Not Your Average Dimple

Problem Area: Dimpled and Recessed Chin

Some may never even notice this problem area, but if you are self conscious about your chin to begin with this could be a game changer for you.  It's funny because I never looked at chins as often as I do now thanks to my partner in crime.  My mentors chin obsession (dramatic connotation, I know) started with her own chin and quickly trickled down to anyone in her line of sight.  But you know what...she's spot on that a good chunk of our patients have weak chins.  On top of having a weak chin, meaning a lack of appropriate projection in profile view, we contract the mentalis muscle and make it even weaker...and the skin looks dimpled, bumpy, and unattractive.  This fix is as simple as our last post about the nasalis muscle.  If I'm using filler in the chin to give more projection, I like to also do neurotoxin to keep the muscle activity quiet.  It is not necessary to do both if you find that projection isn't an issue, just skin dimpling.  When consulting with a patient, it's helpful to talk about what that patient's concerns are first and then build on that by giving your opinion and expertise in relation to their problem areas.  I know I'm getting a little ahead of myself, maybe our conversation here was a bit of a tickler.  For the purpose of this post, we are going to talk about treating the muscle contraction that causes the dimpled chin...the mentalis...and no, autocorrect, I'm not trying to type mentalist!

The Fix: Neurotoxin

To treat this we would use a neurotoxin to temporarily weaken the muscle contraction.  Botox or Dysport are good choices for this treatment area.  An average dose for females for the mentalis is 4-8 units of Botox or 10-20 units of Dysport.

The result is not seen immediately.  It takes 2-3 days for the neurotoxin to uptake into the muscle.  The product is completely active at 2 weeks out.  On average, the result lasts for 3-4 months.  I tell my patients to budget for their treatment 3-4 times a year, if they want to keep the results up.  Some patients are able to stretch their appointments out and others have to come in sooner.  Metabolism, skin quality and condition, under-dosing, and overall desired result can have an impact on how often you will have a treatment.

If you've read my other posts, you'd find that the paragraph above is repeated every time I discuss a neurotoxin onset and result.  From personal experience, not only on myself but coworkers that I see or talk to daily, when the mentalis is treated with a neurotoxin it onsets in a unique way.  On myself, I noticed my chin bunched up and contorted in ways I've never seen during the onset process in other facial muscles.  It appeared to uptake on one side quicker than the other, which can happen with a split muscle like the mentalis.  Once I hit the two week mark, things were looking great.  Just a heads up in the event that you experience this and/or you can preemptively talk about this point with your patients.  At first you'll think that you just need to add more product, but give it the full two weeks before you get trigger happy.

Anatomy Lesson: Mentalis

Your mentalis muscles elevates the chin and wrinkles and dimples the attached skin.  It straddles either side of the midline of the chin.  Feel the muscle contract under your fingers during your assessment.  As you saw on the patient photos above, in anterior view the chin is dimpled and looks like she's pouting or about to start sobbing.  The second set of photos with the chin in profile view, her chin looks recessed and weak due to the muscle contraction.

Treatment Pattern: Two Pokes

To successfully treat the mentalis, plan for two pokes from the injection needle.  One poke on either side of the midline of the chin.  Feel for the muscle activity underneath and plan your treatment accordingly.  General rule of thumb with any neurotoxin treatment...you can always add more at a two week follow up visit.

The bunny lines are coming for ya

Problem Area: Bunny Lines

Your bunny lines/nose wrinkles may not be a problem initially, but they may start to gain some strength after treating your frown lines for a while.  Some people have very prominent bunny lines even with a moderate smile and others may not notice these lines until they have a large grin or smile.  Your bunny lines are formed primarily from the nasalis muscle and some recruitment from the levator labii superioris alaeque nasi (LLSAN) muscles.  The LLSAN muscles help lift the upper lip along with the other levator labii muscles, so we should avoid injecting this muscle to avoid a wanky smile.  I find that patients like this area treated if they have a more oily complexion and their make up tends to settle in these creases, or if they treat the glabella and find that it looks unnatural to have a smooth brow and exaggerated movement through the bridge of their nose.  I can't say this would work for everyone, but a patient I follow had her nasalis treated several times over and it helped atrophy or weaken and shrink the muscle to the degree that her nose had a slimmer appearance.  This could be a realistic outcome for anyone that has a bulky nasalis muscle to start.

Example A: patient never treated with a neurotoxin.  Strong glabellar movement and bunny lines.

Example B: patient regularly treated with neurotoxin in the glabellar area and has some recruitment of the nasalis & levator labii, creating bunny lines across the bridge of nose.

The Fix: Neurotoxin

To treat this we would use a neurotoxin to temporarily weaken the muscle contraction.  Botox or Dysport are good choices for this treatment area.  An average dose for females for the nasalis is 4-8 units of Botox or 10-20 units of Dysport.

The result is not seen immediately.  It takes 2-3 days for the neurotoxin to uptake into the muscle.  The product is completely active at 2 weeks out.  On average, the result lasts for 3-4 months.  I tell my patients to budget for their treatment 3-4 times a year, if they want to keep the results up.  Some patients are able to stretch their appointments out and others have to come in sooner.  Metabolism, skin quality and condition, under-dosing, and overall desired result can have an impact on how often you will have a treatment.

Anatomy Lesson: Nasalis

Your nasalis is a horseshoe shaped muscle that wraps over the bridge of your nose.  When you contract this muscle it creates wrinkles on your skin over the lateral and dorsal aspects of the nose bridge.  As illustrated in the example photos above, these lines are apparent on a patient that has never had a glabella neurotoxin treatment and also on a patient that has regular glabella treatments.  I wanted to clarify this to assure you that these wrinkles are not caused by having your glabella treated.  However, they can definitely become more obvious to some once other areas of the face nearby have a smoother complexion.

Treatment Pattern: Two Pokes

To successfully treat the nasalis, plan for two pokes from the injection needle.  One poke on either side of the lateral aspects of the nose.  Remember the levator labii superioris alaque nasi is nearby, so air on the side of caution and treat higher on the bridge.  Feel for the muscle activity underneath and plan your treatment accordingly.  General rule of thumb with any neurotoxin treatment...you can always add more at a two week follow up visit.

Hung Jury

Problem Area: Crow's Feet

I think the jury is out on this problem area.  I have patient's that are religious about their skincare treatments, diligently conditioning their skin to reduce the appearance of fine lines and wrinkles...yet they say "I don't mind having expression lines around my eyes."  I have other patients that only treat the crow's feet area, and it becomes their nemesis.  I don't have an opinion either way...I say treat what bothers you, not what bothers others.  The expression of winking or squinting at the sun condenses the eye area in a sphincter like pattern.  It also pulls the tail of the eyebrow down in some more than others.  We will talk about the anatomy of the orbicularis oculi muscle in a bit, this is the muscle that we are injecting when treating the crow's feet.

 

The Fix: Neurotoxin

To treat this we would use a neurotoxin to temporarily weaken the muscle contraction.  Botox or Dysport are good choices for this treatment area.  An average dose for females for the orbicularis oculi muscle is 12-30 units of Botox or 30-75 units of Dysport.  In the U.S., I would say it's more common for the left crow's feet to have more lines and activity, possibly due to more UV exposure when in the driver seat of the car.  With this being said, I find that I may need more product on the left eye's crow's feet compared to the right.  Dosing above is total treatment for both eyes and is an average of what I use for my patients.

The result is not seen immediately.  It takes 2-3 days for the neurotoxin to uptake into the muscle.  The product is completely active at 2 weeks out.  On average, the result lasts for 3-4 months.  I tell my patients to budget for their treatment 3-4 times a year, if they want to keep the results up.  Some patients are able to stretch their appointments out and others have to come in sooner.  Metabolism, skin quality and condition, under-dosing, and overall desired result can have an impact on how often you will have a treatment.

Anatomy Lesson: Orbicularis Oculi

Your orbicularis oculi muscles are sphincter muscles that wrap around each eye.  The lateral aspects of these muscles are most active, hence why we tend to see lineage in the "crow's feet" area.  When squinting or winking the eye, the skin of the upper and lower eye lids scrunch together and close off the eye opening.  The tail of your eyebrow also pulls down.  This treatment area is great for someone who has an issue with upper eyelid heaviness.  Unfortunately, upper eyelid issues tend to be a bit genetic, so I find that my patients young or seasoned can benefit from this treatment.  Sometimes my patients will comment on a new found creepiness of the medial portion or inner corner of the eye after we treat the crow's feet.  This is because your body is really smart and the untreated portion of the muscle tries to compensate for the lack of activity it has post neurotoxin.  This happens with the nasalis muscle too post glabella treatment.  We are going to cover the nasalis in my next post.  Keep in mind that not all lines around the eyes can be fixed from treating the orbicularis oculi.  Some lines in the lower lateral quadrant are caused from your smile activity.  I will not inject your zygomatic major or minor to keep you from smiling so don't ask...  : )

 

Treatment Pattern: Four to Ten Pokes

Expect four to ten pokes from the injection needle for a crow's feet treatment.  The treatment dose and pattern is identified during animation of the muscle.  If you have a hooded upper eyelid, and you're looking to get some lift from the tail of the brow by treating the orbicularis oculi, you can just treat the upper lateral quadrant of the muscle.  Many times I will treat the glabella and additionally put two units on either side at the tail of the brow superficially to capture the downward pull of the orbicularis oculi.  Your biggest struggle as a treatment provider is helping your patient understand the difference between crow's feet activity and cheek movement.  Have your patient look in the mirror with you...have them wink/squint at the sun...point out the lines that this creates on their skin...then have them squint at the sun and smile at the same time...highlight to them the increased wrinkling of the lower lateral quadrant.  It is still beneficial to treat this area, but remind your patient that you won't be able to calm down all of the activity due to the fact that they will continue to smile and this will form some lines around the eyes.  Orbicularis oculi muscle is thin and the skin around the eyes is thin too, so the injections should be placed superficially to the point where you see a little wheel, bleb, mosquito bite raised surface.  Caution your patients that this is a common area where patients bruise after a neurotoxin treatment.  Even the most skilled injectors are not immune to bruising their patients.  When patients ask me if they will bruise...I simply reply...I am poking you with a needle, so yes it is possible.  I like to think that I have a good track record, but it is always possible to bruise someone, especially in a vascular rich area such as around the eyes.

Agree to Disagree

Problem Area: Forehead Lines

Unfortunately for my patients that hate their horizontal forehead lines, this is one area that I am consistently conservative.   The muscle causing these horizontal lines across your forehead is called the frontalis muscle.  I get it that people don't like thick, deep lines spanning the width of their face.  Let's agree to disagree because I don't think having some expression lines across your forehead is a bad thing.  I will agree to treat this area on a patient if they have the anatomy to support it, which we will discuss here shortly, and if they agree to entertain other avenues of improving skin quality.   This is one area where ya'll want your cake and to eat it too...if you want an overall lift in your eyebrows...treating this area will give you little assistance in lifting the brow.

The Fix: Neurotoxin, Microneedling, Skincare

To treat this we would use a neurotoxin to temporarily weaken the muscle contraction.  Botox or Dysport are good choices for this treatment area.  An average dose for females for the frontalis muscle is 6-10 units of Botox or 15-25 units of Dysport.

The result is not seen immediately.  It takes 2-3 days for the neurotoxin to uptake into the muscle.  The product is completely active at 2 weeks out.  On average, the result lasts for 3-4 months.  I tell my patients to budget for their treatment 3-4 times a year, if they want to keep the results up.  Some patients are able to stretch their appointments out and others have to come in sooner.  Metabolism, skin quality and condition, under-dosing, and overall desired result can have an impact on how often you will have a treatment.

Microneedling, which is a skin care treatment, can dramatically improve fine lines and wrinkles in dynamic areas like the forehead.  Doing this in combination with a good skin care routine at home can help stimulate new collagen formation and buff out the static lines on your forehead.  We will definitely talk about skin care in more depth in another post but always think ABCs and Sunscreen.

Anatomy Lesson: Frontalis

Your frontalis is a wide banded muscle that starts at your brows and goes back up into your hairline.  You have the ability to express portions of the muscle more than others.  This is why you might be able to lift one eyebrow up and not the other.  Your frontalis muscle splits or bifurcates.   For some, this split takes place below the hairline on the forehead, but for others this split takes place further back on your scalp.   This muscle is responsible for lifting or elevating your eyebrows.  Sometimes there is an asymmetry of the eyebrows, meaning one sits lower or higher than the other.  When appropriate, we can help balance this by adding an extra unit or two to the side that sits higher or we can recruit other muscles to help out in lifting.

Treatment Pattern: Two to Five Pokes

To successfully treat the frontalis, plan for two to five pokes from the injection needle.  The treatment dose and pattern is identified during animation of the muscle.  If you have a hooded upper eyelid to start with, I strongly encourage you have a glabella treatment first, let that settle in and then at your two week follow up visit have your frontalis treated.  You will be so excited with the improvement of your upper eyelids that you will appreciate my caution in treating your forehead lines.  The weakened ability to elevate your eyebrows would cancel out the lift that was created from your glabella treatment.  I don't want it to appear that I never treat the frontalis muscle because I certainly do.  If a patient is looking for more of an arch to their eyebrows, I would treat the frontalis medially and leave the lateral aspects of the frontalis alone.  Or if they have stubborn lines laterally, we could treat the lateral points conservatively.  I would much rather be in the position that we need to add a little more product at the two week follow up rather than being aggressive and my patient feel heavy in the brow for the next month.  General rule of thumb for the treatment provider is to aim high and treat lightly.

Turn that frown upside down!

Sorry for the delay...I should have posted this on the 3rd...life gets in the way sometimes!

Problem Area: Glabella

Let's talk about your 11's, your brow furrow, your scowl...this is a negative expression that we definitely don't need to express.  When you frown your brow, a couple of nasty things happen...your skin creases and forms vertical and sometimes horizontal lines, your eyebrows pull down and in and make your eye space look smaller, your upper eyelid hoods over your eye opening, and I'm sure there's more but these are the things that I notice when evaluating a patient.  A glabella treatment is perfect for someone who is looking for a little lift to their eyebrows to help take some weight off of their upper eyelids.

The Fix: Neurotoxin

To treat this we would use a neurotoxin to temporarily weaken the muscle contraction.  Botox or Dysport are good choices for this treatment area.  An average dose for females for the glabella is 20 units of Botox or 50 units of Dysport.

The result is not seen immediately.  It takes 2-3 days for the neurotoxin to uptake into the muscle.  The product is completely active at 2 weeks out.  On average, the result lasts for 3-4 months.  I tell my patients to budget for their treatment 3-4 times a year, if they want to keep the results up.  Some patients are able to stretch their appointments out and others have to come in sooner.  Metabolism, skin quality and condition, under-dosing, and overall desired result can have an impact on how often you will have a treatment.

Anatomy Lesson: Procerus & Corrugators

Your procerus, which is a triangle shaped muscle in the center of your face between your eyebrows, is responsible for the downward pull of the brows.  Your corrugators are above each of your eyebrows and take on the shape of a comma that has fibers that flare up and away from the midline of your face.  They are mainly responsible for pulling your eyebrows inward toward the midline of your face.  Together these muscles pull the brows down and in.  Someone with a really strong procerus muscle can develop a horizontal line across the bridge of their nose.  This might be an indication to the injector to dose this muscle up a bit more.  Sometimes there is an asymmetry of the corrugator muscles and one eyebrow might pull in and down more.  If the vertical line on one side is more prominent than the other, this could be an indication muscle asymmetry.  The treatment provider would take this into consideration and adjust the dosing accordingly.

Treatment Pattern: Five to Six Pokes

To successfully treat the glabella, plan for five to six pokes from the injection needle.  One to two pokes in the procerus and two pokes in each corrugator.  The procerus sometimes requires two injection pokes if the fibers that radiate up are strong.  This can be identified during animation of the muscles.  Initially the procerus pulls down and then in the following seconds the muscle expresses upward causing horizontal lines on the forehead in the midline.  In this case you would stack your injection sites on top of each other in an inferior and superior fashion.  For each corrugator, one poke to the belly of the muscle and one poke to its tail.  The belly is medial and is the bulk of the movement.  The tail is expressed by the dimpling of the skin lateral to the belly, which tends to be superior to mid pupil.

Botox, Dysport, Xeomin...give me the low down on this show down.

Neurotoxins that are currently approved in the U.S. are Botox, Dysport, and Xeomin. Unknowing consumers refer to everything in aesthetics as botox. This is not true...but understanding the basics of neurotoxins is easy. These products are used to temporarily prevent a muscle from contracting. As a result, the skin attached to these muscles relax and you get less lines and wrinkles in your skin.  Common areas to treat (not necessarily all FDA approved) with neurotoxins are your "11's" or frown lines between your eyebrows, horizontal forehead lines, crow's feet around your eyes, bunny lines on the sides of your nose, smoker's lines around the mouth, gummy smile, chin dimpling and chin crease, frowning down turned mouth, stringy neck from strong platysma bands, and one of my favorites...over active hypertrophic masseter muscle from grinding your teeth!

As stated above, the neurotoxins that are currently approved for cosmetic use in the U.S. are Botox, Dysport, and Xeomin. I rarely use Xeomin, only because in my experience and my patients report it does not last as long as its competitors.  Xeomin is referred to as the "Naked" neurotoxin.  It does not have the protective proteins wrapped around the neurotoxin molecule, as do Botox and Dysport.  The naked neurotoxin in theory is better for someone who may be forming a resistance or tolerance to Botox and Dysport, but I have found that the product just breaks down more quickly and I'm left with an unhappy patient who is back to see me sooner than what they would like.

To recap for you, all of these neurotoxin products are used to temporarily prevent a muscle from contracting.  When dosed properly, most people need Botox or Dysport treatments about every 3-4 months. You should budget for your treatment about 3 to 4 times a year. When comparing Botox and Dysport, I think the easiest way for you to understand how they are alike and different is to think of them as Pepsi and Coke. Reps from these companies are probably cringing right now at this simple statement but it's true. They are both brown colas but some people prefer the sweeter taste of Pepsi and others prefer the extra carbonation of Coke.  When introducing Dysport to patients for the first time, I hear a lot of "oh yeah that's the generic one right?"  This is not true.   I can get the same results for patients with both products, so I encourage you to try both and identify which it is that you prefer. The cost to the end user is the same. The unit dosing is different but this is accounted for in the clinicians conversion between the two products and should not reflect in the price you pay. Dysport does have a quicker onset, which may be advantageous for someone needing a last minute pick me up. Both last 3-4 months when dosed properly. Under dosing or under treating an area could result in a shortened duration of the results. On label, meaning FDA approved, areas for Botox include glabella and crows feet. Glabella is the area between your eyebrows. On label for Dysport is currently only Glabella.

Tune in tomorrow for Day 3 of my Aesthetic Advent Calendar...

Educate, Educate, Educate...

I have patient's that I have been seeing for years, some patient's that are completely new to me and to aesthetic treatments all together, and then patient's that aren't new to aesthetics but maybe seeing me for the first time.  One thing is constant among all of these patients...they all need to be educated about aesthetic treatments!  One thing that makes me cringe is when I ask a patient about their aesthetic history, and they tell me they've had filler a handful of times but can't tell me what was used and where.  This is frightening to me that they simply don't remember or worse their treatment provider didn't take the time to explain to them or show them what products they were using in their treatment.  Let's be frank for one second here...if somebody was injecting something into my face, you bet your bum I'm asking what it is, when does it expire, and how many times have you used this product in this area of the face.  Wake up people!  This is your face and not all products are reversible once injected.  I wish I could tell you to rest easy and trust every person that's holding a syringe in their hand but the reality is that you can't and you shouldn't.

To keep it simple, when talking about injectable products you have two categories...dermal fillers and neurotoxins.  Some companies prefer to distinguish their products and set them apart from the others by calling them volumizers or collagen stimulators.  For purposes of keeping it simple, fillers are anything you're using in the dermis or sub-dermis to provide structure and support to an area of volume loss...a space that needs filling.  Neurotoxins, on the other hand, are products injected directly into a muscle to cause a temporary weakening or paralysis to prevent movement of that particular muscle.  For aesthetic purposes, neurotoxins are generally used to keep a facial muscle from moving to prevent lines from forming on the skin above, around, or near this muscle.

The cornerstone to my practice is education...educate myself, educate my patients, and educate other professionals in the field of aesthetics.  We will dive into the different products you have to choose from as a consumer in future posts.  My hope is that I can help educate you and everyone else who is interested in becoming an educated consumer of the aesthetics field.  Until then...ask questions, get answers, and know what your provider is injecting into your face!