When practiced religiously, the painful regimen pays off.

Q: I am a proud believer of Botox. In my years, I have purchased many pricey eye creams, which moisturize but don’t do the miracle work of a Botox injection. I have been receiving Botox for many years now maybe 3 to 4 times a year. Are there any known long term side affects of having too much Botox? Also, if a person receives lip injections many times starting at a younger age, can a lip start to look wrinkled, kind of like deflated balloon when treatment is stopped?

-Monica M. Trabuco Canyon

A: Botox®, and the recently released, Dysport®, are both similar, botulinum type A proteins which interfere with the impulse sent by nerves to the targeted muscles. In nature, this protein is manufactured by a bacteria which causes food poisoning, and causes its detrimental effects by having the bacteria spread throughout the body and continue to manufacture the protein, which will paralyze vital muscles and can cause death. Botox® the medication is produced in a laboratory (by a local company, Allergan from Irvine) and is the purified protein, without the bacteria, and will only weaken the muscle into which it is injected. It is an incredibly safe medication if used properly, and has been extensively studied.

It’s use was first described for blepharospasm, a condition in which one of the eye muscles over reacts – injecting a drop of Botox® calmed the muscle down and gave the patient relief of their symptoms for about 3 months. Botox® has also been used to help patient with severe neck or jaw muscle spasms and the stop auxiliary (i.e. arm pit) sweating in patients with abnormally active sweat glands. But of course, most of us know Botox® best because of its ability to weaken muscles between our brows, forehead or in the crow’s feet areas, thus makes our wrinkles less noticeable!

The goal of our Botox® injections is to minimize your visible wrinkles, not to paralyze your muscles of expression completely! Once injected into a muscle, Botox® weakens that muscles ability to contract (and cause wrinkles) – it does not travel to other body sites or cause weakness beyond the area of injection. The only complications I have seen from Botox® are temporary muscle weaknesses if the drug was injected beyond the area where the desired effect was to take place. For example, if one injects too close to the outer third of the eyebrow, the eyebrow can sag, giving the patient an appearance of a lazy eye – thus, we do not inject in this area! Likewise, I do not like to inject Botox® into lips in an effort to reduce lip lines because some weakness of the lip will result, for example, making it more difficult to suck through a straw. Used properly, Botox® can give a patient very satisfying results with very little risk.

Let me show you an example of a patient with a pleasing result from a Botox® injection:

46-year-old female, maximally frowning before and a month after receiving 30 units of Botox®. Notice that some lines remain, but the desired effect of softening the furrows and making the patient appear less angry has been achieved.

Same patient, raising her brows, before and after a Botox® injection. Notice that the lines over her lateral brows have not been corrected to avoid the possibility of causing a brow droop.

The second part of your question relates to filler injections. First a little background on fillers. Over the years, many different substances have been tried as fillers. Today, the most commonly used fillers in our practice are the various hyaluronic acid products (e.g. Juvederm®, Resylane®, Pearlane®, Hydrelle®, etc) or microfat grafts (utilizing the patient’s own fat). Hyaluronic acids are naturally occurring polysacchrides (for those of you who remember your college biochemistry, polysacchrides are sugars, long chains of carbohydrates, bound together by glycosidic bonds), which can be purchased in syringes and can be used to fill lines or fill lips. From a patient’s perspective, you should not be able to tell which filler was used – the external results will look the same. The hyaluronic acids last 4-6 months and thereafter are totally absorbed. Your own fat may take as a graft and, while some may absorb in the process, a sizeable portion of the transferred fat will take as a graft and last forever. Thus, my preference is to use a patient’s own fat, but in order to inject fat, one has to first harvest it from a belly or other area of fatty excess, and this process is painful and difficult to do in an office setting, making this a better procedure if a patient is already asleep in an operating room. Many of our patients requesting other procedures like a facelift, breast augmentation or body contouring, have us perform a microfat grafting at the same sitting – this takes but a few minutes and does not add to the patient’s cost. But I do not like putting a patient asleep to harvest fat if someone only wants a microfat grafting procedure (this seems like overkill for a ten minute procedure). If a patient comes in solely for a filler, it makes more sense to open a syringe with a manufactured filler like Juvederm®. 

Now to your question regarding the long term consequences of filling lips with hyaluronic acids or microfat grafts. As we age, most of us loose volume in our faces, lips and tops of our hands, while we park fat over our abdomens, thighs or necks. Lips do become more wrinkled, more so in females than males, for a combination of factors, a natural deflation being one of them. Lines also begin to become more prominent due to chronic muscle contraction, which creates lines perpendicular to the direction of the muscle contraction, leading to mainly vertical lines on the lips. These lip lines can be improved by filling the lips with either fat or hyaluronic acid, by weakening the muscle action with Botox® (as mentioned above, something we do not routinely recommend because the muscles also help with pursing of the lips), or by treating the surface of the skin with either lasers or chemical peels. Which method would be most appropriate for a given patient varies with multiple factors – you should see a qualified physician to go over your options before making this important decision! Many young and healthy patients who have not had any particular fat loss of their lips or faces choose to enhance their appearance by injecting a filler into their lips to make them appear fuller for purely aesthetic reasons. I know of no scientific evidence that beginning to do so at an earlier age has any long term effects on the lips. Specifically, there is no reason to believe that, once the filler absorbs with time, that the patient will be more likely to develop lip lines, or that the lines would be deeper or more pronounced than had the patient never had a filler!

Below are a few different examples of patients whose lip lines were improved with plastic surgical procedures.

 46-year-old female, who was going to surgery for an unrelated procedure, before and after a microfat grafting procedure to restore volume to her lips and consequently, to minimize her vertical lip lines.

And finally, here is an example of a 61-year-old female with marked lines around the mouth, mainly due to muscle action, before and after a CO2 laser resurfacing of the area around the mouth. 

If you have any specific questions about cosmetic procedures, your best bet would be to see a qualified plastic surgeon to review your options. Pease feel free to contact our office at 949.888.9700 to set up an appointment with Dr. Bunkis; you may also check out our web site at www.ocps.com to see further examples of similar patients.

949.888.970 | 30212 Tomas Ste. 275, Rancho Santa Margarita, CA 92688 | www.ocps.com