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.

Old School Anesthesia

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.

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.

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.

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. 

There are diets everywhere. Obesity is at epidemic levels. I get surprised when my patients actually aren't diabetic. It's sad and really difficult to watch.

I've been obese for much of my adult life. Several years ago, at my wonderful wife's urging, I did a fasting blood glucose level. It was too high. I didn't want to suffer what has plagued my patients and family members, so I took my knowledge of human physiology and tried to simplify those principles to see if I could improve things. I identified several problems.

1) most diets look at weight loss as a gauge of success. The problem here is that diabetes can affect those who aren't obese, and a normal BMI doesn't mean you're healthy
2) most people have no immediate feedback as to whether a food is good or bad for you. How many of us have stepped on a scale and been unhappy, only to think "I shouldn't have had that ____ last night!" That's not how the human body works.
3) most doctors get abysmal training in medical school regarding nutrition. What training they do get amounts to someone standing up and either reciting food pyramid nonsense or telling you that carrots contain vitamin A. That's not helpful.

I took the advice of William Davis, a cardiologist, regarding real time feedback. In my eyes, insulin secretion was the root cause of my problems. Over the years, my bombardment of my pancreas with bread, rice, and pasta in addition to sweets caused tremendous amounts of insulin secretion in an effort to drive that resultant sugar/starch into my tissues for storage for the marathon that will never be run. With time, my tissues became insulin resistant and the sugars remain in my blood. Boom, I'm diabetic. Additionally, insulin is a growth factor. In an almost offensively oversimplistic thought, I considered anything that caused excess insulin secretion as a direct cause of what was keeping me fat.

What did I do? I would check my blood sugar before a meal, then eat, and then check 1 hour later. If my blood sugar went up by 15 or more, I analyzed my meal and eliminated the cause. Slowly, over time, I whittled away at the problem. With my wife's help, I was basically eating a paleo diet. I began reading blogs like this one and this one and this one and this one.

I hesitate to call it a diet, however. I prefer to call it "eating". It's not a diet anymore. 60 pounds lighter, amazing lipid profile, lower BP, no more sleep apnea, and a really low A1C level. 

What did I cut out?

• Grains. All if them. Like bread (and it was easy). While the focus is on gluten (Latin for poison), I don't think there is a single health benefit to grains. Even "heart healthy" nonsense like oatmeal and whole grains are empty and don't fulfill a biological need.
• Rice (as a descendant of Persian parents, this is a feat)
• Corn
• Legumes
• Dairy
• Artificial sugars (with time, as I became insulin sensitive, I added back unprocessed forms of sugar, but still minimally)

What do/did I eat?

• Meat/poultry (ideally from pastured animals)
• Seafood
• Eggs (until I realized I was allergic)
• Veggies (not enough of them)
• Fruits
• Nuts and seeds
• Healthy fats/oils (coconut, avocado, olive oil are healthy. I don't eat canola/processed vegetable oil etc). Much to many people's surprise, I eat animal fats from pastured animals as well (like bacon fat)

So how does this link up with your facial appearance? First, losing weight becomes most noticeable in the face. It's the best way to get rid of jowls, folds and shadows caused by excess fat. Gluten elimination (even if you're not celiac/sensitive) makes your skin look better. I've personally seen how eliminating gluten can reverse skin conditions like dishydrotic eczema. I've experienced fewer breakouts since removing gluten.

Admittedly, this post was more about my journey than it was to advise you about how to try to lose weight. The basic premise is that if you're unhealthy and are suffering from what you're putting in your body, it doesn't make a lot of sense to spend money to try surgery or invasive procedures. Taking care of your body will result in improved face and skin health, plain and simple.

The Wrinkle Whisperer cares about everyone, whether or not they come in for a whispering session. It's why I serve Organic Botox. It's for the people.

It's also why I give back. Simply stripping the earth of Restylane and Juvederm? I think not.

This holiday season, I'm taking facial rejuvenation a step further. For every vial of filler purchased through January 31, a matching vial will be planted in a sustainable fashion. In years we will have the ability to harvest that filler and continue the process.

I'd like to see YOUR medspa do that.

As a patient, if you went to your doctor for a gall bladder problem or chest pain, and your doctor simply told you "This is the treatment that will help you" without explaining what the CAUSE of your problem was, you'd be upset. That's paternalistic 70's era medicine.

As I've said before, I treat my aesthetic patients like I treat my general ENT patients: I approach a cosmetic concern seriously and try to educate my patients about WHY something is happening. Many of the blogs out there focus on the before/after pictures that are depicted after a specific treatment is rendered and completely ignore the analysis of the underlying cause.

One of the most common cosmetic treatments I perform is the application of facial fillers. Restylane, Juvederm, Radiesse and other variations are common choices in my office. 

The most common locations for use of facial fillers are:

• the nasolabial folds around the mouth
• the marionette lines (lines from the corner of the mouth downward)
• cheekbone augmentation

Is there a common cause for the need to treat these 3 facial areas? I think so. I think it's all about the midface fat (cheek fat). In youth, that cheek fat pad is sitting near the lower portion of the orbital bone under the eye and near the cheek bone. As you age, that fat pad descends. What happens as a result?

• Hollowing around the eye (you see eye fat, then a groove, then the descended cheek fat)
• a line between the cheek and the upper lip (the nasolabial fold)
• the marionette line

This is why "high cheekbones" are considered to be youthful. Generally speaking, the facial skeleton itself doesn't change much. What has changed is that the soft tissue over the bone has descended, so some of the volume is lost and the cheekbone doesn't look as high.

There are generally 2 treatment options to revitalize the midface: a surgical midface lift where the fat pad is resuspended OR adding volume to the areas where volume has been lost to camoflauge the hollowing that has happened. Which treatment you decide on has many factors to consider: cost, downtime, risk and longevity.

I practice in Portland, Oregon.  By nature, our population isn't going to be like what you see in Beverly Hills or Miami. So I think my approach works pretty well.

So what happens when a patient comes in and says ""Well Dr. _____ put in 3,400 units of Botox every 3 months and that's what I want you to do."? I usually respond by saying:

• No responsible doctor with any amount of formal training would do such a thing
• I suggest you go back to that doctor.

If you are coming to see me, it's not because I serve organic free-range Botox. It's not because my chairs are more comfortable or I have hip Euro-disco music in my waiting room. You're coming to see me for my expertise. I will always err on the more conservative treatment because I can always do more later. If I overdo it, I risk losing you as a patient and, more importantly, I risk tarnishing my reputation as someone who knows that they're doing. 

Skin classification is often done using the Fitzpatrick classification:

So what procedures am I most concerned about? Basically, anything that violates the epidermis (outer covering of the skin) and gets into the dermis beneath. This includes procedures like microdermabrasion, chemical peels, ablative lasers (like CO2 resurfacing), non-ablative lasers (like those used for laser hair removal) and any procedure that needs a formal skin incision.

I am most concerned with skin types IV through VI. In those patients who desire a procedure, I always perform a test spot to see how they're going to respond. For some desires, like laser hair removal, there are options.  Our office, for instance, has a YAG laser that can help with hair removal without touching the normal surrounding skin.

What is the concern? I worry about post-inflammatory hyperpigmentation (PIH), which can look like this:

Once it develops, it can take a long time to resolve. Often, the affected skin never returns to its original character. There are numerous available topical treatments that can help, but it is far better just to avoid the problem in the first place.

For the patient with darker skin who wishes to have a more youthful appearance, I won't perform any peels or fractional CO2 treatments because of the potential for PIH. Those patients are typically surgical candidates, which can affect the tightening that they desire. Unfortunately, however, many don't want to resort to surgery. I also don't offer less invasive laser treatments that claim to cause skin tightening without damaging the skin. In my opinion, these treatments just don't work.