Transcription:
Nonsurgical Facial Rejuvination

Alyne Ellis: When you gaze in the mirror, do you want to look younger? That's easier than you might think with a few shots of Botox. Here to explain how Botox is used in non-surgical facial rejuvenation is ear, nose and throat specialist with additional training in facial plastic surgery Dr. Gita Fleischman.

This is WakeMed Voices, a podcast by WakeMed Health and Hospitals. I'm Alyne Ellis. Welcome, Dr. Fleischman.

Dr. Gita Fleischman: Thank you. Thanks for having me.

Alyne Ellis: What is Botox and how is it used and what is it used for?

Dr. Gita Fleischman: So Botox is basically botulinum toxin. It is a neurotoxic protein that's produced by a bacteria that is used for many things in medicine. And one of the things it does is it causes a chemical denervation of muscle. So it basically makes muscles do less of what they're supposed to do, which is contract.

It is FDA approved for both cosmetic and non-cosmetic uses. And in my world, which is ear, nose and throat and facial plastic surgery, it is used for medical uses such as migraine headaches. And, from a cosmetic standpoint, it is used for moderate to severe frown lines, whether it's in the forehead or the eye area, which people call crow's feet or the nose area where people get bunny lines.

It's also used to improve the smile. So in people who have gummy smiles, we can improve that. We can improve downturned smiles. We can improve the appearance of dimpled chin. and, so yeah, that's what Botox does in the ENT world.

Alyne Ellis: And briefly, how do neurotoxins work on a scientific level? And how long did the effects of it last?

Dr. Gita Fleischman: So a neurotoxin such as Botox, they inhibit the release of a chemical neurotransmitter called acetylcholine. And basically what this neurotransmitter does on a molecular or a biologic level is it lets the nerve give a signal to the muscle that says contract or tighten up. Botox prevents that from happening, and this basically causes a temporary weakening or paralysis of the muscles.

So even though the patient is trying to contract the muscle, it just won't do it. So it gives a much smoother appearance. It lasts about three to four months. And what happens is that in about three to four, three to six months, that nerve-muscle junction regenerate. So the effect of Botox does wear off in that amount of time.

Alyne Ellis: Maybe you could talk a little bit about the safety, because it certainly sounds a little scary to be injected with a neurotoxin.

Dr. Gita Fleischman: So there is a lot of research that's been done about the safety and efficacy of Botox. It's been in use for decades and it was first started as a treatment for people who had conditions in which their muscles would spasm in their eyes and wouldn't release. So the toxic doses of Botox are hundred-fold higher than what's used in cosmetic use or for migraines or temporomandibular joint dysfunction, things like that.

Of course, if patients have neuromuscular conditions or if they're pregnant or breastfeeding, or if they have a Known allergy to any ingredient that's in Botox, we certainly wouldn't inject it. But otherwise, it has a very safe profile.

Alyne Ellis: So compared to the other things we're talking about, where you need more Botox, how much is needed for the desired effect for changing the way your face looks?

Dr. Gita Fleischman: So there's different doses for different amounts of wrinkles or different amounts of lines. Men usually need a little bit more than women because they have stronger muscles, but typically we're talking about 40 units in the forehead and eyebrow region, which is one of the more popular regions that people use Botox for. And the eye area, usually anywhere from 5 to 15 units on each side, so very small doses. The toxic dose of Botox is usually around 200 units or more. So we're not even close to that.

Alyne Ellis: And how do you determine exactly where to place the injections?

Dr. Gita Fleischman: The injections are placed after we do a clinical consultation and we look at the areas where the muscle has the highest amount of activity. Usually, it's in the area between the eyebrows and the area in the forehead where the lines, the horizontal lines of the forehead are made and based on the muscle activity, which we can see and feel, we determined that the injection goes there.

Alyne Ellis: How long does the procedure take? And can you walk us through what a patient can expect during the procedure?

Dr. Gita Fleischman: So typically what happens during a consultation, the patient comes in, we sit down, we bring a mirror out and we talk to the patients about what bothers them from a cosmetic standpoint about their face. And once they have explained sort of their concerns to us, we together look at the muscle activity in the face.

We have them frown. We have them raise their eyebrows. And we look at the furrows, the lines, basically around the forehead, around the eyes and their chin and nose. And we then determine how strong each muscle is because everyone has a slightly different amount of muscle activity at different parts of their face.

And based on how severe the wrinkles are and the muscle, how strong the muscle is, we basically tell the patient how many units we think they will need. And then we make a little chart. We draw out exactly where the injections will be, how many units we would put.

Then we cleaned the face, we obtain consent. We go over all the risks and the benefits and the alternatives. If a patient has never had Botox and wants a topical anesthetic, we can apply that, but most people don't even need it. And then we use a very thin needle to just quickly inject the areas that need treatment. It takes about five minutes, five to 10 minutes at most. And then we just put some ice packs to help reduce some of the swelling that can happen and that's it.

Alyne Ellis: And what precautions to patients need to take before and after the procedure?

Dr. Gita Fleischman: Yeah. Typically, we recommend if they're on blood thinners, they talk to their primary doctor or cardiologist, whoever has put them on it to see if that can potentially be held for a few days before and after the procedure to help with bruising. Certainly, if a patient has a cold sore outbreak or any kind of skin infection, we ask that they wait for that to completely pass before we do any kind of injections to the face.

if they have used any kind of peels or are using Retin-A, any retinoids on the face, we want them to wait at least a week or so before we inject. And those are the main ones, basically blood thinners and active infection.

Alyne Ellis: So what effects does Botox have on the face and other neurotoxins like it in general? And then also, which areas of the face do you usually target? You've gone over a little of it, but I think there are more than I might've ever imagined.

Dr. Gita Fleischman: So there's a couple of different ones we'll go over. So when we look at the face, we divide it up into upper face, mid face, lower face, and the neck. So in the upper face, you have the little frown lines or the 11 that form between the eyebrows and those are made by a muscle called the corrugator supercilii. So we inject that.

Then there's a horizontal furrow that can form between the nose and the eye that can give this sort of fatigued or angry look that's often discordant with reality. Patients say, "I'm rested. I feel fine. I'm happy, but I look like I'm tired." And a lot of times we can target that muscle and that's called the procerus muscle.

And then we can also target the frontalis muscle, which is the muscle that sort of gives horizontal lines on the upper forehead. And that can give a much smoother appearance of the forehead and it really conveys a relaxed, rested and a very youthful appearance.

Going a little bit lower, we can target the bunny lines, which are the lines that are on the sides of the nose that people sometimes when they scrunch up their nose, it makes the nose appear a little bit wider. So we can just relax those muscles even in patients who tend to have a lot of dynamic movement of their face.

And moving over to where the eyes are, we can put tiny injections in the muscle that's right under the eyebrow and to the side of the eye, that's called your orbicularis muscle. And putting just a tiny bit of Botox right under the skin, you can get a brow lift. And a lot of times it's a very subtle brow lift that makes the eyes appear a little bit more open and bigger, makes people look a little bit younger, less tired. And then it also takes away the tiny little crow's feet on the sides of the eye.

And then moving down to the mid face, some people can have really wide or square jaws. This can happen from chronic temporomandibular joint dysfunction, where they're constantly clenching and tightening that jaw and people can get a very square shape to their jaw. We can inject a muscle called the masseter muscle. And it basically reduces the bite force and it smooths out that really square jaw over several weeks and to being more rounded and having less of a masculine appearance in women.

In moving to the lips, some people can have a gummy smile. When they smile, too much of the gums show and the lip goes up too high. So we can target certain muscles above the lip and basically not elevate the lip as much and reduce the gummy smile. Other times we can have patients whose smile is a little downturned. So it gives the appearance that they're always frowning. We can inject certain muscles on the corners of the lips to give a more upturned appearance to the lips.

People don't look as tired and frowny at all times. Some people have dimpled chins. We can inject a tiny bit of product of Botox into the mentalis muscle and get rid of the dimpled chin appearance.

And then finally, we can even inject the neck, the platysmal bands in the neck. With age, sometimes the little muscles in the neck and become very apparent and we can just gently inject along the length of that platysmal muscle to make the neck appear a lot smoother.

Alyne Ellis: And who is the best candidate for Botox?

Dr. Gita Fleischman: There's no age limit, young or old for Botox. Botox works best on what we call dynamic rhytides or dynamic wrinkles. So it's when you furrow or when you frown or when you contract your muscle, it's basically the wrinkles or the lines that form with that frowning. So Botox can soften that.

If someone has very deep resting lines or a lot of volume loss and they have very thick etched line, typically Botox is not the only thing they will need. They may end up needing a laser peel or a chemical peel or fillers in addition to Botox to fix that completely. So neurotoxin Botox alone will not help very deep resting lines or volume loss.

Alyne Ellis: And when should someone start Botox? Is there a particular time you'd recommend?

Dr. Gita Fleischman: There's no particular time to absolutely have to start. We see patients in their early twenties who want it to be more for preventative thing. We can inject some of the hyperactive muscles so that they never get to the point of becoming those deep resting lines. And then we also treat patients as late in life as they want to target certain muscles that bother them.

Alyne Ellis: So you talked to patients about risks and complications, maybe you could go over a little bit of that.

Dr. Gita Fleischman: Of course, in reference to cosmetic Botox, we always talk about a few things that can happen. They don't always happen but are possibilities. Things like bruising, swelling or mild asymmetry in the muscles after injection as possible. The bruising and swelling is typically very temporary and goes away in a few days.

We do have a list of things we tell them such as applying ice, avoiding heavy activity or vigorous activity on the day of the injections, avoid lying down to avoid the swelling and the bruising. Occasionally, you can get mild asymmetry on the left and right side, and that can easily be corrected by just adding a little more product at their two-week visit to correct that asymmetry.

Other things that can happen is something called migration of toxins. So when we inject the muscles sometimes that product or Botox can migrate to a place where we don't want it to migrate. In the eyebrow and forehead region, there's a small likelihood that you could get migration of the toxin into the eyelid area where you can get a droopy eyelid. Now, there's a lot of things we can do to prevent that. And we always watch out for it, but it's something we tell patients that can happen and has happened and have been reported in the literature. So that is one of the low likelihood risks that can happen that they need to be aware of.

Other times people can have headaches, which are temporary, from the toxin being injected, from the product being injected into the forehead, and that typically goes away. You can also have certain changes in appearance. One of the things that can happen is some patients who only get the forehead injected, but don't get the eyebrows injected, they can have a little bit of a Spock look or a quizzical look. In that case, we can have them come back and have a little bit of extra product put on the sides of the eyebrows to avoid that quizzical look. And those are the main complications that we talk to patients about.

Alyne Ellis: And once you do this at whereas often say six months or so, I can assume that you can come back when it starts to wear off and do it again.

Dr. Gita Fleischman: Exactly. Yep. And usually it's about the three to four-month period where we have them come back and get some touch ups.

Alyne Ellis: And how do you make an appointment for a consultation?

Dr. Gita Fleischman: Here at WakeMed, the patients can just call (919) 350-EARS, so E-A-R-S and that's 3277.

Alyne Ellis: Well, thank you, Dr. Fleischman for this reassuring information into how we can look younger without surgery.

Dr. Gita Fleischman: Perfect. Thank you for having me.

Alyne Ellis: Dr. GIta Fleischman is an ear, nose and throat specialist with additional training in facial plastic surgery at WakeMed. To learn more about WakeMed's ENT services and locations, please visit WakeMed.org.

I'm Alyne Ellis with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Stay well.