A woman in her mid 50’s who had blepharoplasty elsewhere 18 months ago and was still bothered by the appearance around her eyes. On examination she has some brow ptosis from the normal deflation that occurs with aging, and the excess skin around her eyes corrects as the brow is elevated. She also has prominent crow’s feet lines with smiling. Although we could consider a brow lift I thought it would be prudent to try Botox first and see how much shaping of the brows and lateral brow elevation that we might obtain. She also has some deflation of the midface and Juvederm Voluma was placed. She had 45 units of Botox and 2 syringes of Juvederm volume. The effect on her brows was dramatic. Her cheeks appear more youthful as well. Additional Juvederm Voluma could be placed to the cheeks but we plan to wait until she returns to repeat her Botox, typically at 4 months.
A woman in her later 40’s who wanted fuller but still natural appearing lips. She is shown before and again, 2 weeks after a single syringe of Juvederm Ultra. Her lip has shape and fullness but is not overly prominent. She does not have “duck lips” or “the trout pout” which my patients do not like. Her friends notice that she looks better but are not sure why.
A woman in her mid 70’s who would like to look a little more rested in her appearance but without surgery. She has prominent “11’s” (corregator lines) of the forehead at rest. Because of age related volume loss the “marionette” lines ( chin-cheek creases) and nasolabial lines (lip cheek creases) are prominent. She is shown before and after Botox to the corrugator muscles and Restylane to the deep “11” lines. The Botox weakens the over active muscles here and the Restylane fills the “ditches” that have formed from this area being creased over and over . This gives her a less stressed look. 2 syringes of Restylane Lyft were placed to her “Marionette” lines and 2 syringes of Restylane Lyft to her nasolabial lines. This gives her a nice improvement that looks better in a natural way.
A woman in her early 60’s who is bothered by an aged appearance and wants to look better, but is not ready to consider surgery. She is bothered by brow asymmetry with her right eyebrow always being higher. Analysis of her face shows a strained appearance in the frown area ( sometimes called the “11’s”), age related volume loss of the midface and jowls, as well as prominent crow’s feet lines around the eyes at rest and with smiling. We decided on a plan of step wise correction. She first had Botox to balance the brows along with Restylane to the deep frown lines and Restylane lyft to the naso labial creases ( sometimes called “the parentheses” ) and chin –cheek lines ( sometimes called “marionette lines” after the lines around a puppets mouth). I then saw her 2 weeks later and placed some Juvederm Voluma to the cheeks. Finally, she returned for Restylane lyft to the “chin notch” and groove in front of the jowls.
She is pleased by her improvement which is natural in appearance. Friends ask her “if she has had her hair done”. This is one of my greatest compliments, because it means that others notice that she looks better but because it is natural, are not sure why, so they attribute the improvement to a new hair style.
A young woman in her mid to later 70’s who has had previous face lift surgery in the Midwest but is bothered by an aged appearance and wants non-surgical improvement.
Evaluation shows a downward sloping position of the eyebrows that gives her a sad appearance. She has volume loss of the cheeks from the aging process. She also has deflation of the subcutaneous volume under the skin of her lips.
She is shown again, 5 weeks after Botox to shape the forehead, and 2 syringes of Voluma to her cheeks. She is also 3 weeks after placement of 3 syringes of diluted Restylane Lyft to the upper and lower lips, and “marionette-line” area.
A woman in her late 40’s who was bothered by a “bump” on her left mid nose. She first noticed this after being struck by a ball in the nose a few years before. On examination she has very thin skin and has a prominent cartilage bump under the skin. A surgical rhinoplasty is an option to reshape the cartilages and add a strip of fascia from her scalp under the skin to add more thickness and help to camouflage this area. I recommended that she might try a “non surgical rhinoplasty” first with the use of Restylane injected under the skin to camouflage the area. This was done in a few minutes in the office with a topical anesthetic. She is shown 2 weeks after and has a significant improvement with ½ cc of Restylane. Although this is not permanent, it typically lasts for a year or longer in this area and is easy to repeat. She is pleased with her improvement. The nose looks straighter, and the “bump” is no longer as noticeable. The side view shows an improvement in the dorsum.
A woman in her late 40’s who has been through a stressful year and wants to look more rested. She has a strained look in the “11’s” due to over-activity of the corrugator supercilii muscles and has creases there at rest. She also has age-related volume loss of the mid face ( cheeks and lower eyelid area). As the cheeks have deflated, the “parentheses” (nasolabial and melolabial creases) have gotten deeper as well, and the corners of the mouth are turning down. She is shown 4 weeks after the placement of 15 units of Botox to the corrugator supercilli muscles combined with 0.5 cc of Restylane to the deep “11” lines and 3 cc of Juvederm Voluma to her cheeks. She returned 2 weeks later and had 1 more syringe of Juvederm Voluma to the cheeks and 2 cc of Restylane to the nasolabial creases and corners of the mouth. She is shown two weeks after this second treatment. Her forehead is relaxed and she no longer has a strained or angry appearance. I did not place Botox to her upper forehead because her brows are a little low and I wanted to avoid a “Mephisto” look that might occur in her case by overly dropping the medial eyebrows and overly elevating the lateral eyebrows. The volume loss of the midface is improved but not overdone. Slightly underdone looks normal but slightly overdone looks funny from across the room. She will plan to return at the 4 month mark to repeat her Botox.
A woman in her mid 50’s who is bothered by a tired and aged appearance. As we analyze her face we notice a strained look in the mid forehead at rest- this can be improved with Botox and a small amount of “filler” to the deeper lines. When we examine her face she has significant volume loss with aging. The cheeks are deflated. The “marionette” lines around the mouth are prominent. She is shown before and again, just 2 weeks after 15 units of Botox to the corrugator supercilii muscles. She has 4 syringes of Juvederm Voluma to her cheeks. And 2 syringes of Restylane Lyft to her marionette line area. She feels that she looks much younger and more rested, but is happy that it is still natural in appearance.
A woman in her early 60’s with deep frown lines she dubbed “the Mercedes” because of its shape. She had received
Botox 1 ½ years before in another practice but it hadn’t worked well and caused too much drooping of her medial brows.
She is shown before and again, 2 weeks after treatment with 25 units of
Botox and 1 cc of Restylane.
Discussion: She has more than normal activity of her corrugator supercilli muscles (the main “frown” muscles) , and needs a larger dose than the typical 15 units of Botox that is used here. She also has deep lines at rest- these won’t go away with weakening of the muscle activity alone, and need to be filled with the Restylane. As the forehead deflates with age ,she is more at risk for over descent of her medial brows from Botox, so I avoided the typical treatment to her upper forehead. This gives her improvement but does not cause the medial brows to drop as much. The “Mercedes” and lines of her forehead are dramatically better at rest, with maximum frown and even with smiling. Her friends ask is she has “lost weight”. When you look better in a natural way, it is difficult for others to determine why, so a typical comment is “did you have your hair done” or “did you lose weight” because you look better but people are not sure why.
So, “one key does not fit all locks”, and one treatment pattern does not fit all patients. Her case illustrates how careful analysis of her anatomy and the aging process can help to give us a good result.
A woman in her early 60’s who is bothered by the appearance of her lower eyes but does not want surgery. On examination she has some of the typical volume loss with aging. She is shown before and again, 3 weeks after the placement of 2 vials of Juvederm Voluma in the office.