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Plastic and Reconstructive Surgeon, San Francisco, CA Dr. Brunno Ristow, American Society for Aesthetic Plastic Surgery
Modern Plastic Surgery
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The Pacific Clinic, San Francisco, CA
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Contact Dr. Ristow by phone 415.202.1507, San Francisco, CA
Contemporary Injectibles

Injectables: A Letter from Dr. Ristow

Surgery remains the undisputed standard of excellence for rejuvenation. However, various circumstances and economic considerations have made many curious about alternative options. Therefore, I decided to write this letter to help explain the various non-surgical remedies available today.

When injectables first became available, I did not use them. I found the available research inadequate, the results had not been sufficiently time-tested, and I always err on the side of caution when it comes to the health and safety of my patients.

Much progress has been made in the meantime. Now that these products have been in use for some time, the medical research has been substantially augmented by rigorous, real-life studies. We have a much better understanding of how hyaluronic acid (HA) and BOTOX behave in live human beings. Additionally, in recent years the development of safer, reversible, longer-lasting, non-animal derived (which almost entirely eliminates allergies) injectables has caused me to embrace their use in my private clinic.

In my clinic, I do all these injections personally, always.

When patients come to me asking about these products, I make an effort, for their knowledge and comfort, to explain the science of these substances. This is necessary for them to make an informed decision. In this letter, therefore, I hope to provide a comprehensive and comprehensible look into popular injectables such as hyaluronic acid (HA) and BTXA (BOTOX). Why are they so popular? What are their advantages? How long do the results last? Why is re-treatment important? And what about the the overall cost?

BOTOX

Let's start with BOTOX. BOTOX relaxes the contraction (flexing) of facial muscles. Once the muscles cease to contract, the wrinkles caused by the contractions relax and soften. Therefore, BOTOX treatment can be extremely effective in removing facial wrinkles.

Among physicians, BOTOX is known as BTXA. There are other types (e.g., BTXB), but BTXA is what we use. At the Pacific Clinic we always use U.S. manufactured BOTOX of the highest quality.

Safety

For BOTOX treatment at the Pacific Clinic, we use 40 to 60 units in a woman and usually 60 units (or less, but not more) in a man. BOTOX can be fatal at 28,000 units -- thus our margin of safety is extremely wide. With such a wide margin of safety, why not use more in one session? Use of higher dosages of BOTOX could cause the body to create antibodies to combat the molecules. In this event, the BOTOX would no longer work for the patient. Thus we have found the ideal balance of effectiveness and safety.

Repeating the maximum dose (especially in very muscular male or female faces) can be safely done after two weeks. This is indicated for those patients who received a full dose, but had only a partial response on the first treatment.

Re-treatment

Results from BOTOX actually improve with repeated treatment. It is recommended that patients return for additional sessions after five months, and then again five to six months later.

Why does the cost vary so much?

The cost (price) of BOTOX treatment depends entirely on the concentration used and the number of "zones" treated.

Concentrations of BOTOX vary among reputable physicians but a maximum dilution of 100 units per 2 cubic centimeters of saline is almost universally accepted. Thus, for example, 100 units in 4 cubic centimeters of saline would be approximately half as expensive as 100 units in 2 cubic centimeters, but also half the concentration, and therefore of more limited efficacy. A person may say, "it is so much cheaper down where I liveÉ" In this case, the concentration may be significantly diluted.

This maximum concentration can be placed on one "zone" of the face, or it may be divided among multiple "zones." In general the zones contemplated are: Zone 1: Frown lines (angry lines); Zone 2: Forehead lines; Zone 3: Crows feet; Zone 4: Bunny lines (middle of the nose).

These are the principal areas that BOTOX is used. Depending on the specific case, BOTOX may also be used on the DAO (Depressors of the corner of the mouth); on chin wrinkles; on the upper lip ridge; on opening narrow eyes; or on the eyebrows.

HA and NASHA

While BOTOX relaxes facial muscles, Hyaluronic Acid (HA) and non animal-stabilized ("cross linked") Hyaluronic Acid (NASHA) act by volumizing the face.

In reality, HA and NASHA are sugars. Once injected into the human body, HAs disappear in one or two days. Cross-linking these sugar molecules to make NASHA gives them relative stability and longevity in the tissues. (We can follow their absorption in humans with MRIs.) Therefore all NASHAs have an intrinsic safety mechanism: they go away naturally, are dissolved! Always.

In the meantime, they give good correction to areas of deficient volume, like corners of the mouths, lips, and nasolabial (NLF) folds. In our practice, Juvederm Ultra is what patients seem to prefer the most, although Restylane is also used. Scientific papers place the longevity of NASHAs at six to nine months. Some seem to last longer -- possibly twelve months or more. The fact is that even a little amount of NASHA seems to retain a lot of water, and therefore gives a good, long-lasting correction.

Ideal Maintenance

In order to maintain optimal results, touching up the sites is best done at 4.5 months and 9 months after the original injection. There is some evidence that the body forms new collagen around NASHA injections which may explain the added longevity.

Injectables Considered

The question, "is it possible to maintain a youthful appearance, or a more vigorous look, temporarily , and then later do some more definitive (surgical) work?" is one I hear often. The answer is "yes." BOTOX and NASHA have made this possible, and it is now possible to do it safely and affordably. These injectables can not create lasting results like the ones you see in our photo gallery (link to photo gallery), but they can reduce wrinkles and help you feel more refreshed and rejuvenated as you contemplate more permanent solutions. In today's world, in which such a premium is placed on beauty and youth, this can be an important feeling.

I sincerely hope that this has helped you understand these complex issues. At the Pacific Clinic, we are at your disposal if you wish to pursue these non-surgical enhancements.

Dr. Brunno Ristow

Modern Plastic Surgery