Botox injection has occupied a seemingly ubiquitous position in medical practice in recent times. There are highway billboards advertising it use, it may be a common question when you are scheduling an appointment (“would you like botox when you are coming to see your physician?”) and undoubtedly can be an efficacious means of improving wrinkles. In fact, some would consider it a prophylactic measure to keep wrinkles from getting worse. Neurotoxins (Botox, Dysport, Xeomin) are proteins that help to relax or strategically weaken certain muscles to minimize their function, and as a result, reduce wrinkles in the face. The muscular relaxation that occurs is a phenomenon that is reversed by the boy using natural mechanisms and usually abates over 4-6 months. This treatment can be especially effective in the glabella (area between the eyebrows, “11s”), forehead and outer eyelid region (“crow’s feet”).
Botox (generic – OnabotulinumtoxinA) was initially used in the late 1970s to help with abnormal movement of the eyes (strabismus). Its subsequent use in the treatment of blepharospasm (spasm of the muscles around the eye) and the serendipitous discovery that it reduced wrinkles around the eye with its use in this manner led to the adoption of these products for cosmetic uses. With further research, its use was approved for aesthetic purposes by the FDA in 2002 and in 2011, facial injection of botox, was the most commonly performed cosmetic procedure in the United States, accounting for approximately 41% of all cosmetic procedures performed.
There are some subtle differences between the three listed neuromodulators. Nonetheless, most of the products have an onset of action within 3-5 days following injection. The duration of action also appears to be fairly consistent in that the effect usually lasts approximately 3-4 months. Botox (onabotulinumtoxin) has the longest record of clinical use and has largely been deemed as a safe and effective way to achieve the desired cosmetic results. Dysport (abobotulinumtoxinA) is a newer product that uses a similar, albeit slightly different, protein. Some clinical studies have shown that it may have a slightly faster onset of action and may last slightly longer (~15-20% of patients showed a response to 5 months). Xeomin (incobotulinumtoxinA) can be considered a “naked” protein in that it does not have any associated complex proteins that are coupled to the active “ingredient” in the injection and this may confer a reduced risk of a patient having an allergic or immune response to this product.
Finally, there are some differences in the way these products are administered from the standpoint of unit dosing. Botox and Xeomin are considered to essentially have a 1 to 1 ratio of dosing (i.e. one unit of botox is equal in effect to one unit of xeomin). Dysport, however, is usually considered to have a 2.5-3 to 1 ratio of effect (i.e. 1 unit of Botox is equivalent to 2.5 to 3 units of disport). While the unit dosing does may not ultimately affect a product’s efficacy or cost, it is just part of the inherent nature of these products.
Aesthetic Surgical Services
Aging is an inevitable fact of life. The changes that are associated with aging are multi-fold and these changes as they are manifested in the face and neck are due to both intrinsic (a patient’s genetic predisposition including the thickness and sebaceous characteristics of one’s skin and underlying tissues) and extrinsic factors (primarily sun exposure and smoking). These factors can lead to changes in the texture and quality of the skin. This can be seen in fine wrinkles that are generally better addressed with resurfacing procedures such as with a laser or chemical peel. The descent of tissues that can be seen as one ages can show itself in the form of facial jowling, deepening of the nasolabial (melolabial) fold, and a loss in the definition of the neck and submental area (beneath the chin). Additionally, these changes can be seen around the eyes in the form of excessive skin of the upper lid, bulging of the fat around the lower eyelid and an overall lowering of the tissues of the brow and forehead. Both fine wrinkling and tissue descent can be treated, albeit with different treatment modalities.
A facelift can be performed using a number of different techniques. This can include the degree of undermining (or freeing the skin from the underlying tissues), the depth of dissection (SMAS, sub-SMAS, deep plane, skin only), the type of suture or suspension that is used to maintain the lift and ancillary procedures that may be necessary (e.g. chin augmentation, liposuction, autologous fat injection, filler injection, platysmaplasty). Irrespective of the technique that is used, the goal of a facelift is to achieve rejuvenation of the face and neck. This involves an incision that extends from the temporal hairline, around the ear and then blends into the hairline behind the ear. This incision is designed in such a way to minimize the resultant scar. Again, depending on the type of facelift that is chosen, the recovery period usually lasts 2 weeks, however the amount of swelling varies from one person to the next and can last for up to 4-6 weeks. The procedure itself usually takes 4-5 hours.
Descent of the brow and forehead is another common reason for seeking consultation with a facial plastic surgeon. With time, the effects of gravity take its toll on the area above and around the eyes. There are a number of muscles around the brow and eye that cause wrinkles of the forehead and glabella (area between the eyebrows). These wrinkles coupled with a lowering of the position of the brow can lead to an unhappy or tired appearance. A browlift can be performed in a number of different ways including the coronal (incision behind the hairline), pre-trichial or trichophytic lift (incision designed around the hairline), mid-forehead (using an existing wrinkle in the forehead), direct (designing an incision immediately above the brow) or via an endoscopic approach (using 5 incisions hidden behind the hairline). These approaches vary in terms of the surgical technique and planes of dissection used during the procedure. Nonetheless, all of these approaches can be very effective in lifting the brow to the desired position without creating an “over-done” or “surgical” look. The recovery from a browlift is usually 1-2 weeks and the procedure takes 2-3 hours. Some people experience numbness of the scalp and headaches following procedures to address the brow and forehead.
Drooping of the upper eyelids can lead to a tired appearance and in some cases may even impair one’s vision. A blepharoplasty of the upper lid involves removing excessive skin to achieve a rejuvenated look of the upper eyelid. In the past, eyelid surgery resulted in a “hollowed-out” look of the upper eyelids, however current techniques aim to achieve a more youthful appearance of the eyelids. Upper Lid surgery usually take 60-90 minutes and the expected recovery usually lasts 7 days. The incision is closed with fine sutures that are removed at 5-7 days following the procedure. Additionally, fine surgical bandages may be applied to the upper lid in the period following the procedure. A small amount of bruising and swelling can be expected, and patient’s area usually placed on an ointment and/or eye drops following blepharoplasty.
Lower eyelids with an aged appearance may have visible bulging and bags, excessive skin and fine wrinkles. Surgery of the lower eyelids (Lower lid Blepharoplasty) can be done via a transcutaneous (incision beneath the eyelid to access the underlying muscle and fat) or transconjunctival approach (incision is made on the inside of the eyelid) depending on the needs of the individual. Dark bags under the eyes may be the result of allergies, or an abnormal deposit of pigment in the lower eyelid. These conditions are not corrected with surgery. Lower lid blepharoplasty improves the bulging quality of the lower eyelid by conservatively addressing the fat that may be bulging through the orbital septum (pseudoherniation of orbital fat). Moreover, this fat can be used to improve a prominent tear trough by repositioning the orbital fat (lower lid blepharoplasty with fat repositioning). Again, the procedure to be performed can be tailored to a patient’s individual needs and desires. Lower eyelid surgery takes approximately 2 hours and the recovery period is usually 7-10 days. As for upper eyelid surgery, bruising and swelling are common, however, if a patient is experiencing significant pain or vision changes, he or she should seek immediate medical attention.
Facial trauma, and in particular trauma to the nose, is another common reason that a patient would see a facial plastic surgeon. In fact, trauma to the nose and nasal bones is the most commonly injured area of the face, owing to the nose’s central location. This can result from motor vehicle accidents, sports-related injuries, inter-personal violence, among a slew of other causes. The treatment following nasal trauma is largely dependent upon the severity of the injury. In some cases, such as in the case of non or minimally displaced nasal bone fractures (fractures that did not cause a significant shift in the nasal bones) without any functional (difficulty breathing) or cosmetic change, no treatment may be necessary. If someone feels that the appearance of their nose has changed following an injury to his/her nose, it is usually best to be seen within a few days as oftentimes, within the first 1-2 weeks following the injury, the nasal bones may still be amenable to re-positioning back to their previous state. This procedure is known as a closed nasal bone reduction and may be done to straighten a nose that has become deviated and may help with breathing problems, especially if the fractured bones are limiting the nasal airway. After closed reduction, an external splint or cast will often be placed that stays on the bridge of the nose for approximately one week. Additionally, it may be necessary to apply some packing material in the nose to help maintain the bones in their normal position after they have been re-positioned. Finally, if the nasal fracture does not respond to closed reduction, or if someone had a nasal trauma some time in the past, functional rhinoplasty (link to other content area) may be a suitable treatment. This procedure is done to re-position the nasal bones (usually with fine instruments called osteotomes to make precise cuts in the bones to allow their mobilization) and cartilage to maximize functional and aesthetic concerns. Additionally, grafts may be necessary to further enhance the surgical outcome. Recover from this procedure is usually 7-10 days and may require fine sutures as well as internal and external splints.
Rhinoplasty (nasal surgery, nose job, septorhinoplasty) is a procedure that is performed to achieve changes in the structure and function of the nose. This can be done to achieve both functional (nasal breathing) and cosmetic (shape and form of the nose) improvements. As the central feature of the face, the size and shape of one’s nose can have a large impact on his/her overall facial appearance. As a result, this is one of the most commonly sought out procedures in all of plastic surgery. Moreover, given the intricate anatomy and complexity of the nasal airway, rhinoplasty is one of the most challenging procedures in all of facial surgery. Rhinoplasty can be performed using an open (using a small incision that becomes inconspicuous after surgery to access the underlying bone and cartilage) or via what is known as an endo-nasal rhinoplasty approach (incisions on the inside of the nose that are not perceptible externally) and the decision for an open or closed approach is largely dependent on the needs of a particular patient. This procedure is well tolerated in general and the recovery period usually lasts 1-2 weeks. An external splint (on the bridge of the nose) usually stays in place for 7-10 days after surgery. If an external approach is used, the fine sutures are removed at 5-7 days following the procedure. A small intra-nasal packing is sometimes placed, however this is usually removed the first day after the procedure. The procedure is usually performed under general anesthesia and usually lasts 3-4 hours.
Many people experience a blocked nasal airway and the resultant difficulty breathing that accompanies this blockage. There are myriad causes of nasal airway obstruction, however there are a number of anatomic causes for this difficulty. This can include an obstructive nasal septum (link to septoplasty portion of site), collapse of the internal or external nasal valve, and post-traumatic deformities that may preclude normal function of the nose. The internal nasal valve is the narrowest portion of the nasal airway and may become obstructed as a result of trauma and/or prior surgery and is usually corrected with a type of graft known as a spreader graft that acts to widen the aperture or caliber of this space. The cartilage used for this purpose usually is taken from the septum that may be corrected at the time of the surgery. The external nasal valve is essentially comprised of the tissues composing the nostril or nasal aperture. In some cases, a patient’s anatomy is such that dynamic forces with inspiration lead to collapse of this area. Again, certain grafting techniques and or cartilage repositioning techniques can be used to correct this functional problem. Prior to any septorhinoplasty, a surgeon will thoroughly evaluate all aspects of the internal and external nasal airway and this will ultimately be the deciding factor in terms of the proposed surgical plan to correct the functional issue. In some cases, insurance carriers may cover, at least in part, the cost of functional rhinoplasty.
If a patient is dissatisfied with the size and shape of his or her nose, a cosmetic rhinoplasty can be oftentimes be performed to improve the appearance of one’s nose. The goal of cosmetic rhinoplasty is to achieve this improvement by having a thorough and frank discussion with the patient in order to determine what is bothering him or her. Patients may note a hump on the bridge of the nose that is felt to be too prominent, disproportion of the overall nasal size compared to the rest of one’s face (i.e. nose is too large or small), a crooked or twisted nasal bridge, and/or asymmetries of the nose. Computer imaging and morphing software is frequently used to facilitate this discussion and serves as a visual tool to help the physician and patient articulate their goals and desires for the surgery. As above, the initial recovery period lasts 1-2 weeks, however post-operative swelling may last for weeks to months before the final surgical result can be seen.
Revision rhinoplasty is nasal surgery that is performed on a nose that has been previously operated upon. These surgeries can range from minor to major surgeries depending upon the needs and desires of an individual. In most cases, revision rhinoplasty is more difficult than primary (the initial operation) rhinoplasty. This is largely due to factors associated with scarring and wound healing. Additionally, the cartilage and bone may have been manipulated at the time of surgery in such a way that grafting (usually with cartilage) may be necessary to improve both the form and function of the nose. The recovery period for revision nasal surgery, especially with regards to post-operative swelling, is usually longer than in the case of an initial septorhinoplasty.
Septoplasty or surgery of the nasal septum (dividing partition consisting of cartilage and bone that separates the right and left side of the nose) is a procedure that aims to improve the nasal breathing by addressing anatomic or acquired abnormalities (septal deviation) of this structure. Congenital or acquired deviation of the nasal septum can result in obstruction of the nasal airway and lead to the sensation of difficulty breathing, nasal blockage and/or difficulty with one’s sense of smell. In order to correct the septum, a small incision is made on the inside of the nose (not visible externally) and mucosal flaps (mucous membranes on the inside of the nose, or the nasal lining) are elevated to allow the obstructing bone or cartilage to be removed. After the septum has been straightened, the flaps are reapproximated and all incisions are closed. In some cases, septal/nasal splints may be placed inside the nose to facilitate the healing process. These splints are typically removed 5-7 days after surgery. The procedure is usually well tolerated and recovery lasts approximately one week.
The nasal turbinates (or conchae) are structures that are on the inside of the nose and increase the surface area of the nose to facilitate warming and humidifying the inspired air. They arise from the lateral (outer) wall of the nose and are composed of bone with a mucous membrane covering. In some patients, the turbinate may enlarge (hypertrophy of the turbinates) and may require reductive surgery to enhance and maximize the nasal airway. Most commonly, turbinates become enlarged due to nasal inflammation that may be the result of allergies or chronic irritation. As noted above, a determination as to the need for turbinate surgery would be done at the time of the nasal evaluation. This procedure is typically done at the time of the septoplasty or rhinoplasty and does not lengthen the recovery.