While aesthetic treatments including Botox®, neuromodulator injections, dermal fillers, and non-surgical procedures have become widely available in various settings, it is important for patients and consumers to seek expert consultation. While many treatments are very safe and predictable, nevertheless, they pose some risk, and providers should be capable of managing such complications.
Not all patients and consumers present with the same problem or respond similarly, therefore, a consultation should inform them with reasonable expectation of the outcome and risk associated with treatments, and alternative options, including both surgical and non-surgical.
In our practice, many patients come in well-informed from their own internet research or through their friends and seek specific treatments. However, during your initial consultation, we spend extensive time evaluating your face, including your current facial features and expected aging changes in the future, your desired outcome/self-image in short-term and long-term, the cost of treatment, and underlying medical conditions.
Our philosophy with medical spa-type treatments is to educate patients on the realistic outcomes from our recommended treatments to achieve natural results, and to focus on building long-term relationships for future maintenance. We achieve this by offering professional, unbiased recommendations and treatments unique to each individual.
Botox
This is the original neuromodulator brand approved for treatment of expression wrinkles of the face, such as the frown line, forehead lines, and crow’s feet. It has been around for over 20 years, and has been used extensively for both medical and cosmetic purposes. While some people express concern because they think of the botulism toxin, Botox medication has demonstrated itself as an extremely safe and effective treatment for relaxing the muscle.
What makes Botox unique compared to other neuromodulator treatments like Dysport, or Xeomin?
Botox is the original neuromodulator brand, which is why some people may say “Botox” in reference to any neuromodulator treatments including its competing brands, Dysport or Xeomin (like the brand Kleenex or Xerox against their competitors). In the clinical sense, Botox and Dysport seem to behave very similarly. In studies, specialists and normal observers cannot distinguish the difference in effect between Botox and Dysport. Dysport may have slightly quicker onset 2-5 days vs 4-7 days for Botox, and may dissolve slightly sooner, although even this is disputed and probably patient-dependent.
Duration of Botox treatment is around 3-4 months. However, for patients who have been going through maintenance Botox regularly every 3-4 months, many will notice that the same treatment will begin to last longer, or that they require less dose to achieve the same outcome. This may be due to the fact that long term maintenance with Botox treatments will cause your facial expression muscle to shrink from disuse resulting in less bulk of muscle for Botox to work on.
Alternatively, some long-time patients may begin to notice that Botox is becoming less effective over time. This may be due to the fact that their body has developed resistance against the Botox molecule and is clearing it out of their system quickly. While all three brand of neuromodulators are essentially derivative of same botulism type A, Xeomin may still be effective if their body has developed resistance against ancillary component in the medication and not the core botulism itself. Trial of Xeomin is the only way to determine whether it is effective for these patients.
Botox treatment has become very ubiquitous now as more providers outside the core-cosmetic specialties (dermatologists, or plastic surgeons) are offering these service, often in the ObGyn office or the dental offices.
While treatment is relatively simple and safe overall, there are some risks that patients should be aware of. Depending on the technique and experience of provider, if Botox reaches an unintended muscle group, patients can develop an undesired outcome, often a brow or eyelid droop. Aggressive treatment, especially around the mouth, can result in unnatural facial expression or frozen face which are undesirable. Experienced providers should know ways to counter-measure if undesired outcomes were to develop, so patients should notify their providers for correction instead of waiting for the treatment to wear out in 3-4 months.
Short term benefit of Botox treatment is relaxation of the expression wrinkles of the face, especially the frown line, forehead line, or the crow’s feet. There are other ways that Botox can be used to enhance facial image including lifting the eyebrows, reducing a gummy smile or nostril flare, reducing the bulky cheek muscle in patients with square-shaped jaw, or turning the corner of mouth from frown to slight smile. These adjuvant treatments are highly variable based on tendency of patients’ muscle use at baseline, and often require some trial treatments with titration over time.
Perhaps more important than these short-term 3-4 months benefit of Botox is its long term benefit. We believe that, along with sun protection and tretinoin-based skin therapy, maintenance Botox is by far the most predictable way of keeping your skin looking youthful for the future. From a facial plastic surgeon’s perspective, while many changes of the face related to aging process are reversible with a one-time surgery, reversing the damage associated with aged skin is the most challenging project and takes time. We emphasize to all of our patients, including those who underwent surgical facial rejuvenation, that disciplined skin regimen as described above is essential for prevention of aging and maintenance of youthfulness.
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Dysport
Dysport has become the most used brand of neuromodulators in our practice. In fact, last year our clinic was the highest volume provider for Dysport and its family of fillers in the central New York area. Most patients rely on Dysport for treatment of expression wrinkles, including the frown line, forehead lines, and crow’s feet. While some people express concern because they think of the botulism toxin, Dysport has demonstrated itself as an extremely safe and effective treatment for relaxing muscle.
What makes Dysport unique compared to other neuromodulator treatments like Botox or Xeomin?
In clinical sense, Botox and Dysport both behave very similarly. In numerous studies, specialists and normal observers cannot distinguish the difference in effect between Botox and Dysport. Dysport may have slightly quicker onset 2-5 days vs 4-7 days for Botox, and may dissolve slightly sooner - although even this is disputed, and we think is patient-dependent. Dysport consists of smaller molecules of active ingredient than Botox brand, so it requires more concentration to have similar effect as Botox. For example, in our clinic, based on our protocol we use 15U of Dysport for the same outcome that would require 5U of Botox. As a side-note, Dysport contains small amount of cow’s milk protein, so people with allergy to cow’s milk should avoid Dysport and they should request Botox or Xeomin as an alternative.
Duration of Dysport treatment is around 3-4 months. However, for patients who have been going through maintenance Dysport regularly every 3-4 months, many will notice that the same treatment will begin to last longer, or that they require less dose to achieve the same outcome. This may be due to the fact that long term treatment with Dysport will cause your facial expression muscle to shrink from disuse resulting in less bulk of muscle for Dysport to work on.
Depending on the technique and experience of the provider, if Dysport is injected into an unintended muscle group, the patient can develop an undesired outcome, often times with brow droop or eyelid droop. Aggressive treatment, especially around the mouth, can result in unnatural facial expression or frozen face which are undesirable. Experienced providers should know ways to counter-measure if undesired outcome were to develop, so patients should notify their providers for correction instead of waiting for the treatment to wear out in 3-4 months.
Short term benefit of Dysport treatment is relaxation of the expression wrinkles of the face, especially the frown line, forehead line, or the crow’s feet. There are other ways that Dysport can be used to enhance facial image including lifting the eyebrows, reducing a gummy smile or nostril flare, reducing the bulky cheek muscle in patients with square-shaped jaw, or turning the corner of mouth from frown to slight smile. These adjuvant treatments are highly variable based on tendency of patients’ muscle use at baseline, and often require some trial treatments with titration over time.
Perhaps more important than these short-term 3-4 months benefit of Dysport is its long term benefit. We believe that, along with sun protection and tretinoin-based skin therapy, maintenance Dysport is by far the most predictable way of keeping your skin looking youthful for the future. From a facial plastic surgeon’s perspective, while many changes of the face related to aging process are reversible with a one-time surgery, reversing the damage associated with aged skin is a most challenging project that takes time. We emphasize to all of our patients, including those who underwent surgical facial rejuvenation, that disciplined skin regimen as described above is essential for prevention of aging and maintenance of youthfulness.
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Restylane
Restylane family of fillers, along with Juvederm, is one of the best known brands of hyaluronic acid gel fillers. Restylane is currently the most used brand of hyaluronic acid dermal filler in our practice. In fact, last year our clinic was the highest volume provider for Restylane and its family of injectables in the central New York area.
There are several lines of Restylane with varying degree of firmness and characteristics designed to treat a broad spectrum of skin wrinkles or volume hollowness of the face. Hyaluronic acid is a complex sugar molecule found naturally in your skin and joint. Like a starch, its function is to absorb water and serve as a cushioning agent or make up the space between the cells. By injecting the purified hyaluronic acid gel into the skin, it attracts the water in your body (up to 1000 times its weight) to volumize, and restore the deeper layer of the skin called dermis.
What makes Restylane unique compared to other hyaluronic acid gel fillers like Belotero, or Juvederm?
Restylane brand comes in several lines which can be overwhelming for some. The original Restylane is an in-the-middle hyaluronic acid filler. Restylane Silk is a softer hyaluronic acid filler and it is ideal for treating superficial and fine lines on the skin and/or defining the borders of the lips. Restylane Lyft, formerly called Perlane, attracts less water than the others, and is designed to provide firm lift of soft tissue, such as the cheeks. Restylane Refyne is a newer brand product used for skin wrinkles, while Restylane Defyne is designed to treat deeper skin wrinkles and folds. To summarize, the Restylane line of products consists of Silk (softest), Refyne, Defyne, and Lyft (firmest).
Many patients ask how long Restylane will lasts. Because hyaluronic acid is a natural substance found in your body, your body also has an enzyme that will dissolve Restylane. Depending on the individual and where Restylane was injected, longevity of the product varies. Generally, it is expected to last between 6-12 months.
Restylane treatment is done in the office procedure setting. With exception of lip treatments which are performed through micro-cannula, Restylane is typically injected through a fine syringe with a slight pinch. There is a small potential for a pin-point bruise at the site of injection, although it is not typical. After treatment you may be informed to massage at the treated site for the first few days while Restylane settles in, but otherwise, there is no activity restrictions after the treatment.
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Sculptra
Sculptra is a filler designed to stimulate the skin to build its own new collagen. Its main ingredient is poly-L-Lactic acid, which is a similar substance used to create dissolving sutures. Sculptra is a very powerful filler for lifting deep tissue. It is also the main treatment implicated in the popular term “liquid face lift”, or a non-surgical face lift procedure.
Sculptra is injected deep into or below the dermis plane of the skin. Most common indications for Sculptra treatments are the hollowness of the cheeks and temples. Vigorous massage for the first five days after the injection is very important to ensure that the product has blended evenly within the tissue and also to provide mechanical stimulation for collagen building.
While Sculptra is a very popular filler treatment in our practice, there are certain weaknesses that prospective patients should be aware of. First of all, Sculptra itself does not contribute to any volume - it relies entirely on your body’s metabolism to build its own. This means there is no immediate benefit noticeable after the treatment. It also means that the outcome is delayed - at least 6 weeks or more. To ensure that we jump start your body to build the new collagen for volume, we recommend that patients commit to at least two treatments at 1-month interval per site if they want to start on Sculptra therapy. However, even with two treatments, many patients end up going through multiple additional treatments before they achieve the outcome they are looking for. Patients in advanced ages have less chance of noticing significant improvement from Sculptra, because their metabolism has likely slowed down. For these patients, we recommend several other treatment options including Radiesse, or surgical procedure such as submalar cheek implant.
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Juvederm
Juvederm family of fillers, along with Restylane, is one of the best known brands of hyaluronic acid gel fillers. There are several lines of Juvederm with varying degree of firmness and characteristics designed to treat broad spectrum of skin wrinkles or volume hollowness of the face. Hyaluronic acid is a complex sugar molecule found naturally in your skin and joints. Like a starch, its function is to absorb water and serve as a cushioning agent or make up the space between the cells. By injecting the purified hyaluronic acid gel into the skin, it attracts the water in your body (up to 1,000 times its weight) to volumize, and restore the deeper layer of the skin called dermis.
What makes Juvederm unique compared to other hyaluronic acid gel fillers like Belotero, or Restylane?
Juvederm brand comes in several lines which can be overwhelming for some. Juvederm Ultra (and Ultra XC with numbing medicine) is an in-the-middle hyaluronic acid filler. Juvederm Volbella is a softer hyaluronic acid filler and it is ideal for treating superficial and fine lines on the skin and/or defining the borders of the lips. Juvederm Voluma attracts less water than the others, and is designed to provide firm lift of soft tissue, such as the cheeks.
Many patients ask how long Juvederm will last. Because hyaluronic acid is a natural substance found in your body, your body also has an enzyme that will dissolve Juvederm. Depending on the individual and where Belotero was injected, longevity of the product varies. Generally, it is expected to last between 6-12 months, except Voluma which has been shown to last up to 2 years.
Juvederm treatment is done in the office procedure setting. With exception of lip treatments which are performed through micro-cannula, Juvederm is typically injected through a fine syringe with a slight pinch. There is a small potential for a pin-point bruise at the site of injection, although is not typical. After treatment you may be informed to massage the treated site for the first few days while Juvederm settles in, but otherwise, there is no activity restrictions after the treatment.
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Radiesse
Radiesse is calcium hydroxylapatite-based dermal filler. Calcium hydroxylapatite is found in the same form in the bone and teeth, except that in Radiesse product, Calcium hydroxylapatite is suspended in a gel to allow smooth and predictable injection into the tissue. Since Radiesse contains calcium based molecule, it has thicker and cream-like texture compared to the other well-known filler brands like Restylane, Juvederm, or Belotero which has clear gel characteristics.
Radiesse is a calcium-based filler that is designed to work in deeper tissue for broader volumization. Areas where Radiesse is uniquely advantageous are the hollowed cheeks, recessed chin, and undefined jaw line. These are areas where we want to add contour and shape - not just diffuse volumization, or reduce the superficial skin wrinkles. Radiesse is typically injected deeper than the other types of fillers. By the way, Radiesse is mixed with numbing medicine, and treatment is typically not any more sensitive than other types of fillers.
At the deep tissue plane, Radiesse will immediately improve hollowness. Then, as the gel begins to dissolve over the next several months, the main ingredient - calcium hydroxylapatite - is left to serve as a scaffold to promote growth of supporting structures such as collagen. Over the following 18+ months, the calcium molecule will dissolve, while the new collagen remains in place.
We like to use Radiesse exclusively for building definition in bony areas like the cheekbone, the chin, nose, or the jawline. It is also a very powerful tool for volumization of broadly hollow areas including the lower cheeks and the temple area. While in select patient, it is also a useful tool to improve skin wrinkles around the mouth, we typically rely on other fillers, mainly because Radiesse when injected superficially against the wrinkles of the skin may potentially cause nodules. Radiesse does not have a reversible agent that can be injected to dissolve it, therefore we avoid using Radiesse to treat fine, superficial wrinkles of the skin, even though its relatively prolonged longevity is compelling.
Double Board-certified Facial Plastic Surgeon Dr. Sang W. Kim at Natural Face™ Clinics specializes in aesthetic enhancement of the face, head, and neck, exclusively. Patients come to see us from the Syracuse metropolitan area and Central New York area, including Rochester. At Natural Face™ Clinics, we specialize in restoring the youthful neck contour, tired appearance of the brows and eyes, and skin laxity. We offer customized treatments, both surgical and non-surgical. Find out more by scheduling your personal consultation today.