FACIAL REJUVENATION 101

By 2010 30% of the population will be over the age 50 and will consist of 81 million people of retirement age. By 2030 the population of age 65 will increase 130% compared to 2000! There is no question that the baby boomers are coming of age and a majority of the population is growing older. With the advancement of medical technology people are living longer, healthier lives. Along with these trends men and women are anxious to halt the appearance of aging and try to preserve a more youthful look.

In the not so distant past people, mostly women, would undergo invasive procedures to maintain a youthful look. These procedures inherently brought the risk of surgical complications, pain, and irreversible results. Patients would go to great lengths to hide the fact they had a cosmetic procedure done. But now notes of cosmetic procedures are compared at social gatherings—how times have changed!

Not only are women more willing to freely admit they had something done but are often declaring it in bragging rights. Men and the young are now joining the ranks in what was once an environment dominated by “mature” females.

With the advent of Botox and dermal fillers non-permanent solutions to facial rejuvenation are now available. Downtime is minimal and results are often the most natural. The greatest benefit is that if someone is unhappy with the results, then they need only wait a prescribed amount of time before they return to their pre-procedure look.

In my practice a recurrent theme seems to pervade: patients don’t understand the difference between Botox and the dermal fillers and which one to use. My intent is to shed a little light on these different products.
BOTOX

Botox is derived from a class of bacteria known as Clostridia. This class is one of the deadliest of bacteria, producing life-threatening diseases such as gas gangrene (C. perfringens), tetanus (C. tetanii), and botulism (C. botulinium). The bacterium itself does not cause harm but all species of clostridia produce a powerful toxin, or poison, that can result in serious health consequences.

C. botulinium was first identified in 1897 after several fatal cases of food poisoning occurred when macerated ham was consumed at a Belgium picnic. The bacteria identified in the spoiled ham produced a powerful toxin that paralyzed major muscles. Many people died due to paralysis of the diaphragm, the major muscle of breathing.

Botox (BOtulism TOXin) has been used in medical practice for over 30 years. The cosmetic use of Botox was discovered serendipitously in patients who were being treated for a condition known as blepherospasm. After administration of Botox in the eye region these patients were found to have a refreshed and younger look-- hence, the genesis of cosmetic Botox.

Wrinkles form when muscles contract and the overlying skin “gathers” just as the waistband on a skirt does. Initially, all wrinkles are dynamic, i.e. they appear only as the muscle is actively contracting, but over time continuous use of particular muscles will result in static wrinkles. Static wrinkles are those annoying lines that persist after we have finished smiling, squinting, etc. and give credence to an aged appearance. Botox paralyzes the facial muscles so that the wrinkles do not form. With continued use the static wrinkles will soften and diminish over time.

In general botox lasts between 3-6 months, depending largely on how animated a person is and what is occurring in their life at that time. Results can be very dramatic but also may vary significantly between patients. An open dialogue with Dr. Bourget will help each patient decide if Botox is the appropriate treatment for you.

DERMAL FILLERS

Dermal fillers are different from Botox. Where Botox relaxes muscles to make one look younger, the fillers accomplish this goal by replenishing the loss of volume under the skin as one ages. The fat pad under the skin thins as we age. For a dramatic example compare the cheeks of an infant to that of an 80 year old woman. This volume loss combined with solar keratosis, or skin damage from years of exposure to the sun, result in wrinkles that add significant age to one’s appearance.

Dermal fillers are considered sculpting agents as they can dramatically change one’s appearance in a mere 20 minutes. Public demand for these ‘lunchtime’ procedures has been fueled by aging baby boomers seeking ways to look younger and better without any downtime and with only minimal risk. Fillers have multiple uses, either by filling pre-existing facial defects or augmenting existing facial structures. When used in combination with Botox synergistic results are often accomplished.

A confusing array of biodegradable, nonpermanent and non-biodegradable, permanent substances exist—too many to list in the scope of this discussion. The semi-permanent fillers have gained increasing popularity over the past few years due to their longevity yet non-permanence. For the purpose of this site I will focus on the most common dermal fillers used today in facial cosmetic techniques.

HYALURONIC ACID

Hyaluronic Acid (HA) fillers have rapidly become the gold standard for soft tissue augmentation. From 2003-2004 they experienced a 700% increase in use. Because hyaluronic acid is found in all vertebrate animals as a naturally occurring substance it has no potential for allergic reaction in its pure form. It is widely distributed in all tissues and binds enormous amounts of water to its core molecule, giving it a hydrating property when found in the skin. With age, the amount of hyaluronic acid decreases in the skin, resulting in reduced dermal hydration and increased wrinkling.

Because of its hydrating and biocompatible properties HA has been used medically since the 1960’s. Unfortunately in its natural form unmodified HA lasts only 1-2 days in human tissue, making it a poor candidate for soft tissue augmentation. In the 1980’s the mechanism of cross-linking was established to address these concerns. By chemically linking molecules of HA together a more stable macro-molecule was formed that had an even higher affinity for water than the native molecule. This new molecule was more stable, more hydrating and still biocompatible with nascent tissue, thus creating the perfect storm for the new dermal filler.

Because of its malleability and low chance of granulation formation hyaluronic acid is an ideal filler to augment the lips. Juvederm and Restylane are the two most common HA’s used in the US. In my practice I prefer Juvederm because of its increased cross-linking between molecules which yields greater durability and prolonged tissue residence times after injection. Historically Restylane has demonstrated allergic reactions in a select few.

CALCIUM HYDROXYAPATITE

Calcium Hydroxyapatite (CaHA) is a ubiquitous substance found in all mammalian bones and teeth. Synthetic Calcium Hydroxyapatite is a high-density compound suspended in a gel carrier. Once injected the gel is slowly absorbed and collagen production is stimulated. Eventually the gel is replaced with new collagen fibers, forming a long-lasting implant composed of CaHA and collagen. Historically CaHA has been used for HIV lipoatrophy and vocal cord dysfunction but was approved for cosmetic use in December 2006, marketed under the label of Radiesse.

Touted as a semi-permanent, long term filler clinical experience has established duration times of 6 months to several years for Radiesse. The average length of duration appears to be somewhere in the 9-15 month range. Volume correction associated with sustainability make Radiesse an excellent filler for most soft tissue defects. Due to the potential to form granulomas and nodules CaHA is not a good candidate for lips.