hylase even up to a year after they have been discovered. If they are related to the Non-HA Fillers the product has to be removed by aspiration or removed surgically. So contact your practitioner as soon as possible and do not leave them there for too long. Surgical removal will leave a scar.

A word must be said about a rare side effect that is staring to be seen around the world and now in Australia too. This is permanent loss of vision , so far seen in one eye as a result of any brand of Filler injected accidentally into a blood vessel that carries the droplet of Filler into the artery that supplies blood to that eye. The droplet of Filler blocks the tiny artery thus stopping the blood flow to that eye. Vision can be lost within an hour if emergency treatment fails to re-establish the circulation.  Cases reported are associated with injections of Fillers around the eyes, the Frown area and around the Nose. You must contact your practitioner immediately if he or she has not detected it while you are still in the practice. You must let him or her know if you have a problem with your vision or pain in the eye while he or she is injecting. This is how fast the side effect can occur.

Injections around the Frown area and the Nose can also produce another side effect referred to as necrosis of the skin in the area of the injections. Necrosis refers to the inflammation and loss of skin in the affected area. This may take a few days to a week or more to be apparent. Contact your practitioner immediately you see blisters appearing in your skin or a dark discolouration or redness around the areas injected. They may be associated with pain and sometimes there is no pain. Scarring will develop after the skin has healed. Healing can take weeks to months.

Always check with your practitioner what to look for if you have injections of Fillers around the eyes, frown area and around the nose to recognize the early signs of any side effects before you leave the practice. Always have his / her contact number handy with you.

Will you look permanently different after long term use of Botox and Fillers?

You are not going to look permanently different but you will look younger provided you are consistent with your follow up treatments.

Every 3 – 6 months with the Muscle Relaxants (Botox, Dysport or Xeomin) and at least once a year with your Filler. Remember that none of these injectables can delay the ageing process. What they can do is to control the way your muscles in the face contract. The analogy is if you are not crunching your clothes as much for a while they are less likely to have as many creases. So when you stop your treatment and the muscles start contracting around your facial skin again the lines will reappear. The lines stay away if you continue to have your treatment regularly.

Is there any evidence that using Botox as a preventive against wrinkles is effective?

Research in the US has shown that when one twin has received regular treatments with Botox over 13  years and the other twin has  received very irregular treatments over the same period of time, the twin who had the regular treatments looks younger with less lines in the face. All the practitioners who have been in a cosmetic practice for over 10 years will have patients who look younger when they compare photos taken over that period of time.

What is the average age you see people coming in to get Botox? Would you advise against those of a certain age using it?

The average age in my practice is between 30 – 40 yr old. A good number nowadays are in their twenties. On the whole the person seeking treatment nowadays is younger than her counterpart, say 20 yrs ago. And more men are seeking treatment these days than they used to.

I do not treat people under 18 yr old.

Have you heard of “Botox Sprinkles“ (smaller amounts of Botox injected for a subtle effect) and is it something you would recommend for first time users?

“Botox Sprinkles“ is nothing new to me. I have always advocated small amounts of Muscle Relaxants whether I use Botox, Dysport or Xeomin to produce the subtle effects I look for in the past 25 yrs. Everyone reacts differently to the amounts ie the number of units he or she needs to achieve the desired effect. I look for the smallest amount required by each person and continue with the same amount each follow up treatment until for one reason or another it stops working and a higher amount is needed. Sometimes the opposite happens, the amount required to get the same result falls instead. Giving anyone more than he or she needs is wasteful, costs more and very often produces undesirable results. The ideal is the subtle result where no one can tell that you have had any treatment and yet can discern that you look good.

Yes, I would recommend the first time users to start on the low side and find the level that works best for her. It may take a few visits to achieve this but worth it in the long run. Remember, you are in it for the long haul to continue looking good.

Are there any areas in the face that you refuse to inject with Botox and why?

The only times when I refuse to inject any particular area in the face are when it is not appropriate for that particular person to receive Botox in those areas. For example, if a person has heavy upper eyelids, then I would not inject any Muscle Relaxants in the forehead just above the eyebrows as such treatments will very likely to lead to droopy upper eyelids even though the person may request the treatment to relieve the lines in her forehead.

Is there any restrictions on how often or how long you can have Botox or Fillers?

There is no reason for anyone to have these products more often that you need to. You only need to have them when their results start to fade away. Remember that the longevity varies from person to person. Generally, the HA Fillers will last about 6 -12 mths and the Non-HA fillers will last a bit longer, say 12 – 24 months. Muscle Relaxants

(Botox, Dysport & Xeomin) will last 3 – 6 months.  Having treatments for the same areas more often than you need to are more likely to produce side effects. If the cup is full there is nothing much more you can make it fuller. However, you can choose to have Fillers more often if they are for different areas that have been injected before. The same applies for the Muscle Relaxants.

You can continue to use the Muscle Relaxants and Fillers for as long as you wish. I have patients who are in their late seventies. As long as you still have that energy and desire to look good you can still have it.

Your tips for finding a medically trained doctor who is also ethically responsible when advising their patients?

The best is word of mouth recommendation. Otherwise give the Australasian College of Cosmetic Surgery (ACCS) a call and they will assist.

Give them an idea what procedures you would like. The college represents Cosmetic Surgeons as well as Cosmetic Physicians.

The number to call is 1800 804 781.

What kind of ongoing testing and audits are in place within the industry to ensure providers are looking after patient safety – not just now but in the long term as well?

On the whole in Australia and in many countries around the world including the US and UK, the regulations surrounding the Cosmetic industry are not adequate. The authorities are always a couple of steps behind. However, they are getting better.

Briefly, it can be said that today Cosmetic Surgery and Cosmetic Medicine together form a special field of its own but this field is not yet recognised as a Specialist Field by the regulatory authorities. So any doctor can call himself or herself a Cosmetic Surgeon or a Cosmetic Physician even without appropriate training. So any Plastic Surgeon, any General Surgeon, any ENT Surgeon, any General Physician,  or any GP can call himself or herself a Cosmetic Surgeon or Cosmetic Physician if he or she has the inclination to do so. There is only one College in Australasia (The Australasian College of Cosmetic Surgery ) which provides teaching and training for the doctors specifically  in Cosmetic Surgery and Cosmetic Medicine including injecting of Fillers and Muscle Relaxants and a whole range of cosmetic procedures. Yet, their graduates are still not officially recognised by the authorities as Specialist Cosmetic Surgeons or Cosmetic Physicians even though they have been trained in that field which is better than other practitioners who have not been trained in these procedures.

The Australasian College of Cosmetic Surgery works closely with the authorities to improve protection of patients in the field of Cosmetic Surgery and Cosmetic Medicine. Its members have to undergo an annual  Continuing Medical Education program related to their work to show that they are up to date with their knowledge and skill to remain a member. They are called Fellows of the ACCS and carry the titles like FACCS or FFMACCS. When you are not sure if your practitioner belongs to ACCS call 1800 804 781 to find out.

In Australia nurses are also allowed to inject Fillers and Muscle Relaxants. However, they must have under gone appropriate training and be under the supervision of a Medical Practitioner who she or he must consult prior to injecting the patient. So it is important for patients to know if there is a covering Medical Practitioner when they have their injections done by a nurse. This Medical Practitioner must be there to provide advice and instruction to assist the nurse in an emergency or when there is a complication. In certain situations the nurse is allowed to Skype her covering doctor if he or she is not in the same premises.

At the moment in Australia there is no tertiary institution where nurses can be trained appropriately. So most of them will receive their training from staff nurses or doctors appointed by the companies producing Fillers and Muscle Relaxants on an ad hoc basis. There are private companies that offer short courses in different parts of Australia.

On top of this there are many beauty parlours  who use injectors who fly in from overseas whose qualifications we are not sure of. To make matters worse fake products have been discovered in some premises. However, the authorities are getting on top of this. In the meantime, it is a Buyer Beware situation.

Never be afraid to ask your practitioner whether he or she is a doctor or a nurse

  1. What level of experience does he or she have in the procedure to be carried out on you.
  2. Where have they received their training
  3. Has any of their patients suffered any complications
  4. Can they tell you what complications are associated with the procedure
  5. How long have they been doing it
  6. Do they have the expertise and the tools to treat the complications (They should have Hylase in the premises at least)
  7. If a nurse is doing the injection make sure she has a covering doctor. Is he or she near by and is he or she available immediately if required
  8. Whether your practitioner is a doctor or a nurse you must have a contact phone number that you can get him or her at any time.

Further Information: Here is an article written by Dr. Soo-Keat Lim