Botox vs. Filler (such as Juvederm)

Do Botox and injectable fillers do the same thing?

They most certainly do not. Botox (the brand name for onabotulinumtoxin A) is a highly purified chemical that blocks muscle activity. Fillers such as Juvederm, Restylane, etc. are naturally occurring compounds that, when injected, occupy space.

When Botox is used, the goal is to limit muscle activity that results in wrinkles or furrows. Technically speaking, Botox interferes with the nerve telling the muscle to tighten. Certainly the most common location treated is between the inner eyebrows where two vertical creases can occur from muscle activity. Other places where Botox can be used are the crow’s feet area around the outer corners of the eyes and between the eyebrows and the hairline where forehead wrinkles have developed. There are other places in which Botox can be valuable, but the principle of its use is to limit, weaken or nearly eliminate muscle activity that results in wrinkles. It is important not interfere with a natural appearance of the face and a to maintain a face that is able to express emotion appropriately. Botox, when used properly, will enhance the face in a natural way, rejuvenating it without giving it an unnatural or imbalanced appearance.

Certain areas where wrinkles or furrows occur you would not want Botox treatment. Those are places where Botox use would interfere with the natural smile or natural function. In these places, a filler can certainly be considered.

Fillers affect wrinkles and furrows in a completely different fashion. In places where wrinkles or furrows have occurred from gravity and not muscle activity or where muscle activity should not be disturbed, fillers can help rejuvenate the face attractively and naturally. Certainly the most common filler I use is Juvederm. Juvederm is a naturally occurring chemical called hyaluronic acid and can be found within most tissues between the cells and as part of the structural component of soft tissue. By carefully injecting a filler into an area where a furrow gives the face an older appearance, that appearance can be softened and improved. This can provide a significant rejuvenation result. The most common place to undergo filler therapy is around the mouth where the furrow extends from the corner of the nose down to the corner of the mouth. These “nasolabial furrows” are very well treated using Juvederm. There are furrows and shadows that develop below the corners of the mouth that can also effectively be made less noticeable with the use of fillers.

Sometimes a filler and Botox treatment can be combined. Not only can they be performed in different locations at the same time, but sometimes one will enhance the results obtained by the other. In people who undergo Botox therapy but there remains a residual wrinkle in the skin, a treatment with filler can reduce or eliminate that residual crease in the skin and further enhance the results of Botox therapy.

Both Botox and fillers are minor office procedures and can be done without significant interference with day-to-day activities and with minimal post-treatment inconveniences.


Do I need an upper eyelid lift or a browlift (or both)?

What is the difference between an eyelid and a brow lift? Do I need only an upper eyelid lift, or both?

An upper eyelid lift (blepharoplasty) will address the problem of excess skin hanging over the upper eyelid. This often gives the eyelids an aged appearance. A brow lift addresses the problem of the eyebrows descending downward, giving the brow a heavier look and, sometimes, making the individual appear older, more tired, or even angry. Sometimes when the eyebrow or forehead descends, or droops, this can result in increasing the laxity of the upper eyelid skin that can worsen eyelid aging changes already present. If a person has both excess looseness of the upper eyelid skin resulting in hooding and folds of skin of the upper eyelids, as well as brow descent, an upper eyelid lift alone will only solve part of the problem. Sometimes an upper eyelid lift should be combined with a brow (or forehead) lift.

In addition to rejuvenating the upper eyelid area and eyebrow area, a forehead lift can also smooth some of the horizontal wrinkles of the forehead and, in fact, lift the area between the eyebrows and reduce the furrows in this area as well.

With an upper eyelid lift, the excess skin of the upper eyelid is removed, any fatty fullness that gives the eyelids a heavier appearance can also be removed, and the incision is carefully closed. This result ins an all but invisible scar that rests within the fold of the upper eyelid. A brow lift, or forehead lift, will elevate the skin and soft tissue of the entire forehead and eyebrow area allowing it to be elevated and held in place in its newly elevated position. A forehead lift can be done through a traditional open technique which will typically provide greater lifting and a longer-lasting result, or be performed through several small incisions utilizing surgical telescopes to elevate and secure the forehead in its younger, more attractive location.

Occasionally I’m asked; “What if all I want is to do an eyelid lift, but my forehead and eyebrows have aged somewhat too?”

In this case, I recommend my patients decide whether the limited, but still significant, improvement that can be provided by an eyelid lift alone is worthwhile. If so, proceeding with an eyelid lift alone is certainly reasonable. If, however, the patient is sure that he or she will not be happy unless full rejuvenation is performed, then both an eyelid lift and a brow lift would certainly be necessary. In general, an upper eyelid lift is certainly a smaller procedure with less swelling and discomfort when compared with a forehead lift. Therefore, many patients elect to proceed with the eyelids only and remain open to the idea of a future forehead lift if further rejuvenation is desired.

The most important thing to remember at all times and in all cases of cosmetic surgery, is that the best surgical plan is the one that is custom-designed and is most suitable for the unique goals of each patient. During your consultation with me, I will help you to understand how best to proceed to reach those goals in as convenient and comfortable a way as possible.


Saline vs. gel filled breast augmentation implants.

I am often asked what type of breast augmentation implants I recommend. While each type of implant has its advantages, it is up to the individual patient to decide which advantages she desires and which inconveniences she is willing to accept. There is no right or wrong answer; there is simply the answer that is most right for you, the patient.

Saline implants are made with a solid plastic (silicone plastic) bag or “shell” on the outside. This implant is placed into position and inflated during surgery with saline solution. Saline is simply salt water that has the same concentration of salt to water as you’ll find in your own body. Because saline implants are inflated once they are in position, a slightly smaller incision can be used (typically 4.5 cm instead of 5.5 cm in length) than are used when placing a pre-filled silicone gel implant into position. In addition, the fill volume of the implant can be varied to adjust for natural asymmetry that the patient may have prior to surgery. By adjusting the saline implant fill volume, we can reduce natural asymmetry as much as possible.

Silicone gel implants have a very similar shell, but are filled with a silicone gel material. This material is a very thick gel that is a lot thicker than was present in 1st, 2nd and 3rd generation gel implants from many years ago. This gel, however, is still softer than solid silicone would be, but not as liquid-like as water.

The strength of the shell of different breast augmentation implants are very similar and the leakage rates are very similar as well. What differs is how the material that the shell is filled with behaves. Saline will have a firmer quality when used for breast augmentation. Gel, which feels a lot like natural breast tissue, will have a more natural, softer feel. Because saline is simply water, there is a tendency for saline implants to feel somewhat like a balloon of water. This means that under many circumstances, some rippling or scalloping around the edges of the implant can be felt. Typically, if the implants are placed below the chest muscle, rippling/scalloping is not visible. There is a “feelable” difference when the plastic shell is felt. In contrast, if there is gel within the implant shell there is a much less noticeable ability to feel the implant. This is particularly true in the lower part of the breasts just above the fold. Silicone gel will have much less of a tendency to have rippling and scalloping “feelable” and consequently it will be even more unlikely to have those changes visible. During your consultation you will have the opportunity to feel both types of implants and be able to better understand the differences.

The main advantage of saline implants is that when they do break (remember, all things break eventually), you will know it in a day or two as the water is absorbed by your body and your breast becomes flat. With silicone gel, however, the gel remains within the scar tissue pocket and you will not see any difference whatsoever. With silicone gel implants, if you want to know whether the implants are intact, a breast MRI is necessary. With saline implants, you just have to look at your breasts to know if they are intact. For that reason, it is recommended that women who have silicone gel implants consider periodic breast MRI imaging to check the status of the implants. I recommend you consider having this monitoring at eight years post-op and then every three years thereafter.  We can refer you to a facility that offers a deeply discounted rate for an MRI for breast implant surveillance.

I am frequently asked if silicone gel breast implants are safe. They are as safe as saline implants in my opinion as they have no known generalized illnesses associated with them should they leak. In fact, what typically happens is that when they do leak, you will not notice any change at all. Countless studies have shown that silicone gel-filled breast implants do not have any higher rate of general illness associated with them (whether they are intact or broken) when compared to patients who have saline implants or have no implants at all.
The only other difference is that silicone gel-filled implants are a bit more expensive than saline-filled implants. On the grand scheme of the cost of breast augmentation, however, the cost of the implants should not be how you make the decision as to which type of implant you want.

So, in general, decide what results you want, saline or gel, and then decide whether you are willing to accept the maintenance necessary for each type of implant. If you are willing to undergo MRI monitoring to check whether the implants are still intact, then silicone gel will be a great choice as it will certainly give you a more natural-feeling result. If you are unwilling to consider the MRI monitoring of your implants for leakage, however, then saline implants might be right for you. Remember, however, you would have to accept that they might be more “feelable” and there might be rippling around the edges of the implant.

Remember, no matter what you decide, the decision will not be made until after you have had a chance to talk to me during your consultation and have any other remaining questions answered. Your care will be customized to your goals and desires.


Do I need to replace my breast implants every ten years?

I am asked this question frequently. If the implant is intact and there are no other circumstances requiring breast surgery, there is absolutely no reason to replace the implants no matter how long they have been in place. If, however, the implant has been discovered to have developed a leak, then it is recommended the implant be replaced regardless of how long the implant has been in place. If a saline implant shell develops a leak, it will be immediately apparent within a day or two when the breast becomes significantly smaller. When silicone gel-filled implants develop a leak, it is usually not apparent to the patient or her physician. The gel that may leak out of an implant shell that has developed a tear will, typically, remain within the scar tissue pocket that naturally forms around the breast implant. This gel is not able to be absorbed by the body as in saline filled implants. Therefore, in most instances there will be no change in appearance nor any symptoms associated with a silicone gel-filled implant shell developing a leak. This is why we recommend periodic MRI surveillance be performed to evaluate silicone gel implants that have been in for a certain period of time. An MRI can determine if the implant is intact or not. Certainly if the implant appears to have developed a tear in the shell, we do recommend the implant be replaced. Please be assured, however, that there is no scientific evidence that a silicone gel implant leak leads to any significant medical illness. Nonetheless, because it is a medical device that is no longer functioning as designed, we do recommend replacement.

If capsular contracture has occurred, the patient will notice a tightening of the breast with firmness developing, perhaps a change in the shape of the breast, and sometimes there may be discomfort associated with the tightness of the scar around the breast implant. At times the breast will take on an appearance that looks somewhat smaller and sometimes rises up on the chest a little bit as well. To correct this problem, surgical release and relaxation of the scar tissue pocket is recommended and, at that time, the implant is typically replaced.

If other surgery is being performed on the breasts of a patient who has undergone breast augmentation many years previously, I typically recommend that implant replacement be performed. In my opinion, if the implant has been present for more than eight years or so, there is an increasing likelihood, over time, that an implant will develop a leak in the future. It seems wise to replace the implants when already in the operating room, thus avoiding the inconvenience of future implant replacement surgery. Certainly recommendations will be tailored to every individual’s unique requirements and medical plan.

So please don’t be concerned that if you have had breast implants for ten years that you will need to have them replaced. If everything is fine and you need no other surgery, there is absolutely no reason to replace the implants electively. You can feel completely at ease enjoying the results of your breast augmentation without having to undergo unnecessary surgery.