My Nose Droops! Can Botox Raise the Tip of My Nose? Or Do I Need Surgery?

Yes, Botox can raise the nip of the nose, especially if your nose droops when you smile.

    

In some patients, their noses droop only dynamically.  This means that their noses don’t point down when their faces are at rest.  Intead, only when they contract their facial muscles (such as when they smile) are their noses pulled downwards.

    

The dynamic droop is caused by a depressor muscle just beneath the nose—in the deep, upper portion of the upper lip.

    

Since Botox is a muscle relaxant, it can be used to paralyze this depressor.  Hence, smiling and other expressions won’t activate the muscle.  The result is that the nose will stay upwards, rather than droopy—even with big smiles.

    

Obviously, some people’s noses droop whether their faces are active or not.  For statically droopy noses, the muscle is not the problem.  So, a muscle relaxant like Botox would not be helpful.

    

However, a rhinoplasty is not necessarily the only solution.  Recently, I have been using injectables (such as Restylane, Juvederm, Elevess, Evolence, and Radiesse) to modify the shapes of noses.  Nevertheless, in many case, surgery remains the most effective option.

Evolence: The New Collagen

Watch out, Restylane.  Get ready for real competition, Juvederm.  Evolence is here.

Evolence's features:

• Evolence is a soft-tissue filler designed to plump up wrinkles, folds, and lips (like Restylane and Juvederm).
• It works immediately.  There is no waiting time for its effects.
• It has been available since 2004 in Europe, where its safety profile has been excellent.
• It is composed of porcine collagen (made from pigs).  (Note to my Jewish readers:  Ironically, Evolence was originally developed in Israel.  A council of rabbis did bless this product and gave it a special dispensation for use by Jewish patients!)
• Unlike older collagen products made from cows, Evolence has produced virtually no allergies, and allergy skin testing will not be necessary.
• Moreover, while the old collagens (even the human collagens) lasted just 1-3 months, Evolence should last 6-12 months--a longevity roughly equivalent to Restylane and Juvederm.
• Collagen products have always been associated with less bruising and swelling.

My opinion is that Evolence could totally supplant Restylane and Juvederm if it continues to perform as well as it has on my initial patients.  Why am I so bullish?  Less bruising and swelling.

Hyaluronic acid products (like Restylane, Juvederm, and Elevess) work like chemical sponges.  They plump up an area by grabbing water.  This process necessarily creates post-injection swelling.  The major complaint amongst my injectable patients has always been swelling and bruising.

In contrast, my early experience with Evolence has demonstrated very little swelling and bruising.  Some patients have even said that they don't need to wear any cover-up make-up after Evolence injections.

This should really boost its appeal to women who have big events in the next few days--or among women who don't want their husbands to know that they are being injected with fillers.  With Restylane and Juvederm, women do wait until their husbands are out of town, so that the swelling and bruising have vanished before the spouse returns.  With Evolence, women should be able to schedule an injection session even when their husbands are in town, or even on the day of a Holiday party when they want to look their best.

From a plastic surgeon's standpoint, the absence of swelling should make it easier for me to do very fine filling and to obtain near-perfect results.  With Juvederm and Restylane, the swelling always partially obscured the fold, and I could never be certain my injection was accurate.  With less swelling, Evolence should provide better results and greater satisfaction.

Cosmoceutical Industry Hit Hard by Recession, Part 3: Mentor Purchased by J&J

During this recession, the third big financial shake-up in the cosmetic-medicine industry has been the purchase of the Mentor Corporation by Johnson & Johnson.

Mentor (based in Santa Barbara) makes a variety of excellent products, including

• breast implants, both saline and silicone
• tissue expanders for breast reconstruction
• liposuction devices (under their Byron division)
• skin care products (called NIA 24)
• a soft-tissue filler (called Prevelle Silk)
• in the pipeline:  a muscle relaxant similar to Botox, supposedly called PurTox

Johnson & Johnson is a health-care behemoth.  J&J has also aquired the rights to market and to sell Evolence, a new collagen soft-tissue filler.  Obviously, J&J is going to make a play for the cosmetics market against other big players like Allergan and Medicis.

More on Evolence in future blogs....

Cosmoceutical Industry Hit Hard by Recession, Part 2: The Portrait Plasma is Gone

The second recent bankruptcy of a major cosmetic-medicine corporation is that of Rhytec (based in Massachusetts), which never sold enough of its Portrait Plasma devices.

The Portrait Plasma rejuvenated the skin with innovative technology.  Rather than heating the skin with a laser, it used plasma--the so-called fourth phase of matter (along with solids, liquids, and gases).

I never used this device, but it did generate a lot of positive buzz.  Supposedly, the results were at least equivalent to the Fraxel re:pair, but perhaps less plagued by depigmentation and color changes.

The Rhytec bankruptcy has left many Portrait Plasma owners scrambling for a source of the disposable nozzles necessary to deliver the plasma energy.  Since the British parent company has remained standing (at least for now), there is a chance that more nozzles may be available in the future.  However, if I were a patient in the middle of a series of treatments, I wouldn't delay my schedule!

Cosmoceutical Industry Hit Hard by Recession, Part 1: Artefill is Gone

The economic recession has resulted in bankruptcy for at least two cosmetic-medicine companies, and another was gobbled up by a corporate giant.

Artes Medical (based in San Diego) never did sell much Artefill, and so I was hardly surprised to learn that the company had filed for Chapter 7 bankruptcy.

• Artefill was an injectable filler, somewhat similar to Restylane and Juvederm.
• The gimmick was that Artefill was permanent (while Restylane and Juvederm last just 6-12 months).
• Permanence can be a good thing (if you are really sure that you want your folds filled up, and if you are tired of annual/semi-annual visits to your plastic surgeon).
• However, permanence can be a bad thing (if you realize that aging can be irregular and unpredictable, such that these implants, over decades, could become bizarrely prominent in your face).  (I have always hoped for an injectable that would last 5-10 years.  None yet exists.)
• Artefill contained a permanent "cement," as well as bovine collagen (derived from cows) as its "vehicle."  Why did Artes Medical choose an animal-based vehicle?  This really turned off a lot of my patients, most of whom support animal rights and many of whom are vegetarians.
• Even worse, non-human collagen necessitates skin testing before any injection.  Hence, patients had to delay any Artefill injection for a month or two while they waited for the results of their skin testing.

Needless to say, Artefill was never a big part of my practice.  Yet, I regret the loss of this option.  I now lack a tool that may have helped in the customized approach for a rare facial-rejuvenation patient.

The Jaw Line: If the Nefertiti Lift Doesn’t Work, What are my Options?

As mentioned in my previous post, improving the definition of the jaw line with Botox (the “Nefertiti Lift”) sounds great but is probably not an effective technique.

    

Surgery (i.e., a facelift) is still the most effective option.  Certainly, traditional surgical techniques can tighten underlying muscles and lift the droopy skin; the result is a smooth, well-defined jaw line with the appearance of a longer neck.

    

On the other hand, most of my patients don’t want surgery!  They have liked the effects of injectables (like Botox) and have preferred the near absence of side effects and downtime.

    

For patients who don’t want an operation but still seek improvement in their jaw lines, hope is not lost!  I frequently use injectable products (such as Juvederm, Restylane, Elevess, Evolence, Radiesse, and Sculptra) to fill in concavities along the lower face.

    

In particular, the depressions just in front of the jowls, just behind and to the sides of the chin (known as the pre-jowl sulci) can be easily filled.  This simple technique (in under 30 minutes, in the office, under local anesthesia) minimizes the appearance of the jowls and “straightens” the jaw line.

    

Advertisements for “Nefertiti Lifts,” “laser lifts,” “thread lifts,” Thermage, and Titan can seduce.  If it sounds too good to be true, it just may be!

    

Be careful when evaluating the before-and-after photographs in advertisements for new products.  They are frequently deceptive because inconsistencies in lighting and camera positioning can “demonstrate” improvements even if none actually occurred.  Always check with your Board Certified Plastic Surgeon before embarking on any new intervention.

The Nefertiti Lift: Can Botox Tighten an Aging Jaw Line?

Many of my middle-aged patients complain that their jaw lines are loose and poorly defined….

    

• With aging, the skin sags, and the cheeks tend "to fall" towards the neck.
• The excess skin obscures the jaw line and effaces the distinction between the face and the neck.
• The lack of well-defined jaw line is a sign of aging and is a cause of reasonable concern.     

Can Botox be a solution?!  Can a “Nefertiti Lift” with Botox restore a youthful lower-face contour?

    

Probably not.

    

In the Journal of Cosmetic and Laser Therapy, Dr. Philip Levy (a dermatologist who practices in both Switzerland and France) describes a new technique for re-contouring the jaw line using Botox.  Proclaimed the “Nefertiti Lift,” 30-40 units of Botox are injected along the lower jaw line and the sides of the neck.  Among Dr. Levy’s 130 Nefertiti-Lift patients, he claims “success” in 126.

    

While the idea is intriguing, Dr. Levy’s experience cannot be interpreted as a breakthrough.  There are methodological problems with his study.

• Dr. Levy did not randomize his patients.  To do a good research study, he should have used Botox on one patient but just plain saline (injectable salt water) on another patient.  Or, he could have injected Botox on one side of an individual patient and the saline placebo on the other.  Good studies require a control.
• Dr. Levy evaluated his own results.  He may have been biased.  Of course, we all hope that our own techniques are effective!  An independent colleague (or a group of colleagues) should have evaluated the treatment.  (And those colleagues should have had no prior knowledge as to which patient--or which side of a patient--received treatment.)
• Dr. Levy did not define "success."  He assumes that his assessment of what is good and bad is adequate.  In fact, there are accepted protocols for measuring aesthetic improvements.  Why not use them?
• Dr. Levy's photographs are not standardized.  Differences in lighting and head positioning can account for what he considers to be improvements from the Botox.
• Many of Dr. Levy's patients, who had "successful" results, also complained of asymmetrical smiles and temporary difficulties in swallowing.  Since one of Botox's main attractions is its safety and the rarity of side effects, one wonders why a patient would risk significant complications with her smile or her swallowing for (only possible) improvements in her jaw line.

 

I apologize for being a Doubting Thomas.  And I certainly don’t mean to pick on Dr. Levy.  I do appreciate his attempts at innovation!  I, too, am hopeful that non-surgical techniques for jaw line restoration are on the horizon.  Perhaps, the Nefertiti Lift will be a solution, but I suspect that Dr. Levy’s results will not be reproducible.