There are multiple factors that contribute to aging. There are intrinsic and extrinsic factors. Intrinsic involve genetics, time, expressivity, thinning of dermis and subcutaneous tissue and bone remodeling. Smoking and sun exposure are important extrinsic factors. By 30-40 years of age patients will start to see redundant upper eyelids and crow feet, glabellar and forehead wrinkles. By 40-50 years of age the eyes start to age with lower eyelid bags, dropping of the outer brows, loss of fat in the cheeks and temple and the skin in the neck starts to become redundant.
Patients in their 56-60 start to notice more eyebrow dropping and thinning of the lips. The mouth becomes problematic with more smoker lines and marionette lines. Jowls start to appear and the neck becomes more redundant with the appearance of platysmal banding. Patients in their 60-70 notice their skin thinning more with continued fat atrophy and shifting of the bony skeleton.
Neuromodulators are Botulinum Neurotoxins that are produced by the bacteria Clostridium botulinum. There are 7 serotypes (A-G) and in the US most use Botulinum Toxins type A. They work by blocking acetylcholine release from the neuromuscular junction (NMJ). This causes a paralysis of the muscle in area injected. The common US trade names are Botox Cosmetic, Dysport, and Xeomin. These are commonly used to reduce or eliminate wrinkles and producing a lifting effect in certain areas injected.
At the Aesthetic Laser Center we inject mostly Botox, Xeomin and Dysport. A meta-analysis of 11 clinical studies was done in 2012. The conclusion was that Botox Cosmetic and Xeomin were equally potent. In other words 1 unit of Botox was equivalent to 1 unit of Xeomin. Published studies have shown that 2.5 -3.0 units of Dysport is equivalent to 1 unit of Botox Cosmetic. When using equivalent doses, the duration of action of 3 months is the same for all three neuromodulators.
We treat the face, and neck with neuromodulators. The glabella and crow feet are FDA approved treatments. The rest of the treatments are considered off label.
Treatment in the upper face also includes the frontalis which treats the lines in the forehead.
In the midface we commonly treat crow feet, bunny nose lines and we can make the upper lip drop with smiling by treating the levator labii superioris alaeque nasi. This prevents a gummy smile from showing.
In the lower face the mentalis can be treated to soften the chin and prevent puckering that some people make. The DAO or depressor anguli oris can also be treated to lift up the cornersof the lower lip. Some patients have large masseter muscles which cause one to have a very square jaw and increased volume in the face laterally. Patients with enlarged masseters also clinch their teeth at night and can have discomfort. Treatment with neuromodulators will cause the muscle to become smaller, clinching will cease and the lateral volume in the lower face will decrease causing a more pleasing oval face.
The neck is another area that can be treated with neuromodulators. Platysmus banding usually begins to forms in their 50. This is most pronounced with animation and talking. These can be treated nicely with neurotoxins.
A new technique being employed in the neck is called the Nefertiti lift. Neuromodulators can be injected laterally under the mandible to lift the neck and sharpen the jaw line. We usually combine the Nefertiti lift with a Microneedling treatment to enhance the tightening effect. Microneedling treatments will increase the collagen production and hence cause more tightening of the neck.