You need to be your own best advocate. It is in your best interest and safety that you ask certain questions of your plastic surgeon when considering any surgical or even non surgical procedure. When you attend your initial consultation, you should have a list of questions already prepared regarding the procedure that you are consulting about. The first and foremost question should be, “Are you a Board Certified Plastic Surgeon?”

If the answer to that last question is “No,” head for the door or better yet don’t go through the door in the first place and waste your time and money for the consultation fee. Ask the question on the phone before you make the appointment. Make sure the office answers BOARD CERTIFIED PLASTIC SURGEON, not Board Certified COSMETIC FACIAL SURGEON, or Board Certified FACIAL SURGEON or some combination of the term PLASTIC SURGEON. You can always verify the physician’s credentials online by GOOGLING the doctor’s name.

During your actual consultation WITH THE PLASTIC SURGEON NOT the physician assistant or nurse or assistant, you should be assessing your own comfort level with the surgeon as far as the surgeon’s genuine integrity and concern for what you want. Does your surgeon “see” and “hear” your concerns about your face, breast, or body? Does he or she empathize with you? Does your plastic surgeon become defensive when you mention that you will be seeing other plastic surgeons? Does your plastic surgeon seem comfortable and knowledgeable about your questions? Has the plastic surgeon taken care of someone you know and respect?

Again, if your plastic surgeon does NOT welcome another opinion then perhaps again you are in the WRONG PLACE.

Personally, as a plastic surgeon, I feel extremely strongly about informing you about what the best options are for YOU given your starting point and your desired endpoint. I do not want you surprised or disappointed with your ultimate results and I feel very strongly about being ethical and doing what is BEST for YOU.

Truly all things ARE possible but sometimes the tradeoffs are longer scars and a recovery that may be longer than you wish but will ultimately give you what you want in the long run. DON’T SETTLE FOR THE EASY WAY OUT, for example, LIPODISSOLVE, if it sounds TOO GOOD TO BE TRUE, it probably isn’t true.

Use your gut instinct and judgment about the plastic surgeon you are meeting with and assess if you have established a rapport with the surgeon so that this surgeon will take a personal interest to achieve what it is YOU want.

Always ask the following questions:

1. May I see several before and after photographs of previous patients? (You should see as many as you want and the surgeon should be able to provide more than 5 such photographs to your liking).
2. May I talk to several former patients of yours that have had similar procedures? (You should be able to talk to at least 1 or 2 former patients and get a first hand experience of the process you are about to undergo).
3. May I return as many times as I wish to ask questions until I am absolutely sure of what it is I want?

All of the answers to the above questions should meet your satisfaction and after you have done your homework by asking friends and the State Medical Licensure Board and the American Board of Plastic Surgeons, then you will have to rely on your own good judgment. Bring your spouse or significant other or a friend for another opinion, that always helps.

BE YOUR BEST ADVOCATE, BE PATIENT, A PLASTIC SURGERY PROCEDURE CAN BE SO REWARDING AND ENHANCE AND CHANGE YOUR LIFE BUT YOU MUST DO YOUR HOMEWORK FIRST. CALL OR EMAIL ME AND I WILL BE HAPPY TO GIVE YOU ADVICE.

WWW.DRMICHELEKOO.COM

Dr Koo wants you to know that research is continually being conducted for the safety and discovery of new products that help reduce wrinkles and maintain healthy skin. The following is the continuation of the her blog with the study by Dr Mary Lupo.

Because of the differences in appearance between the two products, each study site had two investigators: a treating investigator who was not blinded and an evaluating investigator who was. To maintain this blinding, the evaluating investigator was not present during treatment. In addition, the subjects were blindfolded during their treatments to ensure that they too were blinded as to treatment type in each nasolabial fold. The treating investigator injected the appropriate amount of product necessary to achieve full correction but did not overcorrect. Up to two touch-up treatments were allowed. The evaluating investigator assessed the level of correction at 2 and 4 weeks after the initial treatment and, if less than optimal, the treating investigator performed the touch-up with the same assigned filler(s).

Every 4 weeks for up to 24 weeks after the last treatment, subjects were followed for assessment of nasolabial fold severity. The evaluating and treating investigators used the validated, static, five-point Wrinkle Assessment Scale with a photographic guide to score the folds as 0 (none), no wrinkle; 1 (mild), shallow, just perceptible wrinkle; 2 (moderate), moderately deep wrinkle; 3 (severe), deep wrinkle, well-defined edges but not overlapping; or 4 (extreme) very deep wrinkle, redundant fold, overlapping skin. Subjects also performed a self-assessment at each visit using the same five-point Wrinkle Assessment Scale but without photographs. At study end while still blinded to treatment assignment, subjects were asked which filler, if any, they preferred. Treatment site reactions were reported by subjects through day 13 after each treatment, and any additional adverse events reported by the subjects or observed by the investigators were also recorded.

At completion of the 24-week study, subjects were offered the opportunity to return at their convenience for a complimentary repeated treatment with the filler of their choice, and an additional effectiveness assessment was performed just before this treatment. At a subset of investigational sites, an extended follow-up study was initiated to assess injection volume and longevity of correction for repeated treatment. Because this post-24-week period was not blinded, all assessments were performed by the treating investigators, whose evaluations during the pivotal study mirrored those of the evaluating investigators. Follow-up visits for effectiveness assessments after repeated treatment occurred at 4, 12, and 24 weeks after repeated treatment, and an amendment to the extended study protocol allowed even further evaluations at 36 and 48 weeks after repeated treatment. The protocols and amendments for both studies were approved by the applicable institutional review boards, and subjects provided written informed consent for each study in which they participated.

Continued on Next Blog

Clearly this is a very complex and difficult question, and as varied and complicated as every single individual teen that is out there…

As a plastic surgeon and a Mother of 3 young adults, 20, 18, and 15, I have significant professional as well as personal experience with this topic. I am very sensitive about this subject given the fact that my 18 and 15 year olds are young independent headstrong women.

I have so many young teenagers and young adults, boys, and primarily girls that inquire about rhinoplasty and breast and body contouring. Often times, the Mother will bring the patient into my office or if the patient is 18 years or older, they themselves make the appointment, pay the consultation fee and attend the consultation alone or with a friend.

Perhaps more at issue is what is the nature of the plastic surgery inquiry. There are many procedures that truly will enhance the self confidence of the teenager that corrects a genetic predisposition, for example, gynecomastia, in young men.

Some male adolescents develop breasts secondary to rapid weight gain, hormones, and genetics. This can be extremely debilitating for the teenager. He refuses to be seen without a shirt on during PE, any sports activity, and then continues to gain weight thereby worsening the amount of actual breast tissue and fat.

Liposuction for gynecomastia in the young adolescent male can be life changing and extremely uplifting. Breast augmentation for the young adolescent girl, however, absolutely projects a different image. While you could make an argument that liposuction for gynecomastia is a necessity like obesity surgery, you would be hard pressed to say breast augmentation is a necessity because it corrects a genetic abnormality. But truthfully, it does.

So what’s the difference? Again, as a Mother of 2 young adolescent women AND a plastic surgeon, I am always torn as to what is the right answer. The truth is, it is completely dependent on the young woman and her parents if they are paying for it. However, after the age of 18, the young woman has total legal rights to sign her own surgical consent and undergo any procedure. So why am I so torn about the issue of breast implants for a 16 or 17 year old.

So why does it seem so wrong for a 16 or even a 17 year old to ask and want a breast augmentation? First of all, call me naive and ignorant, but I still feel that while they are physically ready to have sex, which is what breast enhancement implies, I think they are still too emotionally immature and do not need yet another complex issue to bring drama and angst into an already too tumultuous life. Yes, of course, the teen may be motivated by lack of confidence and self esteem (which is more perhaps the case when there is severe breast asymmetry) but really the teen is saying I am ready or have already been engaging in sexual activities and now want a breast augmentation.

First of all, the recommendation of the Association of Plastic Surgeons is to wait until the age of 18 for saline implants and the age of 23 for silicone implants. That being said, it is still the decision of the parent to allow this to occur and up to the plastic surgeon to discuss all of the legal and medical risks and implications.

This is when I discuss with the patient and the parent if they are involved, the long term implications of a breast implant, the surgical effect on the breasts, the implications for future mammograms, breast cancer, breast feeding etc, etc, but MOST IMPORTANT of all, I personally assess the emotional stability and psychological maturity of the patient and her relationship with the parents and/or boyfriend.

I then make a recommendation depending on my assessment of the patient, the situation, and what the parent has expressed to me. Oftentimes, the parents have called me first to discuss this consultation prior to the actual surgical consultation and they express their true wishes without their daughter in attendance because they don’t want to say no to the daughter who would then become belligerent, nasty, and relentless. The parents are actually asking me for help to say no to their daughter. The parents want me to guide the daughter into making the decision to wait until she is 18.

I believe that is a reasonable request and I ask the patient to return in 6 months or a year or a set amount of time to discuss the surgery (which I would normally for any patient) but in this case even more important as the passage of time may see the patient turn 18 as well as give her time to think about the surgery and its implications.

My personal advice to parents who are extremely against any plastic surgery for their teen before the age of 18…is you hold the pocket book, you make the decision. More than likely your teenager does not have the resources to pay for the surgery and you have the ultimate power and authority (finacially and legally) so don’t give in until YOU are comfortable with it or until they are 18 and whatever age it is when you feel they are making sound choices.

MORE NEXT BLOG ON TEEN RHINOPLASTY AND LIPOSUCTION

Dr Michele Koo, MD, FACS is a Board Certified Plastic Surgeon in St Louis, Missouri who has extensive experience with Juvederm and other fillers to minimize and plump those deep creases on your face. In 30-40 minutes in the office, Dr Koo will be able to fill those deep nasolabial folds, corners of your downturned mouth, and soften your lips to keep you from looking so sad and gaunt.

As we age and try to eat right and maintain our weight, our faces become volume depleted and the lines seem to deepen as the skin begins to lose its elasticity. With BOTOX AND JUVEDERM (FILLER), Dr Koo is able to soften your face and fill those deep crevices of your nasolabial folds and marionette lines of your chin. She can just ever so slightly plump your lips so your face is not so drawn and shrunken. Dr Koo is very subtle and gentle with her application of BOTOX AND JUVEDERM and you will not appear “done” or obvious with your BOTOX AND JUVEDERM. You will look rested and rejuvenated in 30 minutes!!

Dr Koo wants you to understand the safety of JUVEDERM and the following is the continuation of the article by Dr Mary Lupo as it appeared in the Plastic & Reconstructive Journal, January 2008.

Safety
The occurrence of treatment site reactions was similar for Juvéderm Ultra Plus and Zyplast. The majority of individual treatment-site reactions (e.g., erythema, induration, pain, edema, nodule, bruising, pruritus, and discoloration) lasted for no more than 7 days and were mild or moderate in severity, with no intervention required. No hypersensitivity reactions were reported for Juvéderm Ultra Plus, and there were no serious treatment-related adverse events.

Effectiveness
Initial Treatment Period
Although the mean correction after treatment was similar for both products, nasolabial fold severity scores from the treating investigators for the Juvéderm Ultra Plus filler were significantly better (lower) than for Zyplast at each follow-up time point from 4 to 24 weeks (Fig. 1). Over the 24-week period, the scores for Zyplast nearly returned to baseline (mean, 2.5), whereas the Juvéderm Ultra Plus scores remained low (mean, 1.3-equivalent to a mild wrinkle). Not surprisingly, the level of improvement in nasolabial fold severity score for both fillers was greatest at 2 weeks after the last treatment. At 24 weeks, the mean improvement was still 1.7 with the Juvéderm Ultra Plus product but only 0.5 with bovine collagen (Fig. 2). Clinically significant improvement (defined as mean greater than or equal to a one-point improvement relative to baseline) was maintained with Juvéderm Ultra Plus but not with bovine collagen at 24 weeks after optimal correction was achieved. The proportion of nasolabial folds showing significant improvement was consistently high for Juvéderm Ultra Plus (≥96 percent) but not so with collagen (41 percent at 24 weeks). Furthermore, 67 percent of the Juvéderm nasolabial folds had at least a two-point improvement at this 6-month visit (Fig. 3). Subject assessments of effectiveness were similar to those of the investigators. An overwhelming majority of subjects preferred Juvéderm Ultra Plus (85 percent) versus collagen (10 percent) or no preference (5 percent).

Among the subjects who returned at 1 year or beyond, assessments just before repeated treatment showed that 81 percent of subjects with severe nasolabial folds at baseline who were treated with Juvéderm Ultra Plus had maintained at least a one-point improvement in nasolabial fold severity and that 38 percent had at least a two-point improvement (Fig. 3), with a mean improvement of 1.3.

Repeated Treatment Period
The volume of Juvéderm Ultra Plus required to achieve optimal correction was significantly less at repeated treatment than at initial treatment. The median volume of Juvéderm Ultra Plus injected at initial treatment was two syringes (1.6 ml), and at repeated treatment 6 to 9 months later it was less than one syringe (0.7 ml).

Trends in Wrinkle Assessment Scale scores for the subset of subjects who were followed up to 48 weeks after their repeated treatments mirrored those observed in the initial study period. Although the sample size was small at 48 weeks, clinically significant mean improvement was still observed for Juvéderm Ultra Plus (Fig. 4), and 88 percent of the severe nasolabial folds treated with Juvéderm Ultra Plus in the original study and at repeated treatment still had a clinically significant correction at 1 year after repeated treatment despite the significantly lower injection volume at repeated treatment.

Continued in Next Blog

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI wants you to know that JUVEDERM and BOTOX are an extremely safe, economical way with no down time to soften your face in a significant way by smoothing and filling in the facial wrinkles that make you look tired and older than you are. Why always be asked if you are mad or tired? Take charge of your life and in 30 minutes in Dr Koo’s office rejuvenate your face with JUVEDERM AND BOTOX to lift up the frowns around your mouth, ever so subtlely plump your lips, and fill in those deep nasolabial folds.

Dr Koo wants you to know that JUVEDERM AND BOTOX are extremely safe and has been FDA approved for facial use to fill creases and smooth the dynamic lines of your face around the eyes and forehead.

The following is a continuation of an article by Dr Mary Lupo, published in the Plastic & Reconstructive Journal, January 2008. Dr Koo hopes that this is helpful information to let you understand the fillers that are available and to realize that the fillers are very safe.

One small open-label study in France treated 49 subjects with Juvéderm 30 in either one or two of four possible injection sites, the nasolabial folds (59 percent), upper lip (37 percent), glabella (16 percent), and bitterness folds (10 percent).4 Most subjects had a touch-up at 1 to 2 months after treatment, with a mean of 0.6 ml administered at each session. Wrinkle severity improvement of approximately 50 percent on a five-point scale remained stable up to 11 months after initial treatment.
Interestingly, in our study, the nasolabial folds initially treated with Zyplast returned almost to baseline after the initial 24-week period, but subsequent treatment with Juvéderm Ultra Plus resulted in the same duration of clinically significant improvement as seen in the nasolabial folds originally treated with Juvéderm Ultra Plus.

The most significant finding from our studies is the extended duration of correction for Juvéderm Ultra Plus, in particular, for severe folds. Other resorbable fillers (collagens and hyaluronic acids) have not been proven to last beyond 6 months. The most comparable product, Perlane, was developed to treat deeper folds in that it is indicated for injection into the deep dermis and has larger hyaluronic acid gel particles than its sister product Restylane, both from Medicis Aesthetics (Scottsdale, Ariz.).5 Juvéderm has a different manufacturing process that creates a homogenous gel without a granular consistency.

In a split-face study comparing Perlane to Zyplast in 68 subjects with a range of different wrinkle severities from mild to extreme, 26 percent were classified as having severe nasolabial folds before treatment, although results were not stratified by baseline nasolabial fold severity.6 At 6 months after optimal correction, 59 percent of all Perlane-treated folds maintained correction, as opposed to the 96 percent noted in the Juvéderm Ultra Plus severe folds study. Moreover, at 9 months, only 49 percent of the Perlane folds were rated as superior to Zyplast, with 37 percent showing equivalency between Perlane and Zyplast and 14 percent showing Zyplast to be superior to Perlane.

Given that Juvéderm Ultra Plus outlasts the temporary dermal fillers, perhaps it should be compared with the semipermanent fillers Radiesse (BioForm Medical, San Mateo, Calif.) and Sculptra (Dermik Aesthetics, Berwyn, Pa.). Radiesse consists of synthetic calcium hydroxylapatite microspheres suspended in a gel of glycerin, water, and sodium carboxymethylcellulose.7 Following injection, the gel dissipates, collagen production is stimulated for volumizing, and phagocytosis gradually breaks down and eliminates the microspheres.

In December of 2006, the U.S. Food and Drug Administration approved Radiesse for correction of moderate to severe facial wrinkles and folds such as nasolabial folds and for facial lipoatrophy in people with human immunodeficiency virus,8 although the product had earlier been approved for other uses such as vocal cord augmentation and was used off-label, particularly for deep creases such as severe nasolabial folds.9 The pivotal trial involved 117 subjects treated with Radiesse in one nasolabial fold and human collagen in the other nasolabial fold with up to two touch-ups allowed at 2-week intervals to attain optimal correction (mean Radiesse injection volume, 1.2 ml).8 Rated on a six-point scale using blinded photographic assessments, the mean improvement in wrinkle severity at 6 months was 1.3 (compared with 1.7 on a five-point scale for Juvéderm Ultra Plus at the same time point), and no long-term data were provided.

In a small open-label study, patient self-reports showed duration of nasolabial fold correction of 10 to 12 months for four of 18 subjects and greater than 12 months for 14 of 18 subjects.10 Another open-label study was based on surveys sent to 609 subjects who had received Radiesse injections to the nasolabial folds or other facial areas.11 Responses to the 6-month survey were received from 155 subjects, and responses to an additional survey sent between 12 and 24 months after initial treatment were received from 112 subjects. Average subject satisfaction at 6 months was 3.9 on a five-point scale (with 5 being most satisfied). In the 12- to 24-month survey, 69 percent reported satisfaction, although the most common comment was thought it would last longer. Importantly, 84 percent of subjects (n = 512) required repeated treatments to achieve or maintain optimal correction. Of those, 63 percent had touch-ups at 4 to 6 weeks and 53 percent at 5 to 9 months.

Sculptra is an injectable poly-L-lactic acid indicated for correction of lipoatrophy though, like Radiesse, it is used off-label for cosmetic wrinkle correction and volumizing. The product must be reconstituted with water at least 2 hours before injection, and the correction fades within 1 week as the fluid is absorbed. The mechanism of action is the stimulation of collagen production, which requires several injections at intervals of at least 2 weeks to generate cosmetic improvement.12 Clinical studies on Sculptra have focused on human immunodeficiency virus-positive subjects with facial lipoatrophy13; thus, the longevity of correction in facial wrinkles is unknown.

One salient point about the semipermanent fillers is that they are generally injected through larger needles than used with collagen or hyaluronic acid-based fillers to prevent the particles in the product from clogging the needle. A 25-gauge needle is preferred for Sculptra,14 and a 25- to 27-gauge needle is recommended for Radiesse,15 with a larger needle having greater propensity to generate tissue trauma and pain on injection. In contrast, Juvéderm Ultra Plus is injected through a smaller 27-gauge needle.2 Moreover, Radiesse and Sculptra are intended for placement only in the deep dermis or dermal-subcutaneous junction and do not have the flexibility to treat finer wrinkles and folds, as can Juvéderm Ultra Plus.

CONCLUSIONS
Juvéderm Ultra Plus represents an excellent combination of attributes for a dermal filler. Permanent products bear some long-term risk if the initial correction is excessive or misapplied and can result in an unnatural appearance as aging tissues shrink and make the filler visible.16 Semipermanent fillers, in contrast, are prone to the problems endemic to the particulate nature of these products, may require larger needle sizes, and have limited utility in superficial defects or wrinkles. Juvéderm Ultra Plus may have found the sweet spot of an ideal duration for wrinkle correction with a good safety profile.

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI wants you to have to latest information of the research on BOTOX AND JUVEDERM. This is the continuation of the article by Dr Mary Lupo published in Plastic and Reconstructive Surgery Journal, January 2008.

Dr Koo stays ahead of the learning curve and constantly re-evaluates the products available to you as well as her own results to give you the best and newest most optimal treatments. Furthermore, she performs all of the treatments herself and follows you very closely so as to tailor all future treatments for you so they will be as perfect as possible for your skin and face. Dr Koo believes in custom tailoring your treatment. She is respecful of your budget and time and will discuss all the options available to you for smoothing the wrinkles on your face and softening the years away with filler.

This continues the article on Juvederm by Dr Mary Lupo as published in Plastic & Reconstructive Surgery January 2008.

Subjects in the subset with severe nasolabial folds (Wrinkle Assessment Scale grade 3) were included if they had fully visible bilateral nasolabial folds that were severe at the deepest part (as assessed by the evaluating investigator) and were approximately symmetrical and of equal severity on each facial side. Exclusion criteria included hypersensitivity to bovine collagen or hyaluronic acid; history of atopy, anaphylaxis, multiple severe allergies, or allergy to meat or lidocaine; current immune therapy or history of autoimmune disease; tendency to develop hypertrophic scarring; use of oral retinoids or, in the nasolabial fold area, over-the-counter or prescription antiwrinkle treatments, microdermabrasion, or chemical peels in the 4 weeks before randomization; and any cosmetic procedure or tissue augmentation at the nasolabial folds in the 6 months before study entry.

Subjects were eligible to enroll in the repeated treatment study if they completed the initial 24-week period, indicated at the final visit that the Juvéderm-treated side was preferred, and the repeated treatment was performed between 24 and 36 weeks (±14 days) after initial optimal correction was achieved in the pivotal study. The main exclusion criteria included facial hair that would interfere with the visual assessments of nasolabial fold severity and having undergone or having plans to undergo any tissue augmentation with temporary, permanent, or semipermanent dermal fillers; botulinum toxin injection; laser resurfacing; dermabrasion; chemical peel; or face lift in the lower two-thirds of the face less than 30 days before the repeated treatment or at any time thereafter through the end of the extended follow-up period. Eligible subjects underwent their repeated treatment to both nasolabial folds on the same day with the same Juvéderm formulation that was used during the pivotal study treatment.

Statistical analysis was performed on the intent-to-treat population for effectiveness data and on the as-treated population for safety data. A value of p < 0.05 was used to determine statistical significance. The improvements in nasolabial fold severity score were compared with baseline using a signed rank test, and the proportion of nasolabial folds with a clinically significant improvement (one or more point decrease on the five-point scale compared with baseline) was evaluated using a McNemar test. Mean nasolabial fold severity scores were compared against the control by means of generalized estimating equations analyses.

RESULTS
Subjects
The initial study enrolled 439 subjects through 11 investigational sites across the United States. A total of 87 subjects with severe nasolabial folds (both nasolabial folds rated as a 3 on the five-point scale) were randomized to treatment with Juvéderm Ultra Plus in one nasolabial fold and Zyplast in the opposite nasolabial fold. Nearly all [n = 82 (94 percent)] of the subjects completed the 24-week follow-up period and most [n = 70 (81 percent)] of the subjects returned for the complimentary repeated treatment. Because of varying circumstances (e.g., scheduling issues, Hurricane Katrina), a small number of subjects (n = 16) had effectiveness evaluations 1 year or more after their last study treatment (before any repeated treatment). These subjects were statistically similar to the other study subjects in terms of injection volume and nasolabial fold severity at 6 months. Thus, these subjects’ long-term results (i.e., effectiveness at 1 year or more) can be extrapolated to the overall population.

Demographic data revealed that most subjects were female Caucasians with a mean age of 49 years (range, 26 to 74 years). The full range of Fitzpatrick skin types was represented, and 36 percent of subjects had darker skin types (Fitzpatrick types IV through VI).

Five of the original 11 sites participated in the repeated treatment study, enrolling 17 subjects from the Juvéderm Ultra Plus severe fold baseline cohort, all of whom completed the originally planned 24-week follow-up period after repeated treatment. Although the 48-week time point had already passed for a number of these subjects before the protocol amendment extending the study, eight subjects enrolled and received an effectiveness assessment at 48 weeks. Demographic details for those subjects participating in the repeated treatment study were similar to the original study.

Continued on Next Blog

The advantage of something like BOTOX and Juvederm is that it only takes 20-30 minutes in your plastic surgeon’s office. The disadvantage of course is the cost and you must maintain the BOTOX every 3-5 months and the filler every 12-18 months. However, if you start BOTOX before the lines and creases become deep and relatively permanent, your skin will stay quite a bit more smooth and youthful appearing as you age.

The animation muscles of your face have worked all of your life, your skin is much more resilient during the first 25 years and therefore you see no lines and creases. As you incur sun damage along with age, your skin begins to show the results of that muscle action and sun exposure as well as exposure to toxins such as nicotine from cigarettes if you are a smoker.

It is better to start with the BOTOX in the mid to late 20’s to prevent the deep creases from ever beginning. There really is no age limit on the other end except that the BOTOX and fillers are not as effective if there are so many creases and they are so deep. Same thing for the fillers in that you will need so much more filler if your wrinkles are extremely deep and you in fact may need to have the skin redraped with surgery in addition to the filler to regain softness and volume to your face.

The following exerpt continues the information from the study by Dr Mary Lupo published in Plastic and Reconstructive Surgery, January 2008. Dr Michele Koo hopes that this is helpful and that you understand that outcomes and effects are continually being studied and monitored by plastic surgeons throughout the country to ensure the safety of the products we use for WRINKLE REDUCTION.

Dr Koo is extremely respectful of your time and money and will only use what she feels is the best product for you and will not use any more than you need to address your concerns. She truly believes that often, “less is more” and that subtlety is the key to looking better without looking done.  Why should anyone know what your secret is. Dr Koo will be your best kept secret on the War Against Wrinkles.

With the baby boomer generation firmly ensconced in middle age, there is increasing interest in maintaining a youthful appearance to match this energetic generation. After the 2002 U.S. Food and Drug Administration approval of botulinum toxin type A (Botox Cosmetic; Allergan, Inc., Santa Barbara, Calif.) for treatment of glabellar lines, nonsurgical correction of wrinkles became a possibility. With Botox management of dynamic wrinkles, a plethora of new dermal fillers are vying to address static wrinkles, providing an overall rejuvenation of the aging face.

Among these promising new treatments is the family of Juvéderm hyaluronic acid dermal fillers (Allergan), approved in the United States in 2006 for treatment of facial wrinkles and folds. Juvéderm Ultra Plus Injectable Gel has a high degree of cross-linking, which makes it particularly well suited for volumizing and correcting deeper folds and wrinkles.2 Patients with deep facial wrinkles and folds are generally at a disadvantage when it comes to cosmetic correction, as they require a large volume of dermal filler and their correction may not be sustained; thus, a filler that is specifically designed to treat severe wrinkles is an important advancement.

Results from the randomized, controlled study of three Juvéderm formulations compared with bovine collagen have been published previously.3 We sought to further characterize the clinical characteristics of Juvéderm Ultra Plus treatment (and to compare this to bovine collagen treatment) among subjects who had severe nasolabial folds before treatment.

A multicenter, double-blind, randomized, within-subject, controlled study was conducted as part of a submission for approval by the U.S. Food and Drug Administration. This study compared three different formulations of Juvéderm against bovine collagen (Zyplast; Allergan). One-third of subjects were randomly assigned to receive treatment with Juvéderm Ultra Plus, containing 24 mg/ml of cross-linked hyaluronic acid, in one nasolabial fold and Zyplast in the other. Results presented here are limited to those subjects who received Juvéderm Ultra Plus and had severe folds at baseline.

Blog to be Continued in What age is good to start BOTOX…

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI 314-984-8331 WANTS YOU TO KNOW THAT BOTOX INJECTIONS FOR FACIAL LINES AND WRINKLES ARE EXTREMELY SAFE AND EFFECTIVE. IF YOU DON’T LIKE THE LINES OF YOUR FOREHEAD, “11″ WRINKLES BETWEEN YOUR EYEBROWS, YOUR CROWS FEET, OR YOUR “SMOKERS WRINKLES” AROUND YOUR MOUTH, YOU NEED TO CALL DR KOO AT 314-984-8331 AND SEE FOR YOURSELF IN 30 MINUTES WHAT YOU CAN AFFORDABLY ACHIEVE WITH NO DOWN TIME.

DR KOO IS EXTREMELY PRECISE ABOUT WHICH MUSCLES SHE INJECTS AND CAREFUL NOT TO USE ANY MORE THAN NECESSARY SAVING YOU COST AND MINIMIZING YOUR POSSIBLE COMPLICATIONS. IF YOU THOUGHT ALL THOSE MEDIA PERSONALITIES HAVE PERFECT FLAWLESS SKIN WITHOUT WRINKLES BECAUSE OF THEIR GENETICS OR GOOD LUCK, THINK AGAIN. THEY ALL HAVE THEIR FAVORITE PLASTIC SURGEONS, AND DR KOO WANTS TO BE YOURS.

THE FOLLOWING IS AN ARTICLE THAT SHE HOPES IS HELPFUL FOR YOUR EDUCATION ABOUT BOTOX AND ITS POSSIBILITIES OF SMOOTHING YOUR FACE WITHOUT SURGERY.

BOTOX (R) Injections to Improve Facial Aesthetics

Author: Pramit S Malhotra, MD, MS, Director, Malhotra Center for Plastic Surgery, PC
Coauthor(s): Daniel G Danahey, MD, PhD, Consulting Staff, Michiana Eye Center and Facial Plastic Surgery; Peter Hilger, MD, Professor, Department of Otolaryngology, University of Minnesota Medical School

Introduction

History

Botulinum toxin is best known to clinicians as a deadly poison produced by the Clostridium botulinum bacterium. Only within the past 2 decades have clinical applications for this toxin surfaced. Originally, applicability was found for botulinum toxin in the treatment of strabismus; however, this single indication has now grown into many. Currently, the Food and Drug Administration (FDA) has approved botulinum toxin A for blepharospasm, strabismus, cervical dystonia, and the aesthetic improvement of glabellar rhytides.

Common clinical uses

Currently, botulinum toxin is most commonly used in the management of hyperfunctional lines. Previously, hyperfunctional lines were the source of much consternation for those affected by them. These lines often caused patients to be misinterpreted as angry, anxious, fearful, or fatigued. In the past, plastic surgeons only had surgical options in their armamentarium, including excision or implantation of fat, collagen, or silicone. These procedures often provided minimal improvement and exposed patients to the risks associated with surgery. Injections of botulinum toxin A provide an opportunity to manage these hyperfunctional lines with minimal morbidity. The 3 most common sites for injection are the glabella, periorbital crow’s feet, and forehead areas.

Pathophysiology

Etiology of hyperfunctional lines

Hyperfunctional lines result from the contraction of the underlying facial musculature. The forehead is a complex of the frontalis muscle with insertions onto fibers of the procerus, corrugator, depressor supercilii, and orbicularis muscles. The frontalis muscle, responsible for the surprised appearance when acting unopposed, mediates elevation of the brow and is primarily responsible for horizontal wrinkles. Soft tissue laxity of the forehead and periorbital area causes brow ptosis and reflex contraction of the frontalis muscle to restore brow position, exacerbating forehead rhytides. Treatment of these rhytides with BOTOX® can increase brow ptosis.

The frontalis muscle can also be responsible for the appearance of scowling. However, the main agent responsible for the appearance of scowling is the corrugator muscle. The normal function of the corrugator is as a brow adductor, bringing the eyebrow medial and inferior. Chronic contraction of the corrugator results in deep vertical hyperfunctional lines between the eyes, sometimes referred to as a glabellar crease. The depressor supercilii muscle pulls the medial brow inferior and medially. The last muscle in this group is the procerus muscle, which overlies the nasal root. Contraction of the procerus results in a snout-nose appearance and a horizontal rhytid at the nasal root.

The anatomy of hyperfunctional lines in the orbit is intricate. Contraction of the orbicularis oculi muscle is primarily responsible for the clinically observed periorbital crow’s feet. The orbicularis oculi muscle is bordered superolaterally by fibers of the frontalis muscle and medially by the levator palpebrae muscle. Injection of this area requires special cognizance of adjacent musculature to avoid upper lid ptosis.

Pharmacology

The Clostridium botulinum bacterium produces 7 distinct toxins lettered A through G. All 7 toxins are antigenically distinct; however, toxin A is most familiar to clinicians. Botulinum toxin A (BOTOX®) causes paralysis by inhibiting acetylcholine release at the neuromuscular junction. This is accomplished in 3 steps. First, the toxin binds the nerve. Second, the toxin is internalized into the nerve. Third, the toxin is cleaved by internal proteolytic enzymes, and the degradation byproducts interfere with the normal process of vesicle fusion to the plasma membrane. This results in the inhibition of the exocytosis of acetylcholine.

The toxin requires 24-72 hours to take effect, reflecting the time necessary to disrupt the synaptosomal process. In very rare circumstances, some individuals may require as many as 5 days for the full effect to be observed. The dose of the toxin is measured as 1 standard unit, which is equal to the amount necessary to kill 50% of Swiss-Webster mice injected with that dose.

The effect of botulinum toxin lasts 8-12 weeks.

Indications

Current indications for BOTOX® injections include the following:

Contraindications

Contraindications to BOTOX® injections include the following:

• Pregnancy
• Lactation
• History of reaction to toxin or albumin
• Preexisting motor neuron disease (eg, myasthenia gravis, Eaton-Lambert syndrome, neuropathies)
• Age younger than 12 years
• Infection at the injection site
• Coincident administration of aminoglycosides can potentiate paralysis (relative contraindication)

Treatment

Patient Selection

Several prospective studies by Blitzer et al and Pribitkin et al have examined the effectiveness of botulinum injections for hyperfunctional lines. From these studies, certain characteristics of successfully treated patients have been identified. The ideal patients have thin skin, fine wrinkles, lines that are exacerbated by muscle contraction, and hyperfunctional lines that can be spread out with their fingers. Blitzer et al describe a “glabellar spread test” in which the physician is able to spread out the hyperfunctional glabellar lines to project the maximum benefit that a paralytic injection could achieve.

Candidates that have received minimal improvement from botulinum injections include those that failed the spread test, those with previous surgery near treated areas, those with thick skin or deep dermal scarring, and those with actinic skin changes. Facial lines resulting from the loss of dermal elasticity associated with aging are unlikely to respond to botulinum toxin injections. These areas are more appropriately treated with injectable fillers, which efface the static rhytides.

Treatment

Before the procedure is undertaken, a thorough history (including prior facial surgical procedures) and medication review are undertaken. Attention is focused on looking for those patients with contraindications as previously discussed. Preprocedure photographs are often taken by the individual surgeons’ photography studio. A close-up photograph that isolates the area of interest should be taken, as well as a full-face photograph. Photographs are taken at rest and during muscle contraction.

Physical examination concentrates on the identification of prior facial surgical sites, the assessment of the thickness of the skin, and the quality of the skin. Ahn et al note that thicker skinned patients often require higher doses. In addition, the accentuation of hyperfunctional lines with muscle contraction is noted as well as the ability to smooth out these lines with the spread test. Patients with larger muscles, such as men, also require higher doses of BOTOX®. Follow-up photographs are taken 3-4 weeks postinjection.

Botulinum toxin A (BOTOX®) arrives on dry ice and must be stored frozen at temperatures lower than -4°C. It comes in a 100-U bottle. One unit is defined as the median lethal dose in mice. The median lethal dose in humans is estimated at 3000 U. The toxin generally is mixed with 2.5 mL of 0.9% nonpreserved sterile saline solution, creating a concentration of 40U/mL.

Carruthers et al, in an outstanding consensus panel article, noted that panel members agreed that preserved saline could also be used. An insulin syringe with a 30-gauge needle works nicely for injection. The insulin syringe does not waste any of the solution in the hub of the syringe. Some clinicians are moving to 32-gauge needles, which demonstrate better patient tolerance.

The area of injection can be covered with topical anesthetic cream (eg, eutectic mix of local anesthetics [EMLA]) or can be anesthetized using ice. The solution then lasts up to 4 hours if refrigerated between injections, according to the manufacturer. Hexsel et al conducted a blinded multi-institution study and demonstrated that reconstituted BOTOX® retained its efficacy for up to 6 weeks when stored at 4°C.

Studies by Blitzer et al and Carruthers et al, and the BOTOX® Consensus Group provide some very reasonable dose suggestions, as follows:

• Forehead
  • A total of 10-30 U should be sufficient for this area. The patient is instructed to contract the areas of concern to demonstrate the approximate location of the hyperfunctional muscle. The injections are divided into 2- to 4-U injections. Most authors recommend that all injections be at least 1 cm above an imaginary line drawn horizontally between the middle portions of the eyebrows to avoid brow ptosis. An imaginary vertical line is drawn passing through the pupil for a reproducible reference point.
  • The first injection of 3 U is placed 1.5 cm above the superior bony orbital rim on this imaginary line. The second injection of 3.0-3.5 U is injected at a point 1.5 cm superior and 1.5 cm lateral from the first injection. The last injection uses the same dose but is injected 1.5 cm superior and 1.5 medial to the first injection. In effect, this creates a letter V. This set of injections is repeated on the opposite side. The injections are massaged in a direction away from the orbit.
• Glabellar region
• • This region can be divided into 2 areas. The superior-lateral region is the first area, and it is affected by the corrugator supercilii muscle. This muscle is responsible for the vertical furrow between the brows. Each muscle receives an injection of 10 U as follows: 5 U is injected into the medial portion of the muscle near its origin, and 5 U is injected in the mid portion of the muscle belly.
  • The central and inferomedial regions comprise the second area, and they are affected by the procerus muscle and depressor supercilii muscle. These muscles are responsible for the horizontal furrow at the root of the nose. A 6-U injection is placed into the middle of the procerus muscle belly, which is slightly off the midline (approximately 7 mm) and at the level of the superior orbital rims. The same injection is repeated on the opposite side. Then 3 U is injected into the depressor supercilii muscle, which is approximately 1 cm above the medial canthal tendon. Finally, 3 U then is injected on the opposite side. Great care must be taken not to inject the solution too deep, which may place BOTOX® into the orbit, causing an oculomotor paresis.
• Periorbital crow’s feet: A total of 12 U is used per side. Injections are divided into 3 U each. Using the patient’s right eye as an example, the first injection is approximately 1 cm lateral to the lateral canthus at the outermost portion of the bony orbital rim. This correlates approximately with the 10-o’clock position of the orbicularis oculi muscle (some authors feel that this injection provides a chemical brow lift of several millimeters in the lateral brow region). This is followed by an injection of 3 U at the half-past-9 position. The last 2 injections are placed at the half-past-8 and half-past-7 positions. Once again, the BOTOX® must be placed outside the orbital rim to avoid intraorbital complications.
• Nasolabial: This area has been difficult to inject and offers mixed results. Electromyograph (EMG)–guided injection of 2-3 U to paralyze the levator labii superioris alaeque nasi has demonstrated some success. The authors’ center does not use botulinum toxin in this area because of complications of upper lip paresis.
• Platysma: Platysmal bands can be treated with the direct injection of botulinum toxin into the concerning band. Once the band is identified, 5 U can be injected at 1-cm to 3-cm intervals along the vertical line created by the platysma. Some authors find these areas more amenable to surgical treatment.

Electromyograph monitoring

Many authors have chosen to perform their injections under the guidance of EMG monitoring. This technique involves using a 27-gauge (1.5 in) polytef-coated EMG needle connected to an EMG recorder by an alligator clip on its shaft. The patient is asked to contract the muscle in question. The injection is placed where the maximal EMG recording can be found within the muscle. This technique ensures that the injection is at the portion of the muscle that is contributing most to the hyperfunctional facial line. As these injections have become routine, many centers have obtained satisfactory results without EMG guidance. Many physicians use a readily available 30-gauge insulin syringe instead. However, EMG-guided injections remain a useful adjunct in patients who have residual function after their initial injection.

Reinjection

If a patient feels that little benefit was derived from the original injection, reinjection can be performed 1 week postinjection. However, 2-3 weeks postinjection is probably a more practical time for a return clinic visit. Generally, 2.5-5 U are used for reinjection. Reinjection strategies are still evolving. Once the patient has a satisfactory result, the next visit is at 2-3 months or when the patient requests another treatment.

Complications

The most feared complication is temporary paralysis of nearby facial musculature. Approximately 1-3% of patients may experience a temporary upper lid or brow ptosis; the most troublesome complication to the patient is upper lid ptosis. This results from migration of the botulinum toxin to the levator palpebrae superioris muscle. The ptosis usually lasts 2-6 weeks. It can be treated with apraclonidine (Iopidine, Alcon). This is an alpha-adrenergic agent that stimulates the Müller muscle and immediately elevates the upper eyelid. This treatment can usually raise the eyelid 1-3 mm. The treatment of 1-2 drops 3 times per day continues until the ptosis resolves.

Bruising can occur, particularly if a small vein is lacerated or a patient is taking aspirin, vitamin E, or NSAIDs. Ideally, patients should stop taking these products 2 weeks before the procedure. Headaches can occur after BOTOX® injections; however, in one study by Carruthers et al, this did not exceed the placebo group.⁶ This is thought to be due to the trauma of the injection and not something inherent in the toxin. In fact, botulinum toxin injections are extremely safe. To date, no significant long-term hazards of botulinum toxin injections have been identified in excess of placebo groups.

Future

The popularity of BOTOX® is unmatched in cosmetic surgery. The use and scope of botulinum toxin increases every year. Patients have shown a high degree of satisfaction with the procedure. Current research focuses on using BOTOX® as an adjunct to a myriad of surgical and ablative procedures.

Botulinum toxin A now has been used in significant numbers for 20 years. Its injection has proved to be an extremely safe strategy for selectively inducing muscle paralysis.

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON , ST LOUIS, MISSOURI hopes that this is helpful information. She will only suggest Botox for you if she feels it will be helpful and worthwhile for you based on your cosmetic goals for your face.

Before Juvederm Ultra Plus Injection

After Juvederm Ultra Plus Injection

If you have one hour to spare, Dr Michele Koo, MD, Board Certified Plastic Surgeon, St Louis, MO, 314-984-8331 can fill your deep creases around your mouth, marionette lines and nasolabial folds to soften your face and remove 20 years. This will refresh your face and rejuvenate your look without surgery and down time in one hour and last up to 12-18 months.

Dr Koo uses Juvederm, Restylane, and various other fillers depending on how deep your creases are and the type of skin you have. The injectible fillers are hyaluronic acid which as a normal component in human skin.  Dr Michele Koo performs the injections herself and carefully evaluates the results and designs the perfect fill for you on all your subsequent follow-ups. She makes sure that you have individualized attention and care so as to perform the right filler injection just for you. She never allows an aesthetician or nurse to do the injection and feels extremely passionate that the results of the first injection will guide her to tailoring your treatment so that it is refined and subtle so you look refreshed and rested.

The following is an article by Dr Mary Lupo in the Plastic and Reconstructive Journal, January 2008. This should be helpful to let you know that BOTOX and JUVEDERM are extremely effective and safe and there are studies that actually look at the results and longevity of BOTOX and JUVEDERM.

With the baby boomer generation firmly ensconced in middle age and the ubiquity of botulinum toxin type A, nonsurgical facial rejuvenation is becoming increasingly prevalent. As this generation continues to age, products with greater therapeutic power to correct aging changes will be in growing demand.

A multicenter, double-blind, randomized, within-subject, controlled study was conducted comparing Juvéderm Ultra Plus hyaluronic acid filler with bovine collagen. A subset of subjects classified as having treatment for severe nasolabial folds is presented in this article. Subjects received Juvéderm Ultra Plus in one severe nasolabial fold and Zyplast collagen in the other nasolabial fold; up to two touch-up treatments were allowed at 2-week intervals. Nasolabial fold severity was evaluated every 4 weeks for 24 weeks using a five-point scale. Treatment site reactions and adverse events were also recorded. A complimentary treatment was offered at the end of the trial, with effectiveness evaluations just before retreatment and up to 48 weeks after repeated treatment for a subset of subjects.

Of the 87 subjects, most were female Caucasians, but all Fitzpatrick skin types were represented (36 percent types IV through VI). At 24 weeks, 96 percent of nasolabial folds treated with Juvéderm had maintained clinically significant correction, and 81 percent maintained the correction for 1 year or more. Results were similar for those subjects with follow-up through 48 weeks after repeated treatment. The median volume required for repeated treatment with Juvéderm was significantly less than that for initial treatment (0.7 ml versus 1.6 ml).

Juvéderm Ultra Plus provides correction of severe nasolabial folds through 1 year or more.

Continued in Next Blog