Ask the Expert: Differences between Botox and Fillers


We’ve had a lot of questions regarding the differences between botox and fillers recently, it seems to be somewhat of a hot topic. I (Camilla) have been getting Botox every 3-6 months for the past 5 years, and I swear by it. Although I haven’t had dermal fillers, I am open to the idea if/when I feel I need them. I see Dr Alek Nikolic, and have done since day one – my fabulous godmother referred me to him and I’ve never looked back. He has always taken a very measured approach with me, and I trust him implicitly. He is soft-spoken, kind and reassuring (but also realistic), and I always leave his office feeling, and looking, better.

Dr Alek Nikolic
Dr Alek Nikolic

He specialises in aesthetic medicine and is at the forefront of the latest developments in his field. He has lectured extensively and has performed numerous live demonstrations both locally and internationally. His focus is on skin care and cosmetic dermatology treatments such as lasers, chemical peels, Botox, and Dermal Fillers, and he has performed over 20 000 procedures to date. As the expert in his field, I thought that Dr Nikolic would be best placed to answer all of your burning questions about botox and dermal fillers, and he very kindly agreed. Here we go…

Ingredients and how they work:

I believe the first fact we need to clear up is that there is only one Botox® but there are numerous neurotoxins that are manufactured by pharmaceutical companies worldwide such as Dysport®, Xeomin®, Neoronox®, Azzalure®, etc.

The active ingredient is a single Type A protein that is found as part of the chain that makes up the toxin produced by the Clostridium bacteria. Furthermore, slight differences between these manufacturers are noted by using different strains of bacteria (North America versus European) and whether they use the whole type A protein or certain parts of it.

The neurotoxin works by preventing the release of acetyl choline at the nerve receptors thereby stopping the nerve impulse and therefore the muscle action.

A lot of people confuse Botox® with snake venom or rat poison and this could not be further from the truth. Also many people feel that the toxin is dangerous when used cosmetically. To place this in perspective when we treat a 12-year-old child for severe spasm from Cerebral Palsy they receive 800 units to reduce the spasms in both legs. When we treat the entire face an adult will receive on average between 50 to 70 units which is very far from the dose a 12-year-old child receives. In a nutshell Botox® is a safe treatment in experienced hands.

Dermal Fillers:
There are numerous dermal fillers with different ingredients on the world market, but the gold standard ingredient used in dermal fillers today, and the most popular worldwide, is cross linked (or stabilised) hyaluronic acid (HA). HA is found in almost all living organisms and this is what makes using this ingredient safe as a filler. HA works by absorbing huge amounts of water – this is our moisturising molecule that sits in our skins – one HA molecule holds or binds to a 1000 water molecules. It is the water that does the filling or support when injected into our skins or facial structures.

Where would you typically inject them?

Botox® is typically injected into muscles to reduce their activity; the aim is to relax the muscle but not to completely stop all movement. We can literally inject the entire face, neck, chest, for cosmetic reasons but Botox® is also used to control headaches, migraines, reduce excessive sweating, bladder problems, neurological conditions, pain syndromes, etc.

Dermal fillers:
We can inject dermal fillers anywhere in the face and at any depth. Today we have fillers specifically designed to be used just in the skin, or around the eye area, into fat pockets, into cheeks, jaw line and chin, just above bone, ear lobes, etc.

How long until you see results?

Botox® can start to work within a few days but typically people will notice visible changes within 5 to 7 days and full effects are seen 3 to 4 weeks following the treatment.

Dermal fillers:
Results with dermal fillers are immediate and typically what you see is what you get with HA fillers. If an area looks too big or over treated following a dermal filler treatment, then unfortunately this is what it will look like in the long term (although the effects can be reversed if needs be – more on that later in the post).

How long do the results typically last?

For cosmetic effects the typical duration is 3.5 to 4 months but some people are unlucky and only get 2 months, while others are extremely lucky and get 6 months.

Dermal fillers:
The length of time for dermal filler results will vary between filler and brand used. I predominantly use Allergan’s Juvederm range of fillers including the Ultra and Vycross families, and results with these fillers will be between 12 months (Ultra), 15 months (Volift) and 18 months (Voluma).

At what age would you recommend starting (should you be so inclined)?

The time to start is really dependent on the person, but if one would like to never develop a line or wrinkle, then the best time to start is before they appear or just as fine lines start appearing. We do see patients in their twenties because of this, but it is vital that if you start at this age that you see a doctor who uses Botox® to relax muscles and not to completely immobilize or stop muscle movement so that a natural end result is achieved. Today we have the ability to treat someone who comes to see me and says “I work on stage but need movement to show emotion” all the way to someone who wants no movement at all. We approach patients differently so that we tailor make the end result. By treating certain muscles and leaving others out, and by changing the dose used, we can achieve natural end results and provide a specific effect that suits each person.

Dermal fillers:
Treatment with dermal fillers should start as soon as fat loss or volume loss takes place in the face as this directly impacts the overlying support of the skin and the ageing changes that take place in the skin, and with the underlying structures within the face. Unfortunately, these types of changes take place in our thirties but we tend to not notice them until our forties. Today the main goal of dermal fillers is not to fill in a line or wrinkle or to enlarge lips, but rather to bring harmony and ratio back into the face and, most importantly, to lift facial structures and replace loss of volume or fat. So in a nutshell, we should consider dermal fillers in our thirties if necessary  – but this can only be determined by a proper examination of the face and its support structures.

What are the potential side effects?

Possible side effects include allergic reactions (this is extremely rare), swelling at the site of injection (which disappears within 30 minutes), and eyebrow and/or eyelid ptosis (drop) but this is directly related to the experience of the injector. Very rarely have headaches, nausea, muscle weakness, or flu-like symptoms been reported, but this does not require treatment as the symptoms disappear fairly quickly.

Dermal fillers:
Side effects with dermal fillers are typically divided into 2 broad categories and into 2 sub categories (immediate and long term and mild and severe) but I will list them as follows:

  • Procedure expected: bruising, swelling, itchiness, redness or erythema.
  • Technique related: lumps, nodules, asymmetry, skin discolourations, aseptic techniques resulting in abscess formation and biofilm.
  • Inflammatory related: nodule or granuloma formation happens when an inflammatory response by the body forms a firm capsule around the filler injected, resulting in a hard lump. This can be treated with Hyalase (see below) and cortisone injections when using HA dermal fillers.
  • Severe: emboli if directly injected into an artery which can travel into any vessel, including the ophthalmic artery, arterial occlusion resulting in end artery avascular skin necrosis.
  • Unrelated to procedure: biofilm that develops after 4 weeks or more following the dermal filler treatment. Biofilm is a collection of multiple bacteria around the filler. No one knows exactly how this happens, but it seems to be related to some type of bacteria entry point such as with sinusitis, dental problems, intra uterine device infection, etc.

If you don’t like the effect, can it be reversed?

Unfortunately not, as once the muscle nerve ending has been effected we need to wait for the effect to wear off which may take 3 to 4 months.

Dermal fillers:
Yes, we can definitely reverse all HA dermal fillers. We have a solution called Hyalase that contains the enzyme hyaluronidase, and this is responsible for breaking the filler down when injected. This is a super concentrated form that will remove filler within 2 to 8 hours. This dermal filler ‘eraser’ is the saving grace for the more serious complications or side effects that can be seen with fillers.

A huge thank you to Dr Nikolic for taking the time to prepare this post – I hope that you found it helpful and informative. If you would like to learn more about Dr Nikolic and his practice/make an appointment to see him, you can visit the websites listed below for more information.

3 comments on Ask the Expert: Differences between Botox and Fillers

  • Bianca

    What a great article! I started Botox treatment this year and have had dermal fillers in my cheeks too (Voluma). I can honestly say I have never felt better in my life. The dermal fillers are absolutely incredible – it gave me a very natural lift in my cheek area and has given me some extra definition to make that cheekbone pop, as well as making me look more awake. So happy more people are opening up and talking about these procedures!

  • Lori

    This is a very interesting post. I must admit that until now, I wanted to have nothing to do with Botox and fillers – I suppose I had heard “old wives tales” until now.

    But when the time comes, I will consider it.

  • Marné

    I’m considering Botox, so thank you very much for this post, it answered loads of my questions, thank you

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