Lumped together under the outsize umbrella that is “injectables,” neuromodulators and dermal fillers are commonly confused. The former are botulinum toxins—Botox, Dysport, Xeomin, and Jeuveau—which relax muscles and ease tension, to smooth the skin (their main claim to fame) and encourage features to shift subtly (a quieter capability that savvy injectors have more recently begun to harness). Fillers are gels (hyaluronic acids, like Juvéderm and Restylane), pastes (Radiesse), and suspensions (Sculptra) that lend volume and substance to the skin, to help plump lips and cheeks, restore or remodel our bony framework, and efface etched-in lines. While these substances are temporary in nature, all injectables offer the long-term perk of enhanced collagen production, with the biostimulators, Sculptra and Radiesse, excelling in this regard. “There’s some evidence that toxin can also stimulate new collagen,” according to Dr. Hema Sundaram, a board-certified dermatologist in Fairfax, Virginia, and Rockville, Maryland.
Doctors routinely use toxins and fillers in tandem during the same appointment, but lately we’ve noticed that more and more are taking a toxin-first approach for appropriate patients—treating the face with Botox (or one of its rivals) and then waiting a week or two for the drug to kick in and the muscles to recalibrate before assessing the patient’s need for further treatment. “Sometimes we’ll find that they don’t need any filler, because the correction is enough to make them happy,” says Dr. Papri Sarkar, a board-certified dermatologist in Brookline, Massachusetts. In such scenarios, the toxin alone may have softened a nagging line, opened the eyes a touch, or perked up a lip to the point where extra tweaks aren’t needed. If, upon reevaluation, the patient can still benefit from filler, the good news is, “we can typically use less of it,” Dr. Sarkar says—saving them money and potential downtime.
An important caveat our experts are quick to share: leaning on toxin first or relying on it exclusively are methods usually reserved for those under 35 without major volume loss. For others, restoring volume with fillers first can actually help “rebalance overactive muscles, subsequently allowing for lower dosing and a more nuanced approach with toxin,” Dr. Sundaram notes. And using toxin conservatively in faces where fullness has waned is crucial, she explains, “since we don’t want to compound the [age-related] loss of facial tissues by ultimately atrophying [or shrinking] muscles and diminishing volume further.”
Ahead, top dermatologists and plastic surgeons share eight situations in which “toxin first” can be a winning strategy.
1. If you’re new to injectables
Botox isn’t called a gateway drug for nothing. When someone is new to or nervous about injectables, starting with toxins—which involve less risk and commitment than fillers—can help “relieve any potential anxiety about their first injectable experience and allow them to establish a relationship with an injector,” says Dr. Umbareen Mahmood, a board-certified plastic surgeon in New York City. Dr. Sundaram cosigns: “Toxin is a good way to bond with a new injector and can be a great entry-level procedure for some patients, because it’s quick, has no recovery time, and is virtually instant gratification—only a few days’ wait for results.”
The subtly profound power of toxins also lets us ease into certain treatments we might otherwise be hesitant to try. “Some patients are fearful of lip filler or looking like they’ve had their lips ‘done,’” says Dr. Katie Beleznay, a board-certified dermatologist in Vancouver, British Columbia. But with toxin, doctors can perform a lip flip—turning out the top lip to poutier effect—to give a taste of what’s achievable with lip filler. Oftentimes, “patients are thrilled with the amount of lip eversion they get with a lip flip alone,” Dr. Mahmood adds—and they realize they don’t need filler to achieve the lip look they’re after.
2. If you’re worried about bruising and swelling
Neurotoxin injections involve using tiny needles to deliver minuscule amounts of liquid into muscles at relatively shallow depths. They create very little trauma compared to fillers, which tend to be thicker and demand deeper placement with larger tools. So “if a person is worried about bruising or swelling, Botox could be a good starting point,” Dr. Beleznay says.
As Dr. Sundaram explains, “hyaluronic acid [HA] fillers are hygroscopic to varying degrees—all will pull in some water after injection and give temporary swelling.” Interestingly, HAs also have anticoagulant properties, she notes—meaning that they promote bruising. “I always caution my patients that [it’s] Murphy’s Law—they’ll bruise the one time we don’t want them to, like before a big event, even if it’s just a tiny [black-and-blue mark] at a cannula entry point.”
While good providers take steps to minimize evidence of injections, Dr. Sundaram says she’s become even more mindful about potential side effects this past year. “When people have significant life stress, post-filler swelling or a small bruise can assume much larger significance or be the last straw—and this group [of patients] has expanded during the pandemic.”
3. If you have expression lines while at rest
When people come in complaining of etched-in frown lines (between the eyebrows) or crow’s-feet (radiating from the outer corners of the eyes), Dr. Beleznay tells them “that Botox might not lift the lines out completely” but says that “we still start there, to see how much softening there is of these static lines.” If creases are still visible two weeks out, she’ll discuss adding a small amount of HA, to blur them a bit more.
For tricky-to-treat wrinkles above the upper lip, commonly referred to as “smoker’s lines” or “barcode lines,” “smoothing them first with toxin can reduce the need for filler, avoid a bulky look or unnatural contours when puckering the lips, and also make filler sit better and last longer [if you wind up needing it to get your desired correction],” Dr. Sundaram explains.
4. If your area of concern is risky to inject with filler
Regardless of their intended targets, injectable fillers pose an element of risk: should a drop of gel inadvertently enter an artery and cause a vascular occlusion, skin loss, stroke, blindness, or even death can occur. Certain parts of our anatomy, due to their vasculature, are known to be more dangerous than others—namely the forehead, the glabella (between the brows), the nose, and even the frequently filled nasolabial folds, which have been the subject of dozens of filler studies. So oftentimes, when forehead furrows or angry “eleven” lines are a concern—or a patient is asking to nonsurgically tweak their nose—doctors will inject toxin first, when appropriate, to eke out as much improvement as possible before resorting to filler.
“Countless studies have shown that filler injection into the glabella is extremely high risk, and [since] for me, patient safety is paramount, the first step in treating glabellar rhytides [wrinkles] is neurotoxin, to decrease or block muscle activity—and then we determine the appropriate treatment for the static rhytides that are still present,” says Dr. Mahmood. (Moreover, she notes, risk aside, if you don’t first address the muscles responsible for the wrinkles, other treatments are pretty much doomed to fail.) “Patients are often so pleased with how much smoother this area looks after neurotoxin that they don’t need additional treatments,” she says.
For folks hoping to nonsurgically change their nose, filler may seem an obvious go-to, but “there are a few ways that Botox can save them from having nose filler,” Dr. Sarkar tells us. “Smiling often causes the tip of the nose to pull downward, making the nose look wider, droopy, or longer and, sometimes, less straight—it drives people crazy. But a little neuromodulator at the base of the nose can solve the problem by keeping the depressor alae nasi muscle from pulling as tight.” Similarly, she adds, if people feel their nose is too prominent or enlarging with age, a little toxin in the chin can distract from the nose a bit by “making the chin appear longer and the lower lip appear fuller,” she explains. If the nose is truly crooked or has a bump on its bridge though, filler is typically needed alongside toxin, for a noticeable improvement.
5. If you want to smooth out a pebbly chin
While only filler or an implant can dramatically bolster or reshape a chin, Dr. Sundaram finds that relaxing the mentalis muscle with toxin can smooth a cobblestone chin while “transforming the proportions of the lower face and preparing the skin well for subsequent filler.” Once free of tension, the skin smooths out, allowing filler “to sit better and also last longer, because it isn’t subjected to constant shearing forces from overactive muscles of the always mobile mouth.”
6. If you’re aiming to subtly tweak the shape of your face
You’ve likely heard before that a classic female face is somewhat heart-shaped—wider at the top and more tapered at the bottom. Gravity and age have a way of revising our facial proportions, however, contorting once youthful hearts into peanuts or eggs. But according to Dr. Sundaram, “by injecting toxin superficially, to target the points where overactive muscles attach to the skin, we can subtly reshape the whole face while preserving facial expressions and mobility.” Using low doses of toxin, she strives to “make the upper two thirds of the face more prominent relative to the lower third for women, re-creating—or creating for the first time—the heart shape that’s a hallmark of female beauty.” (For a more significant slimming of the lower face, slightly larger doses of toxin can be shot into the masseters—the muscles involved in chewing, clenching, grinding.)
For men, she notes, the ideal face shape traditionally hinges on “a stronger and more angulated jawline, so [there’s] a more equal distribution of prominence between the thirds of the face.” This too can be accomplished with strategic injections of neuromodulators.
Once the muscles are rebalanced, filler can be used to polish the profile by rounding out hollows, like at the temples, and fine-tuning the contours of the face.
7. If you’re looking for a low-key glow-up
“Neuromodulators are a great place to start, if someone wants a little pick-me-up or to look more refreshed and rested,” says Dr. Beleznay. In fact, one of the most striking aspects of Botox before-and-afters is often the perceived change in the patient’s countenance (e.g., no more RBF).
“If I want patients to look happier or more uplifted,” says Dr. Sarkar, “I try to relax the muscles that cause features to turn or pull downward, like the corners of the mouth and the tip of the nose, connoting anger.”
Beyond the just-back-from-vacation vibes toxin can impart, artful injections can deliver understated airbrushing by improving the quality of the skin, for a younger, fresher look. We see “less oiliness, pore prominence, and redness/flushing [as well as] better skin elasticity or resilience and a radiant skin glow,” Dr. Sundaram says. “My before and after photos typically look as if a filter has been applied—light hits the skin more softly and illuminates a smoother, more even, and [more] reflective surface.”
8. If you want to look more wide-eyed (or fox-eyed)
While under-eye filler is a popular fix for tired eyes, sometimes injectors can brighten the eyes in a more natural-looking way “by injecting minute doses of toxin very superficially into the skin, just below the eyelash line under the eye,” Dr. Sundaram says. “The needle is tiny, it’s a single injection point on each side, and depth-wise, it’s nowhere near the eye.” In the right patient—someone with good skin elasticity and no sagging—this technique will “lower the eyelid by a fraction of a millimeter, to create an appealing wide-eyed look,” adds Dr. Sundaram. By varying her needle position slightly, she can even give the eyes more of an almond shape, for “a subtle and natural-looking version of fox eyes,” she says.
