Mr Guy Sterne, Consultant Cosmetic Surgeon


Anti-wrinkle treatment by injection


Wrinkles are one of the prime signs of aging for which patients consult the cosmetic plastic surgeon. Skin wrinkles fall into 2 types; static and dynamic. Static wrinkles are present all the time and are caused by sun damage, smoking and the effects of aging; namely skin thinning, gravity and laxity.

Dynamic wrinkles occur first in younger people. They are not present with the face relaxed, but appear as a result of contractions of the delicate underlying facial muscles every time we smile, laugh or frown. The more emotion we show the deeper these lines and wrinkles are likely to be. Over time, dynamic wrinkles develop into permanent, static wrinkles.

By treating the underlying cause of dynamic wrinkles, anti-wrinkle treatments by injection can prevent or delay the onset of permanent static wrinkles. Once static wrinkles have formed, injections can help prevent them getting worse, but it cannot eradicate these permanent wrinkles. Other treatments are needed for this.

Anti-wrinkle treatments by injection is currently the most popular cosmetic procedure with over 1.6 million injections being performed last year. For many people, injection treatments represents their first experience with cosmetic surgery. As a quick and effective treatment, with excellent results and virtually no downtime, it is perfect for those patients who have minimal signs of facial aging such as forehead furrows and crow's feet. Whilst injections can often delay the need for more extensive surgery, it is important to stress that it does not achieve the same results as surgical procedures.

What is anti-wrinkle treatments by injection?

The anti-wrinkle treatments is a nerve toxin produced by a bacterium called Clostridium botulinum. In very high doses (>3000 units) it produces the disease called botulism. In much lower doses (20-40) units it can be safely used to temporarily weaken muscles.

How does it work?

When injected into a muscle, botulinum poisons the nerve ending stopping the nerve from sending a signal to that muscle. By doing this, the muscle cannot contract and therefore relaxes. With the muscle relaxed, the overlying skin remains smooth and unwrinkled. Nearby untreated facial muscles continue to contract in a normal fashion, allowing normal facial expression to be unaffected.
Botulinum permanently blocks the nerve ending, but with time, the nerve grows a new nerve ending and the muscle starts working again. This takes about 3-6 months and the muscle recovers completely.

What areas can be treated?

Anti-wrinkle injections are most commonly performed in the upper face. The most common areas requested are the horizontal forehead lines, vertical frown lines between the eyebrows, and crow’s feet (or laughter lines) radiating away from the eyes. While it would probably work around the mouth and chin, it would almost undoubtedly weaken the smile and we do not recommend its use around the mouth. Creases around the mouth are usually either treated by peels or by filling them out with a temporary filler or fat.

Can I have all of my areas treated on the first go?

Usually we recommend that only one or two areas be injected in the first instance, typically the frown lines and crow’s feet. In the interests of safety we usually use the lowest dose at the first visit too because it is not possible to predict how sensitive any one individual may be to the botulinum. If the dose proves to be too little, a higher dose can be used several weeks later.

What will happen at the initial consultation?

During the consultation, you will have the opportunity to talk to your surgeon about the changes that you’d like to make in your appearance. You will be given an explanation of the different options available to you, the procedure itself, and the risks and limitations involved. Pretreatment photographs will be taken and if you choose to proceed with the injection, you will be asked to sign a consent form before undergoing the procedure.

What are the alternatives to anti-wrinkle treatments by injection?
Early permanent static wrinkles can be filled out by injecting a temporary filler material beneath them, or injecting fat beneath them which is more permanent. If the static wrinkles are a little more established, then the skin can be resurfaced by burning the upper layer of the skin off with an acid peel or with a laser. If there is excess, lax skin, the most effective method of treating the wrinkles is to perform a surgical lift of the forehead, midface and neck regions. Combinations of the above can all be used as appropriate.

Am I a suitable candidate?

Obviously only a consultation with a fully qualified consultant will be able to establish this. After taking a detailed history and a performing an examination, your surgeon will advise on the most appropriate method of facial rejuvenation.

Who is the best candidate for anti-wrinkle treatments by injection?

A wide range of patients benefit from injection therapy. It is ideal for younger people (25-60) who are just starting to develop wrinkles. The injections treat existing creases, as well as potential creases before they start. Patients who have had laser resurfacing or a face lift also benefit by preventing repeated wrinkling of newly treated skin. In many cases, wrinkles in people over 65 are caused by sun damage and therefore are not disposed to this treatment; however, each person is different and must be evaluated by the physician.

Who should not receive anti-wrinkle treatments by injection?

  • Pregnancy; although there have been no reports of birth defects with this medicine, no pregnant patients will be treated.
  • breastfeeding; similarly, there is no evidence that botulinum is expressed in breast milk but it is best avoided if breastfeeding.
  • Patients with a history of neuromuscular disease (multiple sclerosis and myasthenia gravis) or other types of diseases involving neurotransmission should avoid this medicine.
  • Patients taking the following medicines should not receive the injections: aminoglycoside antibiotics (Streptomycin, Tobmamycin, and Garamycin injections), penicillamine, and calcium channel blockers (Calan, Cardizem, Dilactor, Norvasc, Procardia, Verelan).
  • Known allergy to human albumin.

How are the injections done?

The procedure itself is simple and safe. The anti-wrinkle treatment is injected with a very tiny needle directly into the affected muscles. Depending on the area treated, between 4-10 injections are necessary. Because the needle is so fine and only a small amount of liquid is used the pain is usually minor, like a sting for a few seconds. Once the injection is complete there is usually no discomfort. No sedation or local anaesthesia is required and as no recovery period is required, you can resume normal activities immediately. You can even drive yourself home or back to your office. Very occasionally some patients experience a slight temporary bruising or redness at the injection site.

What will I look like after my treatment?

Immediately after the treatment, there may be a mild amount of redness at the injection site, but this resolves in a few hours. Bruising is very uncommon.

Will I notice the effect straight away?

The full effects of injection treatments are not apparent for three to seven days. The muscle becomes very weak but is not usually totally paralysed so some movement usually remains. These effects are temporary and the muscle function returns to normal in approximately three to six months. A top up injection will be required after this period of time to maintain the skin smoothing effects.

Are there any side effects?

There are no serious side effects associated with this procedure and there have been no reports of permanent damage caused by the injection. Since the effects of injectable fillers are temporary, so any side effects are also temporary.

The most common complications are:

  • Bruising - there will be penetration of the needle so smaller blood vessels may be injured. 
  • Swelling - may happen and lasts a couple of hours to a few days.
  • Pain - only during the procedure, unless there is a big bruise, which may create pain. Ice packs help with both bruising and swelling
  • Headache - for a few hours mostly. It is safe to take paracetamol to relieve this. 
  • “Ptosis” or drooping of an eyelid is the most common significant complication (less than 1%); this is caused by the botulinum toxin tracking into the upper eyelid muscle. It generally starts after 5-7 days and lasts just a few weeks. Let your doctor know if this bothers you; eye drops can be prescribed to lessen this effect.

Pre-treatment instruction

Cosmetic patients are very unhappy when bruising results as a complication of botulinum toxin injections. The following can decrease the incidence of bruising: 

  • Green Tea; avoid drinking green tea for 10 days before your injection.
  • Discontinue aspirin and non-steroidal anti-inflammatory agents (e.g. brufen, Ibuprofen, Voltarol) for ten days prior to treatment. Paracetamol is permitted.
  • Avoid Vitamin E supplements for two days prior to treatment. Regular multivitamins are permitted.
  • Avoid alcoholic beverages for 24 hours prior to treatment.
  • Remove all facial makeup in any area that you may wish to have treated upon arrival to the office.
  • Some patients claim taking 2 paracetamol 1 hour before their treatment lessens the discomfort of the injection
  • Ice packs can be placed on the area to be injected just prior to injection. This may help decrease the pain of injection (which is minimal) and decrease the incidence of bruising.
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