As I listened to myself the other day droning on, answering the same questions and dispelling the many myths that patients have and believe, I decided I would list some of the most common questions and myths I hear every day and write out some simple answers. So, whether it is the patient thinking of having a cosmetic treatment for the first time, or the Botox patient that is thinking about having filler, or the filler patient that is thinking about having Botox or the laser patient thinking about having Botox or the Botox patient thinking about having laser, everyone seems to say the same things. “I don’t want to look done.” “Do you know that shiny look that women get when they’ve had Botox? I don’t want to look like that.” “I want to look natural.” “I don’t want my boyfriend to know.” “I want to have some expression.” I need to have expression I’m an actor.” “I don’t want to look like a chipmunk.” “You can’t bruise me.” “I’ll be furious with you if you give me a droopy eye.” These are the things I hear everyday at least 15 times a day.

I’d like to know if patient’s really thought that I wanted to make them look too done, unnatural, shiny, droopy. I wondered, did they think I wanted to give them a droopy eye or a bruise on purpose? (By the way, if a doctor tells you that they’ve never given a patient a droopy eye, he/she is either lying or not doing enough Botox). I was amazed how many times I hear, “no, no, no, no, I will never do that” and then a few years later they do it. Actually, as I was thinking (and talking but not really listening to myself because, by now, the words just come out of my mouth) that shouldn’t patients be excited that they were having a cosmetic treatment. I hope the following questions and answers will make you excited to come to my office. I promise, we always have fun.

What is actually happening when we think we look tired or old? What characteristic on the face has changed causing us to look older?

It is not usually noticed that, even people that feel they have a “round” or “fat” face, we all start to lose the elements that give our skin the support it has when we are young. Our faces lose volume as we age due partly to heredity, sun exposure and sunburns as children, smoking, stress, and any combination of factors. As we get older we appear sunken. The area around the temples, all of a sudden, looks like it is hollowing out, the area below the eyes starts to look sunken with dark circles, the cheeks aren’t as full as they used to be and they sometimes also look sunken.

This volume loss is caused by a combination of the breakdown of collagen and elastin fibers, the disappearance of subcutaneous fat, and loss of bone. These are the elements (collagen, elastin fibers, and bone) that provide the support the skin needs to stay supple, not droop, not get sunken, not get dark circles below the eyes. Just as people get osteoporosis and lose bone elsewhere, we lose bone in our face, and fat, and dermis (made of collagen and elastic fibers). We dermatologists and plastic surgeons have changed the way we use fillers, exactly due to of these factors. It seemed obvious to us that if we could give the skin back its foundation, its support, we could put it back to where it used to be. We use fillers, toxins, and lasers to replace this loss of volume and we concentrate on deeper structures than we did before. We are reapplying the “foundation” just as one would do in a dilapidated house on a hillside.

Where are the signs of aging most visible?

I have found that many patients do not know why they look old. They don’t notice where the changes are taking place or what could be done about it. I think the majority of patients that come in looking “older” can’t really tell me why or what area they’d like to address. They say that they just look tired.

I believe that most patients are looking older due to dark circles beneath the eyes and indentations in the area of the temples and cheeks. If we can restore the foundation in these places, we would be addressing the defects of the face by hoisting it up like we would a dilapidated house! This is exactly what we can now do with new technique. The characteristic areas of volume loss are our usual points of attack. Other areas that change as we age are the glabella (the area between the eyebrows), the jawline, the chin, and the mouth.

How do the newer techniques with applying fillers and toxins work to restore a youthful appearance?
Collagen, elastin, muscle and bone all decrease in mass due to chronic sun exposure and as a result of the normal process of aging. When we treat the aged skin, we are literally rebuilding the skin from the ground up applying whatever technique is appropriate for the level we are replacing. As a result of a stronger foundation, the skin lifts, the lines and folds smooth and the patient looks younger and is happier.

What specific conditions or areas of the face/body are fillers and toxins primarily used for?
An experienced dermatologist or plastic surgeon is able to use fillers, toxins, and lasers in all areas of the face, neck and chest. The chances are high that you see people every day that have had cosmetic procedures. It really is too bad that people think that the “shiny” skin, the “pulled” skin, the “frightened” look, the “Dr. Spock” look are the result of (whatever their friends tell them). I could make many people look much better, much younger, much happier, if these myths were dispelled.

What potential risks are there when the fillers and toxins we’ve been talking about are not administered by an experienced Dermatologist? What should patients seeking these treatments know about who exactly is administering the treatments?

This question is difficult for me to answer. It has to do with my philosophy more than it being right or wrong. Every state has its own laws as to who can administer these treatments. I believe that having gone through medical school, doctors are more trained, more educated, than non-doctors. So, doctors know the anatomy better–where the muscles insert, which nerves innervate which muscles, etc. How to treat the antagonistic muscles so the opposite effect occurs, etc. However, a nurse injector who has injected every day for years may be better than a plastic surgeon just out of residency. I learn every day, with every procedure I do. The more you do, the better you are at doing it. My philosophy is to stick with dermatologists and plastic surgeons, who have studied the face more than anyone else. Even here there is a difference. Dermatologists do this all day. Surgeons would be happier in the operating room. So, the individual with the most experience doing the procedure usually does it best.

With so many products available to dermatologists, how do you decide which to use on a particular patient?

As clinicians doing these procedures, we each develop our favorites for idiosyncratic reasons. One doctor may have certain feelings for a product that others may not have. Some are influenced by deals we offer. Some say, do whatever is appropriate to make me look younger, do it today, and don’t bruise me because I have a function to go to tonight, I cannot have a bruise, but please make me look younger now—it’s an emergency, oh but please do it “without making it look too done.”

A common concern among new patients is with potential side effects and downtime. What risks are involved when getting treated with fillers and toxins?

Whenever a needle is used to inject anything, there is a risk of bruising and swelling. So, patients must be prepared for this and they should not book appointments right before important events, premieres, etc. We do many procedures that do not result in any downtime. We must. Actors and models may be called at the last minute to do a job so they always need to look their best. Also, it seems that everyone has something important to go to. Some lasers require downtime but this is discussed with the patient usually during a preceding visit.

Describe a successful procedure you’ve done, and the effect on the patient.

I had been seeing this particular patient for a very long time. She was in her late 70’s when I met her. She had had some tragedies occur in her lifetime that left her physically and mentally exhausted. Sometimes I would only see her once a year. She was still working at a job she had had for 35 years.

When fractional resurfacing lasers first hit the market, we were bombarded with salespeople wanting us to buy their laser. So, naturally we had to try out these lasers on different people. I immediately thought of this patient. She would never have been able to afford to do a procedure of this nature; she wouldn’t have ever entertained the possibility.

Well, we did the procedure on her twice. Her wrinkles went away. Her unhappy mouth turned upward as if in a perpetual smile. She was thrilled. Her spirit lifted. Her friends were jealous. It completely changed her mood and when she comes in now, she always wears make up and looks at least 10 years younger than she did before the treatment. It almost seems to have changed her personality.

What is the best part about performing rejuvenative procedures for you personally?

Well… doing them on myself — naturally.