Botulinum Toxin And Filler Injections - Your Questions Answered
Neurotoxin (botulinum toxin injections) and filler injections are the top two most common cosmetic treatments. These injectables can produce natural looking results with minimal to no down time, and in the right hands, the risks are relatively low. Have you been thinking about botulinum toxin and/or fillers? Read below for common questions and answers. If you have any other questions, send us an email or leave a comment.
- Pradeep Mettu, MD
Neurotoxin Injections
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Rhytids (wrinkles) can be dynamic (present only during a certain facial expression) or static (present with the face at rest). Dynamic rhytids (such as ’crow’s feet’ visible near the outer portion of the eyelids during smiling) can be improved with neurotoxin injections. Neurotoxin injections may also have beneficial effects on certain static rhytids (such as horizontal forehead lines). Neurotoxins weaken muscles, thus resulting in decreased wrinkles that are caused by muscle contraction. It takes around a week to see results from the injection. Results typically last around 3 months, though there is some variability from patient to patient. Dr. Mettu uses both Botox and Xeomin.
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Age is not a factor in determining candidacy for neurotoxin injections. Each patient is unique and has different needs and desires. The best treatment plan to address your concerns will be discussed after evaluation by Dr. Mettu. If you have active inflammatory conditions affecting the face, Dr. Mettu recommends avoiding elective cosmetic injections. If anticoagulation (blood thinners) cannot be held due to medical reasons, some injections may be deferred due to the inherent risks of bleeding. If you have a neurological disorder that causes weakness (such as Myasthenia gravis), neurotoxin injections may be contraindicated. Finally, if there is any known allergy to any of the substances used for injections, you may not be a candidate.
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Neurotoxin injections can typically be provided on the same day as your consultation. If you take blood thinners or over the counter supplements that can thin the blood, injections may be deferred until these are held for 14 days. No medication should be held without first checking with your medical doctor.
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Risks essentially stem from too much medication given at a certain location or from the medicine affecting an unintended muscle. Since neurotoxins weaken muscles, the risks include double vision, droopy eyelids, droopy eyebrows, and dry eye syndrome. Dr. Mettu is an ophthalmologist with subspecialty training in Oculofacial Plastic Surgery and Neuro-Ophthalmology. He has an extensive knowledge of eye, facial, and neuro anatomy. With mastery of the anatomy and the use of skilled technique, Dr. Mettu is able to decrease the likelihood of these potential risks.
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Ice or topical anesthetic cream can be applied before the procedure to help with comfort if needed. The areas treated are customized to each patient. A small (30 gauge or 32 gauge) needle is used to give the injections. The small size of the needle minimizes discomfort. All injections are performed by Dr. Mettu.
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After neurotoxin injections, there will be small ‘bumps’ in the location where the injection was given. These will go down over the course of a few hours. Do not massage the area as that may cause the medication to be distributed to an unintended area and increase the risk of complications such as double vision or a droopy eyelid. It may take up to one week to see the full effect of the neurotoxin. With the exception of avoiding pressure to the face for 24 hours, you may resume normal activity after the injections.
Filler Injections
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Lines and folds (such as the ’tear trough’ visible beneath the lower eyelid and the nasolabial fold) develop due to anatomic changes that occur over time including loosening of tissues, and loss of volume (fat) in the face. These folds and lines can be improved by compensating for the lost volume using injectable fillers. Adding volume to the face can also provide some ‘lift’ of the tissues. The combination of lift and volume results in a youthful appearance. Common areas treated with filler include the cheek, the nasolabial folds, the tear trough, and the lips. There are a variety of different fillers with different properties. Dr. Mettu has extensive training in anatomy, oculofacial plastic surgery, and facial injections and will identify the best filler for you based upon your concerns and your examination.
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Age is not a factor in determining candidacy. Each patient is unique and has different needs and desires and the best treatment plan to address your concerns will be discussed after evaluation by Dr. Mettu. If you have active inflammatory conditions affecting the face, Dr. Mettu recommends avoiding elective cosmetic injections. If anticoagulation cannot be held due to medical reasons, some injections with fillers may be deferred due to the inherent risks of bleeding. Finally, if there is any known allergy to any of the substances used for injections, you may not be a candidate.
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Filler injections are typically not performed on the same day as the initial consultation. A return visit is scheduled to inject filler. Every patient has different needs with regard to the areas to be treated and the amount of filler that may be injected. Thus, the appropriate amount of time can be allotted to help you get the best result possible. Filler injections will be deferred if there is history of dental procedures within the past month as this could increase risk of infection.
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Risks include, bleeding, infection, scarring, inflammatory reactions, decreased blood flow leading to permanent tissue damage including blindness. Dr. Mettu is an ophthalmologist with subspecialty training in Oculofacial Plastic Surgery and Neuro-Ophthalmology. He has an extensive knowledge of eye, facial, and neuro anatomy. Dr. Mettu routinely performs injections around the eye and on the face and only employs techniques that minimize these risks. Being a surgeon, Dr. Mettu recognizes the importance of sterile technique and considers filler to be a surgical implant. He uses a sterile technique to minimize the risk of infection, an uncommon but challenging problem that can occur after filler injections.
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Ice and/or topical anesthetic cream may be applied before the procedure to help with comfort. In certain areas and with certain fillers, local "blocks" are given. This involves giving small volume injections of local anesthetic containing lidocaine to specific nerves. The “blocks” numb the area prior to treatment. After the treated areas have been numbed, the area to be treated and surrounding parts of the face will then be sterilized using a ’surgical prep’. Sterile technique is used to inject the filler. Some filler products are premixed with an anesthetic called lidocaine which will also make the treated area more comfortable. A small needle or cannula is used to give the injections. Dr. Mettu performs all of the injections.
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Swelling is expected after filler injections. Bruising may also occur. Both should improve over the course of a few days, though bruising sometimes persists for a week or more. Based on a recent consensus report (reference below), Dr. Mettu gives the following recommendations to filler patients:
Avoid extreme cold or heat for 48 hours
Avoid massaging the treated area
Avoid strenuous physical activity
Sleep with your head elevated for one night
A skin care routine may be followed only once 24 have passed
Patients should not undergo dental procedures that might lead to gum bleeding in the 3–4 weeks following facial filler treatment
In those patients with a predisposition to bruising, a vitamin K cream or arnica gel may be useful to speed up its resolution
REFERENCE: Urdiales-Gálvez F, Delgado NE, Figueiredo V, Lajo-Plaza JV, Mira M, Ortíz-Martí F, Del Rio-Reyes R, Romero-Álvarez N, Del Cueto SR, Segurado MA,Rebenaque CV. Preventing the Complications Associated with the Use of Dermal Fillers in Facial Aesthetic Procedures: An Expert Group Consensus Report. Aesthetic Plast Surg. 2017 Jun;41(3):667-677.
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We use several different fillers, each with unique properties. All fillers we use are hyaluronic acid (HA) based which can be reversed with hyaluronidase if needed. With a variety of different (HA) fillers, Dr. Mettu is able to treat any part of the face (lips, fine lines, tear troughs, nasolabial folds, marionette lines, cheek/midface, etc.)
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