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An ongoing series of informational entries

What You Didn't Know About Botox

October 15, 2022

1. Botox (onabotulinumtoxin A) is made from the bacterium that causes botulism. Botulism is a protein toxin that blocks nerve impulses from reaching the muscle(s).

2. In nature there are seven distinct serotypes of botulism toxin. Only two, Serotype A and B are used as medications and mostly Serotype A.

3. Pharmaceutical uses of Botox becae mainstream in 1987 and was approved for treatment of a number of conditions.

4. Botox is primarily used in the upper face (forehead wrinkles, “crow’s feet” and the lines that develop in the space between the eyebrows. Use in the lower face is more difficult and may create very abnormal smile shapes and other unintended effects.

5. Botox does not work like the irons we use for fabric. Botox merely makes the lines less or inapparent for about three months. Use of Botox as early as in the 20’s has a preventative effect by lessening tendency to wrinkle later in life.

6. Botox requires a larger dose in men, who have larger muscle mass. It also lasts for shorter duration in people with more expressive faces. As one receives Botox repeatedly over time the amount of Botox needed to achieve the same effect seems to decrease.

7. There are a number of brands of Botulinum toxin A, their prices vary. Botox is the product name for one manufacturer. There are other products available that may be less expensive but equally or almost equally effective. Cost currently varies from $10 to $15 per unit.

8. Botox appears to prevent frowning in a manner that reduced negative moods. Many people feel they have a mismatch between their feelings inside and how they really feel. They fell that people think they are angry when they are not. A key use of Botox is not just to temporarily erase wrinkles but to restore the synchrony of how people perceive you compared to how you really feel.

9. There are some potential complications of Botox, most commonly unintended eye dropping, however thankfully Botox wears off later. Even then, only 1% or less of patients experience complications.

Ian Cummings, MD, PhD

The Miracle that is the Human Face

September 15, 2022

The human face is a complex highly interconnected and extremely versatile structure.

There are a number of well identified layers and compartments.

The fist most important layer is the skin, it is a barrier but also is what the rest of humanity identifies as "us" and our state of mind as well as emotions. Beauty is largely defined by what others see on our face, the proportions of our face, symmetry and contours. A detailed understanding of facial anatormy and cooperativity/harmony of facial structures is key to what makes us human and our appearance as well as attractiveness. Embedded in our social structures is a subconscious constant interaction of our facial structures with our "tribe."

The next layer is the SMAS: superficial musculo-aponeurotic system, a complex divider/amalgamating layer that separates superficial facial components from deeper areas.

Amalgamated within and atop the SMAS are superficial fat pads and some of the mimetic facial muscles (distinguished from, for example, chewing muscles).

The deep layer encloses the very important deep fat pads. Originating from bony anchoring points facial ligaments connect overlying skin to the bony anchor points.

All of these stuctures combine their efforts to sustain and implement function.

Aging involves progressive but reversible changes that include all layers.

The bony facial structures remodel over time with in particular changes to the orbit (where the eyes sit) involve changes in eye orientation and how the eye appears. Fat in the orbit also will sag out through the space below the lower lid.

The fat pads (several of which are key in aging) lose volume and also may rotate and descend in the face, losing the normal "upside down triangle" appearance of the youthful face resulting in a "squared off" appearance and sagging of the "jowl line" of the jaw.

The ligamentous structures also change and become looser (lax) and the lines we perceive in aging/aged faces are the result of ligaments still trying to hold the face in the correct "posture." These include the diagnonal crease below the eyes (the "tear trough", the two parallel lines in the brow above the nose ("quote marks), deep crease marks on either side of the mouth and down to the chin ("marionette lines") and deep lines from either side of nose ("nasolabial folds").

Wrinkles above the eyes are more related to underlying muscle's effects upon overlying skin and generally is treated mostly with botulinum toxins (Botox and other brands) and in some instances fillers.

The age-related changes in contour that most telegraph "aged face" to others are mostly in the lower face/orbits and are generally treated non-invasively with fillers.

While generally safe, fillers if accidentally injected into any of a number of facial vessels can result in necrosis of overlying skin/muscle structures unless "rescued" with hyaluronidase (that dissolves the most common filling material hyaluronic acid). The most feared potential complication (rare but not impossible) is injection around the nose or eyebrows that then enters the blood supply to the eye by a connection from nose to eye and may cause blindness (potentially irreversible)

Given the above it is clear that given the very complex and interacting nature of facial anatomy and the risk of complications or a non-anatomical appearance after injection; It is best to entrust your face to those inimately aware of facial structure, function and anatomy. 

Ian Cummings, MD, PhD

Things you don’t probably know about skin

August 15, 2022

1. There are three layers of skin:

Epidermis: top layer of skin, cells constantly mature and then dry and flake off. 30,000 to 40,000 skin cells are shed per minute. The epidermis is an important protective barrier.

Dermis: the dermis is the tough middle layer where there is connective tissue, hair follicles and sweat glands. Skin grows from the area where epidermis meets the dermis.

Hypodermis: is largely made of fat and connective tissue.

2. The skin is the largest organ of the body with 20 square feet of total area. The skin weighs over 10 pounds and contains more than 12 miles of blood vessels

3. Skin starts aging at 20. Collagen levels start to deplete, fine lines begin to develop and fat compartments of the face start to rotate and sag, creating the beginnings of facial aging.

4. There are six different skin shades identified by the Kilpatrick scale from type 1 (very pale) to type 6 (skin of African origin). Type six skin ages much more slowly and has finer texture and appearance. Skin can change types based upon a number of impacts (sunlight, hormonal balance, climate and age).

5. Skin ages in people at differing rates. Most (probably 90 percent) of aging is related to sun exposure. Smoking may be just as detrimental. Skin health reflects overall health. Skin aging does not seem to be genetically determined.

Ian Cummings, MD, PhD