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

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

Dr Michele Koo, MD, St Louis, Missouri, is a Board Certified Plastic Surgeon who treats facial wrinkles including crows feet, glabellar frowns (11’s between eyebrows), forehead creases, peri-oral (lip wrinkles), and platysmal bands (neck bands) with BOTOX. She also treats nasolabial grooves, chin creases, thin lips, and downturned lips with various fillers including JUVEDERM, RESTYLANE, AND EVOLENCE.

If you’ve been feeling tired and people keep asking you if you are sad or disinterested, then perhaps it’s time to refresh your face with some filling out of the creases and hollows to make you look softer, fuller and more alive.  

BOTOX along with filler and a simple skin care regimen can make a significant difference in the appearance of your face in very little time in the office of Dr Koo. You will have very little if any recovery time and you can do it on a Friday and be ready to go out the next night.

Dr Michele Koo feels that the following information will be helpful in educating you about BOTOX and its safety. She feels if you understand its actions and chemistry that you will feel much more comfortable and understand that BOTOX is very safe used by trained personnel such as Dr Michele Koo, MD, of St Louis, Missouri, 314-984-8331.

Inactivation of the orbicularis oculi muscle by chemodenervation with botulinum toxin type A (Botox, Allergan, Inc., Irvine, Calif.) as a sole procedure or in conjunction with blepharoplasty has proved to be a reliable method to improve the appearance of the periocular area. Botox has the unique and ideal characteristic in that, with repeated use, there is potential for a prolonged clinical effect with smaller dosages. In addition, if a complication does arise—while not aesthetically acceptable and potentially untoward—it is time-limited, and the anatomical area will eventually return to its pretreatment baseline status.

The eradication of facial wrinkles has traditionally been approached with facelifts, blepharoplasties, and various surgical interventions of soft-tissue augmentation, and resurfacing methods. Facial wrinkles are a result of a combination of basic chronologic aging compounded by sun damage and smoking.

Facial wrinkles can be categorized as dynamic (accentuated with animation) or static (present regardless of facial expression) in nature. An example of dynamic facial wrinkles are the crow’s feet wrinkles. These facial creases  are primarily a consequence of hyperkinetic activity of the orbicularis oculi muscle that encircles the eye. With animation, there is hypertrophy of the lateral muscle fibers. Treatment, therefore, should ideally be aimed at the underlying muscular component. One of the most recent advances in the aesthetic arena has been the expanded use of the botulinum type A neurotoxin (Botox, Allergan, Inc., Irvine, Calif.) to improve the appearance of dynamic facial wrinkles.

BOTOX, temporarily prevents these dynamic muscles from working by inducing chemodenervation by preventing release of acetylcholine at the neuromuscular junction of striated muscles. The result is muscle-fiber atrophy and subsequent clinical flaccid paralysis, thereby smoothing out an area that once had facial wrinkles.

This form of therapy is particularly well suited to the muscles of the upper one-third of the face: the vertical midline glabellar groove (corrugator supercilii, procerus, and medial fibers of the orbicularis oculi muscles), the horizontal forehead lines (frontalis muscle), and the crow’s feet (lateral fibers of the orbicularis oculi muscle).

Botox is received in crystallized form (25°C) in a vial containing 100 units of toxin, 0.9 mg sodium chloride, and 0.5 mg human albumin. The toxin is reconstituted with preserved or unpreserved normal saline yielding various concentrations for the obliteration of facial and neck wrinkles. Dr Koo dilutes the BOTOX depending on the location of the muscle and how deep the wrinkles are and how hypertrophied the muscles are and whether this is a first or repeat injection, and when the last injection of BOTOX was.

The toxin is reportedly quite labile and readily denatured; therefore, Dr Koo  prepares the solution immediately before use and prefers to use it within 24 hours. Contingent upon the degree of orbicularis oculi muscle hypertrophy, Dr Michele Koo, St Louis, Missouri, typically uses an average of 7.5 to 15.0 U per side. The patient is asked to perform an exaggerated smile (squint), and equal divided aliquots of 2.5 U (0.05 ml) of Botox are injected into the raised folds of the skin corresponding to the presumed muscle pattern.

Three or four injections are spaced at 1.0- to 1.5-cm intervals, beginning immediately beneath the lateral edge of the eyebrow down to the lateral infraorbital rim. Because there is an inherent spread of Botox both in between and within muscle fibers, it is injected 1.0 to 1.5 cm (a fingerbreadth) from the lateral orbital rim to prevent its migration into adjacent periocular muscles.

Dr Koo performs the injections in the office in 15 minutes and the patient is ready to return to the office or out for the day immediately afterwards. The onset of action, with the loss of muscle activity and rhytids, can be rapid in this area, and although some improvement may be noted 48 to 72 hours after injection, the full effect may take 3-5 days.

Wrinkles in the crowsfeet area can be one of the earliest signs of aging. In large part, they are the result of muscle hypertrophy of the fibers of the orbicularis oculi that encircle the eye. Consequently, blepharoplasty, soft-tissue augmentation, and resurfacing of any depth are only partially effective in reducing their appearance, and muscular inactivation would therefore be the optimal treatment modality. However, given the muscle’s size and the critical function of tightly closing the eyelid, weakening of the muscle with BOTOX is an ideal and preferable method to diminish and eradicate the creases around the eyes.

Perhaps the most common untoward event that occurs when the crow’s feet are treated is bruising which Dr Koo minimizes by holding pressure for a minutes after the injection. This can also be minimized with superficial injections, because the relatively thin orbicularis oculi muscle seems to be satisfactorily affected when the toxin is injected into the subcutaneous space overlying the muscle. This not only reduces the chance of bruising but may prevent intravascular injection and hemodilution, which can affect potency. Furthermore, injection into the subcutaneous compartment may allow for more local and even diffusion over the targeted muscle and provide an additional safety barrier to structures deep to the muscle.

Botulinum type A neurotoxin physiologically denervates mimetic muscles, thereby eliminating the pull on the skin and the appearance of superimposed wrinkles. The improvement in the appearance of crow’s feet can be profound. Botox does not, however, address other stigmata of aging of the eye, such as fat-pad herniation and excess skin, both of which require surgical intervention. Botox injections and blepharoplasty should not be viewed as mutually exclusive but rather as potentially complementary procedures. Dr Michele Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis, Missouri, will advise you as to the best approach for your complaints regarding your wrinkles and the excess skin around your eyes depending on your desires and your anatomy.

Currently available injection suggestions for the periocular area are general and primarily include a safety zone of approximately 1.0 cm (one  fingerbreadth) from the orbital rim in an arclike pattern. To reduce the temporary yet disfiguring risks of periocular Botox injections alone or in concert with blepharoplasty or facial surgery, Dr Michele Koo performs  precise identification of the muscular anatomy and needle placement.

Dr Michele Koo, MD, FACS

Board Certified

Plastic Surgeon

Fraxel® Laser Treatment is a unique, non-invasive laser therapy designed to dramatically improve skin texture and pigmentation, allowing you to once more enjoy the fresh and healthy skin of your youth. Its patented “fractional” technology penetrates deep within the skin for maximum rejuvenation while promoting fast healing and stimulating the production of new, firm tissue to smooth out imperfections.

Fraxel Laser Treatment is most effective for:

·         Improving texture and tone

·         Shrinking pore size

·         Erasing age spots / brown spots

·         Smoothing wrinkles around the eyes

·         Smoothing acne scars

·         Rejuvenating the neck, chest and hands

How does Fraxel technology work?

Fraxel Laser Treatment utilizes fractional resurfacing technology, where only a small fraction of the skin receives the laser light at any given time. The treatment delivers a series of narrow but deep microscopic laser spots to reach the innermost layers of skin and stimulate collagen growth while leaving the surrounding skin unaffected. The healthy cells in the untouched spots promote rapid healing of the entire area, resulting in faster recovery time and minimal side effects. Think of this “fractional” technique as being like restoring a painting one tiny area at a time, or altering an electronic image pixel by pixel.

Fraxel Laser Treatment combines the effectiveness of traditional ablative lasers with the rapid healing of non-fractional non-ablative lasers.

What is the Fraxel Laser Treatment like?

Fraxel Laser Treatments can be performed right in your doctor’s office. First, your doctor will cleanse the area being treated and apply a topical anesthetic.

Your doctor may also apply an FDA-certified blue tint to your skin. This tint darkens the tiny folds and imperfections on the skin’s surface, increasing the contrast against the skin and allowing the laser handpiece to more effectively map the contours of the treatment area. A full-face Fraxel Laser Treatment typically takes 20-25 minutes.

What can I expect after a Fraxel Laser Treatment?

After treatment, the blue tint and anesthetic are washed off. You may be asked to clean the skin thoroughly but gently with a Fraxel foaming cleanser and water, followed by an antioxidant infusion from your doctor as well as a special Deep Hydration Mask to seal in moisture.

Your skin may feel as if it has been mildly sunburned for about an hour after a Fraxel Laser Treatment. After that, discomfort should be minimal. Mild swelling should subside within two to three days, and pinkness—an indication that the skin has been deeply treated—usually fades over five to seven days. There is limited, if any, risk of infection or scarring.

New epidermal skin develops within 24 hours. This new skin may be bronze-tinged for a few days to two weeks. It will likely flake and exfoliate as old skin sloughs off and new skin takes its place. The new skin is also highly sensitive and requires adequate sun protection for several months after treatment. Fraxel Daily Moisturizer (SPF 30) is ideal for this purpose.

Is there any downtime?

While individual results vary, Fraxel offers the benefits of speedy healing and little to no downtime. Many patients return to routine activities and can shave or apply make-up soon after treatment.

When will I see results? How long do the effects last?

Results are immediate and progressive, with optimal improvement usually visible in about two to three months and gradual improvement for up to a year. Each session shows marked improvement in skin quality, resulting in a high level of patient satisfaction.

How many treatments will I need?

Treatment plans vary from patient to patient; your doctor will recommend the number of treatments needed to achieve your personal goals. Clinical studies suggest that an effective treatment plan is three to five sessions spaced about two to four weeks apart. Each session targets a certain percentage of the skin’s surface. By the end of the treatment plan, the entire treatment area will have been covered.