Square pegs into round holes

One of the most common questions I get online and in the office is how someone can know if they "need" Botox vs filler vs a laser or surgical procedure. Let's break it down:

1) Botox and Dysport
These products are ideal for paralyzing muscles that cause wrinkles associated with facial expression. The three most common areas are the glabella, the forehead and the crow's feet. The mechanism of action is simple: because your skin has lost elasticity (from sun, smoking or time), the strategy is to weaken the muscles since your skin can't effectively move with your skin. When those muscles can't move, the wrinkles recede.

2) Facial fillers
There are numerous fillers on the market - Juvederm, Restylane/Perlane, Radiesse and others. The general principle is the same: restore the volume that your face has lost with time. Generally speaking, the normal fat of the midface descends, causing a hollowing around the eyes and the frown lines around the mouth. Facial fillers do add physical bulk but also attract water and aid in collagen deposition. The most common site of injection is around the mouth but it can also be used for a cheek lift or fuller lips. They generally last 9-12 months and are very comfortable with the addition of a local anesthetic to the mixture.

3) Laser resurfacing
Simply put, this helps everything. For minimal downtime, CO2 resurfacing results in tighter skin, fewer wrinkles, smaller pore size and more even skin pigmentation. It is the reset button that really does turn back the clock. Effects generally last for years. This will not get rid of deep static lines that typically need fillers, which is why it's important to get evaluated by a trained professional.

Facelandia

Yes, I live in Portland, Oregon. I sincerely believe that some of the nicest people in the world live here. But as it has been the subject of some fun on the show Portlandia, there's a fair bit of truth to some of the skits. This post will go over some of things we Portlanders do to our faces.

Ear gauges. You've seen 'em. Holes in earlobes so big, you wonder whether there's a strange MC Escher-esque gravitational pull centered around the earlobes. I've seen it done tastefully, but there's the occasional "OH MY GOSH WHAT HAVE THEY DONE". It really becomes a problem when the person decides they no longer want them open, and come in to see me for consultation for closure. As you can see, the sizes of these gauges correspond to measurable inner diameters.

Once you get beyond a zero gauge in diameter, the rate of spontaneous closure after the gauges are removed is quite low. You're then looking at a surgical closure. This can be done in several fashions. Typically, the normal ear lobe is skin sandwiched around fat. To close the area adequately, it is more than just sewing up the skin, because you've lost the central fat that gives the lobe its bulk. I typically place a piece of cartilage harvested from the back of the ear as a new middle layer and close the skin around it.

Facial Piercings
Generally speaking, I like facial piercings. But please get these done at a reputable business. I've seen some terrible infections, particularly from those done around the mouth. Also keep in mind that some piercings will need formal closure or to remove the dimple that results if it does close spontaneously, especially Monroe piercings or the studs placed through the cheek skin.

Tattoos

They're beautiful, interesting, and intricate. Just don't put them ON your face. Many people mistakenly think that tattoos can be removed later with a laser. While the pigment can be faded, you can usually know that a tattoo was still present. There is always a textural difference to the skin following a tattoo.  After all, it is a sharp needle jabbing you in the skin a bazillion times, so it'll have a different texture to it. 

The sun
Yes, it rains here. But most Portlanders don't realize how intense our sun is. Sunblock is not only important from the standpoint of skin cancer prevention, but it is the single most important thing you can do to prevent wrinkles. I recommend a titanium- or zinc-oxide product. I also recommend big sunglasses. This is a separate barrier but also prevents you from squinting, another contributor to wrinkles around the eyes. Here's the Portlander look you should go for.

I love Facelandia. It makes every day very interesting.

Psychiatric Disorders and Cosmetic Rejuvenation

My duties as a practitioner of cosmetic facial rejuvenation go beyond what I've discussed before: facial analysis, appropriate (and not over-) injections and treatments, and honesty/integrity in my determination of what a patient may benefit from.

One of those duties includes, however, whether a patient has an underlying psychiatric disorder that can cloud their judgement when requesting rejuvenation services. Obviously, most patients who come in for my services feel that they would like something about their faces to change.  Whether it be a wrinkle or a furrow, the underlying issue is that my patients look in the mirror and something they see bothers them. While that's fair, I still won't answer the question "What do you think I need?"

What psychiatric disorders can affect a patient's judgement?  Based on the prevalence alone, depression is a huge potential factor. It's important for a practitioner to recognize when a patient's motives may be when asking for a service. This is a topic routinely covered in medical school (which is another reason why you don't let an "injector" treat you).  Other psychiatric disorders like schizoid or histrionic personality disorders can also be problematic, especially when they get a good result but don't see it. That's why pre-procedural photographs are so important!

The most specific psychiatric disorder that can cause problems is body dysmorphic disorder (BDD). Generally speaking, BDD is a possible diagnosis when a patient feels they have a physical "defect", and that this defect is ruining their lives.  The focus on this problem seems markedly excessive and unhealthy. The perceived defect can become an obsession for these patients.  The diagnosis of BDD assumes that there is no other underlying psychiatric disorder that would explain the symptoms.

The identification of an underlying psychiatric disorder is crucial BEFORE that patient is treated. This can contribute to unrealistic expectations and can lead to unnecessary legal troubles.  It's yet another reason why I repeatedly beat the drum of making sure you choose a cosmetic practitioner who's been formally trained, rather than someone who has gone to a weekend course. If I feel that a patient may have something going on, I am up front with them and explain what I'm worried about, and I refer them to a provider who can clear them before they get treated. Contrary to expectations, these patients are always appreciative.

The Sad Puppy Dog Look

One of primary strategies in facial rejuvenation is to match a patient's intended facial expression with what's actually show on their face.  What are some examples?

The lines in the glabella can make it look like you're frowning

The lines of the crow's feet can make it look like you're squinting or tired

Brow drop with horizontal forehead lines in addition to the puffiness and lines underneath the eyes can give a tired appearance.

Facial filler around the mouth is a great way of taking care of one of the biggest facial problem areas.  As our skin loses elasticity, the ability of the skin to move fluidly around the mouth is lost, resulting in deep folds around the mouth.  Why do we get these lines around the mouth, and does facial filler placement really help?

BeforeAfter

Does she still have lines after the filler placement? Yes - intentionally. I don't like completing eradicating these lines, as it looks fake.  But the depth of the fold is more natural after the injection.  For someone her age, she is supposed to have a fold there. Getting rid of the fold would look awkward and unnatural. I don't want attention to drawn to the mouth, so I'm more conservative.

Why is this line there in first place? Time for an anatomy lesson!  Most muscles in the body start on one bone and end on another, and contraction/movement of that muscle affects a movement on the target bone. Facial muscles are unique. They start by attaching to the facial skeleton, but instead of acting on another bone, they insert into the skin, so movement of these muscles affects a movement of the skin it's attached to.  There are several places on the face where different groups of muscles come together on the bone of the face, like a seam on your clothing.  The lines around your mouth (the nasolabial folds) are one of these seams.

These fillers are impregnated with lidocaine and are quite comfortable when injected. Depending on which you choose, they can last up to 1 year or longer. The effects are instantaneous and quite gratifying.

Luscious Lips

In honor of Valentine's Day, I thought I'd discuss the importance of the lips.  Obviously, lips are central in speaking, drinking, and my favorite task: eating bacon. The lips are also a focal part of facial expression, where the most subtle movements can speak volumes (intentionally or not).  Lush, fill lips are associated with youth and vitality.  Thin lips are associated with aging and an expressionless, taciturn look.

The unique anatomy of the upper vs. lower lip must be fully understood before one decides to augment it.  The upper lip has three separate components that make it look like a cupid's bow. The lower lip, on the other hand, is a single cosmetic unit. Additionally, the lower lip is typically about 50% larger than the upper lip.  This becomes important when discussing augmentation. The other relevant anatomy is the vermillion border, which divides the red lip from the skin-colored lip. If your injector distorts this border with a filler injection, the end result will look quite abnormal.

Because I generally think placing facial filler or Botox/Dysport in smoker's lines is a really bad idea, the mainstay for treatment in my hands is the CO2 laser.  This helps to resurface the skin and stimulate new collagen formation, which helps to erase some of the damage done.  While laser resurfacing helps to make the skin around the lips look healthier, I do think that placing facial filler into the lips (mostly the lower lip) is a very effective way of plumpifying your way to a rejuvenated look. Most inexperienced injectors inject only the upper lip or they preferentially put more in the upper lip than the lower lip.  Bad idea.  Unless you're a rabid Oregon football fan, putting too much filler in the upper lip will make you look like a duck.  That looks horrible and obvious. The goal of lip injection is to get a SUBTLE difference. If people notice your lips, it's likely been overdone.

The fillers that I typically use all are embedded with lidocaine, a local anesthetic, so injection is extremely comfortable. I use ice and occasionally a numbing cream on the lips and my patients tolerate it quite well.  Expect some swelling for a day and occasionally some bruising, but the result can look fantastic. Take a look!

Before (left) and After (right) - injection of lower lip only

Before (left) and After (right) - injection of lower lip only