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 late 50’s who is bothered by submental fullness. She is shown before and again, 7 months after a single treatment with 3 vials of Kyballa. The “selfie” view with the chin pointed down demonstrates the reduction in submental fullness. The side view shows a significant improvement in the submental area and neckline.
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.
A woman in her late 50’s who wants to look more rested. On examination she has prominent frown lines which make her appear stressed. She also has significant volume loss of the cheeks which makes her look older and more tired. The frown lines are present at rest, so it is helpful to fill them with restylane as well as weakening their overactivity with Botox. She is shown before and again, two weeks after placement of 15 units of botox to her frown muscles, as well as one cc of Restylane to the deep frown lines of the forehead and 3 cc of Restylane Lyft to the cheeks. I have avoided Botox to the upper forehead in her case to avoid dropping the medial brows and overarching the lateral brows ( a “Mephisto” look). Even with the small dose to the lower forehead she does get some nice arching of the lateral brows.
A woman in her mid 40’s who is bothered by submental fullness. She is shown before and again, 3 months after a single treatment with 4 vials of Kybella. The jowl area was treated as well. She is seen to have a crisper neckline and less fullness under the chin. She can expect to have a little more improvement over the next 2-3 months.
A woman in her late 40’s who is bothered by a tired appearance. Her diagnosis is volume loss of the midface, which gives her an aged appearance. Volume can be restored during surgery with fat grafting, but she is quite thin and does not have enough fat stores for adequate fat grafting. She elected for non-surgical treatment. I prefer the Non Animal Stabililized Hyaluronic Acid (NASHA) fillers such as Juvederm and Restylane, because they are reversible and can be dissolved if needed with an injectable enzyme called hyaluronidase, but have the benefit of lasting. In her case Juvederm Voluma was used, which can last up to 2 years in treatment studies. She has had Botox to the forehead and Juvederm Voluma to the cheeks. She has had a total of 7 syringes of Juvederm Voluma placed one or two at at time over a 3 month interval. And is shown one month after her last treatment. The red mark on her right cheek was an area of irritation from an ice pack that she had used at home.
A one year follow-up in a woman in her early 50’s who was bothered by submental fullness. She is shown one year after a single treatment with 3 vials of Kybella. She has lost 6 lbs since her treatment, which improves her result, but the improvement is much more dramatic than we would expect from weight loss alone. The “sefie” view with the chin down, demonstrates the dramatic reduction in the submental fullness. The jowls have been treated as well, and her neck line is marketly improved in the oblique views. One benefit of Kybella over other cryolipolysis is the ability to tailor the treatment to fit the patient.