Dr. Anson Answers: When should I start using Botox® and Fillers?

I tell my patients to consider Botox (or Dysport, Xeomin, which work similarly to Botox) when they start to notice scowl lines or crow’s feet, even when they’re not actually making those movements. Regardless of age, facial skin wrinkles when a muscle contracts. As we age, and with repetition, the wrinkles stop disappearing when you’re not making the expression. Ultimately, the wrinkles of facial expression become permanent.


I recommend Botox when the wrinkle lasts longer than the expression, but before it becomes permanent.  Typically, that translates to the 30’s but depends on individual skin quality.

Botox works by weakening the muscle, so the wrinkle can’t be reinforced. It works well for wrinkles/ muscles that can be weakened without looking odd (scowl lines, crow’s-feet).

We know that wrinkles occur with age and certain movements. The brow/forehead also seems to drop in many people with age. Some of the drooping is due to ‘deflating’ of the tissues from thinning and volume loss. Some of the drooping is likely due to repetitive ‘pulling down’ of the forehead as the muscles contract. Botox will improve forehead wrinkles directly, but may also influence the degree the brow drops over time.


Fillers (aka soft tissue fillers or injectable fillers) are often the next step my patients take. The most common fillers we use are hyaluronic acids (HAs) which are natural components of the skin. Juvederm, Restylane, and Voluma are synthetic gel hyaluronic acids.  Fillers should be considered treatments for the replacement of the volume we lose with age, and to fill wrinkles that are not appropriate for treatment with Botox.

When I first started in practice the only filler product we had was Collagen which lasted about three months. We’ve come a long way since then.  The HAs now last between nine months to two years depending on where and how they’re used. Allergan boasts two year longevity for Voluma, the newest product.  Even if it’s close, that’s a significant improvement.

I suggest filler when volume loss is early and before wrinkles are deep. The lines responsible for lipstick bleed, ‘smoker’s lines,’ are best injected when they are fine and few. However, I have found we can achieve excellent results with filler in this area even if they are more severe.

My patients often mistakenly focus on the nasolabial folds (smile lines from nose to mouth corner) as an early sign of aging. However, commonly, it is volume loss in the cheeks that has a much greater effect.  The shadows and contour changes that result from volume loss often have a more dramatic impact on the appearance of aging than actual wrinkles. Fillers can be useful beginning in the 30-40 year age range.

Be Proactive!

The MOST important thing we can do, however, is to take care of our skin, which should begin in childhood! Ultraviolet exposure is the biggest contributor to skin aging, so sunscreen is extremely important. Other skin protectants should begin in the 20s once skin has matured. I recommend seeing an aesthetician periodically for light peels and to help guide your product choices. Most people will benefit from topical anti-oxidants and retinol-type products. The most common mistake I see patients make is to use the same products for years. Remember that your skin changes, better products come along and you want to take advantage of multiple mechanisms of ingredient actions to protect and treat your skin.

-Dr. Goesel Anson

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