There are two basic types of wrinkle. Dynamic wrinkles are in response to underlying muscle activity. Contracting the muscle causes the skin to wrinkle. Once the muscle stops contracting the wrinkles disappears or at least lessens.
With the muscle repeatedly contracting, the wrinkles become evident at rest as a static wrinkle – there all the time.
These two types of wrinkle need different or combinations of treatment. Because the dynamic wrinkle is in response to muscle activity, weakening or paralysing the muscle will reduce the wrinkle. Botulinum toxin is probably the most common treatment for this.
Pre-treatment photographs may be taken to determine the starting baseline. The area is then carefully assessed to ascertain the extent and bulk of the muscle. Skin cleansing and preparation is performed. The desired number of units of the toxin is injected with fine sharp needles. Gentle pressure may limit the spread of the toxin and reduce bruising or swelling. Multiple areas can be treated at once.
The end point may be to soften or weaken the muscle or to completely paralyse the muscle. Weakening the muscle allows some movement but the resulting wrinkle is much softer. This allows the person to still have some facial expression and animation. Complete paralysis of the muscle will result in no movement even when trying to contract the muscle.
Static wrinkles are usually treated by filler injections. The most commonly used fillers are hyaluronic acids. These are naturally occurring sugar molecules already present in the body. If the sugar molecules were injected the body would rapidly break them down and absorb the sugars.
During the manufacturing process the longer strands are cross linked. This process makes the filler more viscous and more resistant to absorption. Attracting water adds to the volume of the fillers used. Some fillers are left fairly liquid or runny, these are the shortest lasting but can be injected into areas of fine skin such as the eyelids or hand. Intermediate thickness fillers are used around the mouth and nose for treating the lips, nasolabial folds and marionette lines. Thick fillers are injected more deeply, close to bone to fill and plump up cheeks or chins. Rather than treating wrinkles as such, these are used for the volume effects. Results can be reversed until a few days after the treatment.
Unfortunately the botulinum toxin and hyaluronic acid fillers are temporary. Dynamic wrinkles are softened for three to six months and may take three to six days before they begin to work. The return of muscle function is gradual. The thinnest or most liquid fillers may last six to nine months, the intermediate fillers nine to eighteen months and the thickest or most viscous filler up to three years. The effect is immediate.
There are permanent types of filler injection available but these may be very difficult to reverse especially if the result is not what was desired. A commonly used permanent filler is to use the patient’s own fat. Fatty tissue is taken or harvested, prepared and then re-injected. Once the fat has taken, very like a graft, the result is permanent. Results can be augmented by adding more fat or removed by liposuction.
At times the botulinum toxin may be used to soften the muscle while filler is used to treat it. Combinations are commonly used in the treatment of the corners of the mouth. Filler may replenish lost volume while botulinum toxin softens the depressor muscle.
At the time of consultation all these options are carefully explored and the best treatment or combination of treatment selected.