The Latest in Botox and Other Injectable Cosmetic Procedures

Rush facial plastic surgeon answers commonly asked questions about injectable cosmetic procedures

It's been reported that many people have sought out plastic surgery to improve their appearance on Zoom calls that they've been stuck on during the pandemic. Are you seeing this phenomenon at Rush, and what can a plastic surgeon like yourself do to help them?

Absolutely, we're seeing that. I think even before COVID we were seeing patients take time from themselves in a different manner to seek cosmetic changes. And I think that there is no longer such a stigma about vanity and the kind of initiative to make these changes to our appearance, but certainly in the time of COVID we have seen that to an even larger degree. I think so often when patients are working from home or they're doing Zoom calls or on camera, they're noticing things about their appearance that probably have always been the case, but because masks are giving only a small glimpse of the entire facial appearance, patients tend to key in on areas that they're noticing on camera, or at least they have worries or issues with their self-esteem when they see their image on screen.

That really has led to a large uptick in patients that are finding me in my office to discuss, well, what are these things that I can do to approve, improve the heaviness under my eyes or the dark circles that I see, even though I'm rested well, and I'm feeling like I'm getting the best sleep of all time yet I'm still seeing these signs that I don't like to see when I look in the mirror? So we know that this is a real phenomenon that people are perceiving and kind of paying attention to their facial appearance more than before, and I certainly think the ways that were forced to communicate during the COVID pandemic has led to a lot of patients finding out where to go to start to ask the right questions and get help.

And so where do I fit in, I think the first thing and the most important thing is to sit down and to listen to patients and to hear what are their areas of concern. How long have these things bothered them? To what degree are they starting to affect somebody's self-esteem and their ability to feel and look like themselves? And so sitting next to a patient and listening to their concerns and hearing them out is absolutely the first step, and that often leads the discussion into more discreet areas that we can make a great improvement and really restore some of that self-esteem that maybe times of COVID have kind of compromised for some patients.

And how do you determine what the best course of action is for someone once they've brought an issue to you?

I usually like to let the patient direct the conversation. I'll usually hand the patient a hand mirror and I'll ask them simply to point to areas that they're looking for improvement because it isn't up to me to pin point and circle areas that I feel need improvement, that doesn't do the patient any good. So instead I have them direct me towards areas that they've noticed they would like to seek improvement. And once we've identified the areas of the face that we want to try to improve, that's when I like discuss a host of different options for patients to consider, because the truth is not everybody is looking for a surgical treatment. Not everybody is looking for downtime, that requires healing and recovery.

And so really starting with the most basic treatments, which might involve skin care, could involve injectables that can be done in five minutes in the office, and then leading all the way up to things that may have a greater overall improvement such as facelift or rhinoplasty, but that also incur a little bit more downtime and perhaps a little bit more time healing. All of those things are super important to discuss because the patient's motivation might be slight improvement and not a total overhaul of their facial appearance. I would never want to assume that that's what they're looking for when I first meet them.

So after we identify areas of improvement, then we can really discuss in detail every single option from the least invasive to maybe the more aggressive or more definitive treatments that we offer as well, which give great results. And that allows the patient and myself to a settle somewhere in between where we find the exact right treatment and then can move forward and start discussing that in greater detail.

What are dermal fillers and are they considered safe and effective?

Yes, absolutely. Dermal filler is one of the most commonly injected materials that plastic surgeons and especially facial plastic surgeons offer patients for improvement. And what dermal filler really is, is an ability to safely restore areas of volume that we all tend to lose in certain places of the face with time. So sometimes that can be deep grooves that form, and I'll point to my own face just to demonstrate, the lines that tend to form between the corner of the nose and down to the corner of the lips, or lines that form from the corner of the lips down to the chin.

Sometimes as we age we lose volume in those areas and those creases become deeper. They cast the shadow that might make somebody look older than they feel. And what dermal filler is, is the ability to inject a material under the skin to restore that lost volume, to make the grooves or the creases less deep and therefore overall restore a more beautiful appearance, a more youthful appearance and a more rested appearance. In terms of the safety profile of dermal filler, it is an extremely safe substance to have injected, meaning it is very inert, the body does not react to it or perceive it as foreign.

There are risks with any in-office injectable procedure. The most important thing to avoid any of those risks and to get a great outcome is to see a board certified plastic surgeon who has experience in injecting this type of dermal filler in these exact places. There are techniques done in order to increase the safety profile and to avoid any of the risks that you might hear about from your surgeon before treatment, or that you might read about when you do your own research online. So the experience of the person injecting and the areas and type of dermal filler used for the specific reason that we're choosing it, all of those things allow this procedure to be actually quite safe, very simple to do in terms of time spent in the office and also reduce the downtime in terms of recovery for after treatment.

What is Botox and how does it differ from dermal fillers?

I hear every day from patients in the office who are looking into certain ways to improve their appearance, that they almost consider them to be identical, and the truth is, is that they are vastly different substances and therefore they're used for completely different purposes. Botulinum treatments are an injection that affects muscle, and instead of trying to restore volume like we discussed with dermal filler injections, what botulinum injections do is they relax muscle. So those treatments are great at smoothing away wrinkles that form because as the muscle contracts it almost folds the skin into a crease which shows up as a wrinkle. And if we can relax the muscle that's folding the skin, we can prevent wrinkles from becoming apparent.

The most common places, and the FDA approved uses of botulinum injections include the 11 lines that we all tend to form called the frown lines, the lines that run across the face that we see when we raise the eyebrows, or the smile lines also known as crow's feet that form when you smile, and see the small lines that radiate at the corner. A five minute Botox injection in those areas really does wonders to smooth the skin and make it look more youthful and give the skin a more beautiful and helpful appearance.

How long do dermal fillers and Botox typically last?

The average time for botulinum toxin treatment for wrinkles to last is around three months. That can vary a little bit depending on where it's used in very dynamic areas that tend to move a lot like around the eye as we blink and close our eyes every night while sleeping, the lifespan tends to be a little bit less around three months. In other areas that there isn't as much movement day to day, it can last for as long as four or five months.

In terms of dermal filler on the other hand, that varies based on the type of filler that's used and in general, that can last for six to eight months in some cases, but there are dermal fillers that are meant to be more permanent and can last longer and need to be re-injected a lot less often. So although we always shoot for a treatment that will last for as long as possible, we also want to pick the correct treatment in the correct area to get a safe and natural looking result. If it's a matter of having that reapplied or re-treated three months later or eight months later, most patients love the result enough, and they've been through the first injection that any subsequent treatment that's needed is much easier for them to get through.

What are some other cosmetic procedures that have gained popularity since the pandemic started?

Interestingly, procedures that involve places where masks currently are covering the face have become very popular. And I'll refer specifically to rhinoplasty, a surgery to change the outward shape of the nose. I think the reason that that's grown in popularity is the fact that we wear masks and that can hide swelling or limited bruising that can occur after surgery, even sutures that may need to stay in place for one week can be hidden by a mask and allow patients to actually recover in a much more private and smoother fashion than if they were expected to return to work or face the public, day one after surgery.

What's involved with a facelift surgery and what makes someone a good candidate for one?

We talked earlier a little bit about how inevitably we all lose some of the soft tissue volume of the face as we age, and we all tend to do that in a similar fashion. What we tend to see is the soft tissues of the face, like the soft tissues of the cheeks, with time, and because of the effects of gravity, tend to move down and they can accumulate over the jawline and create situations that have been named jowling or turkey neck. I personally don't like that name, but these are names that you'll read about or hear about. What that does is, it obscures the jawline and creates heaviness under the neck, and it can detract from otherwise very beautiful features of a patient's face, such as their eyes or such as their cheek bones.

When we perform facelift surgery, what we're doing is we're restoring that soft tissue volume of the face and correcting some of the signs of aging that occur with time, to restore it back to a more normal, a more youthful, a more healthy location. And so facelift surgery, although it's done to improve the jaw contour and the midface, is done through incisions that are hidden in natural areas of creases, like the crease in front of the ear or the area behind the ear, in such a fashion that when those scars heal, they're practically invisible.

That lets us then work through limited incisions under the skin to restore a healthy appearance. And at the end of the day after the healing process is over, it leaves behind scars that are practically invisible and achieve that natural, unoperated look that we shoot for. We want patients to hear from friends or family, "Did you just have a great night's sleep? Did you just come back from vacation because you look better, but I can't tell why?" Doing these kinds of things through the incisions and the techniques that we have, really allow a natural result without somebody looking fake or looking unnatural in any way. It's a very, very good tool to restore self confidence in somebody that maybe is observing these changes as they age with time.

How long does it take to recover from from a facelift, and would someone need help while they're recovering?

Recovery time can vary patient to patient. Almost everyone will have a week or two of slight swelling, perhaps bruising under the skin, which is temporary, and which fades away. The sutures that we use for surgery stay for one week and they're removed in the office a week later.

However, in terms of the help that a patient might need as they recover, really that's something that we provide. The day after surgery we have patients back into the office, we wash their hair with shampoo, which feels amazing. We check on all the incisions, we make sure everything looks perfectly clean. We may place a temporary facelift dressing, which is a wrap that eventually and essentially reduces swelling. We have them return to the office a week later to check again, and then maybe at two weeks. In other words, there's very frequent follow up.

Our whole office is dedicated to ensuring that if any questions arise, any issues or concerns, that somebody is able to evaluate the patient, that I am available to see the patient back in the office until they get past those first two weeks when much of the bruising and swelling, and any discomfort is pretty much gone. At that point, the follow up can be spaced out a little bit longer.

So a whole team of people are there for the patient as they recover. There's very little need for family members or friends to be doing any of this at home, and we like it that way. We like to monitor things, and hearing it from us that everything's healing exactly the way we expect, really does go a long way in terms of recovering from something like a facelift that certainly has a little bit more downtime than some of the injectable techniques and procedures that we discussed earlier.

What are the risks and complications that are associated with a facelift?

The risks in general, for any surgery, whether you're having surgery on your big toe or surgery on your face, would include things like an infection, bleeding after surgery or the buildup of blood under the skin. Fortunately, these are things that are very, very infrequent. Because we follow patients closely in the immediate post-op period, they can be identified, treated and corrected.

Long term issues that have a major effect, fortunately, we don't see. Scarring is one issue that can show up down the line and that's why we carefully screen patients prior to surgery. We make sure that their skin care regimen is optimized before surgery. And if there's any factors in their medical history that might suggest they don't scar, or they don't heal quite as well as we'd want them to, then we advise them closely about that.

Now that being said, scarring is something that we have the ability to improve greatly through techniques that we do in the office such as microneedling or steroid injections, or just very good scar fade cream. So a lot of those long term issues can be mitigated by just careful observation as patients heal and recover.

I would include scarring in the list of those general risks of having surgery that kind of exist no matter what, we just them way more seriously because this is the face that we're talking about and you can't conceal it or hide it like you could other areas. And so that's why we do everything we can to minimize and mitigate those risks.

With all these different types of procedures, how can one expect their face to look over time and as they continue to age?

It depends on the patient's desires because some patients want to see a drastic change, others want to see an improvement but they still want to look like themselves. During our initial conversation, one of the first items we discuss is what goals that particular patient has. Let's say a patient does want to see major change and they do want to see the change after surgery last them decades. In the case of something like a facelift, we expect a decade of improvement before time and gravity then changes things to the point where a revision might be necessary.

In terms of the other surgeries that we've discussed and other treatments, such as rhinoplasty, we really don't see any change after the initial period of healing occur. When the surgery's done to improve contour and soft tissue changes with time, that's something that has a lifespan of a decade and may need a revision depending on the patient's desires. Other surgeries such as eyelid surgery or rhinoplasty, which is changing the shape of the nose, those are things that we tend not to need to revise as time goes on, and can be more stable.

But again, it does come down to the patient's desires and their goals and how drastic of a difference do they want to see, and that's something that we take very seriously because everyone is different and everyone is looking for a different amount and a different degree of change.

At what age would you start recommending that someone gets injectables?

I think that's a very personal decision for each patient. What I would encourage is, anyone considering it should make an appointment to come in and sit down and talk about options, first and foremost. I will say, with botulinum injection, which again is that treatment that we perform to weaken and to lessen the contraction of muscle to smooth wrinkles, there is a lot of good evidence that the earlier you do that the more you can avoid the formation of wrinkles in the first place. So there is some preventative action of botulinum injections that would make any patient who understands the risks and understands kind of the goals of treatment, a very good candidate, and that might cut down on their need for future treatment.

However, in terms of facial filler or dermal filler, usually those treatments are done in patients that have greater signs of aging because they might happen to be older. I would say the exception is in the lips, which is an area that even younger patients often desire more volumisation. That's an area that can be injected even in the mid teenage years, depending on the motivations, the understanding of the patient. In general, younger patients would not be good candidates for facelift surgery or facial filler injected into other areas as opposed to botulinum injections, which actually can have some advantages to doing that early.

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