By Lisa Profera

The New Year is well underway, and it’s now time to focus on you a bit more. I hope that the health tips I shared in my last two articles have helped you feel better on the inside. Now it’s time to take a look at the outer you. Aging happens to as us all, and as we age, not only does our skin lose collagen and elastin, but we also lose fat and bone structure.

Our face is the first to show signs of aging. These factors, in addition to the effects of gravity, cause deflation and a diagonal descent of all structures, resulting in an older-looking face. The ideal “upside-down triangle of youth” is flipped, and becomes the “pyramid of aging.” Besides wrinkles, other signs of older facial architecture include flattening of the cheeks, hollowing of temples, orbits and sides of cheeks, and irregularity of the jawline and jowls. So how can we turn back time? We are fortunate that most aesthetic procedures performed today do not involve surgery and have minimal discomfort and downtime. 80% of cosmetic treatments are non-surgical, and many of them can be done proficiently by practitioners that are not plastic surgeons.

That being said, the knowledge, skill, and experience of the person injecting are very important. There are many critical structures in the face that are positioned close together; a thorough understanding of facial anatomy is a must! Your safety and comfort should be a priority. Medical history and risk factors should be evaluated, and you should be provided with a detailed explanation of the procedure and possible side effects.

Make sure all of these happen before signing consent and having the procedure. Botox® (Onabotulinumtoxin A) is best for reducing or effacing wrinkles. It is also great for treating some forms of tension and migraine headaches, TMJ (temporo-mandibular joint) issues (related to jaw tension and clenching), and bruxism (grinding of teeth). There are other brands of neuromodulators on the market, but they all work in a similar fashion. For the sake of simplicity, I will not go into the subtleties of the other brands (Dysport®, Xeomin®).

Please note that 1 unit of Botox® is not equivalent to 1 unit of Dysport®, so one cannot compare pricing this way. Botox® is a toxin derived from the bacteria (Clostridium botulinum) that cause the paralytic disease known as botulism (most commonly from food poisoning). Micro-doses of this toxin are generally safe when carefully injected into the small muscles of the face.

Neuromodulators cause relaxation of the muscles they are injected into by temporarily paralyzing them. Once the muscles relax, the wrinkles that run perpendicular to the muscle fibers are reduced. Some wrinkles (rhytides) may disappear altogether. Younger people are even choosing Botox® injections for wrinkle prevention, partially paralyzing muscles before wrinkles even have a chance to form.Botox® made in the USA by Allergan has been thoroughly researched and is FDA-approved. High-quality Botox® administered by an expert injector is not cheap, but it is very effective. Botox® injections are approved for treatment of forehead lines, glabellar lines (often called 11s) and periorbital lines (crow’s feet).

Other areas that may be treated include the lines along the sides of the nose (bunny lines), creases under the lower eyelid (jelly roll), wrinkles around the mouth (laugh lines, smoker’s lines), rumpled chin, and platysmal bands (located in the upper neck below the jawline). Results typically last for 4-6 months. With any procedure, there are side effects, so make sure you understand what they are. When comparing pricing, one may find cheaper Botox® or other neuromodulators out there. As with almost everything, you get what you pay for. Beware of very cheap or almost “too good to be true” prices; the product used may be manufactured in another country, sold on the black market, or diluted.

Remember, this is a neurotoxin that is being injected into your face; do you really want to cut corners when it comes to this?Wrinkles caused by sun damage, smoking and overall loss of skin elasticity most likely will not be improved with Botox® alone. When the matrix of the skin or underlying structures has been compromised, relaxation of the muscle is not enough. One must look beyond Botox® to the world of injectable fillers. The combination of Botox® and hyaluronic acid fillers work synergistically to address almost all of the issues associated with facial aging, and the two together may increase the longevity of desired outcomes.

Fillers help to add volume back into the face by supporting the underlying matrix and, in the case of Juvederm Voluma®, can help support bone structure as well. Once again, you have to be selective about the expertise of the injector and the products used. I prefer using FDA-approved, reversible HA (hyaluronic acid) fillers. Some of the older fillers on the market are not reversible, so if they are injected into an artery or another critical structure, there is no easy fix. The consequences of poor product placement can be quite serious (blindness, vascular compromise, tissue necrosis). Hyaluronic acid is dissolved by the enzyme hyaluronidase, which acts as an antidote to HA when injected into the same area. It is very important for the injector to have this readily available.

There are several different kinds of HA fillers available that are used for different reasons; discuss the use with your doctor to determine the best choice for you. Results with HA fillers can last for 12-18 months or longer.Of course, the earlier you start correcting the effects of aging, the less expensive it is since less product is required. Delaying treatment for years or decades will cost more in the long run. Once things have gone too far, a face-lift may be the only option. Be proactive and consider fillers early on.

It is amazing to see what great results a bit of Juvederm Voluma® to the cheekbones does to correct downstream changes in the lower face. Of course, genetics and lifestyle decisions such as smoking, sun exposure, and nutrition play a role in facial aging. When looking for a practitioner for non-surgical facial rejuvenation, you need to decide whether you want a “wrinkle-manager” or an artist. Merely injecting an isolated area of the face without addressing the entire face may not give you the results you are looking for.

The “artistry” of non-surgical facial rejuvenation lies in the injector’s skills at assessing the big picture: facial proportions from multiple angles, evaluation of age-related changes at each level (bones, muscles, fat, skin), habits of facial expression and animation, etc. The goal of excellent Botox® placement is effacement of wrinkles while preserving natural muscle movement. There is nothing more distracting than watching a person speak or express themselves with asymmetric eyebrows, a drooping eyelid or a distorted smile.

The same goes for filler placement. Unless you are in LA or a place where the “over-injected” look is in, you might not want “fish-lips” or “chipmunk cheeks.” In my opinion, the best results are subtle. Your friend may comment, “You look great, is that a new hair-style?” or “You look fabulous, are you using a new skin care product?” They’ve noticed an improvement, but it is not obvious that you had work done. So the next time you look in the mirror, ask yourself: “Does my external appearance reflect how I feel on the inside?” Do others think you appear tired, worn out, sad or angry? This is especially important for anyone who interacts with people as part of their business, whether you are in sales or service. Even if you are a busy multi-tasking mom, what kind of nonverbal messages are you conveying to the people in your life?

Recently I had a mom tell me that her nine-year-old son commented to her that she always looks angry, when in fact, that was not the case at all. That was when she decided she needed to do something about it. Non-surgical facial rejuvenation does not have to be purely a matter of vanity; it can be done for practical reasons as well. And what’s wrong with wanting to look as young as you feel? Perhaps there is an event coming up like a wedding, a milestone birthday or a high school reunion. My advice is to plan, as some of these procedures should be done weeks or months ahead of time. Botox and fillers are the new “hair-dye” of our time. You can choose to erase the effects of aging just like getting rid of your grays.

Lisa Profera MDOwner and Founder of PROJUVU MD Aesthetics and Lifestyle MedicinePlease note that the information in this article has been designed to help educate the reader regarding the subject matter covered. This information is provided with the understanding that the author and any other entity referenced here are not liable for the misconception or misuse of the information provided. It is not provided to diagnose, prescribe, or treat any disease, illness, or injured condition of the body. The provider of this information shall have neither liability nor responsibility to any person or entity concerning any loss, damage, or injury caused or alleged to be caused directly or indirectly by this information. The information presented is in no way intended as a substitute for medical counseling or care. Anyone suffering from any disease, illness, or injury should consult a qualified healthcare professional. These statements have not been evaluated by the FDA.