In this edition of “Why does Everyone Look So Weird” I will explain why I do not think neuromodulators such as Botox and Dysport should have a significant place in aesthetic interventions and why you think they should.
You Paid for What?!?!
(By the way this is an image from Botox marketing campaign)
I personally have not been to a high society event or exclusive fashion show in years without seeing a wealthy socialite that I consider a victim of Botox or similar neuromodulator. Shiny flat forehead skin with a disconcertingly unnatural v shape to the brows that have moved far away from each other and just a few strange lateral wrinkles. Certainly not all administrations of neuromodulators result in this clown-like appearance but overzealous dosing and injection help demonstrate the extreme. I must admit, I too have a loyal following for Botox and Dysport and I consistently deliver rests that are subtle aesthetic improvements. Importantly, however, I always try to talk my patients out of it every time. Lets’s take a look at why.
If I am going to inject neuromodulators into a patient’s face I am thinking of true aesthetic improvement and not just treating wrinkles. Thus the goals of neuromodulators in the periorbita (the area around the eyes) is to cause the impression of laterally lifted brow while delivering the appearance of softness to the forehead. In my practice I will use 50 units of Botox or 150u of Dysport for this intervention and charge the patient $850. The delicate nuances of this intervention include artfully bridging the treated and untreated areas of the forehead and balancing the orbicularis oculi(the muscle around the eye) to allow lateral brow elevation. Everyone understands this concept but very few are good at delivering a natural appearing result thus the splaying, dropping brow and sometimes startling “V-face.” I will note here that I do not think it is possible to efficaciously deliver a balanced result with less than the dosage above and thus I think the ever so common 10-20u Botox treatment for a couple hundred bucks is a total waste of money that cannot yield aesthetic improvement. I mention dosing and pricing above because I want to make an argument that everyone can relate to- financial feasibility. If you are to keep a stable neuromodulated experience, you are going to pay about $850 every two to three months every year. This can add up to five thousand dollars very quickly and two months later you have nothing to show for it. Yes I think neuromodulators are a rip off but we will get back to this, lets talk aesthetics to understand why neuromodulators are just not a good answer for wrinkles anyway.
Take a second and think back to when you were thirteen years old. Did you have crows feet? Did you have the “elevens” that Botox marketing has focused our attention on, forehead creases? The answer is clearly no. Now lets consider the muscles that are routinely being paralyzed in the name of aesthetics. Were your muscles of facial animation stronger or weaker when you were thirteen? Well I hate to break it to you, they were stronger. Now on a very basic level does it seen intuitive that the cause of wrinkles is excessive muscle activity or strength? No of course not. Why did you have stronger more active muscles but no wrinkles when you were thirteen? Eureka! You had thicker more robust soft tissue and skin. With age comes thinning of the skin and the subcutaneous soft tissues and our skin starts to exhibit wrinkles. Ok so now the tough one, which sounds like a better treatment for wrinkles: #1 paralyzing weak muscles or #2 restoring the soft tissue of youth?
Before I get deeper into why option #2 makes so much sense given the amazing products and techniques that are available to us today, let me finish explaining why neuromodulators don’t really make sense. In the best of hands there will always be some brow splay or separation which is almost always an aesthetic negative. This can make people look quizzical or confused when extreme. Secondly the relationship of the brow to the dorsal nasal lines of the nose is often disrupted. Although no one really notices this consciously, these features make a big impact on the aesthetic judgement an observers brain creates before we have time to think. Think about what I just wrote and look at the illustration above that is part of the Botox marketing kit. Do you think that looks good? I once again admit to getting very nice subtle results with neuromodulators, however this is not common with the masses of injectors out there.
Lets talk about long term effects and bang for the buck. We have already established that neuromodulators are an expensive recurring cost with zero residual value. To make things worse many people get less sensitive to them with time and they loose efficacy or require higher doses. I commonly explain to patients that if they spend about what one year of neuromodulator maintanance costs( approximately $5000) once on the proper treatment they will have a tremendous aesthetic improvement for years to come without the necessary upkeep.
So what is the proper treatment? In my opinion it is expert application of hyaluronic acid(HA) based fillers, i.e. Juvederm, Perlane, Restylane. I will also note that the technique and applications that I employ and describe are NOT FDA indications. I will also note that in my opinion ALL FDA indicated uses for fillers are not aesthetically sound. We should also note that the FDA just released a statement warning about the use of fillers in exactly the areas I place them daily with warnings of tissue loss and blindness. This is something patients need to be aware of and another reason to pick your injector very carefully. I perform this type of injection daily in my practice and have been doing so for about five years with no such outcomes but it requires care thoughtfulness and meticulous technique.
Now back to why HA fillers are a godsend. It just turns out that much of our body is made up of HA and there is no allergy to it. Now it gets even better. Stem cells, although marketed to be all kind of things they are not , are actually present all over your body. They are all over the microvasculature of your face waiting to be called on in injury to heal and other functions that we honestly do not understand. These stem cells actually have a special cell surface receptor that binds… you guessed it, HA. The receptor signals activation causing the stem cell to make vascular tissue, a process called angiogenisis. The HA fillers listed above are actually long chains of repeating HA and as they degrade, are constantly releasing HA monomers. These individual pieces of HA can bind and activate local stem cells telling your body to make new healthy vascular tissue( very different from the destructive inflammatory scarring caused by other products such as sculptra radiesse and others but that’s for another blog). When these fillers are applied with special techniques such as what I call “Aesthetic Facial Balancing” in my practice, the aesthetic benefits last years and years not the 6-9 months we are told. When they are gone they can leave behind healthier more robust tissue than was present before.
“But wait what about my wrinkles?”
Yes. The wrinkles. It is no secret that I don’t think wrinkles are very significant aesthetic problems, but yes they go away. I usually try to reorient patients that come to me seeking neuromodulators towards aesthetic facial balancing primarily of the periorbita (area around the eyes). The reason is severalfold. Most patients benefit most from having this region rebalanced as we start loosing significant high malar soft tissue as early as the late teens and early twenties. We start noticing bags or tired eyes. Aesthetic Facial Balancing of the periorbita creates a lifted appearance of the cheek and brow and hides the bags. As what I consider a side effect it also treats the wrinkles and crows feet that originally leads the neuromodulator seeking patient into my office. Thus when I am successful in reorienting a patient, they walk away not just with their wrinkles treated(the right way), but they also walk away with a face that glows and appears healthier, happier and usually more than a decade younger. There is no need to rush back for a repeat but I will note that most patients love the results so much they are eager for further refinements. When you treat the actual problem a natural appearing and lasting result can be produced.
I will add one more note on the prolonged use of neurotoxins that no one wants to talk about, particularly relevant to patients with the dramatic V-deformity I referred to at the beginning of this blog. Neuromodulators work by poisoning the neuromuscular junction(NMJ), where a nerve signal is turned into a muscle action. Basic muscle physiology and maintenance requires intact NMJs and some stimulation. A muscle with a cut nerve for example will quickly atrophy and pretty much disappear into a layer of fibrous tissue. Chemodenervation, blocking the NMJ with neuromodulators, does the same thing. Thus with long term use the subtle negative effects of brow splay and malposition can worsen and worsen leaving permanent deformity.
I encourage people to try to undo the brainwashing we have all gone through that glabellar wrinkles coined the “elevens” and crows feet are the most important features that affect our aesthetics. They are not. Its the big picture, the shapes of the facial features and how they relate. There is no time to analyze wrinkles in the less than 300 milliseconds that a human brain uses to generate and aesthetic opinion.
In summary neuromodulators are very powerful drugs with some great uses, however, they are not the right choice for most people with aesthetic concerns and wrinkles. I personally treat my neck and back pain routinely with neuromodulators, they work phenomenally well for trigger points and pain. Restoring healthy soft tissue in an anatomically relevant and aesthetically sound fashion not only saves you money in the long run but it improves the health of your facial soft tissues can render a very significant aesthetic improvement….and it may just keep you from looking weird if you pick the right practitioner!
Rian A. Maercks M.D.
Aesthetic, Craniofacial and Reconstructive Surgery
The Maercks Institute