Amazingly, despite the drumbeat of negative business news about the economy, record numbers of people are requesting Botox treatments from Maine Laser Skin Care this year, definitely outpacing our previous record pace from last year.  Although I have written extensively about Botox in prior newsletters and blog entries,  several questions come up recently and frequently enough to warrant further attention here.

“How do you (Dr. Burke) decide how much Botox to use?”

As many of you may know, Botox is measured in units as opposed to milligrams which most other medications are measured in.  The amount of Botox units that I recommend depends on the area of the face involved, whether the person has had Botox in that area before, and finally how strong the muscles are in that area.  In general, facial muscles in younger people are stronger.  The muscles are also stronger if Botox has not been used in that area before.

The glabellar area (between the eyebrows and just above the nose) possesses the strongest muscles of the upper face and therefore requires the most Botox, especially for the initial treatment.  I generally start with 20 units spread in 3-5 injections, although some younger and first treatment patients may require up to 30 units in that area.

The forehead area wrinkles are formed by a much weaker and thinner muscle called the frontalis.  In this area, I start with 12 units in 4-6 injections and I generally don’t have to go above 15 units.

The “crow’s feet” areas around the eyes are formed by the orbicularis oculi muscle, which is also a weaker muscle compared to the glabellar area.  It is also a circular muscle and very shallow below the skin close to the eye. I use 12-15 units in 6 injections divided between the two sides.

My philosophy is that in this area of medicine, there is a lot of art involved.  Before the operations, I always have people smile, scowl and squint to show me how their muscles function to form their individual wrinkles or lines and how strong these muscles are.  This gives me a good idea of how much Botox to start off with, especially in this initial evaluation and treatment.

“How do you decide where to inject the Botox?”

When I was initially trained in the use of Botox a number of years ago, I reviewed the anatomy of the facial muscles and learned about the recommended sites of injection.  Since the upper face is the most common site for Botox injection, it is important not to inject Botox too close to the eyes.  In those initial courses, precise measurements are made and marks are made on the face to designate the sites of injection.

As anyone can tell by looking at different people’s faces, everybody’s face is slightly different. Some people have high or narrow foreheads; some have high cheekbones or narrow eyes.  As a doctor, I have to analyze each individual person’s face and decide the best sites for Botox injection.  Just as a surgeon does not mark the abdomen when he/she performs an appendectomy or a hair stylist does not have to measure the length of hair that he/she cuts, I no longer mark the person’s face.  Having injected Botox for over 5 years and having treated over 200 people with Botox in 2008 alone, writing on a person’s face is thankfully no longer necessary for me.

I have found that for each individual person’s face, my adjustment of injection sites and the dosage of Botox creates the best results.  By using this method, my patient satisfaction is very high and most patients want repeat treatments when their previous Botox wears off.

I hope that the information above answers some of your questions.  If you have any other questions concerning this article and any other skin issues, please leave a comment on this blog or call our office directly at (207) 873-2158 or email through our website.

Starting off, I would like to thank Marion Kenyon and the staff of Apollo Day Spa for inviting me to participate in their Open House on February 13.  I performed a number of demonstrations using Botox and Juvederm tissue filler and answered many great questions from the observers present.  In fact, their questions inspired me to fill this week’s newsletter with some basic but pertinent information about fillers and their most recent advancements.

The first soft tissue fillers consisted of bovine collagen, a substance first approved by the FDA back in 1981.  As the name bovine would suggest, this product came from collagen collected from cows after they were slaughtered.  The bovine was then ground up, purified, sterilized, and ultimately injected into people’s skin for correcting scars and filling lines & wrinkles.  Even if the concept of being injected by cow material does not sound bad enough to you in a Frankenstein-like way, there were in fact many other disadvantages.  The results did not last long, and patients needed prior skin testing as allergic reactions at injection sites were common.

Fortunately, there have been tremendous advances in filler biotechnology since the days of injecting cow parts into human skin.  Although no perfect filler exists, hyaluronic acid fillers remain the most reliable on the market.  Most of the fillers produced by various companies are based on this chemical.  Hyaluronic acid (HA) is a naturally occurring chemical that is highly concentrated in connective tissue and collagen.  It is ideal to use because it is chemically the same as human tissue, thereby eliminating the need for skin testing and having virtually no adverse reactions.  I have been using these materials in my practice for five years, and none of my patients have ever had a negative skin reaction.

One of the most important features of HA is that it is hydrophilic, meaning that it attracts and binds water.  As a result of this characteristic, it can intertwine with the body’s own collagen, giving the skin area flexibility while also hydrating the area, thereby adding smoothness and substance to the skin.  With aging and damage to the skin (think sun and smoking), naturally formed HA decreases.  This reduction of HA causes dehydration of the skin and loss of flexibility, finally resulting in wrinkles.

If pure, natural HA is injected under the skin, like collagen, it can be rapidly broken down by the body and removed.  The companies that make the current generation of HA fillers form a more stable molecule by a chemical process called “cross-linking”.  This “cross-linking” makes the chemical resistant to breaking down while retaining its ability to attract water.  The most cross-linked versions of HA are essentially thicker or more concentrated, making them last longer. That is why Perlane and Juvederm UltraPlus, the thickest products currently approved by the FDA, are rated to last at least one full year.

I always truthfully tell my patients who are receiving fillers (and observers) that the lines and wrinkles will look better immediately after the procedure and will improve steadily over the next several weeks.  I have even seen cases where the improvement is noticeable over a period of several hours, demonstrating the fullness progressively over that time.

The whole area of dermal fillers is an exciting field where research is ongoing constantly and I have continued to follow new developments through the medical literature and regular conferences.  I will inform you all as new products come on the market, along with information on which products actually work and which you should not waste your money on.

If you have any questions concerning this post and any other skin issues, please leave a comment, or call our office directly at (207) 873-2158 oremail through our website.

This entry was originally written as an e-newsletter exclusively for our subscribers on May 12, 2008.  The following information has been edited to illiminate dated references, but the main points of the article remain unchanged.  As always, feel free to contact us with any questions, or post any comments (within reason) you may have:

Technology Advancements Part II

I am writing this blog to give you more information that I couldn’t quite fit into my last posting.  While I was at the conference in Orlando, I heard another interesting report from the Lupo Center for Aesthetic and General Dermatology, located in New Orleans.  Researchers from that institute were there discussing their studies on the treatment of severe nasolabial folds.  Nasolabial folds are the lines from your nose to the area down around your mouth that form especially as we all grow older.  Some people call them “parentheses lines” because they form into that semicircular line around your mouth.  
 
During this study, 87 patients were treated with with Juvederm Ultra Plus on one side of the face and collagen on the other, similar to demonstrations on television commercials.  The patients had a mean age of 49 years, and they were evaluated every 4 weeks for about six months using a 0-4 scale (with 4 indicating the most severe lines).  Before treatment, the average folds were rated as 3 in the study group.
 
Over the study period, the collagen-treated folds improved to an average of 2.5 while the Juvederm treated areas improved to an average of 1.3 (which is equivalent to a mild wrinkle).  96% of the Juvederm-treated wrinkles were considered clinically significant improvements, and 81% of the patients maintained the improvement for one year or longer. No serious treatment-related adverse side effects were noted.  This report adds to the growing and accepted evidence that Juvederm provides improvements in treatments from previous available products and also provides durable correction of severe nasolabial folds.
 
I have been using Juvaderm for nasolabial folds and other facial wrinkles since it was approved by the FDA in the past several years.  I too have had excellent results with high patient satisfaction, and this study further confirms my experience with this product.  If you have any questions concerning dermal fillers including Juvaderm, give us a call or send us an e-mail and I would be glad to discuss this information further.
 
In upcoming posts, I will provide you with plenty of information from the national laser meeting that I will share with you in the near future.  Summer is coming if it’s not here already.  And even though I stress that sunblock is necessary for every time of year (including winter), you will especially need it during the summer.  Hence, now is the time to stock up on it while it’s hot, particularly now since our brand of SPF-36 replenishing sunblock is on sale.

Thanks again for reading this, and for your consistent support!  You’ll be hearing from me again soon.