FILLERS & BOTOX® COSMETIC Injectable fillers are substances that enhance the fullness of soft tissues, primarily in the face.  Injectable fillers can  be used alone or in combination with other procedures such as wrinkle reduction by injection ( BOTOX® Cosmetic), or to refine the results of surgical rejuvenation. BOTOX® Cosmetic is typically used to treat "dynamic" wrinkles, wrinkles produced by muscle movement; fillers are usually injected to fill "static" wrinkles, wrinkles caused by aging, gravity or loss of elasticity. Some fillers are based on natural substances derived from the human body; others are synthetic forms of these natural substances and may contain synthetic, biocompatible compounds.  The differences among facial fillers are not only in their composition, but also in their preferred applications and the duration of their results.  Some are "dermal" fillers, i.e., they are injected into the skin, and others are "subdermal" fillers, i.e., they are injected below the skin, and therefore are considered "volumizers".   For your safety and ideal results, Dr. Rasmussen performs all injectable procedures herself, not an assistant.  Collagen Collagen is a dermal filler derived from natural protein that comprises the supportive structure of skin.  Injectable collagen formulas such as Zyderm® and Zyplast®, derived from bovine collagen, or Cosmoderm® and Cosmoplast®, derived from the human dermis, are used to soften wrinkles, raise recessed scars such as acne scars, and define the border of the lips to enhance them and make them appear more youthful.  Bovine collagen, unlike human derived collagen, requires prior allergy skin testing.  The results of treatment with injectable collagen generally last 3 months.  Of note, all collagen derivatives have lidocaine in each syringe, making injection slightly less uncomfortable.  Furthermore, collagen generally results in less local tissue reaction, i.e., redness, swelling, and tenderness is usually minimal and generally doesn't last for more than an hour or two. Hyaluronic Acid Hyaluronic acid (such as  Restylane®, Perlane®, and JUVEDERM® Injectable Gel including JUVEDERM®  Ultra and JUVEDERM®  Ultra Plus)  is a natural substance found in our bodies. These hyaluronic acid products are gels synthetically derived from bacteria with formulations of varying densities. Restylane® and JUVEDERM® Ultra are dermal fillers, and are especially well suited to fill facial wrinkles, especially the smile lines, and can be used to enhance the lip border.  Perlane®  and JUVEDERM®  Ultra Plus are subdermal fillers and are used to restore lost volume in the midface or pre-jowl groove.  Although the improvement achieved  will begin to diminish within four to twelve months after treatment, results vary.  Hyaluronic acid derivatives are FDA approved to last 6 to 8 months.  Hyaluronic acid derivatives last longer than collagen derivatives but they result in more local tissue reaction, i.e., redness, swelling, and tenderness which may last for up to 72 hours.  Furthermore, none of these products have lidocaine in them, so injection can be more uncomfortable.  Topical anesthetics applied for 30 to 60 minutes beforehand are very helpful to minimize injection site discomfort. Longer Lasting Injectable Fillers There are a group of injectable fillers that are longer lasting, but with longevity may come more side effects or downsides.  SculptraTM is a synthetic product composed of poly-L-lactic acid.  It is a subdermal filler, i.e., it acts as a volumizer.  It may last a year or longer.  It's disadvantage is that it requires preparation/suspension requiring hours to days prior to injection necessitating strict appoinment scheduling.  SculptraTM is only FDA approved in HIV positive patients, although some doctors inject it "off label". Radiesse® is a synthetic substance based on calcium hydroxylapatite.  As a product made of calcium-based microshperes suspended in a natural gel, it is a subdermal filler, i.e., volumizer, and lasts 12 to 18 months.  It's sister product, Radiance®, is considered a "permanent" filler (3 to 5 years), but due to it's risk of foreign body reaction and "granulomatous formation", it is not FDA approved as a facial soft tissue filler.  It is, however, FDA approved for treatment of vocal cord stenosis and bladder stenosis, and some doctors inject it "off label".  ArteFill® is a combination of bovine collagen and synthetic polymethylmethacrylate (PMMA).  The collagen serves as a carrier gel for the microspheres made of PMMA, one of the most common synthetics used in artificial implant materials. Because it has bovine collagen in it, a skin allergy test is necessary.  It is FDA approved as a "permanent" dermal filler, i.e.,  it lasts 3 to 5 years.  It is important to realize that as a "permanent" filler, if there is any dissatisfaction with the resulting appearance, one has to wait much longer for eventual resorption of the product.  Having injectable filler can be like getting a haircut - sometimes it's a perfect cut, but sometimes it's not, and you can only wait for your hair to grow out.  Dr Rasmussen only offers ArteFill® to her long-time injectable filler patients with whom she is certain are comfortable with her injection technique. BOTOX® Cosmetic BOTOX® Cosmetic is botulinum toxin, produced by the bacterium Clostridia Botulinum. It works by blocking nerve impulses, which reduces the movement of those muscles.  With less movement, the skin surface gradually smoothes out, thereby decreasing forehead furrowing, frown lines and wrinkles around the eyes.  BOTOX® Cosmetic is the only treatment of its type approved by the FDA for the use of frown lines, but can be used "off label" for the treatment of wrinkles around the eyes and forehead furrowing.  BOTOX® Cosmetic takes 5 to 12 days before the full effect (muscle paralysis) is achieved, and treatment usually last three to five months.  Since BOTOX® Cosmetic is used to correct "dynamic" wrinkles, if the wrinkle does  not go away completely despite paralysis of the muscle, injectable fillers may be used as an adjunct to get further improvement for the now "static" wrinkles.