Quick Fixes

Botulinum toxin injections (referred to by such product names as Botox®, Dysport® & Xeomin®) are biological toxins (botulinum toxins) transformed into therapeutic agents known as neuromodulators. Clinicians began working with Botox in the late 1960s for treatment of certain neurological disorders. Today, Botox is used for a variety of cosmetic and neurological conditions. Botox is used for treatment of frown lines, forehead furrows, crow’s feet, lower facial wrinkles, nasal muscles which produce bunny-line wrinkles, and even neck muscles. In fact, Botox injections have proven to be one of the most popular of all cosmetic procedures. The type of lines and wrinkles that respond to Botox injections are those caused by muscles – specifically those muscles that contract during certain facial expressions such as frowning or squinting or raising one’s forehead in surprise.

During Botox injections patients are asked to contract muscles within a given treatment area. This aids Dr. Minoli in identifying the proper injection sites. In most cases, Botox injections penetrate directly into a given muscle through a tiny needle. The effect of Botox injections is not immediate, but usually takes several days to work. For patient comfort, a topical ice is usually applied prior to Botox injections so as to reduce needle discomfort.

BENEFITS

• After several decades of clinical use, Botox injections have proven to be safe. No systemic complications associated with Botox injections have been documented to date.
• There is no downtime. Patients can immediately resume normal activities.
• The treatment is reversible within several months.
• Botox injections are beneficial for a variety of conditions other than cosmetic (e.g., migraine headaches & excessive sweating).

OTHER CONSIDERATIONS

• Botox injections are a temporary solution for the treatment of wrinkles. The effect lasts from 4-6 months. Repeat treatments are required to maintain the effect.
• Possible side effects include local numbness, swelling, bruising, or a burning sensation during injection. Some patients have reported temporary headaches and nausea.
• Most side effects are of short duration.
• A small percentage of patients who receive Botox injections are reported to experience no improvement at all.
• Patients with early signs of aging, as well as those who may not be suitable candidates for more extensive facial aesthetic surgery, may still be good candidates for Botox injections.
• Certain medications (some antibiotics, anti-inflammatories, or aspirin) and even some vitamins and herbs, may increase the potency of Botox and may increase bleeding and bruising at the time of injections. A candid discussion with Dr. Minoli and his staff about all medications and supplements is usually quite helpful in the planning of a treatment.
• Pregnant and nursing women should postpone Botox injections. (It is not known whether Botox injections have any effect on a fetus or whether trace Botox is found in breast milk.)

LEFT – BEFORE NEUROMODULATION / RIGHT – AFTER NEUROMODULATION

Hyaluronic acid is a natural polysaccharide and a versatile soft-tissue filler. It is being used widely for the management of wrinkles; fine lines; contour deformities; and volumetric deficiencies of the face, cheeks, and lips – all of which can be associated with aging, developmental anomalies, and certain individual diseases which can effect soft tissues of the body. Hyaluronic acid is not the final answer as an ideal soft-tissue filler, but it clearly provides a safe, predictable, and user-friendly material. Hyaluronic acid filler injections are typically performed in an office setting. For patient comfort, topical ice is usually applied prior to treatment in order to reduce needle discomfort. Of course, a nerve block may be preferable for some patients.

BEFORE & AFTER (TREATMENTS WITH VOLUMA – photos: courtesy of Allergan)
BEFORE & AFTER (TREATMENTS WITH VOLUMA – photos: courtesy of Allergan)

Hyaluronic acid is a hydrophilic agent, which means that it attracts water much like a sponge. This expansion contributes to the final fill-volume that is attained. Therefore, under-filling is often necessary, and patients may well benefit from a touch-up session several weeks after initial treatment. Over-filling can produce bumps and irregularities which, although rare, create a small, temporary cosmetic problem. Overall results can last more than 6 months in patients. The injections are especially effective for the nasolabial folds, lips, and other areas of facial-contour deformities. Hyaluronic acid injections are also an ideal adjunct to Botox treatments and are frequently combined with Botox during a given session in order to correct persistent lines and creases more thoroughly.

BENEFITS

• Hyaluronic acid is a natural substance that does not require allergic pre-testing.
• There is minimal discomfort.
• There is no downtime. Patients can immediately resume normal activities.
• Patients can immediately apply makeup and return to normal activities.
• There are very few side effects.
• Injections can last for approximately six months.

OTHER CONSIDERATIONS

• Bruising and swelling may occur for a number of days.
• Small bumps are infrequently visible or palpable (but these can be treated with antidote injections of hyaluronidase if irregularities persist).
• After several weeks, repeat injections may be needed to achieve ideal results.

Sculptra (poly-L-lactic acid) injections have been used for almost 2 decades to improve the aging appearance of the face – particularly around the site of skin folds, indented chin surfaces, hollowed cheeks, and sunken eyes. Sculptra was first introduced to the United States for treatment of patients with facial wasting (e.g., immunocompromised patients undergoing treatment). In more recent years the FDA has approved the use of Sculptra for treatment of deep nasolabial smile folds and other facial wrinkles. The Sculptra filler provides up to 80% improvement in the treated areas. It produces noticeable results after a few treatment sessions and usually lasts up to 2 years (in some cases even longer).

The Sculptra procedure is performed in Dr. Minoli’s office in an outpatient setting, typically for patients between the ages of 35 & 65. It is performed in combination with a local anesthetic and topical application of ice so that typically there is minimal discomfort from the needle injections. A treatment can last 15 to 30 minutes, depending on the extent of treatment.

Sculptra is a synthetic poly-L-lactic acid injectable material. The material has been commonly used in dissolvable stitches and soft tissue implants. (Actually, a natural form of poly-L-lactic acid is even produced in our muscles during exercise.) The material, which is biocompatible and can be dissolved by the body, works to gradually produce increasing thickness of the skin.

BEFORE & AFTER (TREATMENTS WITH SCULPTRA – photos: courtesy of Galderma)

BENEFITS

• Sculptra (poly-L-lactic acid) is a substance that does not require allergic pre-testing.
• There is minimal discomfort.
• There is no downtime. Patients can immediately resume normal activities; however they are advised to stay out of the sun in the early stages.
• Patients can immediately apply makeup and return to normal activities.
• There are very few side effects. (Touchup treatments may be required at 6 to 8 week intervals until optimal results are achieved).
• Injections can last for over 2 years.

OTHER CONSIDERATIONS

• Bruising and swelling may occur. (Although it is rare, if a patient experiences unmanageable pain or symptoms that are progressive or abnormal, such a patient would report that to Dr. Minoli immediately.)
• Small bumps are infrequently visible or palpable, but these can be treated typically with a massage regimen if irregularities persist.
• After several weeks, repeat injections may be needed to achieve ideal results.
• Results gradually become evident over the course of several weeks. In the final analysis, since results from Sculptra injections are, temporary (two years or more), treatments have to be repeated in future years to maintain the accrued benefits.

Chemical peels involve the application of acidic solutions to aging, sun-damaged skin. Peels diminish wrinkles and lighten pigmented spots by removing the skin’s top layers while preserving deeper layers which replenish fresh skin. Chemical peels have proven to be a very popular nonsurgical cosmetic procedure – even a potential alternative to laser therapy. Peels vary according to their specific ingredients, strengths, application times, and vigor of penetration. Dr. John Minoli and his staff can help guide you toward the peels that are right for you.

Typically, a chemical peeling solution is applied with a gauze sponge, cotton pad, cotton swab or brush. Alpha-hydroxy acids (α-hydroxy acids or AHAs) are usually the most superficial of chemical peels – and include glycolic acid, lactic acid and fruit acid. Various concentrations of alpha-hydroxy acids may be applied weekly (or at longer intervals) for best results. Trichloroacetic acid (TCA) peel is stronger, and has a greater depth of penetration than light alpha-hydroxy acid peels. Phenol peels usually represent the strongest of chemical peels, providing relatively deep levels of skin penetration (similar to skin-penetration levels achieved with certain ablative lasers). And of course specific compounds of chemical peeling ingredients are used in certain, popular treatments such as the VI Peel™.

LEFT – BEFORE CHEMICAL PEEL / RIGHT – AFTER CHEMICAL PEEL

Alpha-hydroxy acid peels (AHAs or α-hydroxy acids):
Alpha-hydroxy acids are a class of weak acids which penetrate human skin when topically applied during clinical rejuvenation treatments. Ultimately, they refresh and smooth the skin by causing exfoliation (shedding of skin), collagen synthesis, and a slight vital thickening of the skin itself. The alpha-hydroxy acids are often naturally-occurring fermentation products of certain foods and fruits – citric acid (from citrus fruits), glycolic acid (from sugar), lactic acid (from sour milk), malic acid (from apples), mandelic acid (from almond extract), and tartaric acid (from grape wine). At lower concentrations these acids are found in many over-the-counter skin care products; and in higher concentrations they are used for clinical treatments.

BENEFITS

• Alpha-hydroxy acid chemical peeling is a short, safe procedure in which no anesthesia or sedation is needed. The solution produces only a mild tingling or stinging sensation when topically applied.
• Sometimes a single treatment will convey a healthier, more radiant look to the skin.
• The procedure causes no downtime, and no covering or after-peel ointment is needed. Normal activities may be resumed immediately.

OTHER CONSIDERATIONS

• Sun block is strongly recommended: Skin may not tan evenly following a chemical peel.
• The alpha-hydroxy acid chemical peeling process may involve multiple treatments.
• Mild concentrations of alpha-hydroxy acids can be mixed with facial creams or body washes as part of a daily skin-care regimen.
• Some facial skin disorders do not respond to chemical peeling.

TCA peels (Trichloroacetic acid):
TCA peels are used as an intermediate to deep peeling agent in concentrations usually ranging from 15-50%. The depth of skin penetration increases as the TCA peel concentration increases – with 50% TCA penetrating deeply into the skin. (In fact, concentrations higher than 35% are not recommended because of the higher risk of scarring.) TCA peels, as opposed to phenol peels, are preferred for darker-skinned patients.

BENEFITS

• TCA is especially effective in treating darker-skinned patients; and is typically a short, safe procedure.
• TCA peeling generally produces a shorter recovery time than a deep phenol peel.
• No covering or after-peel ointment is necessary.

OTHER CONSIDERATIONS

• TCA peeling may require pre-treatment with alpha-hydroxy acid products or Retin-A (Vitamin A derivative) creams.
• Repeat treatments may be helpful.
• TCA peeling may cause changes which require several days of healing, depending on depth of skin penetration.
• Deeper TCA peels may result in 3 or more days of restricted activity.
• Sun block is strongly recommended, especially after TCA treatment.
• Skin pores may appear larger, and the skin many not tan evenly following a chemical peel.
• Some facial skin disorders to not respond to chemical peeling.

Phenol peels (Phenolic acid et al.):
A deep chemical skin peel, or phenol peel, is the strongest of chemical peels, and is reserved for individuals with deep wrinkles from sun exposure or deep dynamic wrinkles around the lips and chin. The procedure diminishes imperfections in sun-damaged, unevenly pigmented, coarsely wrinkled facial areas by peeling away the skin’s top layers.

A full-face deep chemical peel takes 1-2 hours to perform and is done in a monitored setting. A more limited procedure (such as treatment of a wrinkled upper lip) will generally take less than 30 minutes. A solution is applied to a given treatment area (with much care around the eyes and lips). There is a slight burning sensation, but it is minimal since the solution also acts as an anesthetic. After the peel solution has worked on the skin, it is neutralized with water. Within an hour of treatment, a thick coating of petroleum jelly is layered over the face, covering the protective crust which develops rapidly over the area. This jelly stays in place for 1-2 days.

Some patients experience discomfort after a deep chemical peel, but this can be controlled with medication. A few days after the procedure, the protective crust flakes off and new skin with a bright pink color (akin to sunburn) will emerge; the pinkness will fade within a few weeks. Post-operative puffiness will subside in a few days, but the skin will remain sensitive. Patients should avoid exposure to sunlight and continue to use sun block.

BENEFITS

• The effects of phenol chemical peel are long lasting, and in some cases are still readily apparent up to 20 years following the procedure. Improvement in the patient’s skin can be quite dramatic.
• A normal work schedule and other activities can be resumed after 1-2 weeks.
• Variants in the phenol peel formula can create a milder solution for broader use.

OTHER CONSIDERATIONS

• Possible postoperative complications can include scarring, infection abnormal pigmentation or bleaching. Patients may need to wear make-up to match treated and untreated areas.
• EKG monitoring is advised during the procedure.
• Phenol peels cannot be used on the neck or other parts of the body.
• Phenol peels are not as effective in treating individuals with dark, oily complexions.
• Some facial skin disorders do not respond to chemical peeling.

Advanced Techniques

FAT INJECTIONS (e.g., “autologous” fat – harvested from one’s own body)

LEFT – BEFORE LIP ENHANCEMENT / RIGHT – AFTER LIP ENHANCEMENT

Although the fat injection technique (autologous fat transplantation) is technically a minor surgical procedure, it provides an excellent source of soft-tissue filler material which, to some degree, has a permanent effect. Although the procedure is often done in an operating room as an adjunct to other surgical procedures, it is also quite possible to have such injections done under local anesthesia in an office setting.

Fat injections transfer fat from one part of the body to another – in many cases, helping re-contour the face; diminishing frown lines, crow’s feet & nasolabial folds (smile lines); providing definition to areas such as the cheeks and chin; and even filling out depressed bodily scars. While some fat particles permanently survive the transfer, others do not – so, repeat treatments may be warranted for ideal long-lasting results.

The fat injection technique can be described as follows. The donor site (for example, the abdominal wall, buttocks, or thighs) and the recipient site are injected with local anesthetic. Intravenous fluids may also be injected into the donor site to facilitate fat collection. Fat is extracted through a specialized needle and processed for the removal of excess fluids. It is then re-injected in multiple thin strands within a desired recipient area (e.g., specific areas along the face & lips). Mild over-filling may be necessary in order to counter the natural effects of partial fat absorption during the weeks that follow treatment. Fat also can be harvested during liposuction within one area of the body, then re-injected into another desired area. The longest-lasting effects usually involve repeat treatments.

BENEFITS

• Fat injections are natural and non-allergenic.
• Fat injections are from the patient’s own body, so no pre-testing is required. (A person’s own fat cannot be rejected; however, another person cannot donate fat to a given person.)
• Fat injections can be performed as an outpatient procedure.
• Fat injections cause little down time.
• Fat injections cause minimal discomfort which usually can be controlled with oral medication.
• Fat injections – in part – last permanently.
• Fat injections are cost effective if combined with other procedures.

OTHER CONSIDERATIONS

• There is some swelling and bruising after the injections – mostly within the first 3 days.
• Patients should avoid sun during the early stages of healing.
• The longevity of results can vary from patient to patient.