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How Do I Get Rid Of These Wrinkles?

(Including A Discussion of Botox and Fillers)

Are all wrinkles the same?
I like to categorize wrinkles into two general types. There are static wrinkles and there are dynamic wrinkles. Static wrinkles are present with your facial muscles at rest. That is, you are not smiling, talking or eating. Static wrinkles are present all the time (Figure 19). Dynamic wrinkles, on the other hand, are present when the facial muscles are active. Examples of dynamic wrinkles include worsening of crow’s feet when smiling or forehead lines with eyebrow movement (Figure 20). This distinction needs to be clearly understood because treatment depends on the type of wrinkle. Both types are frequently addressed in an overall treatment plan.

Why do wrinkles form?
I believe that the stimulus for wrinkle formation begins as soon as our facial muscles begin to work. Why they don’t become noticeable for decades has to do with a number of factors. As we begin to age, the deeper skin tissue called collagen begins to disappear. This allows the skin to lose its’ shape and thin out. The ability of the skin to keep its’ fullness and elasticity diminishes. Coupled with the constant contraction of the facial muscles, creases begin to form. These eventually become wrinkles.
I believe that part of a person’s ability to retain a youthful appearance has to do with heredity, their genes. However, I am also a firm believer that this can be modified in many ways. The single most important external factor prematurely aging the skin is sun exposure. It is often stated that 80% of your total lifetime sun exposure occurs before the age of 30, yet the effects are not seen until decades later. Unfortunately, it is very difficult to convey to young people the dangers of sun exposure in later life. I recommend to all my patients that they use sunscreens all year long with a block protection of at least 20. For women this should be easy to do because most facial moisturizers now contain sunblocks. These products are used everyday by most women. For men, this becomes more difficult. I personally use a moisturizing sunblock on my face all year long. I never sunbathe and I avoid prolonged sun exposure (even on the golf course!).
In addition, I believe that proper nutrition combined with a good exercise regimen can only enhance the anti-aging factors of the skin. Regular exercise increases blood flow to the skin, which clears out harmful chemicals that predispose to aging. Drinking plenty of water adds to the firmness of the skin. There is some evidence to believe that sleep patterns might contribute to premature wrinkling. There may be some theoretical advantage to sleeping on your back if you are comfortable doing this. I personally am not. I also recommend a daily vitamin with antioxidants. There is evidence to suggest that antioxidants are beneficial to general eye health as well.

What treatments are available?
The most important treatment is to minimize those factors that can accelerate aging of the skin. We discussed these in the previous question. For those patients that do desire treatment for their wrinkles, the first determination needs to made about what type of wrinkles are present—static or dynamic. Usually it is a combination of both.

Altering the skin surface usually treats static wrinkles. The techniques vary by modality used and the depth of penetration into the skin. These include:
1.Dermabrasion: an abrasive instrument is used to smooth the surface of the skin. This technique causes the most bleeding and is the least predictive.
2.Chemical peels: with this technique chemicals are used to remove the “bad” skin and new skin will replace it. Usually this new skin is of a better quality than the skin being removed. The strength of the chemical will determine the depth of penetration into the skin. These treatments are very effective.
3.Laser ablations: laser resurfacing was introduced about ten years ago. The CO2/Erbium laser is still the gold standard. However, the difficulty with CO2/Erbium laser resurfacing is the prolonged healing and downtime. This has led to a decrease in its use. Newer types of lasers called non-ablative lasers are being used. The problem that I see with these lasers is they are less effective than the CO2/Erbium laser. Results are not as impressive. The one big advantage is the significantly reduced downtime.
4.Fillers: fillers are substances that are injected under the surface of the skin. They are usually used as adjuvant treatment for persistent deeper furrows. We will talk more about this in the subsequent sections.

The best treatment for dynamic lines and wrinkles is botulinum toxin (Botox). Wrinkles usually result from muscle contraction and the aging changes of the skin.

My experience with most patients is that they have varying forms of both static and dynamic wrinkles. Usually treatment will consist of some combination of an ablative procedure (i.e. laser resurfacing, chemical peel), fillers and botulinun toxin. As mentioned above, non-ablative skin rejuvenation procedures have recently become popular because of decreased downtime allowing for a more rapid return to normal activities. Let’s explore these in more detail.

Botulinum toxin (Botox) has been approved by the FDA for crossed eyes and eyelid spasms since 1989. It had been used investigationally since the early 1980’s for these conditions. In 2002, botox was approved by the FDA for wrinkles between the eyebrows (glabella). Off label uses are commonly used for other wrinkles and frown lines (i.e. crows’ feet and lip lines). Botox blocks the ability of muscles to contract by blocking the release of a chemical necessary for contraction. With less movement, the skin gradually begins to smooth out. Sometimes an anesthetic cream can be used on the skin 30 minutes to one hour before treatment. In my experience, I rarely use any anesthetic in most patients. Ice packs frequently work nicely to help with any discomfort from the injections. The effect is usually seen in 2-3 weeks but can occur in the first week after treatment. The effect is temporary, lasting anywhere from 3-6 months. A number of different types of botulinum toxins are produced commercially, type A (Botox and Dysport) and type B (Myobloc).
Included in Table 1 is my consent form that discusses botox treatment and possible side effects.

Botox treatment involves making a number of injections with a very tiny needle to relax the desired muscles. The treatment is quick and minimally invasive. Patients return back to their
regular routine immediately. Most of my patients do not complain of significant discomfort. I still believe the expressions of the face should be maintained. I believe the results should be subtle with a refreshed look.

Dermal fillers have recently undergone resurgence in interest and usage. Fillers allow facial features to achieve more fullness. Fullness defines a more youthful look. Fillers restore volume to the skin and allow for the correction of moderate to severe facial wrinkles and folds. One such fold, the nasolabial fold of the lower face is probably the most common area treated with fillers.
Dermal fillers can be classified into two broad categories:
Degradable (effects lessen with time)
1. Collagen ( usually last less than 3 months)
a.bovine: these include zyderm and zyplast
c.bioengineered human: more recently approved cosmoderm and cosmoplast

2. Hyaluronic Acid: Hyaluronic acid is a naturally occurring substance in the body-often referred to as “sugar gel”. The most popular hyaluronic acids are restylane, perlane( a thicker restylane) and hylaform. Hylaform is avian derived whereas restylane and perlane are non animal derived. Hylaform tends to last about three months whereas restylane tends to last four to six months. The hyaluronic acid fillers have been associated with minimal allergic reactions. They absorb water and hence last longer than collagen fillers.
3.Autologous Fat: this is fat taken from one part of your own body to be used as a filler. This is probably the safest, but the effects are variable.

Let’s talk in more detail about restylane. Because restylane is a non-animal based product, the risks of animal-based disease transmission or allergic reactions are minimal. Unlike collagen (except for cosmoderm and cosmoplast), restylane requires no pre-allergy testing. As with any invasive procedure, any medications that can increase bleeding (such as aspirin and Vitamin E) should be stopped before the injections. Usually bruising, redness, and swelling occur after the treatment. This will resolve within the first week. Restylane has been primarily used on the lower face. Recently, however, treatments for lower eyelids and brow are being investigated with encouraging results. Based on these early results, I feel that eyelid and brow uses for restylane will continue to expand.

Non-Biodegradable Synthetic fillers that are currently available in the United States can be classified as injectables (Artecoll and Silicone) and implants (GORE-TEX and Ultrasoft). These fillers tend to be used for longer-term correction of skin and soft tissue defects. They tend to be associated with more problems. I have very little experience with these non-biodegradable synthetic fillers.

It must be remembered that the use of dermal fillers is really an art- like sculpting. Everyone needs to be individualized and touch-ups may be necessary.

Copyright © 2009 Atlantic Eye Physicians