The Wrinkle in Botox
Why you can still expect to have a Facelift
Wikipedia’s definition for wrinkle “is a fold, ridge or crease in the skin.” Botox is a wonderful medical break-through that has altered how some women smile, or lack thereof. Just like many medical breakthrough products, Botox is often over-sold to the general public giving them an unrealistic expectation of results and, often, misconceptions about turning back the clock or stopping the aging process altogether. Medical technology has yet to advance enough to alter our DNA and stop the aging process, but has given us products such as Botox that can help prevent wrinkles from occurring to some degree.
Botox is a product that paralyzes the muscles in the injected area. Since most wrinkles are created from the stress of the underlying muscles, paralyzing those muscles helps to prevent the muscles from contracting thus it prevents skin folds from occurring. When used prior to the appearance of wrinkles, then Botox is preventing those folds from occurring, thus the signs of aging. When used after the signs of aging are present, then Botox assists those muscles from contracting thus relaxing the fold, or wrinkle. Most patients can see visible improvement over time after consistent use. However, the “wrinkle” in Botox is that is does not erase those deep wrinkles once they are formed, but can help minimize their appearance.
Deep wrinkles are the manifestations of muscle contractions over a period of time. Wrinkles are more than just folds, they are the visible signs of soft tissue having been broken down from the stress of the muscle contracting. A tissue replacement, such as artificial fillers or fat grafting, is often recommended to achieve the desired result of minimizing the appearance of wrinkles beyond the capabilities of Botox.
Common areas for Botox Cosmetic are the forehead, glabella (between the eyebrows), and the crow’s feet area around the eyes. Injecting Botox to frown lines is not advisable unless you wish to paralyze your smile for about 4-6 months. Even if you could obtain some benefit from Botox injections to the frown lines (laugh lines – or the parentheses lines that extend from our nose down to the corners of our mouth), then the manifestations of aging would still exist as gravity is a proven cosmetic disadvantage to our facial structure. Botox injections cannot prevent gravity from pulling down the soft tissues of our cheeks contributing to those laugh lines and creating those jowls which in turn help create marionette lines from the corner of the mouth extending down the sides of the chin.
Since it is clear no one would want to Botox those frown lines, the aging process in that area will continue thus leading to a more traditional procedure such as a facelift. Other factors that can help minimize the appearance of wrinkles are skin care, using sun-block protection, drinking plenty of water to keep the skin hydrated, and maintaining a healthy weight. Botox is a great product for the prevention of forehead wrinkles, but one should understand it isn’t a magic potion for all areas of the face.
In our current healthy and image conscious environment many people choose to maintain fitness by running, jogging, or high impact aerobics. While these exercises are great for cardiovascular fitness they are extremely bad for facial aging. First and foremost facial aging is primarily a result of loss of skin elastic tissue due to sun damage, environmental factors and smoking. Pounding the pavement has an adverse effect on facial aging in the face of poor skin elasticity. Compression garments can be worn to hold firm abdominal, thigh, and buttock tissues as protection against the effects of running on these tissues. No such garment can protect the face from the deleterious effects of extreme exercise. Runners are usually thinner than others of the same age. It is a well-known fact that while healthy, thin faces age quicker than faces with some fat content. The opposite is true for necks – little fat in the neck is good whereas a fat neck is difficult to contour. Many people who exercise heavily do not maintain adequate hydration. Drinking large amounts of water help keeps skin hydrated and less likely to manifest dryness, fine wrinkles, and laxity of aging. There are plenty of aerobic exercises and machines that provide a serious workout without the up and down pounding that can exacerbate the facial aging process.
There is a certain subset of patients who, by genetics or trauma, will require a true septo-rhinoplasty to correct breathing problems and to straighten an injured nasal pyramid. There is a much larger group of patients who have relatively minor cosmetic nasal problems, usually confined to the tip or the bridge of the nose. It is a well-known that the tip of the nose tends to lose its support as we age causing the nose to tilt over the upper lip and gives the impression of a longer nose. Minor nasal tip cartilage problems can create the impression of a “boxy” tip or even a “pointy” nose. Minor bridge problems can be addressed with small operations.
The use of filler in the nose has only recently become popular. There are a few situations where fillers may improve the nose without surgery. Small discrepancies of the nasal bones usually due to trauma and certain small tip and bridge asymmetries may be improved with the judicious use of fillers. To this point in time the “perfect filler” is still your own fat. Harvested and processed fat is long-lasting and usually does not require secondary procedures.
The nasal refining procedures do not require general anesthesia and are not covered by insurance. These procedures are for refining the nose and as such do not change to overall ethnicity of your nose. Think of your same nose yet more refined, elegant, and at a greatly reduced price. For some people a major nasal reconstruction may be necessary due to trauma, for those who want a completely new nose, or those with significant nasal breathing problems.
Dr. Paul Howard
View rhinoplasty before and after photos on Dr. Paul Howard‘s web site.
There are literally hundreds of companies developing, manufacturing, and selling laser systems to treat a wide variety of ailments. Some of these laser platforms actually work, but for the most part they never live-up to the expectations created by their marketing campaigns. There are many companies that sell the exact same technology as others but offer new “bells and whistles” as well as more attractive packaging. Doctors have a bewildering number of choices with conflicting claims of “remarkable” results. Complicating the marketplace even further is that the companies market their laser and other “do-dads” directly to the patient hoping that patient inquiries to their doctors will drive the marketplace rather than scientific studies which determine the efficacy of a specific laser treatment.
Concomitant with the latest marketing schemes a lexicon has evolved to describe the wondrous things these lasers can do. Certain words reappear frequently such as: powerful, pain-free, immediate visible results with superior comfort, fast treatment times, and the ubiquitous product that produces superior results and a great ROI (return of investment).
Besides shooting down enemy missiles (ICBM) and providing the “red dot” for laser guided weapon systems, today’s lasers are useful but not required to treat the following: tattoos, vascular skin lesions, superficial facial wrinkles, acne scarring, and for skin rejuvenation in its most generic form. It is human nature to want to look younger with no surgery, no down-time, and no pain. Unfortunately, this is rarely if ever possible. The best plan is to consult first with a physician you trust that has knowledge about Plastic Surgery and skin rejuvenation. Hopefully he or she can help you make sense of the aesthetic industry and give you useable information regarding your particular wishes. Many times a laser may not be necessary at all when much simpler explanation and recommendation will suffice. Sometimes common sense will lead you to the right answer. It is always true that a claim that is too good to be true frequently is.
There are a number of newer technologies now available that are not lasers but make fanciful claims. Intense Pulse Light (IPL), cold therapy (Zerona®), mesotherapy, and radio frequency (RF) tissue healing are out there with little to no data proving their efficacy. A very thoughtful Plastic Surgeon once said, “I’d rather not be the first to jump on the new technology band wagon, nor do I want to be the last.”
Dr. Paul Howard is Board Certified by the American Board of Plastic Surgery. To learn more about Dr. Howard and his Plastic Surgery practice in Birmingham, Alabama please go to his web site:
The development of liposuction about 30 years ago was driven by our patients who asked for a method to reduce body fat without the scars associated with the usual tummy tuck procedures. Our primary focus is the safe removal of isolated pockets of fat to improve body contours. While the goal (fat removal) has always been the same, the methods of anesthesia for liposuction have changed through the years making the procedure more “patient friendly,” yet achieving the same contour results. Most of the technological advances are intended to make the fat removal easier and, even more importantly, an attempt is being made to tighten loose skin and improve the appearance of cellulite utilizing the latest surgical laser technology. Most plastic surgeons believe that the skin tightening effects have not been as impressive as the manufacturers claim. Each manufacturer slightly alters the laser platform so their product can be claimed as “unique” while there is no discoverable clinical difference in the final result. Laser assisted liposuction is marketed under any number of trademarked names including Smartlipo, Vaser, Slim Lipo, Cool Touch, etc. The marketing department of the manufacturer uses the trade names to market these laser liposuction platforms directly to the patients. The laser can be purchased by ANY practitioner, even those with no laser or surgical training. Regardless of the laser manufacturer, the practitioner is told that the patient referrals will be generated through their web marketing and the practitioner is allowed to use the trademarked name (Smartlipo) in their practice marketing efforts.
This marketing strategy is similar in design to the pharmaceutical companies who advertise their drugs directly to the public and offer the names of certain physicians who prescribe their products. All of these marketing schemes are evidently legal, but in the laser liposuction example, the machines are sold to any doctor with the money, training is offered but not required, marketing and patients are guaranteed without checking the doctor’s credentials. The red elephant in the room is that laser liposuction is inherently more dangerous than standard tumescent liposuction techniques and in many instances is performed by non-plastic surgeons who are damaging their patients because of a lack of basic education and the need to market the trademarked product that they own rather than choosing the proper technique for each individual patient.
Many of these doctors ask you to ignore their training and credentials and emphasize their marketing skills. In the final analysis, patient education is not advanced with unclear or even false advertising and many people have suffered as a result.
There are a number of techniques to smooth the forehead and elevate the brow. Practitioners always tout the technique they use as being the “best” but more likely the procedure some view as “the best” is primarily the operation they are more comfortable with. Surgeon’s comfort should not triumph patient results for browlift or any procedure where the results of the two procedures are different.
The antiquated browlift requires an incision in the forehead skin – the so-called “direct browlift.” In an attempt to hide the scar and elevate the brow without the hairline, surgeons flocked to the pre-hairline incision and many claim the very long incision is easy to camouflage and causes no problems. Common sense belies these claims and most surgeons have abandoned this procedure due to the scarring involved.
The last 10 years has seen the development of endoscopic techniques which minimize the scars by placing the two short incisions behind the hairline while allowing access to the three glabella muscles and the forehead muscles from beneath the skin. Elevating the brow must be accompanied by some sort of fixation to hold the forehead skin and brow in the raised position for at least 2 weeks. The brow elevation may relapse to its pre-operative position without fixation while the muscle surgery used to decrease glabellar rhytids (wrinkles) and sometimes forehead wrinkles is not fixation dependent. These rhytids are improved by effectively weakening the forehead and glabellar muscles that cause wrinkles.
Over the last 8 years or so we have developed a unique and quite elegant way to fix the brow and forehead in the raised position with bio-absorbable screws that dissolve after the golden 2 week period of required fixation. The polymer chosen must be strong enough to withstand screw placement in bone, must maintain its bio-mechanical properties for at least 2 weeks and must eventually be cleared from the body. The material chosen is a co-polymer of polylactic acid.
The “Modern Browlift” is a well researched procedure with at least 8 years of documented results, short incisions, no hair loss, no prolonged numbness in the scalp and minimal to no elevation of the hairline.
Read more about brow lift and view brow lift before and after photos.
Call today to schedule your consultation 205-877-PAUL
Botox and Restylane have become the mantra for those seeking facial rejuvenation without the inconvenience of having a “surgical procedure.” While these off-the-shelf products are enticing, they are expensive, temporary, and can be painful to inject, especially in the lips. For more Plastic Surgeons, these artificial fillers (Restylane, Juvederm, Strattice) are appropriate only for temporary improvements where there are time constraints and the need to be in public within a couple of days. Searching for the perfect facial filler had been elusive until recently. The emergence of fat from your own body (autogenous) has paralleled the refinements in fat harvesting and injection techniques that have elevated the “take” of fat injections to the 80-90% range. Coupled with improvements in local anesthesia and anesthetic agents make the overall experience with the new fat injection techniques less painful and more likely to give a permanent, elegant improvement in facial contours and rhytids (wrinkles). Many non-surgical practitioners complain of the donor site for obtaining the fat. While we must respect the donor site, offering the patient an improvement in body contour by harvesting fat for injection offers the patient the benefits of a liposuction (method of harvesting fat) procedure and cosmetic improvement of the donor site as well as the areas of the face injected with fat.
What does the future hold for facial fillers? Ongoing research using stem cell and growth factor technology may lead to even further improvements in fat injection techniques while artificial filler research tries to make their artificial substances last longer and the cost with longer lasting substances is naturally higher and will continue to increase over time.
Fat injection techniques have proven to be a vast improvement over foreign-body injections for facial rejuvenation. Fat is permanent, soft, cannot be rejected by the body, natural, and requires only small (3-4mm) stab wounds for injection. The patient can request which body area is preferred as a liposuction donor site obtaining body contour improvement at no additional charge. The well informed patient will usually choose the elegance of fat injection over the expediency of foreign material injected in the face.
As an extension of fat technology, we have begun fat injections in the back of hands for hand rejuvenation. The injected fat decreases the appearance of prominent veins, knuckles, and tendons that become more pronounced as we age. No one should let their hand reveal their age when we have the procedures to reduce the signs of the aging hand.
Read more about top fat grafting surgeon Dr. Paul Howard and view fat injection before and after photos.
Facial aging is complicated by genetics, environment, sun damage, smoking, and drinking. There is not a single procedure that works for everyone, therefore it is important that individualized evaluation leads to an operation which is specific for that person. The uniqueness of all faces as well as the patient’s desires may lead to a slightly different surgical approach for each individual. Another way to say this is that the one-size-fits-all facelift has become antiquated. To facilitate individualized care we prefer to look at each part of the face separately leading to a unique surgical treatment plan.
We divide the face into its component parts; forehead, eyes, midface, and neck with primary emphasis on the midface. Midface aging is characterized by sagging of the facial soft tissues causing a deepening of the nasolabial folds, dark circles beneath the eyes, and the development of marionette lines from the corner of the mouth to the jaw line. The jaw line becomes less defined as the sagging facial soft tissues drop below the mandible causing jaw line “bubble.” In addition to the sagging soft tissues aging always involves a loss of volume and a loss skin elasticity. It is the surgeon’s charge to address individual manifestations of aging for each component part of the face. Elevating the soft tissues must be done and requires a specific vector or direction of elevation which may be unique for each face. This maneuver defines the jaw line, improves the deep nasolabial folds, addresses the marionette lines, and elevates the lower eyelid skin. This procedure is always required and must be performed accurately with minimal incisions. Elevation of the cheek tissues is so important that it must be done under direct vision with the results being technique dependent. The incisions are much less obvious than the old facelift scars. While elevating the cheek and malar tissues some augmentation of the malar prominence (cheek bones) is achieved. The need for additional volume can be affected by adding autogolous fat to the procedure. As a rule of thumb, we rarely, if ever, remove fat from the midface but frequently add fat back to replace the soft tissues we lose over time.
The next issue to be addressed is the blending of the cheek elevation with the lower eyelids. These procedures are typically done together; that is lower blepharoplasty and facelift. The elegance and effectiveness of the mid-face lift sets up the rejuvenation of the remaining parts of the face.
Read more about Dr. Paul Howard’s Howard Lift Facelifts