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CMDRC.com- Fifteen years ago, if you wanted to get rid of wrinkly and sagging skin, there was basically one way to do it—a surgical face-lift. But today a range of minimally invasive alternatives exist. Botox, as we’ll discuss, can be used to reduce frown lines, “worry lines,” crow’s feet and even provide a “brow lift.” Dermal fillers can be injected into those “nasolabial folds, marionette lines, thinning lips and furrows between the brows, taking years off the face–and all can be done during your lunch hour, with no invasive surgery and virtually no recovery time. In many cases the results can be so appealing that facelifts—an expensive and invasive intervention—can be avoided altogether. Frequently Botox and dermal fillers are used to compliment one another. This will make more sense as you learn about these products

Botox–is it for you?

As you all know Botox is the most commonly used cosmetic procedure in the United States. When properly administered you can still smile and have other facial expressions—but without those lines between your brows. Botox diminishes those lines between your brows that result from muscle movement and the passage of time. It works by temporarily weakening those muscles so that they don’t draw the skin together causing those deep furrows. Botox is also used to treat other areas of the face, this includes forehead creases (d), skin bands on the neck and even the lines known as “crow’s feet (areas g, h, i).” Properly injected Botox can also create a “brow lift” (area e)

There are situations in which Botox is not a good option and these include: wrinkles caused by sun-damaged skin or wrinkles around the mouth. Weakening the muscles around the mouth would be undesirable as you need them for talking and eating!

The results you can expect from Botox depends on several factors including your skin type, its thickness and how well developed your facial muscles are.

What is Botox?

Botox is derived from a bacteria that is found in the soil—Clostridium Botulinum. There are seven different types named A through G. Botox is a therapeutic agent derived from Clostridium Botulinum type A, also known as Botulinum Toxin Type A.

What is Botox used for?

The FDA has approved Botox for cosmetic use—specifically to improve the look of fine lines and superficial wrinkles between the brows caused from every day facial expressions(See areas ‘a’ and ‘b’ above)—specifically furrowing. However, Botox is also very effective for wrinkles—and their prevention– that result from smiling, frowning or squinting.

And there are other uses of Botox too. It’s commonly used to control excessive sweating (hyperhydrosis) in such areas as the palms of the hands, soles of the feet and underarms.

How does Botox work?

Whenever a facial muscle (or any muscle) is activated a message is sent from your brain to your spinal cord and through a nerve that activates the muscle. The transmission of the electrical impulse from the nerve to your muscle is facilitated by the chemical acetylcholine. Botox works by blocking the nerve endings from releasing acetylcholine.

You can see from the drawing above that just beneath the facial skin is an intense array of muscles that produce and endless number of facial expressions—no doubt you’re making some now! Botox is approved for the Procerus and Corrugator muscles but can be used for the ones in the forehead, in the outer corners near your eyes (crow’s feet) as well as others.

What to expect at your first appointment

If you’ve never had a Botox treatment this will be an opportunity to learn some of the “BOTOX BASICS.”

A. Expectations

It’s important to review your expectations and determine if they’re realistic.

B. Risks

In general the use of BOTOX posses few risks. BOTOX may cause temporary headaches, bruising or temporary drooping of the eyelid. Rarely, it can cause temporary double vision. Obviously you will need to tell us about any medical condition you have. Certain antibiotics—Levaquin, Cipro or Clindamycin—shorten the therapeutic effect of BOTOX,so you may wish to complete your antibiotic treatment before receiving BOTOX injections.

C. Contraindications

BOTOX should not be used if you are pregnant, breastfeeding or are taking certain medications (aminoglycosides antibiotics).

D. How is it given? Is it painful?

Botox is given by fine needle injection. The number of injections will depend on the number of areas you wish to have treated. Most women say that the pain is minimal. A typical treatment takes 10-15 minutes—again, depending on the number of areas you wish to have treated.

E. What can I expect afterwards?

There may be some temporary swelling and occasional bruising. The swelling typically lasts a few hours so you don’t want to have this done just before an evening out on the town. After treatment you will see the effects of BOTOX within 1-3 days although the full effect may take 10-14 days. Some doctors ask their clients to frown or squint a lot so that the medication settles in. It’s important that you don’t lie down or bend over for 4 hours after injection. It is generally asked that you not exercise for 4 hours afterwards as well.

F. Things to avoid

Do not lie down or bend over for 4 hours after your treatment. Minimize your exposure to the sun and wear sunblock!

G. The two-week visit

If you’re a first time patient you may wish to make a 2 week appointment so that we can evaluate how it worked for you. Obviously, if you’re having any problems—bruising or eyelid drooping—you’ll call us immediately. The 2-week visit is an opportunity to see how it worked and if you’re satisfied. Occasionally, some “touching up” is necessary at the 2 week visit for optimum results.

H. How long does it last?

For most people BOTOX seems to last 3-4 months. The effects wear off gradually and you’ll be the best judge of when to come in for your next appointment.

I. How much does it cost?

The cost varies with the number of areas that are treated. A complete price-list is available to you upon consultation.

J. Is there anything else I should know?

Avoid aspirin and non-steroidal anti-inflammatory drugs (Ibuprofen, Advil, and Aleve) for at least one week prior to your planned treatment. This will reduce the possibility of bruising afterwards. Also, avoid Ginkgo and ginseng, Vitamin E, Fish Oil supplements and red wine for at least a few days prior to treatment—again to avoid bruising.

Dermal Fillers

As I noted above the use of injectable dermal fillers is one of the most popular facial rejuvenation procedures—about 1.9 million being performed in the U.S. annually.

As we age the underlying skin structures that keep it looking youthful and firm begin to break down. The causes are familiar—gravity, too much sun exposure, diet, smoking, genetic factors and the simple accumulation of years of squinting, frowning, smiling and other facial muscle movement. Over time we all develop lines, wrinkles and folds in the face.

Your skin consists of two layers known as the epidermis and the dermis. The epidermis is the skin’s outer layer and protects us against the environment. The dermis, or innermost layer of the skin, is composed primarily of connective tissue and provides the skin with its support structure. Most facial wrinkles and deeper folds occur within the dermal layerof the skin. Facial fillers, also known as “dermal fillers” and “injectables” are temporary to long-lasting solutions administered through a few tiny injections to specific areas of the face. By re-establishing volume to the areas within the dermis and just beneath the dermis many skin folds and wrinkles can be softened and even be eliminated.

Dermal fillers can be used for reasons other than the softening of lines and wrinkles. Some women choose to use them to enhance their lips and even their cheekbones.

Perhaps nothing is more gratifying for a woman than having an immediate correction of deeply furrowed lines in the nasolabial folds, the corners of her mouth (marionette lines), or from pre-existing scars.

The “perfect” dermal filler would be inexpensive, safe, painless to inject, hypoallergenic and long-lasting. In addition, it should have consistent and predictable results, feel natural under the skin, take little time to inject, and require little “down time” for the patient. Although the “perfect” filler doesn’t exist the ones available today are excellent provided you understand their benefits,limitations and costs. As with all elective cosmetic procedure be financially smart, establish a budget for yourself and ask your MedSpa to work within that budget.

By definition, a dermal filler is a product that is injected or placed into the dermis. Patients are instructed not to manipulate the treated areas, because the product may shift. The best way to reduce swelling is to immediately apply a cool pack to the areas that were treated. In current practice, several dermal fillers are available for use in the United States. In the material below we’ll review some of the more commonly used fillers and the areas for which we recommend them. We’ll review 2 classes of dermal fillers—hyaluronic acid fillers (Juvéderm® and Restylane) and calcium hydroxylapatite (CaHa) microspheres (Radiesse).

Hyaluronic acid (HA) is complex sugar (polysaccharide) that is hydrophilic (attracts water molecules) and is found in all living cells. It attracts and binds more than 1000 times its weight in water which explains why it hydrates and adds volume to the skin. Juvéderm Ultra, Juvéderm Ultra Plus, Restylane and Perlane are all made of hyaluronic acid. The differences are among the long list of things you’ll want to discuss with us before considering their use. Radiesse is both a dermal filler and a bioactivator. It contains 30% synthetic CaHa microspheres which supports the growth of new collagen in your skin.

Please note that we do not endorse a given product. We have no financial arrangement with any company. The Juvéderm products are made by Allergan. Restylane and Perlane are made by Medicis-R and Radiesse is produced by BioForm Pharmaceuticals.

Hyaluronic acid is complex sugar substance that occurs naturally in your skin. Hyaluronic acid has been used for many years as an injection into arthritic joints to aid movement and also for wound repair. You cannot be allergic to hyaluronic acid.

In general, hyaluronic acid fillers help add volume and hydration to your skin. HA fillers are non-allergenic and require no skin testing. Additionally, they can be used for all skin types and tones.

HA fillers are used to plump fine to deep wrinkles, creating a fuller more youthful appearance. The results, as with other dermal fillers, are immediate and last 6-12 months. Juvéderm comes in two formulations—Ultra and Ultra Plus–depending on the depth of wrinkles and folds that are being treated. Unlike some other fillers Juvéderm can be used to add more volume to your lips. Restylane and Perlane are the two formulations produced by Medicis-R, their manufacturer.

Okay, I don’t know if Halle Berry uses or needs any dermal fillers. We can agree that she’s a beautiful woman and part of it is her lips which are full, symmetrical and work well with her face. The point is this, if you’re interested in augmenting your lips you want to make subtle changes that work with your particular face. Asking to have “Angelina Jolie’s lips” may simply not work for you and in fact, depending on your face, may give you a look you definitely don’t want.

Dermal fillers require that you discuss, in detail, your expectations and whether or not these are achievable. Remember, that you can always “under-correct” and add dermal filler at a later time but you can’t remove it once it’s there—and it lasts for up to a year!

As I already mentioned, JUVÉDERM® comes in two formulations—Ultra and Ultra Plus. The Ultra Plus is used in places where greater volume is required to correct deeper tissue folds and wrinkles.

What is cross-linked hyaluronic acid?

In your reading and internet searches you might read about “cross-linking.” Cross-linking is the process by which naturally occurring hyaluronic acid is transformed into a gel. The amount of cross-linking determines the thickness of the preparation and how long it lasts. Products with a greater percentage of cross-linking are thicker and longer lasting.

How are HA fillers used in treatment?

HA fillers are injected into the skin using a fine needle to temporarily fill in and smooth moderate to severe facial wrinkles and folds. These areas include the nasolabial folds (folds of skin between the corner of the mouth and corner of the nose)—also called “parentheses” or “smile” lines. It can also be used to treat “marionette lines”. HA fillers temporarily add volume to the skin and may give the appearance of a smoother surface.

What will treatment with HA fillers accomplish?

HA fillers will help to smooth moderate to severe facial wrinkles and folds. Most patients need one treatment to achieve optimal wrinkle smoothing. A single treatment could smooth your lines and wrinkles for 8-12 months.

Is treatment with HA fillers painful?

Injections may cause some discomfort during and after the injection. HA fillers are injected directly into the skin using a fine needle to reduce injection discomfort. We generally anesthetize the area with a topical anesthetic and ice just prior to the injection. When HA fillers are injected into the lips I will suggest several different approaches including a local anesthetic called a dental block. Unlike other physician’s offices we can also provide you with some conscious sedation if you feel you require it.

How long does treatment usually take?

The actual treatment process itself takes only 10-15 minutes. However, you will spend considerably more time with me discussing your expectations and discussing the procedure and how can most benefit from it while keeping to your budget. There will also be “before” pictures taken so that you can compare “before” and “after.”

Good results depend on a good common understanding of what can and cannot be achieved.

Does the correction last forever?

No. Correction is temporary; therefore, touch-up injections as well as repeat injections are usually needed to maintain optimal corrections.
How long do results last?
Results generally last for 8-12 m0nths and vary from one woman to the next. This depends on the area being injected, your lifestyle and how you metabolize the filler.

What are the possible side effects of HA fillers?

Most side effects are mild or moderate in nature, and their duration is short lasting (7 days or less). The most common side effects include, but are not limited to, temporary injections site reactions such as redness, pain/tenderness, firmness, swelling, lumps/bumps, bruising, itching, and discoloration. As with all skin injection procedures there is a small risk of infection.

Calcium Hydroxylapatite fillers (Radiesse)

As we already noted above Radiesse is both a dermal filler and a bioactivator. It differs from the HA fillers by stimulating natural collagen growth. For this reason, Radiesse, may last longer than other dermal fillers and in the long run may require fewer “maintenance visits” and “touch ups.” Another advantage of Radiesse is that after it’s injected in can be contoured and molded for several weeks afterwards.

Complications from Calcium hydroxylapatite fillers are about the same as for hyaluronic acid (HA) fillers and therefore they have about the same profile. Radiesse, unlike the HA fillers cannot be used for injection directly into the lips.