Think about the first image that crosses your mind when you hear the word Botox or facial filler. It is likely one of a plastic, frozen faced woman with evidence of one too many facial plastic surgery procedures, unnatural facial proportions, oversized lips and unnaturally tight skin.  These are the extremes that websites and the media have convinced us are common place.  For this reason, many of my patients are hesitant or scared about using these products as they don’t want that unnatural look.  But they are still in my office asking about what can be done.  So where is the happy medium?  Reverse aging changes in a way that doesn’t appear artificial.  Herein lies the art of facial plastic surgery.  Artfully using these medications can yield great improvements in facial appearance.  Misuse or overuse can do the opposite at great cost to you.

The key to Botox/Dysport is putting the right amount in the right place.  That seems intuitive, but results can vary greatly by the technique used and experience of the injector.  Botox is popular because it works and most people who are happy with their Botox treatment get a nice flattening of the lines between the brows, on the forehead and in the crow’s feet.  When improperly placed, brows drop or have a “Spock” appearance, lower eyelids can sag, and the face may look too inanimate to be real.  To get a natural effect, first start with an experienced injector, one that will study your facial expression and target the problem muscles, rather than just injecting in a standard pattern.  Then, expect to be invited back after the first week to ensure the proper result was attained.  Sometimes, I feel I’ve given my patients enough to relax the forehead evenly, but after a week I need to add a few more units to the outer forehead muscles.  This allows me to better map out the face and subsequent injections will be on target.  Where a few get into trouble is wanting to eliminate every facial wrinkle with Botox and convincing someone to inject them.  Your face needs expression, which is an underappreciated part of facial beauty.  An appropriate dose of Botox will allow for this movement and still soften the telltale signs of aging.  If your doctor takes his/her time and follows up, your results should end up exceeding your expectations.

In like fashion, the key to good filler is the right filler, in the right amount, in the right place.  Again, that seems intuitive, but many people get into trouble when they want either the wrong type of filler or too much filler placed.  An experienced injector will have a preference for certain brands and types of fillers in different areas of the face.  This is usually based on their experience and results. It is in your best interest to let the injector direct you on what filler they want to use.  If you have a strong preference, seek out a person who specifically advertises using that brand.  With regard to the amount of filler placed, many people think more is better.  This is where the unnatural appearance is most likely to enter the picture.  Overinflated lips, cheeks and tear troughs are dead giveaways that work has been done.  My advice is start slow and add as necessary. Fillers all come by the vial.  An injector can inject part or all of the vial and save the rest for a few days until the initial swelling has resolved.  This allows a metered approach and can give you a maximum improvement without overdoing it.  The flip side to this comes when patients expect a maximum improvement at a minimal cost.  Often two to three (or more) vials are necessary to get a significant improvement, especially in the smile lines and cheeks.  With one vial retailing for around $500-600, many people aren’t willing to spend that much on a non-permanent procedure.  This is where you need to have a frank discussion with your injector about what result you can expect and whether you’d be better off saving for a surgical procedure or maximizing other less invasive treatments.  Having appropriate expectations is key to your satisfaction.


Facial aging takes a toll on our lower face as skin thins, fat atrophies and descends, and wrinkles form. Three common problems people come in for are deep nasolabial folds (the crease from your nose to the edge of your mouth), vertical lip lines (sometimes called smoker’s lines, but not exclusive to smokers), and small or fading lips. All of these changes are tell-tale signs of aging, but there are products available that do a great job of reducing their appearance. Let’s look at each one.

Nasolabial folds:

nasolabial folds

Nasolabial folds (arrow)

These folds are present in everyone who ever smiled, but as your facial skin becomes less elastic and facial fat shrinks away, the cheeks descend and form permanent nasolabial folds. These can be accentuated by significant weight loss, sleeping on your side, and skin damage due to tanning. Preventing them is ideal, but aside from using sunscreen, which won’t guarantee they’ll stay away, you can’t do much to avoid them. There are three main ways they are treated. 1) facial fillers such as Juvederm, Restylane and Radiesse are used to fill in the lines, restoring some of the lost volume. These can be injected both directly beneath the crease, but also into the cheeks above creating some minor lifting. In both instances, dramatic reduction of the lines can result. With most of these products, some improvement from baseline can be seen for about a year (more or less varying by individual). There are some risks, such as rare severe reactions to the fillers as well as over-placement of product. Restylane and Juvederm can be dissolved in place with a second injection, but Radiesse has to be expressed or surgically removed. All will fade with time if left in place.

Radiesse to the nasolabial folds

Nasolabial folds and mental crease (chin line) treated with Radiesse.

Vertical lip lines:

vertical lip lines

Vertical lip lines

Loss of fat around the mouth along with facial movements can lead to formation of vertical lip lines. Many people find these objectionable because they are associated with smoking and they make the person appear tired or unhappy.  Other than using sunscreen and not using your lips, you can’t do much to avoid them.  Four different treatments are commonly utilized.  Botox can be injected in small amount in several places along the lips to relax the muscles causing the lines.  This can, however, cause your mouth to move differently and look irregular when you smile.  Fillers, most commonly the hyaluronic acid varieties such as Juvederm and Restylane, can be injected in various patterns to soften the lines’ appearance.  Some people also inject collagen, but this tends to last for a much shorter time. Laser skin resurfacing has also been shown to improve the appearance of these lines.  Finally, dermabrasion, which is essentially sanding down the skin to remove the wrinkle, can be done.  I prefer the injectable fillers as they are not permanent, can be reversed if too heavy handed, are very unlikely to cause inadvertent scarring, and won’t generally affect your mouth movements.


Fading (flat) lips:

Progressive addition of Juvederm to the lips

Thin lips with progressive addition of Juvederm for volume

Lip fullness can be something you lose with time, or something you just never had. The ideal proportion of the female lips are about 40/60, or if you look straight at the total height of the upper and lower lips closed, the upper lip should be 40% and the lower lip 60% of the height. Most commonly, the upper lip is more flat or rolls in and under as we age, making it appear thin. To regain that ideal shape, you must replace volume. Similar to above, dermal fillers work very well for this. They are injected along the vermillion border (junction of normal skin and pink lip skin) near the central portion of the lip, as well as within the body of the pink tissue of the lip. The outer edges near the corners of the mouth are avoided to prevent that fish mouth appearance. Maintaining the proper proportions and being conservative with volume changes will make the lips appear full and youthful, not inflated.

Call our office at (801)264-4420 for a consultation to discuss dermal fillers and your options.

I came across this video segment from ABC news about men and facial plastic surgery.  Botox use and eyelid surgeries among men are becoming increasingly popular.  I’ve seen and operated on quite a few men the past few months, many of whom were told by their wives that it was time to address their drooping eyelids. Check out the video below.

We now have 2 good products on the market for smoothing out dynamic wrinkles: Botox and Dysport. Both are forms of botulinum toxin, a potent chemical that blocks signals at the junction between nerves and muscles. Botox (onabotulinum A), has been around for about 30 years and was initially developed to treat disorders of muscle spasm, such as frequent uncontrolled blinking (blepharospasm). Doctors noted that their patients who received Botox around the eyes had decreased wrinkles, an unexpected benefit of the treatment. An enterprising pharmaceutical company, Allergan, sought a cosmetic indication from the FDA. Botox Cosmetic was introduced to the market, approved for treatment of glabellar wrinkles (those vertical lines between your eyebrows). As is often the case, doctors experimented with injecting Botox in many areas of the face and today it is administered all around the eyes, face and lips.

In 2009, a second product came on the market called Dysport (abobotulinum A), which is very similar chemically to Botox. Many doctors have now gained experience with both medications, but which one is better? Patients who have tried both often prefer one over the other stating that one has a faster onset or lasts longer. A double blind randomized trial (the gold standard for research) was conducted in which patients were injected at the crow’s feet on one side of their face with Botox and the other side with Dysport. They were photographed at the time of injection and at 30 days after. They were also asked to rate which side they liked better. Among the 90 patients studied, they rated Dysport better 2/3 of the time and the researchers also rated Dysport as better for smoothing crow’s feet than Botox. The difference was mainly noted when patients were smiling very vigorously. At rest no difference was noted. In other studies, the risks and side effect profiles were equivalent.

In my experience, Botox and Dysport both work well.  Patients who have used both comment that Dysport seems to have a quicker onset (1-3 days vs. 3-7 days), but that hasn’t been universal.  Dysport can be slightly cheaper as the company that distributes it in the US often offers rebates to the patients. If you have been using Botox and it is working well for you, I’d continue with it.  Occasionally people develop a tolerance to one drug and then you could switch over to the other and likely still get good results again. If you have never tried either, the choice is yours. They both work well and are safe.

If you are interested in trying Botox or Dysport, call our office for a consultation at 801-264-4420.