Facial Aging, Wrinkles (rhytides)
Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center)
Aging typically results in decreased elasticity of the skin and soft tissues of the face. This often results in the formation of lines across the glabella (wrinkles between your eyebrows) and crow’s feet. Since it’s initial approval by the Food and Drug Administration (FDA) in 2002, cosmetic use of Botulinum toxin has allowed surgeons to noninvasively treat facial aging. These treatments are widely popular due to their efficacy and noninvasive nature. Patient’s may receive in-office treatments without prolonged recovery time. Botox Cosmetic is currently FDA approved for treatment of glabellar lines, crow’s feet, and forehead lines. Off-label uses in various other areas of the face are common however. These injections use various forms of botulinum toxin to temporarily paralyze muscles activity. There are several brands of Botulinum Toxin-A used for aesthetic purposes. Botox (also known under the commercial names BOTOX Cosmetic, Vistabel, Vistabex; Allergan, Inc. Irvine, CA) is the most well-known brand. Other products include Dyport, Myobloc, and Xeomin. Botox works by blocking acetylcholine, a chemical that is responsible for transmitting electrical signals that result in muscle contraction. This results in temporary muscle paralysis, weakening overactive muscles that may be contributing to increased facial rhytids (wrinkles). When injected into these muscles, it results in a more relaxed and smoother appearance. Botulinum toxin is also used to treat other conditions including cervical dystonia (involuntary contraction of neck muscles), hyperhidrosis (excessive sweating), chronic migraines, muscle contractures, sialorrhea (excessive production of saliva), and various other conditions.
Injectable fillers play a prominent role in facial rejuvenation, with more than 1.9 million treatments a year in the United States.1 Correcting facial volume loss with aging is the most common application. The immediacy, predictability, and safety of these procedures with no recovery time makes them a particularly useful therapy, much like Botox. Injectable fillers add volume, allowing for shape restoration, to the aging face and can be used in combination with various other treatments (laser therapy, Botox, brow lifts, etc.) allowing for a more complete approach to the aging face. Dermal fillers may be biocompatible or synthetic. Biocompatible fillers are typically resorbable and have a period of duration lasting approximately 6-12 months. Synthetic fillers are permanent but have previously been associated with migration, granuloma formation, and eliciting an immune response. There are few indications currently for use of synthetic fillers to correct age-related changes. Your doctor can discuss further questions regarding filler type.
Botulinum Toxin can be used for: smoothening of crow’s feet, forehead furrows, frown lines, lip lines, and ‘bunny lines (wrinkles adjacent to the nose). It can also be used to diminish neck bands, improve dimpling of the chin, improve a gummy smile, lift the corners of the mouth for improvement in smiling, or soften a square jaw line.
Dermal Fillers may be used to: plump thin lips, enhance shallow facial contours, soften facial creases and wrinkles, improve appearance of depressed scars, augment contour deformities of the face, decrease shadows due to lower eyelids.
However, in certain patients, surgery such as facelift, brow lift, or blepharoplasty may be a more appropriate approach for facial rejuvenation. This may vary on your anatomy and your doctor will counsel you regarding the most appropriate approach for your specific concerns on initial consultation.
What to Expect at Your Otolaryngologist Office Visit:
Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications.
To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals in terms of your appearance after your procedure. The risks, benefits, and realistic goals will be discussed.
Tell your doctor if you have received any type of botulinum treatment within the past four months. Also, inform your physician if you are taking any muscle relaxants, sleeping aids, or allergy medications. In certain circumstances, if you are taking blood thinners, you may have to discontinue them for several days prior to your injection. This is in order to reduce your risk of bleeding or excessive bruising. You will be asked to discuss this with the physician that manages your blood thinning medication prior to cessation of this medication.
Most individuals tolerate injections without significant discomfort. Your doctor may use one or more of several methods to numb the area prior to injection. These include: topical anesthesia, or ice and vibration anesthesia, using massage to reduce discomfort. These injections are performed in the office and do not require general anesthesia. A thin needle will then be used to inject aliquots of botulinum toxin into your muscles. The number and dosage of injections will vary depending on many factors, including the extent of the area being treated. Following, the procedure you can expect to resume your normal daily activities.
Initially, you should attempt to refrain from rubbing or massaging the injected areas as this may cause the Botox to migrate to adjacent areas. Botox will typically take effect in 24-72 hours after injection. Its maximum effect is seen in about 1-2 weeks following injection. The aesthetic effects of Botox typically last three to four months. As the treated muscles regain movement, lines and wrinkles may begin to reappear prompting patients to return for further treatments. Over time, these lines and wrinkles may appear to be less noticeable due to retraining of the muscles to relax and a decreased reliance on them for expression.
Treatment with dermal fillers is similar to that of Botox. Anticipated injection sites will be cleansed with antibacterial agent. Injections are typically well tolerated with minor discomfort as above. Depending on the extent of treatment, the entire process may take 15 minutes or as long as an hour. An ice pack will be used following treatment to decrease swelling and alleviate minor discomfort. You are then able to resume your normal activities.