Botox, Fillers, Surgery – Which Do I Need?

Article courtesy of Mark Epstein, M.D., F.A.C.S.

In my busy aesthetic surgical practice, I see many patients desiring to rejuvenate their facial appearance, but they are not sure as to what they need. They ask me if they should get Botox or dermal fillers which is less invasive than surgery, or go with surgery for a more long-lasting result. What I will share here is my approach, which is integrated from both plastic surgery and dermatology.

The key to a successful facial rejuvenation is no different that that for any medical problem; accurate assessment or diagnosis of the problem followed by correct treatment. I have defined six key areas to assess.

1. Skin quality – Years of chronic sun exposure as well as environmental and genetic factors can induce fine lines and wrinkles, pigment changes, loss of elasticity and overall complexion problems. Here the treatment is to address the skin with topical agents. Botox, fillers and surgery have really no role here. Our aesthetician can refresh the facial skin using various types of peels and other topical agents. This does require compliance, but the reward is fresher, more radiant and youthful skin. Think of it not as a short term treatment to fix a problem, but rather as ongoing maintenance just as is proper diet and exercise.

2. Dynamic lines – These are wrinkles produced in the skin as a direct result of the contraction of underlying facial muscles. Examples include horizontal forehead lines, vertical glabellar (the area of the lower forehead between the eyebrows) lines, crows-feet(the area just outside the eyes) and vertical lip lines. Treatment requires the muscles to be relaxed. Botox is the best way to achieve this. Thorough understanding of facial muscle anatomy and function is required to selectively relax these muscles to give a more youthful appearance without producing a mask-like or surprised appearance.

3. Static lines – These are lines produced not by facial muscles but by a combination of loss of facial fat with aging and also stretching of skin and sagging due to gravity over time. Examples of these lines include the nasolabial folds (the oblique lines between the cheeks and the upper lip extending all the way down from the nose to the corners of the mouth) and the marionette (puppet) lines, which are extensions of the nasolabial folds further down the face. Although surgery can be helpful here, a very popular and effective way to treat these lines is to restore the lost volume to the face. This is done with fillers. Examples of fillers include Collagen, Restylane, Juvederm, Perlane and Radiesse. The longevity of the result varies among the different types of fillers used. For a more complete discussion of Botox and fillers, please visit

4. Loss of facial volume – As we age, even as a small child, there is loss of fat under the skin which can become pronounced when we are in adulthood. The cheeks hollow and a “tear-trough”may develop under the eyes at the junction of the lower eyelids and cheeks. Fillers work very nicely here, but surgery can improve these areas as well.

5. Sagging of facial structures – Gravity, loss of facial skin and muscle tone result in the descent of important facial features such as the eyebrows, malar area (the prominent part of the cheeks under the eyes) and the development of jowls. In this case surgery is usually the best option (browlift, facelift) although Botox can do a nice job of elevating the tail of the eyebrow and fillers can sometimes reduce the depression between the jowls and chin, giving the “illusion” of a smoother, more unified jaw line.

6. Redundant skin – Loss of skin elasticity and gravity as well as genetic factors weigh heavily on the development of redundant or excess skin. This develops over the entire face. During surgery, the skin is re-draped over the deeper facial structures permitting removal of the excess skin. Although Botox and fillers have no role in correcting redundant skin, they may be useful adjuncts after surgery to restore lost facial volume and correct wrinkle lines due to facial muscle activity

Our practice offers the services of myself, a plastic surgeon, as well as that of Elyse S. Rafal, M.D., a dermatologist (both of us board-certfied) as well as Irene Maher, an aesthetician. All of us would love the opportunity to meet with you for a complimentary evaluation.

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