What You Should Know About Combining Dermal Fillers With Neurotoxins

Dermal fillers are gel-like substances that are injected into the skin, plumping it up and reducing the appearance of lines. Fillers are intended specifically to make the skin look smoother and fuller. Their effects typically appear immediately and can last years. In 2011, there were more than 1.6 million dermal filler treatments performed in the U.S.

Key takeaways:

Today, more than three million people get dermal fillers each year. Neurotoxins are the only non-surgical cosmetic technique used more frequently than dermal fillers, and the two are often used in combination as part of an anti-aging strategy.

Approved types of dermal fillers

There is an array of dermal filler products that are approved by the U.S. Food and Drug Administration (FDA). Below we discuss several materials that are used to develop these fillers.

Hyaluronic acid

Hyaluronic acid, which is a substance that normally exists in our skin, keeping it hydrated and plump, is one of the most common ingredients in dermal fillers. Restylane and Juvederm filler products use hyaluronic acid. An advantage of these fillers is they can be dissolved and therefore removed if the patient does not like the change the fillers cause to their appearance.

Calcium hydroxylapatite

Calcium hydroxylapatite is a substance found in our bones. It is included in fillers like Radiesse. Calcium hydroxylapatite has long been used in reconstructive forms of plastic surgery as well as in dentistry for years with a positive safety profile. Results from fillers that use this material tend to last approximately a year.

Polymethyl methacrylate

Polymethyl methacrylate is more durable than some of the other filler options, but it can also form visible lumps. The longevity of its effects must therefore be considered relative to its potential aesthetic complications.

Poly-L-lactic acid

Poly-L-lactic acid is a substance that was developed to treat severe facial wasting in people with human immunodeficiency virus (HIV). It is now approved to treat facial aging, and its effects can last for two years. It is synthetic and works primarily by stimulating the production of collagen.


Transferring fat from the patient’s own body to rejuvenate the face is increasingly common. Referred to as autologous fat transfer (AFT), this technique appears to be associated with lower complication rates than other filler materials because the material comes from the patient’s own body and is therefore unlikely to cause immune reactions. It is also associated with high patient satisfaction.

FDA-approved filler purposes

The FDA has approved the use of certain dermal fillers in people who are at least 22 years old and want to correct moderate-to-severe facial wrinkles or acne scars. They have also approved fillers to increase the fullness of parts of the face and the back of the hands. In those with HIV, dermal fillers have been approved to restore fat loss in the face.

Most of the complications associated with dermal fillers occur soon after filler injection and resolve within a few weeks. Common complications include bruising, swelling, rashes, redness, pain, itching, and tenderness. Other complications such as infection, inflammatory nodules, and nerve damage can occur.

To avoid complications, the FDA advises that people undergo allergy testing when dermal fillers contain collagen or other materials that come from animals. In rare cases, dermal fillers may be accidentally injected into blood vessels and cause serious side effects like stroke or blindness.

Dangers of under-the-table fillers

The appeal of dermal fillers combined with their high financial cost has led to the development and marketing of unapproved dermal filler products, many of which can be purchased online. These do-it-yourself kits often involve injecting silicone into the body, which can lead to serious injuries and death. The FDA has therefore warned against the use of these types of products.

Combining fillers with neurotoxins

While some of the black market filler products have known risks, the risks associated with combining approved fillers with neurotoxins are not well understood. According to the FDA, the safety of combining dermal fillers with botulinum toxins like Botox has not been formally evaluated with clinical trials.

There is therefore little expert guidance on if and how these anti-aging treatments can be used together to address cosmetic concerns. Nonetheless, because they claim that combination treatments become more important as people age, clinicians often do combine fillers and neurotoxins and report on the effects.

Recent research on combining cosmetic botulinum toxin with hyaluronic acid fillers found that compared to when the toxin when used on its own, the addition of fillers produced better effects that lasted longer and improved patient satisfaction with the anti-aging intervention.

At the same time, a smaller dose of the neurotoxin was required to achieve these results. As more data become available on combining dermal fillers and neurotoxins, it will become more apparent how to best use these products to achieve desired results.

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