Surgical Injection

Botox

Some wrinkles are the result of overactive muscles. A popular treatment for this is Botox. Botox (a controlled toxin) is a paralyzing agent injected directly into the muscles to reduce muscle activity. Common places to inject include the horizontal forehead furrows, vertical lines between the eyebrows and "crow's feet" around the eyes. Botox is temporary (3-4 months). It is an office-based procedure that does not require anesthesia and has little to no downtime.

Injection of Botox for Smoothing Wrinkles

Dynamic wrinkles are caused by contractions of the delicate underlying facial muscles every time you smile, laugh or frown. The more emotion you show, the deeper these wrinkles and lines are likely to be.

While you may have earned every one of your worry lines, you don't have to show them anymore. Now, dynamic lines can be dramatically softened with Botox injections to improve the appearance of worry lines, frown lines, laugh lines, crow's feet, and other dynamic wrinkles.

Botox blocks impulses from the nerve to the tiny facial muscles that are related to expression lines. Botox relaxes the muscles so they do not contract. After treatment, the overlying skin remains smooth and unwrinkled while the unrelated facial muscles contract in a normal fashion, allowing normal facial expression to be unaffected

Botox, a product of Allergan, Inc., has been used in recent years as an injected cosmetic treatment to reduce frown lines, crow's feet, and forehead lines.  With it, peri-oral wrinkles can be softened and at the same time, by relaxing the peri-oral muscle, lips take on a fuller appearance.

Precise unit doses are injected to targeted muscles.  It then works by blocking the transmission of nerve impulses to the specific muscles.  This temporary paralysis decreases muscle activity and reduces lines created by muscle movement such as frowning and squinting.  The effect varies with each patient, often lasting about four months.  If treatments are stopped, lines usually revert to their pre-treatment appearance.

Botox has been used for many years by neurologists ophthalmologists, and otolaryngologists to correct facial asymmetry due to muscular imbalance, for blepharospasm (a condition that causes uncontrollable blinking), for strabismus (weak ocular muscles that cause cross eye), and for spasms of the vocal cords.

Some patients have found that their Botox injections seem to last for longer intervals after they have received several treatments.  This may be due to weakening of the targeted muscles and also to breaking the habit of frowning, squinting and other hyper-dynamic facial movements that over many years cause wrinkles to develop on the surface of the skin.

Unlike surgery, these injections are fast, simple, and minimally invasive with no downtime.  Within a few days after the treatment, wrinkles begin to disappear.


Collagen:

Collagen is an injectable filler made from cow protein and is used to fill or plump wrinkles or furrows. Popular places to inject include the lines between the eyebrows, lines between the nose and lips (nasolabial folds), lines to the side of the mouth, and lines around the lips. It is done as an in-office procedure, and does not require anesthesia. Recovery is usually one day. Keep in mind; collagen is temporary (3-4 months), therefore, repeated treatments are needed. Also, a test dose is required for first timeusers to determine the possibility of an allergic reaction.

Collagen

It is helpful to understand the basic construction of facial skin in order to appreciate the various facial cosmetic treatments, including Collagen implantation. The skin is made up of two principal layers; the outer layer is called the epidermis and the inner layer is the dermis. The inner layer supports the surface skin and gives it shape, tone and texture. This inner layer contains an important network of interwoven fibres consisting of a protein substance called collagen. In the young skin these fibres are firm and elastic, and the skin looks smooth and soft and has the necessary resilience to recover from the lines and wrinkles created by facial expressions. With ageing, these supportive fibres lose some elasticity and lines and wrinkles start to become a permanent feature. Ageing is genetically controlled, but other factors can influence formation of these lines - smoking, exposure to sunlight and the frequency of your facial expressions of smiling, frowning etc., and also infection and disease.

Injectable Collagen treatment is a simple technique for reducing, often eliminating, specific facial lines, wrinkles and acne scars. Frown lines, laughter lines, "crows feet" , creases on the top and bottom lips can all be improved significantly by collagen implantation. It is suitable for both men and women of any age who have individual lines and wrinkles which need treatment, and where the general condition of the skin remains elastic and firm. Acne scarring can also be improved providing eruptions have ceased.

Once injected into the skin, collagen becomes part of the naturally present surrounding collagen and does not migrate or translocate to other parts of the body. However, it is eventually metabolised by the body so collagen implantation is not permanent - it varies from person to person as to how long the effects last but a guide is upwards of nine months. It can be "topped-up" as required, say every nine months to a year. It is normally estimated that for every three ampoules of collagen required for the initial treatment, only one will be required for follow up treatment.

The surgeon injects natural collagen just beneath the skin into the dermis at the site of the line or wrinkle to be treated. After one or more treatments the line or wrinkle is filled and smoothed out so it is no longer noticeable. The treatment is performed on an outpatient basis. A sensitivity test is required initially to assess any reaction to the highly purified form of bovine collagen which is used. This test involves a minute quantity of the collagen being injected into the skin on the forearm, and this area being assessed by the surgeon twenty eight days later for any adverse reaction. Only about 3% of people (i.e. 3 in 100) are found to be sensitive to collagen. Some medical conditions such as rheumatoid arthritis make treatment by this method unsuitable. Each procedure takes about an hour. One or more treatments may be required, each about two weeks apart. Results are immediate and there are really no adverse after effects. Some people have been known to experience temporary itching or burning or reactions such as redness, bruising or swelling, despite a response-free skin test, but this is rare. Most patients find the injections themselves are relatively painless, as the collagen is combined with a local anaesthetic. Some do report mild discomfort. Make-up may be used twenty four hours after treatment. It is advisable to avoid direct sunlight for a few days after collagen injections. Post-operative care instructions given by the surgeon should be closely followed.

Finally, collagen is a natural substance and can be used without surgery to eliminate or improve specific facial lines, wrinkles and scars, and as such it adds a whole new dimension to skin care. It has helped over 300,000 men and women to look their best since its development over ten years ago.


Fat Injections:

Fat taken from your own body is used as a soft tissue filler material. Since it is taken from your own body there is little possibility of an allergic reaction. Fat is taken from areas such as your abdomen, buttocks, or thighs using a small needle attached to a syringe. This is a day case procedure, where the fat is injected in multiple thin strands into the treatment area. It is a  belief that autologous fat injections may be long lasting or even permanent. I have doubts. Keep in mind; your body will absorb some of the fat and therefore repeated injections of stored fat may be needed for optimal results.

Alloderm:

Alloderm is a soft tissue filler made from cadaver dermis. It comes in a sheet and is soaked in a salt -water solution prior to insertion. It can be used to enlarge lips, fill lines between the nose and lips, and in areas where soft tissue augmentation is needed. It is hard to predict the longevity of this product, however, it seems to have a long-lasting result. Unfortunately, there are some patients that absorb this material sooner than expected. The product is processed in such a way that infections from the donor or patient rejection are not a concern. Alloderm acts as a structural framework for the body and becomes an integral part of human soft tissue starting at two to three weeks.

Cymetra:

Cymetra is an injectable, soft tissue filler that consists of micronized Alloderm. Popular places to inject include the lines between the eyebrows, lines between the nose and lips (nasolabial folds), lines to the side of the mouth, and lines around the lips. As with Alloderm, this filler may have long-lasting results if used correctly. Unfortunately, multiple treatments are needed to obtain a long-lasting augmentation. As with Alloderm, some patients metabolize or absorb the Cymetra sooner than expected. Cymetra injections can be performed in the office simply with manufactured syringe preparations.

Porex:

Porex is a non-absorbable, permanent facial implant made by Med Pore. The material is made of Porous Polyethylene. It is fabricated in various shapes and sizes. It is used in cheek augmentation, chin augmentation, and nasal re-profiling. Its main advantage is tissue adherence and lack of implant movement. Dr. Farella has used Porex successfully to augment the ethnic nose.

Gore-tex

Gore-tex is a non-absorbable, permanent, soft tissue implant that is used in cheek, chin, lip, and nasoabial(nose-lip line) augmentation. It can be purchased in various shapes and sizes. This material is soft and flexible. The multi-strand Gore-tex product has been used successfully in nasolabial augmentation (with the benefit of not being able to feel the implant).

Artecoll

The search for a safe and persistent biomaterial for use in soft-tissue augmentation has been underway for many years. For all of us that have enjoyed the convenience and relative safety of collagen, but have desired more permanence to satisfy this often heard patient complaint, Artecoll may be the answer. Dr. Gottfried Lemperle, professor and plastic surgeon in Germany, developed Artecoll in 1994 and based on much of his own research performed while at Yale. It has been in widespread use in Europe, South America, Central America and Canada where over 100,000 patients have been treated since then with a serious complication rate of less than 1 in 10,000.

It provides a long lasting correction for wrinkles and other skin defects. Its basic element is microspheres of polymethylmethacrylate (PMMA) which we all know as cranioplast and orthoplast. This material has been implanted in humans for over the past fifty years in such forms as the cement for fixing hip joint replacements, repair of skull defects, a bone substitute, artificial lenses and dental implants.

Artecoll is freely available in India.  Artecoll consists of homogenous polymethylmethacrylate (PMMA) microspheres evenly suspended in a solution of 3.5% collagen which serves as a vehicle for deep dermal implantation, and 0.3% lidocaine for pain relief. It is near totally polymerized so that there are no methyl methacrylate monomers in the microspheres, and this virtually eliminates the risk of allergy to PMMA. A complicated process creates definite sized microspheres of 32-40 microns in diameter. They are completely round, and have the polymerized exceptionally smooth surface free of residue or contaminants. The final injectate consists of 25% microspheres and 75% collagen by volume which allows for the best flow through a small gauge needle. The material and process and mixture makes Artecoll unique and safer for several reasons. The process to produce these microspheres is unique and produces extremely round and uncontaminated PMMA microspheres. This is important because it is the smooth surface of PMMA microspheres which facilitates rapid encapsulation with the patient's own collagen. Smooth round surfaces also are theorized to have very few electrical charges as opposed to materials with edges or irregularities where electrical charges accumulate and attract macrophages. This absence of electrical charges accounts in part for the decrease in macrophage activity and infection. So, smoothness and decreased electrical activity facilitate encapsulation and prevents migration and phagocytosis respectively. In addition, the PMMA microspheres are not biodegradable and too large to become phagocytosed by macrophages but just small enough to pass through a small gauge needle. Macrophage activity and thus infection, migration, and granuloma formation, are considered decreased by particle size, chemical form, and surface characteristics. Following implantation the collagen vehicle is degraded over time and the microspheres are permanently fixed in the tissue as the host collagen replaces the collagen vehicle in roughly equal amounts. The microspheres become quickly encapsulated so that they and the collagen which forms serves as the structure for filling the defect. Rapid encapsulation, lack of electrical charges, smooth surface, biocompatibility, polymerization, and chemical characteristics all contribute to decreased migration, decrease infection, and stability over time.

Histologically, there have been no detectable changes up to four years after implantation. Artecoll is stable at room temperature but should be refrigerated where it there has a shelf life of approximately ten years. Many doctors impulsively judge this as just another foreign substance similar to silicone and fraught with the same set of potential risks and complications. This is simply not the case. Silicone, whether liquid droplets or Bioplastique, has irregular surfaces and edges, is much different in biological activity and side effects. Silicone is very inert and therefore not encapsulated and can easily migrate through the tissues, usually as a response to gravity. The irregular surfaces and electrical charges stimulate macrophages and giant cell formation. Silicone is non-polymerized and this raises the risk of allergy, often seen as a type IV allergic reaction and granuloma formation many years later. The indications for usage are roughly the same as for collagen and include wrinkle lines, lip augmentation, and treatment of acne scars. Crows feet and other very superficial wrinkles in thin skin are not as good for Artecoll. Patients have an almost identical experience to that of collagen injection with some pain on injection, minimal punctate bleeding, and minor swelling all which resolve quickly. There is slightly more redness in the injection site which lasts days to weeks and eventually resolves. Because Artecoll contains collagen, a skin test is required prior to treatment. Since it is permanent and not as forgiving, overcorrection is not recommended. It is available in .5cc syringes to use with a 26 or 27-gauge needle for injection. Artecoll is a viscous gel-like substance that is more difficult to inject and generally requires a good topical or field block anesthetic. Greater injection pressure applied firmly and continuously is needed for placement, but an experienced practitioner easily and quickly masters this. Linear threading technique is preferred and it is sometimes necessary to draw the needle back and forth to develop a tract beneath the wrinkle for product placement. Serial puncture technique may also be used but is not recommended as it may create a “string of pearls” result. It should be implanted deep in the dermis at the fat interface and not intradermally or more superficial. The amounts needed for correction roughly equal the amount of collagen normally required so estimation of patient needs is fairly straightforward. Occasional second or third implantation may be needed to obtain the desired result but very little volume is usually given in these sessions. Complications span the spectrum of redness, pain, bruising, swelling and other more localized phenomenon. Scarring and acute allergic reactions are very rare. Granuloma formation is rare but can occur and may require steroid injection or excision. There have been no reports of migration or carcinogenesis.

 

 
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