Non Surgical Treatments

Injectable filler gels have become very popular in recent times as a quick way to correct facial wrinkles and add volume to lips, cheeks and other areas of the face. These gel injections can enhance and rejuvenate the face in a subtle or more drastic way as desired by the client. The choice of the right patient (indication), the right type of gel (product) and the precise technique used are all very important for getting good results.
Given below are some basic facts about gel injections which will help you decide if gel injection is right for you.

Why use fillers?
With age, one loses fat and water from the facial tissues, resulting in wrinkles, under-eye hollows area and cheek. The skin also becomes less elastic. Also the shape of the face changes from oval to a square shape which is less youthful. The lips also become thin with time. We needed a way to improve water content, restore lost volume and improve tissue tightness. This led to the discovery of injectable gel products. Now we have a variety of gels some of which have become standard treatments.

What precautions are needed before gel therapy?
No aspirin for a week before procedure
you should remove all the make-up
Avoid doing it immediately after exercise or walking in the heat.
There should be no local infections.
Declare all allergies and medical conditions.
Declare if you have had prior gel injections including the type of gel.

How is the treatment done?
A cream is applied to numb the skin [sometimes an injection may be give to numb the whole area] followed by gel injections in the correct site and layer of the face according to specific technique. The area is then massaged in a specific way to distribute the gel. The procedure takes 20-40 min.

What is the after-care?
Cold packs are applied to reduce bruising. Usually no medicines are needed. You may use a Vitamin K cream such as Auriderm XO for 3 days post procedure to reduce bruising. Especially sensitive patients may benefit from starting themselves on Arnica Montana pills 3 days before and 3 days after the procedure. Sun-bathing, steam, sauna are not allowed for 3 days and facials & massage are to be avoided for a week. Minor bruising can occur which may require make-up to hide. So it is not a good idea to have social engagements for 3 days post procedure.

How long do the gels last?
This depends on the type of gel:
Temporary ones like Hyaluronic acid [HA] last 9-12 months.
Remake and Radiesse can last 2-3 years.
Bio-Alkamid, Aquamid can last 3-5 years.
Permanent gels are rarely used

Can I have more volume if I desire?
Yes; after 3-4 weeks you may have a top-up or additional areas can be injected but only to reasonable limits. Two or more gels should not be mixed.

Popularly known as Botox [after Botox by Allergan] the correct name is Neurotoxin injection therapy. It is a treatment for wrinkle reduction. It is considered a major advance in aesthetic practice. It reduces the activity of specific facial muscles thereby softening the wrinkles produced by their actions. This is turn makes the face more relaxed and serene as well as looking refreshed.
Although most have heard of “Botox” from the media, very few really understand what it is for. So we get calls from interested clients asking for Botox for lips or for Buttocks! This informative section has been prepared to lay down the principles of the use of this medicine and to explain what it can do and what it cannot. Since Botox is a trade name of one manufacturer, in this leaflet we will call the drug Botulinum toxin or Bo-toxin for short.

What is the major effect of this drug?
It is a toxin produced by certain bacteria called Clostridium botulinum. It binds to the nerve-muscle junction (NMJ) and blocks signal transmission from nerve to muscle. In itself this does not sound like a good thing but when used correctly, the drug can be made to block unwanted and excessive muscle contractions. The effect on the NMJ is permanent but the body overcomes this effect in 3-5 months by producing new NMJs. Similarly it also blocks the nerve endings on sweat glands thereby decreasing sweating in the injected area.

How do deep wrinkles and lines form?
Muscles of the face are attached directly to the skin and form the various facial expressions when they contract. In the older population and even in some young persons, skin creases form whenever the muscles contract. These creases may persist if the skin is not elastic enough to recoil. It then leads to formation of wrinkles.
Older skin is thinner, has less water content and elasticity. Genetic background, lifestyle, smoking habit and habitual frowning may all contribute to poor elasticity and to wrinkles. Due to gravity and age, the eyebrows start drooping over the orbit rim and sitting on the upper eyelid making it heavy. The forehead muscles have to work constantly to raise the eyebrow out of the way. This leads to horizontal creases on the forehead. Habitual frowning leads similarly to vertical ‘frown lines’ in between eyebrows. Smile lines or ‘crows feet’ may also develop around the eyes
On some people, these creases look good [George Clooney is a prime example] while on others it does not.

How does Bo-toxin eliminate wrinkles?
By blocking muscle over-activity, the drug stops the wrinkles from developing. Already established lines also become softer. By selective usage on specific points, we can get a brow-lift effect. When combined with other treatments to improve skin tightness, this effectively makes the face look younger.

How long does the effect last?
As mentioned before the drug blocks the NMJ permanently but the body finds a way around it by forming new NMJs. The effect of the drug thus lasts only 4-5 months. In some it may last a bit longer. With regular use however, less Bo-toxin is needed each time and the effects may also last longer.

Can I stop it at any time?
Yes, if you think it is not for you, you may stop the treatments. Everything will be back to what it was in a few months’ time. No permanent changes are produced.

Does it always work?
The drug will work on the muscles always, true failures are extremely rare. It may fail due to development of antibodies or improper storage of the vial. The drug is very sensitive to heat and handling and must be kept and transported cold. Selecting the right candidate is also very important, hence consultation with the plastic surgeon is essential. It is not a solution for every problem on a face or for every wrinkle.

So what is it NOT for?
Bo-toxin is NOT useful to plump the lips or cheeks (you need a filler gel for that) nor is it for lifting sagging tissues in the lower face. It is not useful if the eyebrows have dropped too far down (a brow lift surgery is needed) or for heavy skin folds on the upper eyelids and bags under the eyes [a blepharoplasty operation is indicated). It has limited use for smoker’s lines around the mouth.

What is therefore the commonest use? How do I know if I am a candidate?
Bo-toxin basically helps to rejuvenate the upper third of face. You may be a candidate for Bo-toxin:

• There are strong frown lines between eyebrows
• There are horizontal lines on the forehead
• If people comment that you look angry, stressed or tired when you are not
• If you feel that you are frequently lifting your eyebrows in order to ‘clear’ your vision
• Vertical bands are seen on the front of the neck (going from chin downwards)

What about side effects?
There may be early bruising, mild pain and headache in some for 1-3 days.
There can also be asymmetry in eyebrow position. This can be corrected in most cases by additional points of injection. Rarely the drug may move (diffuse) from its intended location and block another muscle such as the one that opens the eyelid. In such a case, the upper lid may droop. This effect will reverse itself in 3 months.

Why is it somewhat expensive?
The drug itself is expensive and then there is the professional skill involved in injecting it correctly in the correct muscles. Cost can be reduced by sharing the cost of the vial with a friend, both coming on the same visit. There is usually enough drug in one vial for two persons. Individual patients will have to pay in full as the left-over drug cannot be kept for long.

Where else can it be used?
Very cautiously and in highly selected cases only it may be used to reduce wrinkles around the mouth, deep lines by the side of nose and the wrinkles in the chin [quivering or animated chin]. It can also be used by an expert to convert a down slanting lip corner (sad) to an upturned one (happy).These are to be done only by an expert.
Bo-toxin injections are very effective in blocking excessive sweat in the under arm skin and to control excessive sweating in palms and soles of feet. There are some people who sweat excessively in the under-arms while others may want to block slightly more than normal sweating in order to feel more comfortable. For some it is an issue of bad odor which is not getting controlled by anti-perspirants and deodorants. Bo-toxin is safe in all of these conditions. This treatment has been life changing for many sufferers.

What are its medical uses?
Medical uses includes controlling movement disorders of the face such as hemifacial spasms and blepharospasms, reducing excessive salivation and relaxing spastic muscles in cerebral palsy, after stroke, neck spasms and muscle imbalances on the body, some migraine headaches and in excessive sweating (hyperhidrosis)of palms, soles and under-arms. It is also useful in treating non-surgical treatment of anal fissures. In my clinic I use these toxins injections for all the above indications.

Collagen is one of the building blocks of tissue and its amount in face decreases with age with resultant loss of volume and firmness. Sculptra is a new treatment based on the concept of stimulating your own body to produce more collagen. After injection, the molecules of Polu L lactic acid (PLA) stimulate the human body to produce more new collagen. Sculptra helps to restore volume and firmness to facial tissue. It works immediately to give volume due to the gel carrier and later leads to new collagen production gradually. Effects last from 1.5-2years; it is completely bio-resorbed.

This treatment helps to tighten the facial skin over several sessions. The device contains several microneedles that penetrate the skin for depth of  0.5 to 2mm making multiple micro puncture tracks. These tracks induce formation of new collagen and tissue tightening; also allows medications or PRP to penetrate better.  Procedure is done under local anesthesia cream so it is painless. The cost is low and recovery is fast.

Scars, minor skin lesions etc can be removed in the plastic surgeon’s office with minimum scar under local anesthesia. Old cuts marks and bald scars in eyebrows and moustache area can also be revised ensuring that hair grows back.

Radiofrequency devices generate high frequency low power precise electromagnetic waves that can be used to do a variety of things on biological tissues. Plastic surgeons take advantage of this tool and its many accessories to do skin surgery for minor problems, superficial blemishes, warts, moles, skin cancers, Xanthelasma, scars. It can also be used to coagulate varicose veins in clinic and to vaporize surface lesions. Dr. Mohan has over 16 years of experience in Radiosurgery. Advantages over normal cautery are greater precision, quicker healing, less unwanted damage.

Spider veins and reticular veins can be erased by sclerotherapy done in the clinic. Fine veins need laser and bigger veins need surgery.

The new technology of thread lift or feather-lift is able to offer an instant lift to facial and non-facial tissues using the power of barbed threads. These threads are fixed on special needles. Such needles are used to place the threads in specific directions and planes. These threads go easily in one direction but resist pulling in the other directions. This way the surgeon can lift the tissue along the thread and be sure that the tissue will not fall back. A lift is thus achieved without open surgery.

Only modest improvements can be achieved in this method; it is best for correcting early changes of ageing.  Thread lift is not suitable for heavy tissues. In selected cases however it has the advantage of subtle improvements achieved in office without surgery and without too much down time. The cost is also reasonable. Improvements can last 2 to 5 years. The procedure can be repeated anytime.

This method is useful for elevating the eyebrows, lifting the sagging mid-face and cheeks, enhancing the prominence of the jaw-bones, cleaning up the jaw-line and for lifting the neck.  Both permanent and absorbable threads are available. Good brands such as APTOS, Silhouette, and Easy lift are used.

When combined with fat grafting, it offers even more dramatic improvements.