Initial consultations with patients are a great time to get to know patient motivations. One topic that has come up recurrently (especially within the past month), and has been mentioned by people of every age group that I treat, has been about facial asymmetry. It is usually not the first thing mentioned, but when the mirror is out, I have the patient looking at themself in the mirror, and they start telling me their story, it comes out eventually.
In the ideals of beauty, facial symmetry is seen as something that adds to attractiveness and is associated with things ranging from personality to mate selection. I don’t think this is on the mind of my patients when they talk to me about it; rather, they are talking about things that make them pause when they look in the mirror. I do not minimize this complaint, as it is a real concern of patients. However, I don’t think that all asymmetries need to be treated.
When I think of static facial asymmetries, I am looking at the anatomy of the relaxed face. I feel the position of the bony prominences of the face, their relative projections, heights, and shapes. Then I take a step back and look at the patient at rest. This is my soft tissue exam. I am looking at how the muscle, fat, and skin drapes over the bone. To try to figure out how much of the asymmetry is from the muscle as opposed to the fat, I feel the tissues and also have the patient smile and animate, as muscle “flexes”, or contracts, while fat does not.
After evaluating static asymmetries, I look at how the the face moves, and is supported. This exam is actually done before the static exam, as it usually takes place during the patient interview, though I think about static asymmetries before dynamic ones. Does the right upper lip raise higher when smiling? Is the left “smile line”, or nasolabial fold, deeper than the right when speaking? Are the crow’s feet or forehead furrows deeper on one side than the other?
To Treat or Not To Treat
My first discussion about facial asymmetries is usually about how we are all asymmetric. Nobody is microscopically symmetric, and we do not need to be. However, static asymmetries can be troublesome for people, and they may prefer to be photographed on their “good side”. Sometimes these are easy to treat.
The easy cases are ones where there is a static asymmetry of the cheek that can be evened out by filler, or the asymmetric placement of filler. If both cheeks have lost volume, but the left side has always been “thin”, then we can place more filler on the left side, giving a more symmetric look. I find that many patients have one tear trough deeper than the other, and asymmetric placement gives great results (and more importantly, happy patients).
Dynamic asymmetries, I feel, give your face a certain “character”. I usually discourage treating these. If your lips look symmetric at rest, but when you smile, one half looks a little more full or elevates a little less than the other side, you will find me talking you out of trying to “balance” this with filler or Botox. Your facial muscles may be weaker on one side than the other. Your mouth has a characteristic right corner that raises when you smile. Great! This is one of your unique facial signatures. Your friends may not tell you, but this is one of the things they love about you!
Think twice before you treat these. After you have thought twice, think twice again. Have you ever looked in a “true” mirror that flips your view so that you are looking at yourself as the world sees you rather than a flipped mirror image? Were you kinda freaked out by this? What you are seeing is your dynamic asymmetry flipped.
Most of my patients that have tried treating these dynamic asymmetries in the past have had results that they did not like. Not all of them can pinpoint why. A few have had good results. Given these odds, my first instinct is to try to talk people out of this. Why would I try to do a treatment with great odds of freaking a patient out?
Let me give you a better option. Enjoy these asymmetries, and know that you are better off for having them.
Have you ever tried to research how much it would cost to get laser hair removal? We look into prices before buying computers, phones, and a lot of other material goods, as well as services, such as haircuts, oil changes, and massages. People post prices online, or nicely tell you how much something will cost if you call them, if not entice you to come by showing you how their service differs from others.
Look up laser hair removal prices, and you have a totally different experience. Trying to find out how much laser hair reduction costs makes shopping for a gently used car seem fun. What you can easily find is what percentage off you get! Yay! I have no idea how much it’ll cost, but knowing that it is 95% off makes me feel SO much better.
Jos. A. Banks
The only parallel I can think of that is as hard to figure out is suit shopping for men. If you’re in the market, you come across several major brands with good reputations. You may even be enticed along the way by Jos. A. Banks. They have such a huge selection of suits! Every color imaginable! And by the way, they are ALWAYS on sale, so good luck figuring if “75% Off” is a better deal today than the “Buy 1, get 3 FREE!!” from last week. Look up the listed price, and you see HUGELY inflated prices, which I don’t think any human being has ever paid, given that they are ALWAYS on sale. There is even a class action lawsuit taking place because of the sham “Regular” prices. To quote the lawsuit, “These purported free apparel promotions and discount offers are false because the referenced ‘regular’ price is, in each instance, fabricated and inflated…”
Beyond Laser Hair Prices
Laser Hair Removal prices are important. The comparisons in pricing should be taken in context, however. Laser hair reduction is a medical procedure, and the skill of the practitioner performing the service is the key. The laser is the tool used, but the practitioner is the one that delivers the service. A skilled laser hair practitioner can use settings and techniques to minimize risks while still focusing on what you went for – lasting removal of hair.
An unscrupulous practitioner can use minimal settings, which minimizes risks, but also may minimize results. A person being treated would never know the difference between this and a real treatment. And the solution to this? More treatments! Who pays for more treatments? You! This is why the practitioner’s reputation and reliability should be the main consideration of choosing a provider, not just cost.
Back to Laser Hair Removal Prices
When we started offering Laser Hair Reduction at Nuance Facial Plastics, we decided to use market rates based on what people actually ended up paying for their services and post these online. We believe that posting these prices benefits our patients so that they know what to expect.
This is only a part of the story, however, because the skin type, hair color, and hair texture determine how much reduction in hair growth you can expect after 6 treatments. A package of 6 treatments will get different people different results. This is why an in person discussion about candidacy and expectations from a course of treatments is the most important part of the equation.
An inevitable part of any surgical discussion is one about facial scars.
- Will I have a scar?
- How big?
- Now noticeable?
- Where is the scar?
- Will it heal better than my scar when I fell on a shovel?
- I don’t want a “botched” scar.
- I heard there’s a new scar gel that can make all scars disappear.
Though the list above is not exactly how the “scar talk” goes, these are all things that I have heard asked, and not just once. Some of us have scars that people can see, and sometimes these scars are the physical representations of past traumas. I don’t want to minimize the impact that scars have on my patients or people in general. However, not all scars are the same.
Traumatic scars are not planned, and can happen in any part of the body. They are often made by objects that are less sharp than a surgical scalpel, and at skew angles and in prominent places on the face. Some traumatic wounds involve a loss of tissue or an infection that leads to a widened scar. Burn injuries sometimes heal by the skin growing from the periphery of an injury inwards, leaving a star-shaped, or “stellate” scar. Often times, the visible scar is accompanied with an emotional scar, invisible to the observer, sometimes dwarfing the visible scar.
Surgical scars are a totally separate entity. Surgical scars, made with scalpels or other cutting surgical instruments, in a sterile environment and with a planned purpose, heal much better. There is an element of control involved, even when there are unplanned diseases such as skin cancers. Though we cannot control the size and location of the skin cancer, we can control the subsequent scars to reconstruct the defect that the cancer left. This control enables us to hide the scars in places and orientations that are the least conspicuous.
When the skin is incised, or cut, perpendicular to the skin surface, the closure can gently evert the skin edges. As the scar matures and thins, it heals at the level of the skin rather than as a depressed scar. In traumatic wounds, the angle of the cut is determined by the trauma, and the closure is limited by what nature has given the patient (and the surgeon).
Scar placement is sometimes a luxury, but when it comes to cosmetic surgery of the face and neck, it is the norm rather than the exception. We can plan incisions to be as inconspicuous as possible, placed at natural transitions of the face and neck so as to not draw attention. They can be hidden behind shadows and given an irregular shape, as the eye is drawn to straight lines. We make them parallel the natural creases of the face and neck, called the “relaxed skin tension lines”. This not only hides the scar in a parallel direction to the natural facial aesthetic lines, but also makes them heal thinner and less noticeable.
My Experience With Facial Scars
I am not saying that my patients do not have visible scars after surgery. After having a week of blue stitches, most patients will always remember their scars from surgery. However, the rest of the world is not inspecting your face for scars. When I ask my patients about comments about returning to work after surgery, I got the following responses:
- “I was asked if I got new glasses.”
- “I got comments about how good my hair looks.”
- “My co-worker said that I must have had a relaxing vacation (I told her we were going to the beach before I took time off).”
Nobody so far has mentioned the scars. This may be because people are too polite to point such things out, or it may be because they are too busy reacting to the new contours of the face to look for them. You can see some examples of surgical patients, and may be able to find their scars on my Before and After Gallery. Practicing facial plastic surgery has taught me that the anxiety about scars is not to be minimized, as they are one of the noticeable changes after the bandages are taken down. However, in comparison to the “across the room” impression, or even the “across the table” impression, people are almost always more distracted by the new look to notice scars.
When the Snot Hits the Fan: Over the Counter Solutions to Seasonal Allergies and Lower Eye Bags
The Spring and Fall are high allergy season for many of us, and while some of us have the typical symptoms of nasal congestion, sneezing, itchy watery eyes, and a clear runny nose, others only see one thing: lower eye bags. Some pockets of the United States, with Charlotte being one of these lucky “pockets”, are especially bad for seasonal allergies. Luckily, for all of us allergy sufferers, there are great over the counter solutions to treat all of the symptoms listed above.
Any patients that I have with the above complaints are first questioned about their symptoms and triggers for these, as allergies are common, but there are more rare causes of nasal congestion and facial pain (such as migraine headaches triggered by perfumes rather than pollen) and also other causes of lower eye swelling (such as thyroid conditions or excess orbital fat). In the absence of these, and when people have annual symptoms like clockwork, the probability of having allergies is quite high, and the diagnosis is made (though without formal allergy testing).
My initial regimen is a three pronged approach, which involves:
- Nasal Rinses
- Nasal steroid sprays
- Oral antihistamine (non-sedating)
My preferred nasal rinses are the NeilMed Sinus Rinses, as they physically remove the pollen, mold, dander, or other nasal irritant from the lining of your nose. The other medications treat the lining of the nose, but physical removal of the irritants makes the remainder of the job easier. Other nasal rinses are available, as well as powered nasal washers that have now crept up on the market. I have no experience with these, and continue to use the NeilMed Sinus Rinse and recommend it to my patients. Of note, distilled or boiled water should be used with these rinses, as rare infections are possible with using tap water.
Nasal Steroid Sprays
These sprays were prescription only just a few years ago, and since becoming over the counter and going generic, the cost has come down quite a bit. I used to pay $30 for a one month supply, and now these can be had for under $4. My preferred nasal spray is fluticasone propionate 50 mcg spray, the generic form of Flonase. Costco has a version branded Aller-Flo, costing much less than I used to pay for a prescription. The alternative to this spray is Nasonex or its generic form, mometasone.
Proper use is one spray in each nostril twice a day. Do this spray with your chin down, and aiming the spray toward your ear. Inhale gently during spraying. Snarfing this while spraying will just put the steroid into your throat, which does not help your nose at all. If you taste this about 5 minutes after spraying, then it has spent enough time hanging out in your nose to do its work. It decreases the swelling of the lining of your nose, and improves nasal congestion and sneezing as well. Nasal steroids should be thought of as a “maintenance treatment” not an “as needed” treatment, and they take a week of regular use before you see results. Use them for a month at a time rather than only when you feel congested to get the best results.
Oral antihistamines, which many people use as the primary treatment of allergies, are not my favorite treatment of allergies. My philosophy is that if someone’s symptoms are primarily nasal, such as sneezing, runny nose, and nasal congestion, then treating the nose is the best option. If itchy, watery eyes are a bigger problem, or if the nasal treatments treat the nose well but these ocular symptoms remain, then I add oral antihistamines. My first choice is fexofenadine 180mg, the generic form of Allegra. This was a prescription medication a few years ago, and has gone generic and over the counter, making it a powerful anti-allergy tool. Prior to that, only lesser antihistamines such as Claritin, Clarinex, Zyrtec, Xyzal, and Benadryl, were available, and I call these “lesser” because their primary drawback is the side effect of sedation. Fexofenadine is not sedating like the rest, which makes it “the best” in my opinion. This is available at Costco as Aller-Fex and can be taken twice daily safely.
Some people have bags under their eyes that are due to excess orbital fat, and this can get worse with time, as the fat “bulges” out due to a weakening of the tissues holding the fat pockets back. These eye bags require surgical removal of the fat, which can be a permanent solution. If you have both — fat and fluid, my solution is to treat the fluid first, and if the eye bags are still worrisome, then to remove the fat.
I personally have no relationship to Costco other than being a customer there, and have found that the products listed above have helped quite a few of my patients with their allergies as well as reduce the bags under their eyes. If you find better deals on these products, then please share them in the Comments section of this blog posting so that others in the community can benefit from it as well.
Botox vs Dysprt vs Xeomin.
This is the third post in a series about the similarities and differences between the three FDA approved injectable neuromodulators currently available in the US market. For comparisons between the products, please check out Battle of the Neuromodulators, Part I, and Battle of the Neuromodulators, Part II.
Throwing all of the FDA-approved players into the mix today, let’s look at the three neurotoxins available in the US today, and explore their similarities and differences.
Medically, how do you find out how two things are different? You perform a clinical double blinded clinical trial and put them head to head. “Double blinded” means both that the doctor does not know what he injected, and the patient similarly does not know which treatment they got. The observations are done by third parties to maintain objectivity. This is a single medical study. It is limited in its power by geography by the number of people that you can sign up for the study, and cost, as these are expensive products.
When you amass several studies that have been done all over the world, you have enough data for a “meta analysis”. This is a “study of studies”, and is much more powerful than a single study. Instead of having just 50 patients to analyze in one study (for example), you do a study 50 studies that were done of 50 patients each, giving you data from 2,500 patients. Three meta analyses about the three injectable neuromodulators currently available, Botox, Dysport, and Xeomin, have been done in recent years, and they are all well designed and systematic in their approach to review the question. Furthermore, they are very open to the limitations of each study they included in their meta analysis.
- Chemodenervation for the Treatment of Facial Dystonia: A Report by the American Academy of Ophthalmology. Ophthalmology. 2018 Apr 10. pii: S0161-6420(18)30687-0.
- Conclusion (in my words): All products equally efficacious (they all work).
- IncobotulinumtoxinA for Aesthetic Indications: A Systematic Review of Prospective Comparative Trials. Dermatol Surg. 2017 Jul;43(7):959-966.
- Conclusion (in the authors’ words): “The weight of the evidence from comparative clinical trials indicates that incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA have similar efficacy for aesthetic applications”
- A Comparative Assessment of Three Formulations of Botulinum Toxin Type A for Facial Rhytides: A Systematic Review with Meta-Analyses. Plast Reconstr Surg. 2016 Apr;137(4):1125-40.
- Conclusion (in my words): All of the products work better than placebo
Think about these meta analyses as people are trying to sell you on the difference between these products. While there are some differences between them about how they are formulated and how much protein they contain, I think we would all agree that the similarities far outweigh the differences. And for anyone that argues that these differences matter, all I say is: prove it. Because it hasn’t been proven as of today, and it isn’t from a lack of trying. If a single study were to prove it, it would be in the face of a lot of peer reviewed published data that shows the products are equivalent, so it would take a lot to sway my opinion today.
For every time I hear “Dysport spreads more than Botox”, I think of the three studies above. Every time someone says “Xeomin doesn’t last as long as Botox”, you really have to wonder if this is true. A significant amount of money and energy has gone into asking just this, and none of it has proven that this is the case, and as we discussed in “Battle of the Neuromodulators, Part I”, there is some serious motivation by any one of these companies to come out as the “best” or to make it into a two-player market by showing one product as inferior.
I will end with this: medical studies evaluate more than a single patient’s experience, and more than a single practitioner’s experience as well. There are some people that have a better experience or result with one product compared to another. While the scientist in me thinks that this is due to the injector rather than the product, I do leave open the possibility that not every product is equivalent in every person, and that is why we offer all three at Nuance Facial Plastics. If you had a bad experience with Botox when it was on Groupon (and you blame the Botox rather than the injector), we have more options for you to try.
Botox vs Xeomin
This post is very similar to the previous blog post, “Botox vs Dysport: Battle of the Neuromodulators, Part I”, with some parts borrowed directly.
Botox and Xeomin are both formulations of botulinum toxin type A. For reference the bacteria Clostridium botulinum makes eight different types of toxins (A, B, C1, C2, D, E, F, and G). The molecule naturally occurs as a protein-toxin complex, with a large carrier molecule and comparably smaller toxin molecule.
Botox (onabotulinumtoxin A) is made by Allergan, and is supplied as a lyophilized (dried) form, and a vial of Botox contains a small amount of human serum albumin (a protein), sodium chloride (salt), and the neurotoxin complex, a protein-toxin complex with a mass of 900kD. Botox is typically available in 100 unit and 50 unit vials. The vials have to be refrigerated and stay that way until they are reconstituted with normal saline, and then injected.
Xeomin (incobotulinumtoxin A) is made by Merz, and is also supplied as a lyophilized powder, with vials containing human serum albumin, sucrose, and the neurotoxin. The big difference between Botox, Dysport, and Xeomin is that Xeomin does not contain the carrier protein that the other two products have. Proteins are quite sensitive molecules, as any change in pH, temperature, salt concentration, or agitation may disrupt them (turn the proteins inside out and therefore ineffective). Lacking a protein, Xeomin is stable at room temperature and does not require refrigeration before or after reconstitution with saline. To help me sleep better at night, and since we have the room, I do keep my Xeomin refrigerated, as I do not have a compelling reason not to.
Does the small, pure toxin travel much farther in the body because it is not as “heavy” as Botox? It does make sense. Though, not everything makes sense. See this example:
- Dried grapes are raisins
- Dried plums are prunes
- You walk around the grocery store and see a lot of grape juice. No raisin juice in sight.
- You walk around the grocery store and see a lot of prune juice. No plum juice in sight.
- CAN SOMEONE PLEASE EXPLAIN THIS TO ME!?
Not everything that makes sense actually works the way you think, and just because something is a good idea on paper does not mean that it actually works. I see the marketing folks (understandably) try to really press on this size issue, as it is the key difference between these two products.
Multiple studies in the peer reviewed medical literature have been done, with a couple listed at the bottom of this posting. There would be a lot (billions of dollars) to gain if someone can prove that their product is in fact superior to others. This should be easy enough to do, as these products are being injected constantly and globally in all skin types.
There are no such studies. There are, however, several studies that show that they are equivalent. As Xeomin is a newer product than Botox and Dysport, there is much more literature comparing the latter two compared to each other than there are that involve Xeomin. At the end of the day, these are all products that are the same flavor of toxin, but just formulated to be different sizes. I am not convinced that anyone has shown that this difference actually matters.
Medical Literature Citations:
The warmer months present a great opportunity to enjoy the outdoors, including activities like gardening that put us closer with nature. For some of us, however, they represent the return of unwelcome seasonal baggage. Seeing our friends post pictures of their reunion with the outdoors on Instagram can give some of us a feeling of hesitation. What is this baggage that comes with warmth? Allergies. And living in one of the allergy centers of the country, the baggage that comes with allergies — lower eye bags.
How are allergies related to lower eye bags?
Lower eye bags can be caused by excess fluid in the lower eyelids, extra fat around the eyes, loose skin, or any combination thereof. Allergies (and some rare medical conditions) are responsible for the fluid buildup of the lower eyelids, which can come and go with the season. This fluid also may be responsive to gravity, being worse in the morning (after a night of lying down) than in the evening. The veins in the head and neck do not have valves, so blood flows in either direction in these vessels. Anything that increases pressure downstream is felt upstream.
An environmental irritant (like pollen) is inhaled in the nose, causes swelling of the lining of the nose, making the veins upstream (around the eyes) get congested and swell. To add insult to injury, allergies make blood vessels “leaky” so the bloated streams leak fluid into the tissues, making a perfect recipe for baggage. If you are burdened by such baggage, then this story is all too familiar to you.
Simple Treatments for Baggage
Knowing that allergies are the cause of the fluid component of the eye bags is the key, as there are several good (and safe) over the counter solutions can address your concerns. My first preference is a non-medicated nasal sinus rinse, which will physically remove the irritants from the nose. Any medical treatment that you do on top of this treats your response to the irritant, but physically removing the irritant is the first step. There are several products available, and the NeilMed Sinus Rinse is my preference. Distilled or boiled water should be used with these products.
Using a nasal steroid spray is the next step, as the clean lining of your nose is now still swollen and irritated, and the spray is a good way to soothe and thin the lining. These nasal steroid sprays were prescription medications just a couple of years ago, and since going over the counter, they have become much cheaper and are widely available. If you decide to use these, do it on a month by month basis. My preference for these sprays are fluticasone (the generic form of Flonase) and mometasone (the generic form of Nasonex).
Oral medications do have a role in treating allergies, and my preference is using fexofenadine (the generic form of Allegra), as it is the least sedating, especially compared to the other popular over the counter allergy medications Claritin and Zyrtec, which are both more closely related to Benadryl, and can cause sedation despite their “non-sedating” claims.
A Natural Cure
The treatments above will treat the allergies, but a “cure” of allergy requires a “re-wiring” of you immune system. There are allergy shots available for people that have symptoms that are not well medically managed. These are based on challenging your immune system with escalating doses of the irritant, whether it is tree pollen, grass pollen, or cat dander. Eventually, these repeated challenges steer your immune system away from allergies.
A natural solution is to introduce a fine sampling of local pollens into your bloodstream by getting raw, unprocessed local honey and placing it under your tongue and holding it in place for 2 minutes. This is done twice daily for several months or years, and is the only over the counter solution that is a potential cure for allergies. Eating the honey does not have the same effect, as it is filtered by the liver and “inactivated”. This is another way to challenge your immune system with the pollens that you are allergic to, and eventually change your body’s response to those irritants.
Other Types of Bags
If you have done everything you can to address excess fluid around your eyes and still have baggage, your bags may be due to more complex causes than fluid, such as excess fat around the eyes, loose skin on the lower eyelids, or a loss of tissue over the bony orbital rim. These are more complicated to address, and may require treatments such as surgery or a dermal filler to treat the specific causes of your bags.
Whatever the cause of your baggage, knowing that there are simple and natural ways to address these complaints is the key to liberation from them.
Botox vs Dysport
What is Botox?
What is Dysport?
Botox vs Dysport: Different Units
Botox vs Dysport: Conclusions
Botox vs Dysport: The Proof
Medical Literature Citations of Botox vs Dysport:
The Nuance Facial Plastics Blog is here to give you the most honest, up to date information from us to you, in our “sponsored by nobody” style. Our discussions will include topics that interest our readers, with a focus on facial plastic surgery. We will use this space to answer frequently asked questions and also discuss current trends, new products, and emergent technologies. Information is widely available on the internet, but good information that is not marketing material in disguise is hard to find, and often times constitutes a majority of what patients read as their “research”. The Nuance Facial Plastics Blog differs, as we are an independent practice that has no exclusive deals with any vendors, companies, or other entities that would influence the quality and honesty of the information we provide you.
Our First Series
One of the most common discussions that we have with patients is about the differences between the products that we offer, as there is some overlap. The single most common question we get asked is, “what is the difference between Botox and Dysport?”. Our first three-part series will explore the differences between the three neuromodulators currently available in the USA, Botox, Dysport, and Xeomin. Several topics, such as differences in the strength, longevity, or “spread” between the products will be discussed. Despite being broken into a three-part series, there is quite a lot of information, as the information from these posts is rooted in science, and the claims are supported by multiple articles published in high quality, peer-reviewed medical literature.
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