Facial Plastic Surgery Blog

Is there a new, quicker-acting alternative to Botox®?
A study on a new type of botulinum toxin type A for treating facial wrinkles was published in the March/April 2009 issue of Archives of Facial Plastic Surgery.  The article, titled “Long-term safety and efficacy of a new botulinum toxin type A in treating glabellar lines”, details the results of a Phase 3 study (for explanation of FDA study phases, see here) of patients who received a new type of botulinum toxin type A, called Reloxin.  The primary goal of the study is the evaluate the long-term safety of repeated administrations of Reloxin in treating the frown lines between the eyebrows (glabellar lines).  Secondly, the study sought to determine how well Reloxin works (effectiveness and duration).
The study was a multi-center trial, involving 21 separate sites across the United States.  Twelve hundred patients were enrolled, and each patient received at least 1 treatment with 50 units of Reloxin.   Four more treatment cycles followed, and in each cycle some patients were dropped from the study (for a variety of reasons).  In the end, 177 patients received five full treatments of the glabella with Reloxin.
Adverse events are recorded in this type of study, and range from the somewhat innocuous or expected to the more serious.  In this study, the most common events were ‘injection site events’ which occurred in 18% of patients.  According to the authors, these were generally considered ‘mild to moderate’ events.  The second most common events were headaches, and these occurred in about 15% of subjects.  Finally adverse events around the eye were reported in 9% of subjects, and typically resolved within 3 weeks.  The exact types of events were not defined, though the authors did point out that ‘ptosis’ (drooping of the eyelid or brow or both) occurred in about 1.3% of subjects, which is comparable to Botox®.
The effect of Reloxin was seen typically around 3 days after injection, and as soon as 1 day in some subjects.  Contrast this with Botox®, in which the effect is typically observed at around 5-7 days (though it may start earlier).  Duration of effect was typically around 90 days, which is comparable to Botox®.   No reduction of effect was noticed in subjects who underwent repeated treatment.  In other words, there was no development of reduced response over time (or resistance to Reloxin).
What does this mean for you?   It may mean that a new type of injectable botulinum toxin type A is around the corner.  Reloxin showed similar duration of effect as Botox®, and seemed to show its effects more quickly.   Complications of treatment were similar to its long-used cousin.  Of note, Reloxin has been in use in Europe for 15 years (where it is called Dysport).  Bringing this drug to the United States will mean more options for patients who would like to treat wrinkles in the upper face.
It should be noted that the study was funded by Medicis, the company that manufactures and plans to market Reloxin in the United States.  Furthermore, one of the study’s lead authors disclosed that he owns stock in, has been a consultant for, and has received research support from Medicis.
For more information on Advances in Facial Plastic Surgery, be sure to visit www.drmost.com or www.sfrhinoplasty.com.

The Facial Rejuvenation Revolution
Sam P. Most, M.D., F.A.C.S.
www.drmost.com
In the past few years we have seen a significant evolution in thinking about facial rejuvenation.  In this space I hope to shed some light on this, and what this means when you visit the doctor’s office.  In the past, facial aging has been thought of as primarily a battle lost to the effects of gravity.  We understand now, however, that the process of aging is a complex one, and involves more than simply sagging of the skin on the face.  Recent research has shown that the changes that occur are, to use an oft-used phrase, ‘more than skin deep’.
For example, we know that what we see in an aging face is partly due to changes in the skin at the microscopic level—changes in pigment cell and collagen fiber organization, as well as loss of elasticity (the ability of the skin to stretch and “bounce back”).  While in the past it was thought that fat should be removed from the face (especially in areas such as the upper and lower eyelids), we realize that one of the stigmata of facial aging is loss of facial fullness, partially due to fat loss or redistribution .  Finally, we are just starting to understand the interaction of the facial fat and muscle with the cartilage and bony skeleton, and what makes a young face look the way it does.  All of these have changed the way we (as facial plastic surgeons) approach our patients.

What can I do?

What can YOU do to reduce the effects of father time?  First, take care of yourself.  Eat a healthy, balanced diet.  Don’t smoke. Cleanse, moisturize and protect your skin.  Avoid the sun .  Even if you do all of the above, there are some things you will not be able to control.  You can’t go back in time and tell your twenty-something self to be more careful with your skin.  You cannot stop the biology of aging (despite what you may read on the internet).  No anti-aging cosmeceutical yet exists that can penetrate your skin and change the process of aging .  Even if you do all of the above, the time may come when you search for ways to rejuvenate your face.
“It’s not your mother’s facelift anymore”
As I alluded to above, the old way of thinking about facial rejuvenation was ‘tighter is better’.  Given what I discussed above, I’m sure you can appreciate that our approach to facial rejuvenation has likewise changed.  While in the past the primary approach for facial rejuvenation was surgery (a ‘facelift’); we now have many non-invasive techniques that can be used to restore a youthful appearance to the face.
Non-invasive facial tightening
Chemical peel, dermabrasion, and laser peels are tried-and-true methods for removing skin wrinkles.  You have probably heard of these procedures, or you may know someone who has undergone one of these.  While these techniques have been around for a while, most all of the new research has centered on improvement of the laser.  Specifically, the goal has been to reduce the ‘downtime’ associated with it maintaining its benefits.  The latest technology involves treating only a fraction of the skin with the laser, thereby stimulating rejuvenation with less downtime (this is called a ‘fractionated laser’; some brands include Pixel and Fraxel).
You may have also heard of techniques that promise ‘nonsurgical facelifts’.  One of the first such techniques was Thermage®, but many similar techniques have come along.  The premise of these technologies is to transfer energy (often in the form of heat) to the deep tissues of the face, thereby ‘tightening’ the tissues that have ‘loosened’ over time.  The results on this have been mixed.  Some studies have shown that about 1 in 3 patients will have a noticeable effect.  Unfortunately, we cannot tell who those patients will be.
Injectables
There are 2 main types of injectables.  Muscle ‘freezers’ and facial fillers.  Botulinum toxin type A (most commonly Botox®) is the most commonly used ‘muscle freezer’ and is one of the most common facial rejuvenation procedures in my practice in the San Francisco Bay Area (as it is nationwide).  It works by temporarily blocking the muscle from getting a nerve signal.  Since muscle movement causes some types of wrinkles, it is only effective in treating so-called ‘dynamic’ wrinkles.  Note that Botox® is FDA approved for use in the glabella (the area between the eyebrows), but is commonly used ‘off-label’ in other areas of the face.  It takes about a week to show its effects, and lasts typically 3-4 months.
The other main category of injectables are the fillers.  Classically, collagen was used to ‘plump’ the face, especially the lips.  Given what we now know about loss of volume throughout the face, our use of fillers has expanded to include virtually all areas of the face.  Our repertoire of materials has also expanded far beyond collagen.  The hyaluronic acid (a naturally occurring substance) derivatives include Restylane®, Perlane®, and Juvederm®, to name a few.  Radiesse® is derived from a calcium base.  Other, more permanent fillers, include Artecoll®.  The ultimate injectable is your own tissue, namely, your own fat.  In this procedure, called fat transfer, we move small droplets of fat from an undesirable place to areas of the face that need more volume.
What about surgery?
The non-invasive procedures can only do so much.  When you and your surgeon feel the time is right, surgery may the best choice to give a natural, more long-lasting result.  As you can see, there are a number of options available prior to taking the plunge into a surgical procedure.  Surgery of the face to reverse aging includes brow rejuvenation (endoscopic browlift), eyelid lifts (blepharoplasty), and lower face/neck lifts (rhytidectomy).  These procedures can be done alone or in combination.  Each of these has undergone its own evolution, the discussion of which is beyond the scope of this summary.  Suffice to say that the trend is towards more conservative and natural-looking results.
OK, I want to take that first step…

Do your research.  Find someone who has experience and limits their practice to the face.  Importantly, this person should be familiar with the full range of facial treatments (surgical and nonsurgical).  Finally, it is important to find someone you trust will give you an honest assessment.  The goal of facial rejuvenation in 2009 is just that—rejuvenation.  This implies a natural restoration of facial youthfulness.  Our goal as facial plastic surgeons is to achieve this as safely and effectively as we can, with as minimally invasive a procedure as possible.