Botox vs. Fillers: What's the Difference and What's Right for You

Botox and Fillers Are Different Treatments With Different Purposes

Interviewer: Cosmetic injectables seem to be just about everywhere right now and, frankly, so is the confusion around them. People use words like Botox and fillers as if they're the same thing and maybe assume one treatment will improve something that they see in the mirror. And on top of that, social media has poured fuel onto this confusion, mixing real information with myths about frozen faces, this idea of preventative Botox, and fillers that don't seem to go away.

To help us better understand what these injectables are and better understand what they can do, we're joined by Dr. Sarah Akkina, who is a facial plastic and reconstructive surgeon and the Division Chief of Facial Plastic and Reconstructive Surgery within the Department of Otolaryngology at University of Utah Health.

Botox Relaxes Muscles That Cause Dynamic Wrinkles

Now, Dr. Akkina, let's kind of start at the foundation, and let's start with Botox, because I think that's the one that people actually know the name of, and they can ask for it, and they kind of have a sense of what it is. What is Botox really? And what is it doing underneath the skin?

Dr. Akkina: Yes. So I think the thing I always think about, and I really encourage my patients to see it as, is Botox relaxes and filler fills. So they are super different. They're entirely different categories of really what you get out of the medication, the effect.

So for Botox, you know, Botox itself, of course, is a brand, so kind of like Kleenex or tissues. Well, people use it kind of as a broad term for botulinum toxin. Important to know these are, again, injections, as you said. So it is a needle that's injecting a medication into your face a lot of times. And the Botox or botulinum toxin, Dysport is another name, Xeomin is another name. So these are all brands of botulinum toxin. And those toxins are meant to basically be injected into a specific muscle to have a specific relaxing effect in that area.

So the nuance that you get is depending on what muscle you're injecting it into. If it relaxes that muscle, it can just purely relax wrinkles in that space. So a common place for Botox is your forehead. If you have very prominent forehead wrinkles or obvious forehead wrinkles, you can get Botox injected in that area to relax the muscle so that the wrinkles relax and they're not getting formed because the underlying muscle is not contracting.

Now, if you inject muscles that are causing depressing action, so, for instance, people talk about a Botox brow lift, which is a little bit of a misnomer, but in the sense that you can inject Botox to actually stop or relax the function of the depressing muscles around the brow, that then makes it look like the eyebrow can raise a little bit more. It's this push-pull mechanism. And that's also why it's so important to go to someone who's very experienced and knows where the facial muscles are and exactly what you're injecting.

Interviewer: Sure.

Dr. Akkina: So that's kind of a global picture of Botox or botulinum toxin, how it works, and reasons that you might want to get it for a lot of the kind of simple, overarching cosmetic reasons that people talk about.

Fillers Restore Lost Volume Rather Than Relaxing Muscles

Interviewer: Understood. And let's move on to fillers, the other injectables that we have. You said that it fills spaces. So I guess is this also helping with wrinkles, or is there other stuff? And what exactly are these injectables?

Dr. Akkina: So you can use filler to fill around wrinkles, but I would say the best way to use filler is truly to basically plump something up. So one of the most common places to use fillers is lips, right? And that's a very, as I said, commonplace. I think it does work really nicely for someone who just wants a little bit more volume in their lips. So that's exactly what you think of it: a filler fills. So you can fill the lips. You can fill the spaces around wrinkles. You can kind of fill spaces under wrinkles to try to make the wrinkles less prominent or to try to make depressed areas in the face less prominent. So, for instance, another really common place to use filler is around the melolabial lines, or that natural wrinkle we all have that extends from the base of our nose on the side of the nose to the corner of the mouth.

Other common areas are just around the cheeks to try to give volume to the cheeks. As we age, we lose a lot of that natural volume that we have. So adding that back with some filler can look really nice.

Now one thing you started in your intro to say, which I do want to touch on, is super important: there are different types of fillers. So there are hyaluronic acid-based fillers, which are the "dissolvable" fillers, because there is another medication that we can use to dissolve it. It also means that the body dissolves it over time. So manufacturers say that the filler will dissolve on its own after a year.

We have to be really careful with that expectation because I think it's a classic example of you put a medication in an individual body and that individual body is going to have a lot of variability with how it responds, right? So any individual, that filler is going to last a specific time for that individual. And what we're finding is with people really starting to use a lot of filler, we don't necessarily see all the filler dissolve, even when it's a "dissolvable" filler. So people, I think, just need to be careful with that knowledge and understand that anything that you inject in your body, it's possible, from a filler side, that it may not go away completely.

Botox Works Best Before Wrinkles Become Permanent

Interviewer: So when it comes to, say, let's say crow's feet was one that I saw a lot in my research, do we do that with Botox? Do we use filler?

Dr. Akkina: So that is one primarily done with Botox. The reason is crow's feet are produced by contractions of the orbicularis oculi muscle, or this sphincter muscle that basically rounds our eye. So anytime you think of like, oh, when you squint your eye, right, you actually can really clearly see where that muscle, which is very superficial and has very thin skin upon it, it contracts in that area. So crow's feet are where you inject Botox, or managing crow's feet, I should say, is when you inject Botox around that orbicularis oculi muscle, typically along the lateral side or the side that's more towards the side of the face. And that can relax that muscle, so it's not squeezing the overlying skin and causing the deepening of those wrinkles.

Here's another really important part of Botox, though: once you have deep wrinkles or wrinkles that we call static wrinkles, that even when you're not moving the muscle or animating that area, you still see the wrinkle, those we can never truly make go away with Botox, right? So Botox can relax the underlying muscle, but it's not going to change the character of the overlying skin. And the reason that's important is once you have a permanent wrinkle, I would consider it very hard to get rid of a permanent wrinkle. So this is where people talk about, right, preventative Botox, in the sense that if you're using it to relax the underlying muscle before you get a permanent wrinkle, that can in some sense prevent you from getting the permanent wrinkles, because that muscle is not constantly pulling the skin to cause that permanent divot in the skin.

That being said, for people who do have static wrinkles or wrinkles that you can see even when you're not moving the muscle, doing Botox can still really help the appearance of that, right, because if you're not deepening the wrinkle with the muscle activity in the area, it can still make the appearance look nicer.

For Botox, the most common reason to use it, again, is to relax the underlying muscle. So the regions that people often use are the forehead, the brow, and around the eyes, for wrinkles around the eyes. And then now, more commonly, people are even doing it in certain places in the lower face. So you can do what's called a little lip lift, which just gives you a very subtle flare of kind of your lip margin if used around the lip. You can also use it around, say, the nose to relax what we call bunny lines around the nose, or around the chin to relax some of those chin wrinkles that you can get. And then you can even use it around some of the depressor muscles in the mouth to try to make the corners of the mouth actually look a little bit more lifted. Again, these are related to principles of decreasing the activity of depressing muscles so that the elevating muscles can work better.

Botox is often also used in the masseter muscles. That can actually help pain around your TMJ or your temporomandibular joint. And it can also give you a little bit of a contoured jawline to help reduce the bulk of the muscle in that area.

Fillers Can Soften Facial Folds but Cannot Lift Sagging Skin

Interviewer: And you had mentioned that fillers are used a lot in lips. Are there other places in the face that we use fillers, and when would we want to use that instead of Botox?

Dr. Akkina: Yes. So filler, common places are lips, cheeks. Recently there's been a lot more jawline filler to try to help define the jaw. Other places that people use filler are those melolabial creases or, again, that crease from the nose to the corner of the lip or some melomental creases, so that crease from basically that kind of corner of the lip down to the jowl, essentially. So it can help soften a lot of those areas.

A really important thing to think about for filler, though, is filler does not lift. And this is a huge common misconception and one you have to be really careful of because many of your influencers, on Instagram, TikTok, whatever social platform you go to, are going to try to convince you that injectables can lift. And you have to be incredibly careful of that and, honestly, in most cases, not believe them because truly fillers fill, right?

Interviewer: Yeah.

Dr. Akkina: And you can make it look like there are places that maybe have a lift just because you're filling a depression, right? So that can give you the appearance that another area is lifted, but it's not truly lifting that area. So if you're someone who's in the mirror and you're lifting your cheek and you're like, oh, this is what I want, just be aware that it is a facelift or a neck lift. It is not an injectable.

Results From Botox and Fillers Last for Different Lengths of Time

Interviewer: Understood. And when it comes to Botox and fillers, how long can people expect injectable results to last?

Dr. Akkina: For Botox specifically or botulinum toxin, again, any of the brands, Botox on average lasts three months. So that's what we typically tell everyone. Again, every individual is different. I have patients on the opposite end, who their Botox, they feel like maybe lasts them six to eight weeks. So again, it's that bell curve, where everyone is going to sit on that bell curve somewhere.

In general, the other thing to know about Botox is it doesn't work right away. So it does have a one- to two-week onset period. So if you're planning for a nice event, a wedding, what have you, remember that you would want to get your Botox a couple weeks in advance to make sure you know what the effect is going to be. And that's going to be in that kind of prime window, two weeks to two months really, where it's the most active. After that, it kind of tails off and then again is variable in terms of when you see the effects.

For filler, that is, one, very dependent on the type of filler. So for the hyaluronic acid-based fillers, the manufacturers will say that it lasts for a year before the body works it down. This is where I think there's much higher variability. So in some people who we've done lip filler on, I mean, I still see that filler really a few years down the road, perhaps a long time.

I will share my own experience. In residency, we were training and educating, and I volunteered as a model for one of my colleagues. So I had lip filler, and I still think it's there. And I am about five years out from that.

So every individual is different. And I think, across our subspecialty, we're really seeing that a lot of filler probably lasts longer. So just, again, be careful with it. And certainly if you are filling on top of other filler or filling on top of a place that you have had filler before, you have to be extra careful and aware that you're more prone to develop some irregularity over that area just because that filler is then going to dissolve in different time frames, right? So things to be aware of.

Safe Results Depend on the Product, the Injector, and Proper Medical Care

Interviewer: I guess that leads me to kind of my next question here. You keep mentioning being careful. What are some of the safety concerns or even like result concerns that come when we are talking about injectables? And what do you tell your patients before they get anything injected into their face?

Dr. Akkina: Yeah, safety question number one. Where did the injectable come from? Is it an actual brand-name product, or is it a knockoff product that you're buying from the internet, and you have no true idea where it's coming from? I have had patients come in and say, "Oh, I saw this ad on my social media or on Amazon about this injectable that's supposed to act just like Botox." That is a hard red flag for me. So you always want to make sure this is a medication that you're injecting into your body; you do not want a knockoff product. You need a brand-name product that has the reputation behind it.

I think safety issue number two is your injector, right? You're trusting someone to know the anatomy of your face and be able to evaluate you as an individual. Our faces are all 100% unique, and you want someone who can really look at you and say, "Hey, this is where I think you can be helped, depending on what your concern is and what you'd like to improve."

And I think safety number three is also making sure you're going to an office that can take care of you if you do have complications.

Injectables Carry Real Risks That Require Experienced Providers

So what are complications from injectables? From Botox, you can have an allergy to Botox. That is pretty rare, but it's something to be aware of. And certainly, if it happens, you want to be taken care of by a strong medical team who can help you through that. Other things: for Botox, the injection can spread to other muscles that you're not necessarily intending to treat. So for instance, if you're injecting around the eye, you can develop a droopy eyelid. And these things can be treated by, sometimes, eye drops or other medications. But it's just, again, you want to go to a care team who's aware of those things and can help you through it.

Filler, the scariest complication is that you're injecting into a blood vessel that can then kill the soft tissue around where you're injecting. It's a relatively rare complication, but it is a known serious complication. Patients who, for instance, have had filler around their nose have killed the tip of their nose or the side of their nose or something else. So again, you want to make sure that your injector is highly educated, highly aware, and then highly competent to be able to take care of anything if that does happen to you. Filler around the eye can cause blindness, right? These are rare but super serious complications. So you just want to trust your care team.

Choosing a Qualified Injector Is More Important Than Choosing a Location

Interviewer: And is there anything that they should be, say, looking for if they're looking at different care teams somewhere in this country?

Dr. Akkina: Yeah. I think the gold standard for injectables, right, is a physician who has specialized training in the muscles and the anatomy of the face. Ultimately, there are a lot of injectors who are wonderfully trained by physicians and other well-qualified people. So yes, I think there's certainly a little bit of a ladder, right, in terms of experience, understanding, and all those things. So I think the gold standard is still to go to ideally a facial plastic board-certified surgeon. But a lot of us surgeons don't spend as much of our time doing injectables, to be fair, right? We're operating a lot of times. So certainly if you can't get into a board-certified facial plastic surgeon, there are wonderful nurse practitioners, PAs who are trained by those surgeons, who I'd really trust.

There's a lot of medispas these days and a lot of other places that you can go to. And I think a lot of those folks do have exceptional training by the right people. But do the homework and make sure that you're seeing who trained those folks and if they're competent, again, to take care of you if something like the worst should happen.

Interviewer: So for the listener who's maybe curious about injectables, maybe there's a concern they have on their face, and they're on the fence, what do you want them to know walking in and whether or not they should be making this kind of decision?

Dr. Akkina: Yeah. So injectables are an awesome tool to help relax wrinkles, in the case of Botox or botulinum toxin, or to help fill space, in the case of different fillers. We have to be careful because they are medications that have complications. So you do want to go to someone who's really well-versed in the anatomy of the face so that they can really help you identify what can make a difference for you and your appearance.