The Gummy Smile

Many people are unhappy with the position of their upper lip when they smile. In some patients who have overactivity of certain muscles, the upper lip overelevates when they smile and shows excessive gums (the "gummy smile").

There are two separate muscles (adjacent to each other) that are responsible for this overelevation of the lip: the levator labii superioris alaeque nasi and the alar nasalis muscles. The elevation tends to be symmetric although occasionally, one side elevates more than the other. In my opinion, the levator is the more dominant of the two muscles for this particular motion. This has implications for treatment location.

What are your options? There are surgical options, but they seem quite extreme. Some involve excision of excess gum tissue, and other attempt at repositioning the lip lower on the gumline. With the appropriate application of botulinum toxin, however, this can be prevented.

For this non-surgical treatment, a practitioner can use Botox, Dysport or Xeomin. A very small amount is injected to relax these small muscles. Undertreating the area is key, as if the practitioner injects too much, it could affect lip function (extremely rare). Having the patient smile during the examination allows the injector to feel where the muscle is on either side of the nostril. This area is then marked and injected with a single injection. Treatment costs are routinely under $100, and for effects that can create a subtle drop for 3-4 months at a time with no downtime and little risk, it just makes sense to try it out if you're interested.

Numbing It Down

Old School AnesthesiaOne of the primary reasons that people choose non-surgical facial rejuvenation over surgery is that you don't need general anesthesia for what can be done in the office. General anesthesia has some risks associated with it (although very small), is more costly, and can leave you feeling off for a while. There are ways to perform surgery without general anesthesia, using IV medications to create a twilight experience (like when getting your wisdom teeth out).

Even then, however, IV sedation is more than some people want to have. So they prefer something easier and less invasive. This also goes along with the philosophy that much can be done in the office without the need for sedation. Also, knowledge of office-based techniques can often prevent the need for a deeper anesthetic.

What techniques can I use in the office to make treatments less painful?

• Needle size: I use a 32 gauge needle for my botulinum toxin injections. The tips are more expensive because of their size, but it's worth it. Obviously, the smaller the needle, the less pain there is.
• Pressure: I was trained to use skin pressure with my finger immediately prior to an injection. It serves to temporarily anesthetize the area as the needle is introduced. I think it helps.
• Numbing gel: creams like EMLA (lidocaine/prilocaine) left on the skin for 15-20 minutes can really numb an area. I use this frequently when I'm going to introduce facial fillers or for my CO2 laser skin resurfacing procedures.
• Ice: Using ice is amazing. I use it after procedures to soothe an area, but ice is great before injections. It seems to be best applied when I'm using facial filler for cheek augmentation.
• Drugs: Sometimes, if a procedure is more stimulating than a patient cares for, mild oral medications that wear off easily are utilized. I use this most for my CO2 laser procedures. A combination of Xanax, Benadryl and Vicodin creates a mellow sleepiness in about 30 minutes.
• Injected agents: Like at the dentist, medications like lidocaine can be used to pretreat an area so it's more comfortable. In my practice, this is almost never necessary. If I do inject, it's often so I can utilize the other component of the injection (adrenaliin) to decrease bruising, especially when injecting filler around the eyes to correct tear trough shadowing.
• Combining ingredients: Many facial fillers are available with lidocaine built into them. Radiesse doesn't have it built in, but it's easy to mix lidocaine in immediately before application. These make the injections very comfortable.

Make sure to talk to your practitioner about your concerns. As you can see, there are multitude of options on how to make your experience a pleasant one.

Curves on the Face

Facial analysis BEFORE performing a procedure is the single most important factor that can predict success of a cosmetic intervention. It's not about the type of botulinum toxin used, or the type of laser, or the type of surgery. If your practitioner doesn't know how to analyze the face, then the treatment rendered may be inappropriate.

I've previously written about the efficacy of rhinoplasty. When I plan to change the appearance of the nose, I don't just look at the nose. I look at the nose in the context of the remainder of the face. The same is true when I perform a botulinum toxin treatment around the brow.

The brow tip esthetic line is displayed here. The human eye notices disruptions in this line. Starting at the central portion of the brow, the "ideal" brow tip line will gradually curve down towards the tip of the nose. For females, this curve is more noticeable. In men, the curve is more blunted.

Disruptions in this line are very noticeable, particularly when it comes to the nose. Nasal trauma can cause a shift of the nose to one side, disrupting both of the lines. Reestablishing the unbroken continuity of this line is the key to getting a satisfactory cosmetic result.

Male Brow vs Female Brow

For the inexperienced injector, the forehead can be the trickiest area to inject with Botox, Dysport or Xeomin. The most important factor is knowing what parts of the forehead to inject to achieve specific results. This depends on the underlying anatomy in addition to what the patient wants to achieve with these injections.

Normal brow anatomy differs from male to female. The typical male brow is flatter with minimal arc over the outside aspect of the eye. The female brow, however, has a gentle upward arc towards the outside portion of the eye. The position of the brow depends on two primary muscles. The first is the forehead muscle, called the frontalis. The other is the muscle around the eyes, called the orbicularis. These muscles play tug-of-war, so if the injector is not aware of the effects of paralysis of one of these muscles, it can have catastrophic effects on brow position.

For instance, if the central portion of the forehead is paralyzed but the lateral portion of the forehead is not paralyzed, one can achieve subtle brow elevation. In some patients, however, especially those with hyperactive frontalis muscles, injecting only the central forehead can give unopposed elevation of the lateral forehead and a sinister look. Picture Jack Nicholson.

Conversely, if the injector paralyzes the entire frontalis muscle, one can get a droop of the brow, called brow ptosis. In men, this is better tolerated because of the flatness of the brow position. In women, however, this looks quite awkward and can be very difficult to fix.

Ultimately, as I've written about previously, you must make an informed decision. You should choose someone with formal experience. That experience pays off the most in the actual ability of your injector to analyze the subtleties of facial anatomy. Choose wisely.

Three's a Crowd: Xeomin

For years, Botox dominated the market for wrinkle reduction. Several years ago, Dysport was introduced, giving Botox its first realistic competitor.

Now, there's a third player: Xeomin.

What's the difference between these products? The active chemical product between the 3 players is the same. There is a 150 kDa protein at the core of all 3 products (the actual botulinum toxin), but the difference is with the proteins that surround this core protein. Botox (onabotulinum A) is made up of a large protein (750 kDa) whereas Dysport (abotulinum A) has an overall smaller protein (350 kDa with some larger proteins). Xeomin (incobotulinum A) is often referred to as a "naked" toxin, but in reality there are still some proteins surrounding the toxin, although it's quite minimal.

So there are microscopic differences, but how does that translate for which one you should choose? To the first time patient, if you are visiting a practitioner who is reliable, I recommend listening to the physician. While it's tempting to go with what's on sale, ultimately you want the best result and I feel that best result is going with what your injector is most comfortable using.

Generally speaking, I think most of these products give the exact same results. While it's hard to prove in peer-reviewed journals, some practitioners (myself included) think that Dysport works a little faster than Botox does, but the significance is minimal, as we're talking about noticeable onset in 3 to 4 days with all products. Not enough is known about Xeomin yet, but I think it will more closely resemble Botox than Dysport. The main advantage of Xeomin is that it's shelf-stable (unrefrigerated) until it's reconstituted whereas Botox is typically kept frozen and Dysport is refrigerated.

The best part about Xeomin? The introduction of a 3rd player will inevitably drive down the costs of all of the choices.