Facial Plastic Surgery Blog

“Does Botox® go to the brain?”

This is a question that has been bounced around quite a bit since the paper published by an Antonucci, et al. in the April 2, 2008 issue of Journal of Neuroscience.

Having published in this journal myself, I know that it is very highly regarded in scientific circles.  So I wanted to read this article myself.

Before going any further, it is worth pointing out that Botox® is a term that should be reserved for botulinum toxin type A (there are multiple types) that has been purified and is approved for use in humans, and is produced by the company Allergan.  The material used in the study noted above is indeed botulinum toxin type A, but it is a research grade (ie, not for human use) product whose composition may differ (based on purification methods and units of activity per weight of product).  So, Botox® itself was never tested in this study.

Having said that, the botulinum toxin type A (hereafter referred to as BoNT/A, for brevity) used in the study is the same basic molecule, so we can make some assumptions regarding the mechanisms.  It’s just that using a differently purified product in another species can complicate matters.

BoNT/A works by blocking the signal from the end of the nerve that causes the associated muscle to contract.  The signal is the neurotransmitter acetylcholine (ACh)  and BoNT/A blocks its release from the end of the nerve (the nerve terminal) by altering a molecule that is necessary for the machinery that is involved in releasing ACh.  That molecule is SNAP-25.

Each BoNT/A can alter many SNAP-25s.  Because so very little BoNT/A is around after injection, and thus is very hard to detect, the researchers in the study measured the amount of altered SNAP-25 present instead.

Before we go further, you must realize that cells in the brain (neurons) are wired to each other by sending long projections to other parts of the brain or out to muscles in the body.  These projections are called axons.  For example, the neurons that cause your face to move are located in the brain, and send out axons to the muscles of your forehead, etc.  There, the nerve terminals that activate the muscles release ACh to cause the muscles to contract.  That’s why Botox® is injected into the muscles…it finds its way to the nerve terminals and deactivates them.  (Funny thing…my honors thesis at the University of Michigan as an undergraduate was a study of ACh in rat neurons.)

Here’s where it gets interesting.  The axons have transport mechanisms that allow molecules to move back and forth between the nerve terminal and the cell body, in the brain.  The researchers in this study propose that BoNT/A is transported along the axons back to the brain.

As I mentioned above, there is no good way to measure BoNT/A, as the amounts used are so minute. So, the researchers measured SNAP-25 that had been altered by BoNT/A.  They injected BoNT/A directly into the brain (something we do not do routinely!) and measured altered SNAP-25.  They found altered SNAP-25 in other regions of the brain—regions that were connected by axons to the areas injected.  In addition, they injected the whiskers of the rats, and found altered SNAP-25 in the neurons (in the brain) involved in whisker movement.  If you are following this, you realize that this does not prove that BoNT/A is actually moved along the axon to the brain, but that SNAP-25 is.  This is a big issue, because it is not surprising at all the the degraded SNAP-25 would be moved along the axon.

To address this, the authors devised an indirect way to examine if it is actually BoNT/A or just altered SNAP-25 that is transported along the axons.  This was done with the direct brain injections, not with the facial muscle injections.  Without getting into the details, I thought this experiment (which was a small portion of the study) was the weakest and found the results less than convincing.

What does this all mean?

First, we should remember that these studies were done in animals, and any time you try to compare animals studies to human studies you can get into trouble.  Second, the composition and concentrations used may differ from that Botox®.  Third, the primary molecule measured was NOT BoNT/A, it was the molecule it alters—this is a big difference.  Fourth, no direct evidence of active BoNT/A in the brain was shown.  Fifth, only a small part of the study was done in a system similar to the muscle injections performed in humans, and the results there were not that surprising.

Finally, it is worthwhile to remember that millions of cosmetic injections of Botox® have been performed over the last decade(s) and (to my knowledge) no adverse events related to effects on the brain have been reported.

With any drug, it is always useful to have more studies to examine its mechanism of action.  Hopefully, future studies will clarify some of the questions raised by this article.

Dr. Most has published his most recent research on the effectiveness of over-the-counter anti-wrinkle creams.

Visit:

http://archfaci.ama-assn.org/cgi/content/abstract/9/5/340

Facial Plastic Surgery Videos

To learn more about Facial Plastic Surgery techniques, from the minimally invasive technologies (such as Fraxel, Pixel, and Thermage) to the latest twists to more traditional surgical techniques, look for online lectures on these topics.

We have posted several videos on topics such as these online, and these can be found on YouTube or at http://www.drmost.com/video_main.html

Furthermore, you can view Dr. Most’s most recent lecture on the Research Channel.
To check on airtimes, or to watch this video online now, click here.

Seminars in Facial Plastic Surgery (Fraxel, Pixel, Thermage, Facelift and Botox discussed!)

Dr. Most will be hosting his next Seminar on the latest Advances in Facial Plastic Surgery on Monday, April 30th at 6 pm, at 801 Welch Road, Stanford, CA.

Topics to be discussed:
• Lasers peels and types (CO2, Fraxel, etc)
• Chemical peels and types
• Botox®
• Restylane®
• Radiesse®
• Thermage®
• Facelifts, minilifts
• Eyelid Surgery

Refreshments will be provided.

Please RSVP to info@drmost.com or call 650 736 FACE (3223) to reserve a seat!

Our seminars have been very popular and informative in the past—we hope you join us!
For directions or maps, please visit www.drmost.com

Reconstruction after removal of skin cancer (mohs surgery)

Skin cancer reconstruction in the San Francisco Bay Area (including San Jose, Oakland and Walnut Creek)

Clearly, the dangers of uv radiation are well-known. The number of people who bake themselves in the sun is decreasing (though not eliminated). Unfortunately, we are still paying the price for damage done 20, 30 or more years ago. In this case, the damage I speak of may be wrinkles or discoloration of the skin. However, in the worst case, it can be skin cancer, such as basal cell or squamous cell carcinoma, or even worse, melanoma.

Basal and squamous cell carcinoma are two of the most common cancers of the skin, and indeed, of the whole body. I see younger and younger patients with basal cell carcinoma, for example, for plastic surgery repair of the area after removal of the cancer by a dermatologic cancer specialist, or mohs physician. (Melanoma is not amenable to mohs surgery, for reasons beyond the scope of this blog).

What kinds of things can one expect when diagnosed with basal cell or squamous cell carcinoma of the skin? Well, the most important issue is to have it removed by a competent dermatologist (if you live in the San Francisco Bay area, or Seattle area, feel free to contact me for recommendations). In many cases (though not all) this means a dermatologist trained in moh’s surgery, a technique that minimizes the amount of tissue removed and has higher cure rates than traditional excision techniques.

What does this have to do with a facial plastic surgeon? I often work in partnership with moh’s physicians to repair the defect after skin cancer removal. Of major concern to many skin cancer patients is the repair. How will it look afterwards? Often, the defect is complicated or on a portion of the face that is quite visible (such as the nose, cheek, or lip). In these cases, I am often asked to participate. It is important for patients to realize that the cancer does not follow the ‘rules of aesthetic surgery’. It does not limit itself to less noticeable areas or shadow lines of the face. The defect created by the mohs doctor by removing the cancer thus represents a unique challenge in each patient. Anywhere there is an incision, there will be a scar. The trick is to make the scars as inconspicuous as possible. Matching skin color, texture, and levels is paramount, and this is often done in stages (i.e., may require more than one surgery). I tell my patients that no guarantees can be made with regard to outcome, and that the postoperative healing period is a ‘journey’, and that it can take a year (or more) to get to the final destination. Getting to that destination requires a partnership between physician and patient. I find these partnerships one of the most gratifying aspects of my practice, as do my patients.

I have been fortunate to have trained with some of the pre-eminent facial repair surgeons in the world, and have built up a large experience with facial repair myself over the years. I, in turn, have been able to pass this knowledge on to my fellow physicians at a course in Facial Plastic Surgery that is internationally recognized for its excellence. I find this type of work both challenging and rewarding, and hope to continue to help heal patients with facial skin cancers in the years to come.
For more information, visit http://stanfordface.com/mohsrepair.html

Non-invasive revision rhinoplasty

Revision rhinoplasty is one of the most challenging procedures in facial plastic surgery. Nationally, rates of revision range from 3-10%, and result when significant imperfections occur after rhinoplasty surgery, or when breathing obstruction occurs.

Traditionally, imperfections are corrected by reduction (if the imperfection is a bump) or addition (if the imperfection is a depression) of tissue to the nose, and is performed surgically.

With the advent of newer, longer-lasting filler materials, we can now fix imperfections of the latter variety in the office. My preferred method is to inject saline in to the area to first test what it would look like and how the patient likes it. We can then use the filler material to fill in the area. Typically, however, the filler is not permanent, but results can last for a year or more.

I have had success with this technique and think it’s a great addition to our tools for revision, especially in patients who do not want to undergo another surgical procedure.

For more information on rhinoplasty, visit www.sfrhinoplasty.com or www.drmost.com

Fractionated laser treatments
A lot of excitement has been generated by the introduction of the ‘fractionated’ laser treatment. There are a few different varieties of fractionated laser, such as PIXEL and FRAXEL. The reason for the excitement is that these lasers offer the opportunity for reduced ‘downtime’ after treatment.
The idea (simplified here) is that with each laser pass, the amount of skin actually ‘hit’ with the laser is only a ‘fraction’ of the area covered. That is, a single pass with the laser may only actually ‘hit’ 25% of the skin. The benefit is that the surrounding, unaffected skin can more quickly heal over the affected areas. This is in distinction to standard ‘resurfacing’ laser techniques, whereby the entire surface of the skin is affected.The earliest fractionated lasers are non-CO2 (e.g., Erbium-based). These fractionated lasers typically require several treatments to see results. At the Mid-Winter meeting in Vail, Colorado in January 2007, some of these results were presented (though not by me). While these early fractionated lasers show some results, treatment of rhytids (wrinkles) is not as effective as one may like. Interestingly, more than one speaker mentioned that we are ‘going back’ to CO2 laser treatments. A new laser has been introduced which combines fractionation technology with CO2.

I already have begun using this laser in a handful of patients (I had previously used the standard CO2 extensively). I can say that these patients are seeing some nice results. The recovery is typically a few days (versus weeks or months with standard CO2 laser). While I cannot compare this to the non-CO2 fractionated lasers, all indications are that fractionated CO2 lasers may be more effective at reducing wrinkles than their fractionated, non-CO2 brethren. However, it is perhaps not as effective as a standard CO2 laser or deep chemical peel. In time, the answers to these questions will become more clear.

If you have questions about fractionated CO2 laser treatment, feel free to post here or email info@drmost.com.

For more information, visit www.drmost.com

ADDENDUM (April 2008):

I have now been able to compare the ActiveFX and Pixel lasers.  I have been impressed with the Pixel, and I am using this fractionated erbium laser in many patients.  It can be used as an adjunct to eyelid surgery, to remove crow’s feet, for scar reduction, or to improve facial skin texture.  In addition, I am pleased to offer now two different intense pulsed light (IPL) treatments.  These can be used to reduce redness (rosacea) or prominent blood vessels (telangectasias) or freckles/age spots on the skin.  For more information, email info@drmost.com.

Mid Winter Facial Plastic Surgery Meeting – Vail, Colorado

The annual Mid-winter meeting is an opportunity for specialists from around the country to discuss the latest techniques in a more relaxed atmosphere than the traditional fall and spring meetings.

As usual, I enjoyed the meeting and was able to both present some information of my own and learn what’s going on around the country.

A few tidbits:

-Laser resurfacing procedures. We now know that there really is no way around the fact that to get a nice result, there are some risks involved. Generally speaking we are talking about more down time and higher risks of changes in pigmentation of the skin. Lasers that reduce these significantly also demonstrate lesser results. Some comments were made during presentations that before and after photographs are often difficult to distinguish with the ‘no downtime’ lasers, even to the trained eye.

-MidFace lifts. More and more people in their upper 30’s to early 40’s are opting for midface lifting. The endoscopic technique remains a good option, but there are a number of other non-endoscopic techniques as well. The effects are sublte, but as we treat patients at an earlier and earlier age, we do not expect ‘dramatic’ changes as the aging process is not as advanced as in patients in their 60’s or 70’s.

-Endoscopic browlifts. These continue to grow in popularity and are generally accepted as standard and effective treatment of the aging upper 1/3 of the face.

-Eyelid lifts (blepharoplasty). One of the older techniques in facial plastic surgery, we generally approach this in a much more conservative fashion than 5 or 10 years ago.

-Facelifts. Also one of the older procedures in facial plastic surgery, but one of the most highly evolved. Over the past few years, we have seen multiple versions of ‘minilifts’ introduced, often by non-surgeons. Our assessment at the meeting was that these procedures may indeed offer less down-time, but generally are less effective both in the short and especially long-term.

-Thermage. A nice presentation was given regarding this procedure, and the person speaking compared their current thoughts to three years ago, when this particular speaker was a major proponent of the technique. The fact is that this procedure works in about 1 out of 3 people to give some subtle but detectable tightening. In 2 out of 3, there isn’t much to see. If we could determine who the ‘responders’ and ‘nonresponders’ are, we would be in good shape. However, there does not appear to be any pattern. So the procedure should be used with full disclosure regarding its limited efficacy in many patients. Current protocols for Thermage feature much reduced power settings compared with three years ago, and thus entail lower risks.

I hope this quick review of the Midwinter meeting is useful to you. Obviously, much more was covered than is written here. If you have questions about the above, or other procedures, please feel free to post questions here

For more information, visit www.drmost.com

Lunch-hour facelifts or Minilifts

One of the most pressing concerns regarding facelift procedures is the ‘downtime’ associated with them. This is the time for any bruising or swelling to go away, or the time it takes to get back to work or play without being noticeable. For a standard deep-plane facelift, this can be 2 or 3 weeks. Minilifts promise zero (which is unlikely) to a few days ‘downtime’. It should be noted that by ‘downtime’, we don’t necessarily mean ‘recovery time’, which is the time that it takes for you to feel good enough to be up and about. This is generally much quicker, about 2 or 3 days or so after a deep-plane facelift.

However, for some people, even this would be too much bruising. For this reason, the ‘minilift’, which comes in many different flavors, has come along. You may hear about ‘S-lifts’, ‘MACS-lifts’, ‘Might-mini lifts’, etc. These are all variations of a minilift procedure. The idea here is that we try to use a slightly smaller incision around the ear, and less of the tissues of the face are actually operated on. We try to minimize this because it reduces the amount of bruising. Of course, it always compromises the result (no matter what anyone says, this is the case, and it makes sense). Not that a compromise is necessarily bad. One just must be aware that the result (a) might not be as dramatic or (b) last as long as a traditional lifting procedure. As long as these are understood, the procedure can be a good one.

Some have begun advertising the ‘lunchtime lift’. This, again, means different things to different people. I have seen it mostly promoted by dermatologists who have experience in skin surgery, who are venturing into the facelifting arena. Alternatively, I have seen it used to describe non-invasive procedures such as Botox®, fillers such as Restylane® or Radiesse®, or Thermage® and Titan®. The bottom line is, whatever it is called, it is likely not anything new but a perhaps a variation on minilifting (though I can’t imagine this being done at lunchtime) or the above non-invasive procedures.

I am fortunate that I can discuss and offer all of these types of procedures, from the least invasive to the traditional ones, to my patients. I think it is important that the physician discussing your options with you is well-versed in all of these options (not just some), or it may lead to bias. For me, it is important that my patients be satisfied with their results for years, not just for months. Thus I make sure we both are on the same page regarding the positives and negatives of each procedure that’s out there.

So to summarize:
•Minilifts come in many flavors
•Offer less bruising/swelling, quicker return to normal state
•Can be done under local anesthesia
•Cost less than traditional facelifts
•Are a good option if you don’t mind a ‘lesser’ result

If you have questions comments about Minilifts, or your own experience with a Minilift or Lunchtime Lift, please post here.

Each fall the American Academy of Facial Plastic & Reconstructive Surgery meets. Here, leaders and students in the field of facial plastic surgery meet to discuss the latest advances in the field. For me, it is an opportunity to visit with my colleagues from around the country and learn what they’re up to.

One common theme the past few years has been an increasing emphasis on non-invasive procedures. Several techniques have now been around for a number of years, and we can start to see which ones work and which ones don’t. Below are a few of my observations, which are, of course, simply my opinion and should not be construed as medical advice.

Injectable fillers
These continue to be quite popular. Several new fillers are likely to be FDA-approved in the next few years, and will likely add to our arsenal of materials to use to treat wrinkles or depressions that occur due to aging.
Hyaluronic Acid Derivatives (e.g., Restylane®, Perlane®, others)
These remain popular and are well-tolerated. Hopefully, longer-lasting formulations will be coming.
Hydroxyapetite Gel (e.g., Radiesse®)
Also a good choice for the face, but probably not for the lips, as there have been some problems with injections in that area. I have been using this to revise other folks’ rhinoplasties with good success (see www.sfrhinoplasty.com)
Sculptra
Not really a filler, as it induces your body to make collagen and ‘fill’ itself in. This product was initially greeted with great fanfare. The consensus seems to be that it certainly is effective, but may not be for everyone. Repeat injections are necessary to get the effect, and it is rather expensive.
Collagen-may be making a comeback in the next few years, stay tuned!

Threat lifts
Thread lifts made a big splash last year. These were hailed as the end of the modern facelift procedure. Featured on Oprah, huge publicity followed. We now know that the technique certainly is intriguing and may have its place in certain situations. For example, it may be used for isolated, shorter-term treatment of the aging face in younger (40-ish) patients, or at the same time as a mini-facelift. However, it is definitely not a replacement for the traditional facelift, which remains the most reliable and best procedure for treatment of the aged face and neck. AND I’m glad to say the manufacturers of the technology agree with the surgeons on this point! I think the technology is exciting and as surgeons we can look to use this as an additional tool to treat the aging face…..
MORE ON THE LATEST IN MINIMALLY INVASIVE TECHNIQUES TO FOLLOW!

For more information on the lateset in minimally invasive facial rejuvenation, visit www.drmost.com