Botulinum Toxin

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img_0625-e1425455248933Botulinum Toxin can make a person look years younger and has gained wide spread acceptance over the last two decades. It is a very safe procedure and in the hands of a skilled practitioner can make a dramatic difference to one’s appearance. A lot of patients I see typically have the same set of questions and I have addressed them here to enable you to gain a better understanding of the procedure.

What is Botox and how does it work?

Botox is a brand name for Botulinum Toxin. This is a substance that works by paralyzing muscles at the nerve-muscle junction and when used appropriately can produce a marked change in dynamic facial wrinkles. This leads to the face appearing many years younger, more relaxed and calm.

Is it safe?

Yes. When done by a trained professional Botox has virtually no side effects.

How long does it last?

On an average effects of Botox last for 4-6 months. On repeated injections the effects can start lasting longer.

Is there a limit to the number of Botox injections I can take during my lifetime?

No. Botox is safe for however long one may choose to use it. Some patients can develop antibodies to Botox in their blood and in these group of patients Botox stops working as well but in the vast majority this is not a problem.

How long does the procedure take?

A typical session of treating the upper face takes about 20 minutes from preparing the injections to doing the procedure itself.

Does it hurt?

Yes, a little. Many patients who take Botox regularly choose to do so without any anaesthesia since it saves them time and the pain is minor and very bearable. For new patients however I always recommend applying a numbing cream 1-2 hours prior to the procedure since this makes the procedure painless.

Are there any precautions after the procedure?

Yes. One should not lie down for 4-6 hours after the procedure and using the muscles injected during the procedure is encouraged. It is also advisable to avoid heavy weight lifting, facial massage and steam for 7 days after the procedure.

Are results visible immediately?

No. Results start appearing from the 3rd day onwards and peak at about 14 days.

Are there some people who should not take Botox?

Yes. People with certain neuromuscular diseases (e.g Myasthenia Gravis), pregnant or lactating women and hypertensive patients are not ideal candidates for Botox. Additionally patients on certain drugs should avoid Botox (blood thinners, aminoglycosides, calcium channel blockers, quinine, penicilllamine).


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img_0625-e1425455248933So what exactly are fillers and how can they improve one’s appearance?

To understand this one must understand a little bit about how the face ages. Aging is a complex process involving both internal and external factors. External aging occurs due to environmental stressors like UV radiation and pollution while internal aging occurs on account of the internal programming that each cell of the body has. These lead to the breakdown of structural proteins in the skin, of which the most important is collagen. The same factors also lead to the depletion of something known as hyaluronic acid (HA) from the skin.  HA belongs to a class of skin proteins called mucopolysaccharides or glycosaminoglycans and it is these proteins that fill in the deeper layers of the skin producing healthy firm skin structure. Think of these as gels that insert between the structural proteins of the skin (viz. collagen) and thereby support the skin. Facial fat, unlike fat in other parts of the body, is organized into well defined fat pads that are strategically located to produce outward facial appearance. Now when the supporting structures of the skin deplete  with age (called volume loss), this leads to the sagging of these fat pads under the effect of gravity, and this produces problems like lines along the sides of the nose (nasolabial lines) and mouth (mentolabial lines), hollowing of the mid face producing grooves under the eye as well as dark circles, and excess skin hanging over the sides of the jawbone (jowls).

Anything which is injected into the skin to correct this volume loss is called a Filler, or more appropriately, a Dermal Filler. In the past this included temporary fillers like collagen (e.g zyplast, zyderm) as well as permanent fillers like silicone. These days the most popular fillers are those containing Hyaluronic Acid (HA). As we saw earlier, this is a key structural support and volumizing agent in the skin. Popular brands include Restylane, Perlane, Juvederm and Fortalis. All of these contain the same molecule (HA) but in differing concentration and viscosity (thickness). Thicker fillers last longer and need to be injected deeper, producing volume correction, while thin fillers are injected more superficially and can smoothen out superficial wrinkles. They each have their role and can even be combined if required. There are other fillers like Radiesse (a calcium salt), Sculptra (poly-L-Lactate) and Aquamid (polyacrylamide) and they can all give great results when used appropriately but the one advantage that HA fillers have that others don’t, is reversibility. What this means is that given the unlikely situation of you not liking your look after the filler, it can be dissolved and removed in a matter of days restoring your previous appearance. This is done with an enzyme called Hyaluronidase. The availability of this enzyme makes HA fillers the safest fillers on the market and enable doctors to tailor results to just how the patient likes it.

So, do you need filler?

Well that can only really be assessed through an in-person consult but here are some broad guidelines. Fillers can be used to enhance or correct. For the former usually a small amount of filler is sufficient – something like Juvederm Ultra/Ultra Plus or Restylane can be injected into strategic points in the face to enhance a person’s appearance. Indications include augmenting the cheekbone, defining and shaping the lips, correcting nose droop and filling in temple hollows. For these indications even a little filler can produce amazing results. For correcting signs of skin aging more filler is required and this is injected deeper to both fill depleted areas as well as act as a scaffold for correcting structural changes that have happened with age (e.g lifting the jowels, filling in lines along the nose and/or mouth). Juvederm Voluma, Perlane and Modalis are fillers that do a great job at this.

How long do fillers last?

The perennial question. The answer to this is that there is no one time frame that will work for everyone because how fast a filler is used up depends on factors like how mobile that part of the face is, what other procedures the patient got done after filler, how much filler was injected relative to patient need and how fast the person’s body breaks down the filler material. That said thinner fillers (e.g Juvederm Ultra, Restylane) usually last about a year while thicker fillers (e.g Juvederm Voluma) last two years or more.

Are there any side effects?

The newer HA based fillers are very safe and have virtually eliminated problems which sometimes occurred with older fillers like allergic reactions, bumpiness and skin nodule formation. So apart from occasional, temporary, bruising (lasting 7-10 days or less) the procedure carries no real risk. There have been rare cases reported in the literature in which inadvertent injection of filler material into a blood vessel produced skin necrosis, however this is not a real problem for the common areas that are injected and even in the cases reported patients recovered with adequate management.

What if I don’t repeat a filler again after this one wears off, will my face become worse than before?

No it will not. You will just lose the benefits of the filler and your face will gradually go back to how it used to be. Repeated filler injection can also stimulate collagen synthesis, according to new data which is emerging, and in patients who have taken fillers for 5 years or more there may be long term benefits of this collagen even if they stop taking fillers.

How long does the procedure take, and is it painful?

Patient’s may complain of some discomfort during the procedure but this can be minimized by injecting very slowly and applying a numbing cream on the area to be treated for 30-60 minutes before the procedure. Alternatively fillers with built in anaesthetic (e.g Juvederm Ultra XC, Restylane-L) can be used to make the procedure painless. The procedure typically takes between 30-60 minutes. There may be mild redness and swelling for a few hours thereafter but you can go right back to work the next day.

Will the filler make my face look artificial?

This is where the skill of the person injecting the filler comes into the picture. A good injector will produce results that are completely natural and apart from compliments about how good you look, no one will notice that you had something done. A novice injector will not produce the same results and hence it is well worth the time spent researching your doctor before taking the plunge.

What is the difference between Botox and Fillers?

Botox is a protein that works by temporarily paralysing or relaxing some muscle groups while fillers have no such action and work by producing a volumizing effect. Botox cannot do what fillers do and vice versa. Broadly speaking Botox has more of a role in treating the upper face (above the eyes) while fillers have more of a role in the mid and lower face (below the eyes). For this reason they are often used together to enhance both parts of the face simultaneously. Fillers give immediate results while Botox takes about 7-10 days.

Chemical Peels

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img_0625-e1425455248933Chemical Peels are seeing a resurgence in use. Popular since the 1960’s and 70’s they took a backseat for a while with all the innovation in the laser and light industry but they are now making a comeback, due in large part to their safety and the large variety of peels available to treat all skin types. The word chemical peel brings to mind images of a horrid chemical being applied on the skin to produce benefit by peeling off the top layer through burning. Historically speaking this was true, but now with the array of peels available to a dermatologist the procedure can be tailored to a patients specific needs, and many peels have virtually no down time – patients come in for peels in their lunch breaks and go right back to work after.

So lets get into it. Peels are of three types – superficial, medium and deep. These terms reflect how deep the peel penetrates into the skin. The skin has two layers that are of importance to us to understand peels – the epidermis and dermis. The epidermis is the thin superficial layer of the skin while the dermis is the thicker deeper layer. Think of it like a potato – the epidermis is analogous to the potato skin and the dermis to the inner bulk. As explained in my post on dermal fillers that bulk is made up of structural proteins like collagen and elastin and ground substance consisting of proteins known as mucopolysaccharides.

The outermost layer of the skin, the Stratum Corneum, has an important bearing on how the skin looks. If the cells in this layer are more in number than normal or are disorganized, the skin will look rough, scaly or dull. Cells below this layer contain skin pigment scattered through them and the average turn over time of these cells is about a month. Pigment is produced by the basal layer of the skin and rises up through other cells of the skin as they move towards the surface ultimately dying and becoming cells of the Stratum Corneum.

The principal of ‘controlled damage’.

So how do we get the skin to turn back the clock and look younger? Is there a way to get it to make more structural proteins since these are lost with age and are the main cause of problems like skin wrinkling, enlarged pores and skin sagging, and if so what? This is where the principal of controlled damage comes into the picture. The trick is to make the skin believe it has been injured. This makes it put into place skin healing mechanisms normally recruited in recovery from injuries, like when a cut is healing for example. Principally this involves increased cell turnover and the production of  new collagen, the all important dermal component. Luckily its easy to trick the skin and it doesn’t take much to make it turn on the repair mechanism.

A peel helps in two ways – a) it breaks the bonds between the cells of the Stratum Corneum thereby making them easier to shed, and b) it increases cell turnover by encouraging the production of new skin cells; these cells are less pigmented and better organized than the older cells and as long as they are protected from UV light with regular sunscreen use they will remain lesser pigmented thereby causing skin lightening. At higher concentrations peels also stimulate collagen formation.

So what does a peeling session entail?

A typical session takes just 10-15 minutes and consists of cleaning the skin followed by application of the peeling agent. There are various types of peels and the two most basic ones are glycolic acid peels and salicylic acid peels; the former being better for skin pigmentation and the latter for acne. The peeling agent is then left on for about 5 minutes (this will vary depending on your skin sensitivity and the number of peels you have had), and then neutralized with either water or a sodium bicarbonate solution (the salicylic peel is self-neutralizing and just needs to be wiped off). This is followed by the application of a skin recovery agent, typically a soothing cream, followed by a sunscreen.

Can I get a peel on my first visit to a doctor?

Yes you can but I prefer to prime the skin for about 14 days before starting peeling since this maximizes benefit. Also your doctor may want to do a test peel and wait 7 days before performing a full face peel. A test peel involves the application of a small amount of peel to the area behind the ear and is done to check for any sensitivity or allergy to the peeling agent. This is essential with TCA peels.

How many peels does it take to see a difference?

This varies from patient to patient and the indication being treated, but expect to see visible improvement by the 3rd or 4th peel. Typically 4-6 peels are done at regular intervals of 10-14 days followed by maintenance peels every 4-6 weeks for a few months. I encourage my patients to think of peels as a lifestyle modification and not so much a treatment course.

I have heard that peels cause thinning of the skin, is this true?

No, quite the contrary. Regular peels cause an increase in the overall thickness of the living part of the epidermis and a decrease in thickness of the dead cells of the stratum corneum. Both of these are good things and overall the skin thickness is increased.

What skin problems can peeling help?

Peeling can help a number of problems – active acne, post-acne pigmentation and erythema, blackheads, open pores, fine lines, uneven skin tone, freckles, melasma, other superficial skin pigmentation, dark circles, and dull skin.

Can peeling help scarring?

I see quite a lot of patients who have read or heard that chemical peeling can help scarring, particularly acne scarring. It is true that certain deep peels (as were popular in the west for caucasian skin) can markedly improve acne scars, however these peels actually burn the skin and have a significant down time (4-6 weeks). These peels are not safe in darker skin types and are therefore almost never done in India and other Asian countries. Even for white skin these peels have been replaced by laser and other treatments due to more consistent results and less downtime. On occasion very superficial acne scars might improve but this is often because of the scars become lighter on account of the peels. So to answer the question – No, the most commonly used peels today have no significant benefit on acne scarring.

Are there any peels I can do at home?

Yes there are a few peels made for home use. These are typically low power peels with limited benefit and are best used as maintenance after 4-6 sessions of traditional peeling with your doctor. Home peels are available as lotions, soaked pads and masks. Glycolic acid is also available as leave on creams or gels which can be left on overnight.

Skin Rejuvenation

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img_0625-e1425455248933Your skin is exposed to a lot of irritants in modern city life. Pollution, UV light exposure, stress and hectic life styles all take a toll on your skin. Over time these lead to problems like premature aging, pigmentation, open pores, wrinkles and uneven skin stone. Other problems like excessive oiliness of skin, though determined by your skin type and hormonal drive for the most part, can also be made worse by these factors.

So what can be done to prevent these unwanted skin changes? I will detail a basic skin regimen in another post but here I would like to talk about skin rejuvenation. Skin rejuvenation consists of various methods to remove old dead cells from the skin, encourage newer skin to rise to the surface and keep this younger skin better hydrated and as best protected from external irritants as possible.

Amongst the simplest things which can be done for the skin is a once a month facial. This consists of cleansing the skin and removal of any blackheads, followed by something to stimulate facial blood flow like a massage and finished off with a pack of some kind. A pack can have ingredients varying from simple clay masks to fruit concentrates like papaya to cooling mint masks to more expensive masks with sea weed extracts and antioxidants. This is mostly done by aestheticians and will not be discussed in more detail here.

As dermatologists we have access to more advanced techniques for skin rejuvenation. Amongst the most basic of these is a Lactic Acid peel. This is a peel derived from sour milk and Lactic Acid, the active ingredient, has a two pronged effect. Firstly it removes the outer dead layer of cells (called the stratum corneum) by loosening attachment to the lower living layer of the skin and secondly it enables the skin to retain moisture better. Lactic acid is in fact used in many moisturizers, and apparently was even used by Cleopatra to maintain her ethereal beauty in the form of sour milk applied to the skin. Lactic acid peels are safe for even sensitive skin, and unlike a lot of other peels, can be used around the eyes to lighten dark circles.

Microdermabrasion is another tool in a dermatologist’s armament. Microdermabrasion is a technique where a physical method is used to remove the outer damaged skin. Most commonly this is a stream of aluminum oxide crystals which hit the skin at pressure and are then sucked back away from the skin by a vacuum pump. A disc with diamond particles can also be used and this called Diamond Microdermabrasion. When you use an exfoliating scrub at home you are in fact performing a mini-microdermabrasion! Microdermabrasion is a painless procedure and usually takes less than half an hour. The face may be slightly red for 15-30 minutes after the procedure but then goes right back to normal. Microdermabrasion can smooth away superficial skin irregularity and even help mild pigmentation. Done fortnightly for 4-6 visits and then once a month, it is an excellent way to keep your skin looking the best it can be.

Mesotherapy is another skin rejuvenation technique. A needle is used to place a beneficial molecule directly into the skin. The topic warrants a post of its own and I will do one in the future but I will briefly cover how it can be used for skin rejuvenation here. Mesotherapy can be done by a variety of techniques (e.g point by point, nappage) and for skin rejuvenation a very superficial injection technique called Nappage is used. Here the mesotherapy solution is injected into the most superficial layer of the skin and components like hyaluronic acid and vitamin C help make the skin better hydrated and lighter and both these changes enable the skin to reflect light better, thereby giving it a certain glow. For this reason Mesotherapy is a popular pre-party technique. Benefits last a few weeks but can be maintained with regular touch ups.

Coming to other injectable products for skin rejuvenation. There are two that I use and would like to talk about. The first is IAL. This is a non-cross linked hyaluronic acid product and comes in two flavours – IAL system and IAL ACP. A typical regimen consists of one session of IAL system followed by two sessions of IAL ACP at 2 and 6 week intervals. The thin gel is injected into the most superficial layer of the skin resulting in the raising of small blebs at half inch intervals. These blebs flatten in a few hours and the product absorbs water over the next few days; hyaluronic acid is a unique product in that one molecule of hyaluronic acid can hold 1000 times its weight of water. The increased water content of the skin results in a smoother skin surface and consequently improved cosmesis. The second product is Restylane Vital. This is injected similarly but is given deeper in the skin. No blebs are raised, except maybe on the forehead. Again the product is hyaluronic acid. IAL can be thought as working from the top down while Restylane Vital works from the bottom up. Vital sessions are given once a month for 3 months and then maintenance sessions can be scheduled once or twice a year as desired. Treatment is not limited to just the face, areas like the neck and the back of the hands can be treated as well, with excellent results.

So to summarize there are a lot of options available for someone who wants to begin taking care of their skin, from the humble facial to sophisticated injectables. Of course along with whatever one chooses a good skin care regimen is a must. A post on this to follow.