There are multiple options for the treatment of wrinkles, which involve in office procedures with minimal down time. These procedures include Botox injections, wrinkles fillers, chemical peels and various laser treatments. When talking to patients about facial aging, I feel it is most important for patients to be on a good skin care regimen. One of the most important things a patient can do to decrease early signs of aging or prevent these early signs, is to take good care of their skin and to use a topical vitamin A product, such as retin-A, renova, avage or tazorac. These products increase cell turnover, clear acne, and reduce fine lines. Vitamin A products are the only available skin care products, which have scientific evidence of decreasing wrinkle formation, and are therefore the most important part of a skin care regimen. We will also recommend using a hydroquinine product if the patient has problems with uneven pigmentation of their skin. Antioxidants such as vitamin C have most recently shown promise in helping fight the aging process.
Botox is a purified form of Botulinum toxin which bonds to the muscles where it is injected, eliminated their function. It is used most commonly in the corrugated muscles, between the eyebrows which cause the frown lines. It is also commonly used in the frontalis muscles of the forehead, which causes the horizontal forehead wrinkles. It can also be used on the outside corner of the eye eliminating the crow’s feet wrinkles. Botox lasts for approximately three to four months and then it must be injected again to continue the results. Botox is found to be extremely safe and effective. The amount of Botox used and the placement of the Botox can be adjusted for each individual patient, depending on their concerns and desires for improvement. The procedure takes approximately five to ten minutes. A series of several injections are performed in the office setting. The patient is given the option of topical anesthesia if desired. The effects will be noticed within two to seven days after the injection. Risks of procedure are bruising, bleeding from the needle sticks, asymmetry or incomplete results needing further injections. A very rare risk is ptosis of the upper eyelid. This is primarily seen after injection of the frown lines between the eyebrows, if the Botox is injected too close to the muscle which elevates the eyelid. If this occurs, eye drops can be given to help elevate the eyelid until the Botox wears off in approximately three weeks time period. It is common to notice after the injection, around the time when the Botox is starting to work, a pressure sensation in the area where the Botox was injected. This is normal and does become less noticeabe over time. Depending on how the Botox is injected and where it is injected, you may notice a change in your eyebrow shape. That is why it is important to discuss your goals of Botox with the physician before injection.
In contrast to Botox, which stops the muscles beneath the skin from working and therefore decreases the formation of wrinkles, wrinkle fillers plump up the wrinkles and do not affect the muscles beneath. There are multiple types of wrinkle fillers available. Human and collagen injections were the first wrinkle fillers developed and are still used today, but are the shortest lasting fillers available with an approximately three to six weeks duration. Hyaluronic acid fillers are the most commonly used fillers and are made from Hyaluronic acid, which is a chemical naturally produced in the skin, but is chemically produced for the filler. Common names of Hyaluronic acid fillers are Restylane, Juvederm, and Elevess. Fillers are injected beneath or within the wrinkle and through several needle sticks to plump up the wrinkles. The more extensive the wrinkles, the more product that will be necessary to get the best results. Patients will notice swelling and possible bruising for a few days after the procedure. They may notice redness, which can be covered with makeup. They also will occasionally notice firmness in the area, but if placed properly this will be minimized. Ice can be used after the injection to help swelling. The product lasts anywhere from six to 12 months, lasting longer in areas which there is not a large amount of movement. The patients do not need to have the skin before the injection as the chance of allergic reaction is quite rare.
Chemical Peels are used to resurface the skin. The depth of resurfacing is dependent on the chemical agent used. Superficial peels, such as glycolic acid and alpha hydroxyl acid remove the upper layer of dead skin cells allowing them to penetrate into the upper layer of dermis. The peels allow increased penetration of skin care products, dry up acne, soften fine lines, stimulate collagen growth, and give the skin a rosy glow. Superficial peels have minimal to no downtime with mild burning and redness. They are performed in the office by the nurse or aesthetician.
Medium depth peels involve higher strengths of glycolic acid or a stronger solution known as trichloracetic acid(TCA). The medium peels remove fine lines, improve skin texture, even out irregular pigmentation and reverse effects of sun damage. TCA peels are performed in the office under topical or local anesthesia. Crusting and swelling occur for 2-4 days after the procedure and redness lasts 1-3 weeks.
Deep peels use higher concentration TCA or phenol. The deep peels are the most effective at reducing or eliminating fine lines and work amazingly well for wrinkles around the mouth. These are also done in the office under local or topical anesthesia. The swelling and crusting is greater lasting 5-10 days. Redness can last for several months and there is a chance of permanent lightening of the skin where the peel is done.
Treatment of Spider Veins
Sclerotherapy is an office procedure to treat spider veins of the legs and hands. The procedure involves injection of a solution into the veins, which irritates the vein walls causing them to collapse and no longer fill with blood, resulting in reduction or elimination of their appearance. Sclerotherapy generally requires 1-3 treatments 4-6 weeks apart. The procedure is done in the office and does not require anesthesia. Burning or cramping with the injection is common but tolerable.
Spider veins may also be treated by laser therapy. It has been our experience that both methods can work well, but that some patients respond to sclerotherapy more than laser therapy and vice versa. We will often start with sclerotherapy, as we have found the injection to be less painful and better tolerated than the laser therapy. If the patient desires, a small test patch with the laser will also be performed so that we may compare the results and determine what is the best option for the second treatment.
The procedure can take 15-60 minutes depending on the size of the areas to be treated. Compression stockings are ideally purchased before the procedure and worn for 23 hours/day the first 4-7 days. For best results, you should avoid high impact exercise or excessive standing for 1-2 days after the procedure. Bruising, swelling, itching, redness can be seen the first few days after sclerotherapy or laser therapy. Fading of the veins is usually seen at 2 weeks with continued improvement up to 12 weeks. Rare risks of the procedure include discoloration, leg cramps, scarring, blistering, ulceration, infection, and vein clots.