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We are a boutique office providing injectibles services, both neurotoxin (Botox®, Dysport®) & hyaluronidase fillers (Restylane®, Restylane Lyft®)
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These medicines are injected with a fine needle under the skin and usually take two to five days to take effect—they do not work immediately. Once they take effect, the muscles soften and are weak, reducing the wrinkles on the overlying skin. Some of the wrinkles can be quite deep, and even with minimal or no muscle activity, the wrinkles persist (although they are often markedly improved). The medicine usually lasts four to six months, after which the muscles strengthen again.
What Does It Do?
What is Botox?
The quality of the results is often tied to how frequently treatments occur, along with the dose. The ideal interval between treatments is four to five months, but it can vary. When a patient is treated for the first time, or when they are treated with the muscles at full strength, the results are often impressive but limited—the muscle weakens but often not completely. In the ideal setting, the next treatment is then given towards the end of the cycle, when the muscles begin to gain strength but before they are back to full strength. Treatment at that point—when the muscles haven’t regained their complete strength—results in a more profound effect.
With subsequent cycles, the results get better and better with marked softening and a beautiful, smooth effect. Furthermore, the muscles start to have a mild atrophy—meaning they thin out—which helps some of the most stubborn creases and lines flatten. Most patients find that the Botox® or Dysport® lasts around five months, so that repeat treatments are scheduled at approximately four to five months. These durations vary among patients; some need to be treated every three months while others can wait longer.
Botox & Dysport: How Often do I Treat?
The side effect profiles of Botox and Dysport are usually mild and temporary.
Swelling and bruising:
With each injection, there is mild swelling and occasional bruising; ice can help minimize both of these concerns.
Persistent wrinkles/muscle activity:
Botox and Dysport will weaken the muscles, but sometimes the muscles are quite strong and even a significant dose does not fully weaken them. In our practice we use a very large dose, yet strong muscles will still have some activity. The best approach in this setting is to narrow the treatment interval. These strong, recalcitrant muscles and resultant wrinkles need to be retreated before the current dose wears off, and with each cycle, the area softens, muscle weakens, and wrinkles dissipate. Treating more frequently is the best solution to stubborn wrinkles and persistent muscle activity and is often much more effective than adding more product in an area that already received a high dose.
Eyebrow asymmetry:
Although similar amounts of material might be injected on each side of the forehead, sometimes the muscles are stronger on one side or the other and that can result in eyebrow asymmetry. Fortunately, this concern can be fixed promptly with a little more product just above the higher eyebrow (it pushes the eyebrows down).
Peaked eyebrows:
Depending on the forehead treatment pattern, sometimes the eyebrows can peak abnormally on one or both sides. If this occurs and is undesirable, a small amount of product can be injected just above the peak and bring it down slightly.
Low eyebrows:
This is a common problem, frequently with a well-intentioned cause. The forehead muscles raise the eyebrows, and it is that muscle activity that creates forehead wrinkles. To soften the forehead, Botox or Dysport is injected. These materials act by weakening the muscles of the forehead, which creates two simultaneous effects: (1) the wrinkles soften, and (2) the eyebrows drop. Therefore, the more product is placed into the forehead, the lower the eyebrows. In some cases, less product is placed towards the sides, creating arched eyebrows. If the eyebrows are too low, there is no good immediate solution, but fortunately the eyebrows frequently start rising on their own within a few weeks. Paradoxically in these instances, once the eyebrows rise, there is a prolonged period of appropriately located eyebrows with a smooth, wrinkle-free forehead.
Eyelid ptosis:
If the product migrates into the fine muscles that elevate the eyelid (levator palpebrae superioris), it can create a droopy eyelid that is particularly frustrating. This effect usually occurs within three to five days of treatment, and fortunately resolves within two to three weeks. There are eyedrops that can reduce the effects (an alpha-adrenergic agonist such as apraclonidine), but usually the problem resolves on its own. It is believed that injections just above the eyebrow are at highest risk of migrating into the eyelid muscles.
Concerns & side effects
There are three main treatment areas, and then many other areas that can be injected. The main areas are the glabella (the region between the eyebrows), the forehead, and the crow’s feet (just to the outside of the eyes). These three areas are the standard areas treated because they respond reliably, effectively, and with minimal side effects.
Other areas of the face and neck are treated by some practitioners, with varying degrees of success. For example, “bunny lines” (wrinkles on the sides of the nose) can be treated in patients who have excess wrinkles there, and the vertical banks on the neck will soften with injections. Some patients have excess sweating in the axillae (armpits) and injections at that site will often reduce sweating. Other areas of the face are sometimes injected, such as the muscles that pull down the corners of the mouth, and in the sides of the cheeks to reduce facial width. Many of these other treatment areas work with less reliability and sometimes can have untoward effects.
Most practitioners will routinely treat the three main areas (glabella, forehead, crow’s feet) which can markedly improve a patient’s appearance, and in very limited circumstances treat some of the other areas.
Botox & Dysport: What areas are treated?
Fillers:
Restylane & Restylane Lyft
Most fillers used today are made from hyaluronic acid, which is a natural material that is made synthetically and injected into the soft tissues. This material is a soft, clear jelly-like substance that “fills” the tissues, much as air fills a balloon. Its use is based on the concept that the face often loses volume over time, so that putting some volume in selected places helps reverse some of those effects.
What Is It?
What are Fillers?
The various fillers have different longevities, and how long they last depend on the material used and where it is injected.
The hyaluronic acid in fillers can be cross-linked to different degrees. Restylane® is less cross-linked, softer, and is absorbed more quickly (often around 9 months), and Restylane Lyft® is more cross-linked, firmer, and is absorbed slower (often around 18 months). The more the cross-linking, the thicker the agent, and the longer it lasts.
Filler can be absorbed more rapidly in particular areas of the face; for example some patients note that lip filler does not last as long as the same material injected into other areas at the same time. Similarly, filler placed under the lower eyelids (teartrough) can sometimes last longer than it does elsewhere on the face.
One factor that can complicate appearance is that certain areas can swell dramatically with the injections and can lead to confusion as to the effects of the filler. For example, injections into the lip can cause profound swelling; this swelling can last up to a month. Once the swelling has fully subsided, the effects of the filler become evident and then the filler would usually last from six to nine months. The confusion arises at the end of the first month, when the swelling subsides, it can be confused for the filler going away. The swelling can sometimes appear attractive and desirable, and the swelling subsiding is confused for the filler absorbing; the effect of the filler is actually what is present after the swelling subsides.
Fillers: How Long Does Restylane & Restylane Lyft Last?
Bruising:
The filler injection can cause bruising, especially as the needle used is larger than that for botox. Bruising from fillers usually resolves within a week but can be more significant than that seen with Botox® or Dysport®. Application of ice following filler can help minimize bruising and is encouraged in the hours following filler injection. A second potential concern of filler is
Palpable Lumps:
Fillers can sometimes cause clumping or nodules. The filler is often injected as small aliquots under the skin, and these small aliquots can be palpable and sometimes visible as if there are beads under the skin. Usually, over several weeks, these clumps dissolve and dissipate, and if needed, they can be massaged to settle them. These small nodules virtually always disappear within one to two months.
Vascular Compromise:
A final and serious concern of filler is it can occlude a blood vessel and damage tissues. This complication—vascular occlusion—is rare but has been reported to happen. The most feared situation is occlusion of the vessels of the eye, which could cause blindness, and while this is extremely rare, it has been reported in the literature. Occlusion of vessels elsewhere on the face can cause areas of compromised blood flow, and potentially even tissue loss. While these are very rare, if ever there is concern about any of these complications, please notify your provider immediately so that steps can be taken to address the problem.
Concerns & side effects
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Tailor-made solutions designed to achieve your desired outcome.
Personalized Treatment Plans
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Fillers are used based on the concept that the face often loses volume over time, so that putting some volume in selected places helps reverse some of those effects.
Fillers
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Botox® and Dysport® are neurotoxins that work to soften the skin by weakening the underlying muscles
Botox
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