Botox and Fillers, Hello all, thanks for coming back to read some more about dermatology topics. Based on a question about botox and fillers that I saw on DPM, I thought I would devote this post to a basic cosmetic outline. While no means exhaustive, I will try to highlight the most common aesthetic procedures that are done and the ones that I believe are most relevant to our group of ladies.

As with all things dermatologic, I am a firm believer in the importance of working with a core MD for your cosmetic care. What is a core MD? A core MD can be a plastic surgeon, dermatologist, some ophthalmologists (oculoplastics for example) and some head and neck surgeons. A core MD will have the level of knowledge of anatomy to understand where to work to get the results you want; and to keep you out of trouble! This cannot be learned in a weekend course and takes experience- I will say that I am always learning and by no means consider myself a master as there are new techniques always coming out. But I do know that I, along with core MDs, had dedicated training for facial anatomy and that goes a long way to getting excellent, safe cosmetic outcomes. Safety should always be paramount! So please make sure you know who’s holding your injection, so to speak.

The most common cosmetic procedure is performed is injection of botulinum toxin. The first brand was Botox, so that’s the term I will use, but there are other excellent botulinum toxins available, such as Dysport and Xeomin, with more coming out all the time. Botox was introduced over 20 years ago and has an excellent safety profile- there are complications that can occur but overall is very safe and well tolerated.

Botox is typically used on the upper face, meaning the forehead, global and around the eyes, but experienced injectors can use the product in many areas. Botox targets the actual muscles that cause wrinkles in these areas, and works best for wrinkles that are “dynamic.” This means wrinkles that are not present at rest, or at least not strongly at rest, but are present when the muscle moves, or when a person is making expressions. (Botox will work with wrinkles that are static, but it won’t be as effective.) Injection of botox relaxes the muscle contractions so that the skin above cannot wrinkle as well.

Botox can be done in many ways, and depends on the hands of the injector and the patient’s desired endpoint. Botox can be injected in low volumes or diluted to spread out over an area, both of which provide less muscle paralysis. This results in the appearance of smoother skin and what I call a “fresh” look but is not typically very tight nor does it give too much brow or forehead lift. It also does not halt expressions. Botox can also be done in higher volumes or higher concentrations for a tighter look with less movement. This can look very crisp and can provide focussed lift for certain areas, like a less drooping brow or more open eye. It will also allow for less expression. An experienced injector can talk to you about what you would like and help guide you towards a safe, aesthetic outcome. There is no cook book for botox- each patient is unique and has unique anatomy that the MD must be understand and know how to manipulate.

Botox usually takes about 10 days to have its full onset- so if you need it for a certain event, plan for it 2 weeks in advance. On the day of botox, you may get small bumps on the areas injected, like mosquito bites, but those go away quickly- botox is something that can be done over lunch with minimal downtime- another reason why it’s so popular! The most common side effect is a mild headache, and some may bruise- again an experienced injector will avoid injecting over a vein to avoid bruising- I sometimes will even draw out any veins I see to avoid them. Some describe a tingling sensation upon onset of the botox effect, which is usually a few days after.

So what about serious side effects? Botox is truly a very safe procedure with predictable results with proper placement. However, if placement is not correct or there is shift of the product, then there are a few things that can happen. If placed too close to the eyes, it can cause eyebrow or eyelid droop or, in exceedingly rare cases, double vision. This can be avoided with precise, planned injection and injection of low volumes to begin with, and adding in more at a 2 week touch up appointment, especially for first time Botox patients.

So what’s the downside? Well, Botox does wear off- usually it needs to be repeated every 4-6 months. For some patients, it does require higher units as time goes on, and for some, Botox efficacy can wane and you have to switch to another type of botulinum. Why do some people need more as time goes on? Most commonly, as the anatomy changes, so too does the location and amount of botox to achieve good effect.

In summary, Botox is a great initial foray into the world of injectables. It is safe, predictable and has minimal downtime with good results, provided it is done by an experienced core MD injector. Almost everyone can benefit from Botox, either for a light freshening of the face or a non-surgical tightening and lifting of facial structures.

Now we will talk about filler, the second most popular injectable available. Fillers are meant to smooth lines and also to fill up lost volume. The most popular fillers today are hyaluronic acid fillers, but there are several other excellent products, such as collagen, calcium hydroxyapatite, and more. For the sake of simplicity, I will focus on the HA fillers as they are the most common. These include Juvederm, Restylane, Voluma and more, but again, I will refer to these as HA fillers.

Each filler on the market has it specific indications based on its physical properties. Some are wonderful for smoothing fine lines and others are great to pump up the volume. Fillers are safe, but are certainly only to be done in the most experienced hands, as they have several side effects and complications beyond that of Botox. HA fillers are typically used on the lower half of the face, but an experienced injector with outstanding knowledge of facial anatomy can use them in other areas.

A basic filler would be Juvederm or Restylane, which has been around for over 15 years. Juvederm is used in around the lips and the nasolabial folds mainly, and can assist with smoothing lines there. Juvederm is also often used in lips for smoothing and plumping as well. A filler such as this lasts around 4-6 months and will last for less time in an area that moves, ie around the lips vs around the nose.

Fillers are excellent for static wrinkles, ie the wrinkles and folds that are present at rest. Fillers can be placed at different levels of the skin to achieve different effects; the right filler must match to the correct level of the skin. Conversely, a filler placed at the wrong level will, at best, be a waste of money, and at worst, cause discoloration and possible skin damage. Fillers are where you really need to know your injector!

Filler is also outstanding for volume loss. As the face ages, the bones and fat pads start to recess back and move around and this happens in all ethnicities, though somewhat slower in non-caucasian groups. This can be noticed very well in side profile, where the cheek bone or chin seems flatter or the lower face appears “droopy” vs the upper face. There are actually really interesting bio-metric anatomic face studies that use 3D models to show this- the nerd in me loves this kind of thing! The right filler can help to fill and lift these areas, which restores a more youthful appearance.

The most common concerns I get with filler are: “I don’t want to look cheeky, like the cat lady” (for those of you who don’t know cat lady just google it, along with cheeks and you will know what I mean) or “I don’t want to look fake” or “I’m not 20, I don’t need pouty lips.” I am in complete agreement with these statements, and I also do not seek to erase all signs of age. However, treating the right areas with the correct amount and placement of filler can provide subtle improvement and a more refreshed look without coming off as fake. For example, filler around the mouth can lift up mouth corners in a way that makes lipstick stay on better and allow for more definition of the lips without a pouty look. Filler in the cheek or sides of face can provide a touch of non-surgical lift which can take a couple years off. (Note, some patients will need surgery- fillers and Botox can do a lot, but an experienced injector will know when a surgery is required for the intended results.)

With respect to complications, filler does have a few notable ones. Many patients will get bruising- even with avoidance of veins, it is much more common to bruise with filler. With incorrect placement of filler, patients can have lumps and bumps and sometimes those lumps can be discolored which is called Tyndall effect. The good news with this kind of thing is that filler can be dissolved with hyaluronidase but then you’ve wasted your money, though you haven’t had any damage. The real damage come with vascular occlusion, which can occur, albeit very rarely, with filler. This is where the filler inadvertently gets into an artery causing occlusion and necrosis. Necrosis leads to ulcers, which are painful and take time to heal.

This is where the injector must know facial anatomy, the danger zones of the face, where arteries anastomose, and most importantly, what to do when this happens. Rather than tell stories of things I have personally seen and those that colleagues have, when it comes to fillers, or really any cosmetics, ask the MD if they have a plan for handling complications. Do they know what filler necrosis is and how to fix it? Do they know about Botox ptosis and how to manage it? What about burns with laser hair removal? An experienced injector knows how to avoid these things but is humble enough to know that things happen and is smart enough and cares enough to have a plan to handle complications.

In summary, filler is a great tool for softening lines and lifting and filling. Fillers come in a plethora of types, so you really have to trust your injector and make sure they understand what you want. Of course, you really have to know that they have the knowledge to do it well and safely.

The third most common cosmetic procedure is laser hair removal. Interestingly, laser hair removal or LHR is the most common aesthetic related lawsuit, mainly related to the proliferation of non-MDs or even non-mid levels doing the procedure. It is also the one that most frequently results in a pay out. Setting that aside, LHR is a very effective and safe technique. It should be done by MDs or at least by an RN or NP where the MD has verified the settings each time. This is exceedingly important for ethnic skin, which is so sensitive to hyperpigmentation. The ideal laser is a long pulse nd:yag which bypasses the epidermis and aims directly for the hair follicle. While it is not as effective as it cousin, the diode, it is incredibly safe for ethnic skin. And don’t be fooled by fair skin; we DPMs come from a diverse genetic pool and fair skin can respond in unpredictable ways. This is also true in Hispanic and general Asian populations. LHR typically takes several sessions to catch each hair in its particular growth phase. While LHR will reduce hair volume and density it is important to note that it does not guarantee complete and permanent hair loss. Hormone changes, including pregnancies, can shift hair growth and further LHR may be needed. I have been asked about when to start LHR and that’s an individual question, depending on what the person feels about their hair and how much there is etc.

LHR is generally safe with the right laser and appropriate settings. The lawsuit are from unsupervised providers using either the wrong laser or grossly incorrect settings, hence the payouts.

So there you have it, the most common and I believe, the most effective non-surgical cosmetic procedures. Each are distinct and useful in their own ways, and the decision as to when and how to start is individual- an experienced MD can usually help guide you with this and tailor a treatment plan, just like we do for our medical conditions. And again, please be safe! Do your research, know your doctor and ask all the questions you need- and have fun!