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These two categories
of products have flamed the tremendous increase
in cosmetic procedures since their introductions.
According to statistics of the American Society
of Plastic Surgeons, non- surgical procedures like
Botox and fillers, have increased 100% in two years.
This increase is also due to non- plastic surgeons
offering this to their patients or expanding their
practices to include these non- surgical treatments.
Furthermore, indications and applications of Botox
have expanded since its original application in
eye disorders. Overall, complications are minimal
and I will discuss these specifically later.
Even though I am sometimes combining Botox and fillers,
there are distinct and varied differences between
them. Botox is a toxin derived from anaerobic bacterium
Clostridium Botulinum and it produces its effects
by paralyzing the muscles that it is injected into.
It is manufactured by Allergan (Irvine, California)
and is supplied as 100unit/vial of Botulinum neurotoxin
type A complex to which one adds a differing amount
of solution, usually saline, and preferably bacteriostatic,
to minimize the burning upon injection, which yields
a varying amount of liquid suspension.
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| BEFORE BOTOX INJECTION |
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AFTER BOTOX INJECTION |
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A common dilution
is to add approximately 3 cc of bacteriostatic normal
saline to the vial provided to achieve a 33 and
third unit per cc dosage. One normally injects this
suspension with a tuberculin 1 cc syringe with a
fine gauge needle (30 gauge or even 31 gauge). The
patient is asked to contract the hyperactive muscles
and the needle is introduced into the muscle and
a small (approximately .1 cc dose) is injected into
it. A topical anesthetic can be applied prior to
needle insertion to help relieve the pain of injection
(it is allowed to remain on the skin for about 15
minutes for maximum effectiveness). This process
is then repeated for different muscles that one
wishes to paralyze. There is really no end point,
except for a slight raising of the skin. No dressing
is placed.
Some bleeding and possible ecchymoses can occur
and is usually controlled by applying pressure.
The wheal usually disappears within one hour. Patients
with more hyperactive muscles, like males, may require
more units of Botox injected or it may not cause
the desired effect or last a shorter time.
By paralyzing the muscles, they will no longer contract
and the crease which is a direct result of the muscular
contracture may subsequently diminish. Botox can
be injected into virtually any muscle causing its
paralysis, but usually for cosmetic purposes is
limited to the muscles that cause frowning, namely,
the corrugator supercilii, procerus, and orbicularis
oculi. Since these muscles are also depressor’s
of the eyebrows, some elevation of the eyebrows
may result due to the unopposed action of the frontalis
muscle.
Another common area treated is the forehead as well
as the crow's feet area. The latter will only show
improvement when one squints. Other areas such
as the chin and even the wrinkles above and below
the lips can be carefully treated, but one needs
to worry about paralyzing muscles that are required
for proper smiling and so, at the very least, smaller
doses are used. Botox applications have been extended
into many other areas for cosmetic improvement like
to attempt to diminish platysmal neck bands,torticollis,
masseteric and even calf hypertrophy or enlargement,
and common migraine headaches with variable and
uneven success. Botox is also quite useful to gain
symmetry by paralyzing the functioning muscle on
the opposite side from a paralyzed muscle like in
facial or Bell's palsy.
It takes from about two to 10 days after the injection
of Botox for it to produce its desired effect, and
this lasts from weeks to months, depending on how
quickly it is metabolized.
Fortunately, the complications from Botox are usually
minimal and transitory. Even though allergy has
been reported, I have not seen this. One of the
most significant problems as I have alluded to,
is the unwanted paralysis of adjacent muscles. This
is a specially disturbing when the levator superiores
is paralyzed, which results in a drooping of the
upper eyelid. Fortunately,an antidote in the form
of eye drops can sometimes relieve this until this
unwanted effect disappears, usually in a matter
of weeks. Overall, the effects of Botox are positive
and beneficial, and this is why we have seen such
a tremendous increase in its use.
Let us now turn our attention to fillers. These
work in a totally different manner by filling the
offending crevice or line. Fat harvested from one
part of the body and injected into another was probably
the first filler used. Unfortunately, consistent
results are yet to be had. Each physician has his
or her own technique to increase the transferred
fat’s survival. The patient who would most
benefit from fat transfer usually is the one that
has the least amount of fat available for transfer.
Some physicians had even stored the harvested fat
cells for future injections. However, the latter
fat cell’s survival is even more limited. |
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| AUTOLOGOUS FAT INJECTION-FACE
BEFORE |
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AUTOLOGOUS FAT INJECTION-FACE
AFTER |
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| BEFORE FILLER |
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AFTER FILLER |
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| FILLER TO NASO-LABIAL LINES
BEFORE |
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FILLER TO NASO-LABIAL
LINES AFTER |
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There are many
artificial or man-made fillers available at this
time. For many years, the only artificial filler
was Collagen. This material was manufactured from
highly purified bovine collagen. A skin test was
required and allergy to this material was not infrequent,
as evidenced by a small lump or bump. When Collagen first appeared in the marketplace, it was touted
as very long lasting, if not permanent. It became
quickly apparent that this was not the case. None
of the other available fillers now make this claim.
Collagen is now still effective and used but has
been supplemented by a plethora of new injectables.
Within the past few years, many fillers have faded
from the marketplace like dermalogen, fascian, while
new fillers have been introduced here and abroad.
Only a few have gained FDA approval, among them
restylane and sculpta. Fillers can be broadly categorized
into those that are derived from chemicals like
Restylane, Perlane, Hyalaform, Captique, Radiesse,
Sculpta or those derived from byproducts of either
humans or animals. Artecoll fits into both categories
for it consists of a combination of bovine collagen
and polyglyic acid. However, even though it is available
overseas, it is presently in clinical testing only
in the United States and awaiting FDA approval.
The abundance of fillers attests to the fact the
ideal filler still has not been found, i.e. that
is non reactive and permanent. For the goal, is to
provide a long lasting filling effect with little
or no reaction to the material from the patient.
All have only partially succeeded, for they may
cause local and even, unusually, systemic reactions
and all are absorbed in differing periods of time.
However, most patients are not sensitive to their
injectables,though granulomatous reactions by the
body to them have been reported and can be troublesome.
If the patient is hypersensitive to other materials,
like creams, has any autoimmune type diseases, they
should not be exposed to these fillers for their
chances of reactions are greater.
Most of these fillers are mixed with carriers which
themselves may precipitate allergic reactions and
result in a loss of remaining volume and a return
of the crease within a variable period of time.
Collagen is mixed with approximately 40% Xylocaine.
The latter dissolves quickly and,therefore, the
patient will notice its effects partially disappearing
quickly. Therefore, some overfilling is acceptable
and even desirable. Because of this same effect,
Restylane which is the active material but combined
with a gel carrier was repackaged and now is supplied
as a 1.3 cc vial instead of 1cc. Even Radiesse is
used off- label in facial filling pending FDA approval,
loses approximately 20% of its injected volume,
usually in the first three months after injection.
With Sculpta, only the polylactic acid remains after
the added water, used to reconstitute the product
suspension, is absorbed.
Let me also mention silicone or Silskin as its injectable
form is called today. It is a wonderful filler and
the results last longer than any other available
material. However, the sometimes disastrous effects
that occurred many years after silicone injections
in the past, and were extensively reported in the
1990s have, apparently, conveniently been forgotten.
Even though only droplets are now recommended and
used, unwanted migration and granulomas with an
inability to remove this material still may occur.
So, the myriad of fillers available and those others
awaiting FDA approval, give the physician many probably
confusing choices. This, ultimately, depends on
what the individual physician feels the most comfortable
injecting and what he feels works the best for his
patients! However, it may not be so bad that the
paralysis of Botox or the filling of the fillers
is relatively short-lived!
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Schedule your consultation with Dr. Domanskis
Financing is available for all our cosmetic surgery procedures.
You can go to efinancing-solutions.com to find out more and even submit an application online to see if you qualify.
Also visit Reliance Medical Finance and Care Credit.com.
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EDWARD JONAS DOMANSKIS, MD - 1441 Avocado Avenue Suite 307
Newport Beach, California 92660
Telephone: (949) 640-6324 Fax: (949) 640-7347
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