Injectables (Botox)

• The Steps You Should Take When Choosing an Injector [Video]
• The Importance of Choosing a Qualified Injector [Video]

Botulinum Toxin Injections

Botulinum toxin injections (BTX), often referred to by the product names BOTOX® Cosmetic or Myobloc®, are biological toxins (botulinum toxin) transformed into a therapeutic agent. Work with BTX began in the late 1960s to treat neurological disorders. Today, BTX is used for the treatment of frown lines, forehead furrows, "crow's feet," lines and wrinkles of the lower face, and even nasal muscles (to decrease nostril flaring). BTX injections have proven to be a very popular nonsurgical cosmetic procedure; see current American Society for Aesthetic Plastic Surgery (ASAPS) statistics. Aesthetic plastic surgeons have found that the type of lines and wrinkles that respond to BTX injections are those caused by the muscles-specifically those muscles that contract during facial expressions such as frowning or squinting.

Technique:

The patient is asked to contract the muscles in the area being treated so the surgeon can determine the proper location for injection. In most cases, BTX is injected directly into the muscle with a tiny needle. It takes a few days to realize the effect of BTX injections.

Benefits:

No downtime. Patients can immediately resume normal activities.
Long experience has proven BTX to be safe. To date, no systemic complications associated with BTX injections have been documented.
Treatment is reversible within several months.
May be beneficial for treatment of migraine headaches.

Other Considerations:

BTX injections are a temporary solution for the treatment of wrinkles. The effects last from 3-4 months and require repeat treatments.
Possible side effects include local numbness, swelling, bruising, or a burning sensation during injection. Some patients have reported temporary headache and nausea. Most complications are of short duration and can be avoided with proper injection techniques.
A small percentage of patients are reported to experience no improvement at all.

ASAPS Position:

The American Society for Aesthetic Plastic Surgery (ASAPS) maintains that BTX injections for aesthetic purposes appear to be safe and effective. Patients who show early signs of aging, as well as those who may not be suitable candidates for more extensive aesthetic facial surgery, may be good candidates for this procedure. Certain medications (some antibiotics, anti-inflammatories, or aspirin) and even some vitamins and herbs may increase the potency of BTX and may increase bleeding and bruising at the time of injection. Therefore, patients should be candid with their surgeon about all medications and supplements. Pregnant or nursing women should postpone undergoing this procedure. It is not known whether injection of BTX has any effect on a fetus or whether it is found in breast milk.

Collagen Injections

Collagen injections were approved by the FDA in 1981. They have proven to be a very popular nonsurgical cosmetic procedure; see current American Society for Aesthetic Plastic Surgery (ASAPS) statistics. Injectable Zyderm and Zyplast collagen, natural substances derived from purified bovine (cow) collagen, essentially replace the natural collagen that the skin loses over time. Human collagen are also available. Collagen injections are most useful in the treatment of frown lines, "crow's feet," and nasolabial folds (smile lines). To improve deeper creases or enhance lip fullness, there also are filler materials, such as soft ePTFE (expanded polytetrafluoro-ethylene) that can be surgically implanted.

Technique:

Collagen, which contains local anesthesia, is injected with a tiny needle into the skin depressions being treated. Several injections may be needed, depending on the length and depth of the wrinkle. The procedure for both injections and implants takes less than an hour. Implantation procedures for the lips and nasolabial areas are done with a local anesthetic. A tiny incision is placed at either end of the site. Then the implant is inserted and positioned. Incisions are closed with a suture.

Benefits:

Safe, time-tested, effective treatment that provides immediate results.
No downtime for injectables-patients can immediately resume work and all normal activities.
No need to obtain tissue from another part of the body.
Human collagen products do not require pre-testing

Other Considerations:

Collagen is only temporarily effective. Repeat treatments are needed every three to six months.
There may be some slight bruising.
Pretreatment testing for allergic reactions is recommended. Allergic reactions can cause itching, redness, or other symptoms.

Fat Injection

Body fat makes excellent soft tissue filler material. Fat injection (also called autologous fat transplantation) transfers fat from one part of the body to another to recontour the face; diminish frown lines, crow's feet and nasolabial folds (smile lines); and provide definition to areas like the cheeks and chin. It can also be used to fill out depressed scarred areas on any part of the body. Fat injection is not permanent, and may require an effective maintenance program.

Technique:

The donor site (for example, abdomen, buttocks or thighs) and the treatment site are injected with local anesthetic. Intravenous (IV) fluids also are injected into the donor site to facilitate fat collection. Fat cells are extracted through a small needle attached to a syringe. The fat is then processed to remove excess fluids and reinjected with another needle in multiple thin strands in the desired area. "Overfilling" is a necessary corrective due to fat absorption in the weeks after treatment. Fat also can be harvested during a lipoplasty (liposuction) procedure in one area of the body, and then reinjected in another. For longest-lasting effect, patients generally receive 3 to 4 treatments over a six-month period.

Benefits:

Natural, non-allergenic.
Outpatient procedure that generally takes under an hour.
Injections may last from several months to permanently.
Little or no downtime.
Minimal discomfort, which can be controlled with medication.
Because fat is from the patient's own body, no pre-testing is required and the fat cannot be rejected.
Good alternative if the patient is allergic to bovine collagen.
Cost effective if combined with another procedure like lipoplasty (liposuction).

Other Considerations:

Longevity of results can vary significantly from patient to patient.
Some swelling, bruising-usually about 48 hours. Patient should avoid the sun until the condition subsides.
Not every area is appropriate for fat injection. Injecting fat into the breast, for example, makes cancer detection via mammography more difficult and is strongly discouraged (see ASAPS' Position Statement, "Fat Injection for Breast Enlargement)."
Lasts longest when reinjected in relatively stationary areas (such as the cheeks).

Hyaluronic acid

Hyaluronic acid is a natural polysaccharide, that in appropriate form, is a versatile soft tissue filler. Currently available as the product name Restylane (also Restylane Fine Line and Perlane) distributed by the Medicis company, and Hylaform distributed by a company named Inamed. Hyaluronic acid is being widely used for the management of wrinkles, fine lines, contour deformities, and volumetric deficiencies of face, cheeks, and lips associated with aging, developmental anomalies, and certain diseases. Restylane/Hylaform does not represent the final answer in the search for an ideal tissue filler but provides a predictable, safe, user-friendly approach.

Technique:

Restylane/Hylaform is usually injected when the patient is in the office, rather than requiring a hospital visit. The areas of the skin to be treated are first coated with a topical anesthetic, which is usually sufficient for the patient's comfort, although a nerve block may be preferable for some patients. Hyaluronic acid is a hydrophilic agent, which means that it attracts water much like a sponge. This expansion contributes to the final volume that is achieved. Therefore, underfilling is necessary, and many patients will benefit from a touchup session in about three weeks after the first treatment. Overfilling can lead to bumps and irregularities which, although rare, can represent a small, temporary cosmetic problem. For many, but certainly not all patients, the results can last up to six months. It is especially effective for the nasolabial folds, lip augmentation, and areas of contour deformities. It is also an ideal adjunct for Botox treatment and is frequently used in conjunction with Botox to correct lines and creases that persist.

Benefits:

A natural substance that does not require pretesting for allergic reactions
Injections can last for approximately six months
Minimal discomfort
Very few side effects
Can apply makeup immediately and return to normal activities

Other Considerations:

Bruising and swelling can occur
Small bumps are infrequently visible or are palpable
After about three weeks, repeat injections are often necessary to achieve an ideal result

Glossary of terms: Injectables and Dermal Fillers

See examples of Injectables in the photo galleries.

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