The Anti-Aging Series: What To Do About Those Pesky Wrinkles? All About Botox + Resurfacing
Photo by JC Gellidon on Unsplash
Wrinkles are probably most associated with the aging process, and although I think they signify a life well-lived, I personally like to keep them in check. All wrinkles are not created equal and in this post, I will walk you through the nitty gritty of telling them apart and how to treat them.
The wrinkles you may notice first are the ones from repetitive muscle movement that likely are more pronounced when you make certain faces like:
“Crow’s feet” — around your eyes when you smile
“11’s” — in between your eyebrows when you’re deep in thought or squinting
These “dynamic” wrinkles, also known as rhytides, develop from the pull of frequent muscle movement on the overlying skin. Depending on how expressive you are, these wrinkles tend to show up in your 30s and usually go away when your face is at rest. Over time, these wrinkles can become fixed and be present even you’re not making faces.
Bad news.
No serum or cream is going to help these wrinkles go away (no matter what advertising tells you). Because the underlying cause of these types of wrinkles is muscle movement, the most effective way to address them is to stop them from moving.
Look how tiny that needle is!
How the heck do you do that?
Botulinum toxin, produced by bacterium Clostridium botulinum, stops muscle movement by blocking the chemical signal (acetylcholine) sent by motor nerves to your muscles. Essentially, your muscles aren't getting the message to move, so they don't contract and stay nice and smooth, leaving you with a wrinkle-free babyface.
The purified toxin (which I like to think of as a liquid time machine), is administered directly to the muscle using tiny needles. This seems to scare people, but it just feels like little quick bee stings. The little welts resolve on their own in the next few hours. All my first-time patients that come in apprehensive tell me it isn’t so bad, even without topical numbing medication before treatment.
Once you get injected, it takes 5-10 days for muscle movement to stop and for the full effect to be seen. You'll start to see movement again in about 3 months and be back to your baseline in about 4-5 months.
Where do you get toxin injected?
Botulinum toxin can be used anywhere where there is repetitive muscle movement leading to wrinkles. The most common areas it is used is:
between the eyebrows — also known as the glabella
the forehead
the muscles around the eye — a.k.a. the crow’s feet
the “smoker’s lines” around the mouth
in the chin — to smooth out lumpy, bumpy “peach pitting.”
What's the difference between Botox, Dysport, Xeomin, and now Jeuveau?
No, they aren't the names of towns in Alaska. They are different formulations of Botulinum neurotoxin and I'm going to break down how they differ.
Botox, Dysport, and Xeomin are all Botulinum toxin serotype A, which has been shown to be most effective at blocking acetylcholine release (the chemical message sent by nerves to your muscles) via cleavage of a protein called SNAP-25.
Botox (onabotulinumtoxinA) was the first to market (1997) and is the most widely used brand of toxin. It has the most approved indications and is the only one approved for the treatment of hyperhidrosis (excess sweating). This is my go-to toxin — I find that its effects tend to persist longer than other formulations, although this is entirely anecdotal.
Dysport (abobotulinumtoxinA) was approved in 2009 and is made using a different purification procedure than Botox. Other than that, Dysport has been shown to have a greater spread in the muscles once injected, thus leading to more diffusion of the product. Practically, some patients find that it gives them a smoother appearance. In my experience, I've found that many people report that it wears off faster than Botox.
Although Dysport is often listed as less expensive than Botox, it is important to remember that 3 units of Dysport are equivalent to 1 unit of Botox. So, that means if you need 30 units of Botox to treat your glabella and your forehead, to get the same effect, you will need 90 units of Dysport.
Xeomin (incobotulinumtoxinA) was approved in 2011 and does not have any accessory complexing proteins. This is meant to reduce the risk of antibody formation, which can make the toxin less effective. There is little head to head comparison data between the products, but I did find one study in hyperhidrosis (excessive sweating). Although both had equivalent efficacy in stopping sweating, Botox had a faster onset and long duration than Dysport.
Jeauveau (prabotulinumtoxinA-xvfs) is the newest kid on the block, just released in 2019. Its price is about 30% less than Botox and it touts a shorter time of onset, meaning your muscles stop moving sooner. If you have developed antibodies to other neurotoxins, like Botox, it might be worth trying this one. Since it is so new, I don’t have much more to say about it.
Photo by Cristian Newman on Unsplash
When should you start doing it?
Well, it's different for everyone, but if you see lines stick around, even when you're not making a face, it's probably time. Studies have shown that using Botox earlier can prevent the formation of wrinkles a.k.a prejuvenation, and keep you smooth and line-free for longer.
What about those fine lines that are not due to repetitive muscle movement?
Wrinkles that are often referred to as “fine lines” have a different genesis. These are from chronic sun damage (yet another reason to revert a nocturnal lifestyle). UVA exposure penetrates the deeper layers of the skin (the dermis) and over time, destroys the structural integrity of the elastic fibers and collagen fibers that give your skin a smooth, youthful appearance.
You can see this change under the microscope as solar elastosis, a lavender-blue amorphous material that has replaced well-defined collagen fibers within the dermis. The wrinkles resulting from this microscopic change show up as fine lines in areas that don’t have dynamic movement, but it also makes dynamic movement wrinkles worse. Think 88 year old woman who’s had a lifetime on a beach and also owns a tanning bed.
This damage is deep and beyond the penetration range of topical products, thus the lack of efficacy of most products touting “anti-wrinkle” properties. Be skeptical about marketing claims!
On the right is normal collagen in the dermis (the supportive scaffolding below the top layer of the skin, the epidermis). On the left is how the collagen and elastic fibers look after MANY years out in the sun.
It's pretty much turned into mush that we call solar elastosis. That mush doesn't have the same supportive integrity as the normal collagen fibers. It's like making a macaroni sculpture with uncooked vs. cooked pasta.
Do anti-wrinkle creams help reverse this collagen damage?
This damage is deep and beyond the penetration range of topical products, thus the lack of efficacy of most products touting “anti-wrinkle” properties.
Topical retinoids have some data showing improvement in collagen, however in practice, I have only seen mild improvement in fine lines, and it’s usually in patients that are religious with it and have been using it for years and years.
So if topicals don’t really work, how do you address the wrinkles from chronic sun damage?
Fix the collagen! So there are a few ways to go about doing that, but they all utilize the same principle of getting rid of solar elastosis and stimulating the formation of brand new, healthy collagen.
Microneedling is probably the least costly resurfacing technique. Essentially, the skin is pierced with extremely tiny needles, damaging the old collagen and stimulating the growth of new collagen. The downtime is about 5-7 days and a series of 3-5 treatments is recommended for the best results.
There are many lasers that are used to resurface the skin. The OG method was to fully destroy the top layers of the skin, using something called a C02 laser (think Samantha in Sex in the City).
A newer, less invasive device, is the fractional laser. This device uses focused energy to produce small columns of thermal injury, which in turn stimulates the regeneration of healthy collagen. This method is less traumatic with less downtime (about a week), but you'll likely need multiple treatments.
Having ownership over what exactly bugs you when you look in the mirror will help guide you to the best treatments for you. I hope this elucidates some of the smoke and mirrors behind what happens in the aging process.
Stay tuned for the next post on when to think about using dermal fillers!
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References:
Small R. Botulinum Toxin Injection for Facial Wrinkles. Am Fam Physician. 2014 Aug 1;90(3):168-175.
Vergilis-Kalner IJ. Same-patient prospective comparison of Botox versus Dysport for the treatment of primary axillary hyperhidrosis and review of literature. J Drugs Dermatol. 2011 Sep;10(9):1013-5.
Walker TJ, Dayan SH. Comparison and Overview of Currently Available Neurotoxins. J Clin Aesthet Dermatol. 2014 Feb; 7(2): 31–39.