Cascade Facial Surgery and Aesthetics
Frequently Asked Questions:
1. What are dermal fillers?
“Fillers” are substances that are injected into the deepest part of the skin to soften fine wrinkle lines.
Some fillers can also be injected underneath the skin into a deeper area, just superficial to the cheek
bone for example, to fill in an area of volume loss.
2. What is the difference between Botox and Juvederm?
Botox is not actually a filler. Botox can be thought of as a “muscle relaxer,” in that it relaxes expressive
muscles that cause wrinkle lines. Unlike fillers, it is not actually filling in wrinkle lines, it is just keeping
muscles from wrinkling the skin. Juvederm is a dermal filler so it does volumize deep to fine lines in the
deepest layer of the skin.
3. What areas can be treated?
There are a number of areas on the face that can be treated with Botox, Juvederm, or both. Generally,
Botox is most commonly used to treat wrinkle lines in the “crow’s feet area,” the vertical furrows we get
in between the eyebrows, and for the horizontal wrinkle lines across the forehead. It can help with
wrinkle lines around the lips, across the chin, and for relaxing the muscles that pull the corners of the
mouth down, but it isn’t used in these areas as often as in the upper face areas. Dermal fillers are used
in a number of areas. The most commonly injected areas are the nasolabial folds (lines extending from
the nostrils to just above the corners of the mouth), the “marionette lines” running down from corners
of the mouth, the dark rings under the eyes, and the lips. In the lips, fillers can be used to volumize a
thin red lip, and they can help soften the fine lines that radiate out from the vermillion edge of the lip
across the upper and lower lip skin (these lines cause lipstick “bleeding.”) Fillers can be injected
superficially for fine lines in a number of areas around the face and can sometimes even fill in depressed
areas of scar. Both fillers and Botox are sometimes used to treat deep furrows, especially for deep
vertical furrows between the eyebrows
4. Are there other off‐brand uses for dermal fillers and is this safe?
There are a number of “off‐label” uses for injectable fillers and Botox. Some are safe and some carry an
increased risk for undesirable outcomes. The safety or each product used off‐label depends on the
technique utilized, the filler being used, where the filler is injected, and the experience of the are
Cascade Facial Surgery and Aesthetics
provider doing the injections. As a generalization, very soft or “liquidy” fillers are usually safe to use for
most areas of the face where you would want to soften fine lines, but more firm fillers that are typically
injected only into deeper soft tissue areas under the skin, are less likely to produce an outcome that you
would like if injected too superficially. When considering whether or not to have a certain type of filler
injected into a specific area, make sure you that you have a discussion with your injector regarding his or
her past experience with this product in this area, and the potential risks of injection relevant to the
area of concern and the specific filler proposed for use.
5. Which dermal filler is best for forehead wrinkles?
Our clinic uses mostly Botox for forehead wrinkles as most of the wrinkle lines in this area are caused by
hyperactivity of the forehead muscle, call the frontalis. Fillers can be useful across the forehead for
deeper lines if relaxing the forehead muscle does not sufficiently soften the wrinkle lines. Bear in mind,
however, that relaxing the forehead muscles can also cause the brow to drop since the only muscle
group keeping the brow up is the frontalis muscle group.
6. Can I be allergic to dermal fillers?
You can be allergic to dermal fillers, but this is a rare phenomenon. The main substances in most
injectable fillers these days are manufactured versions of materials that naturally occur in our body’s
tissues. For example, hyaluronic acid (HA) is one of the most common key components in dermal fillers
and it is a component of the extracellular matrix (like a “mesh”) that lies between our bodies cells in a
number of different tissues on a microscopic level. It is also a component of synovial fluid, which is the
clear fluid like “egg whites” in a number of our bone joints, like the shoulder and the knee.
7. I’ve heard of Voluma, is that different from dermal fillers?
Voluma is an HA ‐ based filler made by Allergan, the company that makes Botox. Voluma is unique in
that it has been formulated to give greater improvements in restoring deeper soft tissue volume loss
with greater longevity. Voluma’s consistency makes it ideally suited for deeper tissue injection and it is
presently FDA approved specifically for deeper tissue restoration injections in the cheeks. It is different
from dermal fillers in that it is not FDA‐approved for dermal injections, or injections into just the deep
layer of the skin for fine wrinkle line improvement.
8. Can dermal fillers be used with other treatments?
Yes. Dermal fillers can be used with Botox injections and they can be used before or after a number of
laser and lifting surgical procedures.
9. Can I use dermal fillers on my lips?
Yes. Dermal fillers are commonly used on the lips. However, you must bear in mind that the lips have
very complex, fluid movements so we typically only recommend the softest HA fillers for lip injections.
Cascade Facial Surgery and Aesthetics
These substances are less likely to make the lips seem unnaturally bulky or lumpy, or hinder normal lip
10. What is the best dermal filler for anti‐aging?
This is a tricky question that I feel has a different answer for every patient. In my opinion, the best,
“antiaging” filler effect really depends on your own specific concerns about aging‐related changes in
your facial appearance.
11. Are dermal filler injections painful?
Everyone has a different threshold for discomfort. The fillers are injected with a needle and syringe but
the needles are relatively small. A little discomfort is anticipated but is typically minimal. If you’ve ever
given blood, the needle used for most fillers is significantly smaller than the blood donation needle.
Many fillers also have numbing medication in the injectable substance which will help with the
discomfort of the filler volume ‐ but it doesn’t help with the pin prick sensation of the needle at the skin
surface. Most of the time, you can request application of a topical numbing cream or ointment prior to
your filler injections. The numbing cream application may prolong your appointment by 20 minutes or
so, but it can really help if you’ve had significant discomfort from the injections before. In our office, we
also offer numbing injections for the lips, like at the dentist, as the red lip is an especially sensitive area.
12. Can Dermal Fillers take place of a facelift?
The short answer is that dermal fillers can not take the place of a face lift. The longer answer is as
follows: You can experience some modest lifting, often referred to as the “liquid lift” effect, with
volumizing filler injections. Filler injections are also known to induce collagen remodeling. However, the
degree of lift and tightening from the collagen remodeling is usually minimal in comparison to the
effects of surgical lifting procedures. In determining whether fillers or a facelift is right for you, the most
important thing you can do is try to focus on what specific concerns you would like to improve. If fine
lines bother you most, then fillers or laser resurfacing are probably what you are looking for. If wrinkle
lines from facial expression bother you most, then a muscle relaxing injectable like Botox, Dysport, or
Xeomin would likely give you the most benefit. If furrow lines from deeper soft tissue laxity and volume
loss bother you the most, then filler injections can soften the lines and fill in areas of volume loss, but
fillers will not lift lax areas of significant soft tissue laxity the way surgical lifting procedures will. In
making treatment decisions and considering treatment goals, I recommend that you write down any
questions or concerns that you have, and have a consultation with your care provider prior to injectable
treatments to make sure you have a clear understanding of what the risks, anticipated benefits, and
limitations are for the injectable treatment you are considering.
13. Who should I trust to treat me with Dermal Fillers?
Injectable treatments can be done by physicians and nurses. First and foremost, you want to make sure
that your potential injector is a licensed professional care provider. Generally, you should consider