Everyone knows that aging, sun exposure and smoking all contribute to the creation of wrinkles on one’s face. But the real culprit is something that can not be avoided, the movement of the overlying skin from the underlying muscles of facial expression. If the face didn’t move there would be far fewer wrinkles. (hence why Botox is so popular) But facial wrinkles do not form in a random manner. Wrinkles on the skin develop in an orientation perpendicular to the movement of the underlying muscles. This is why vertical wrinkles form on the upper lip, crow’s feet develop on the sides of the eyes, horizontal wrinkles appear on the forehead and the dreaded 11’s are created between the eyebrows.

The effects of time, gravity and sun exposure all make for the eventual wrinkles that appear on everyone’s face. These wrnkles appear along predictable and classic locations that are usually perpendicular to the movement of the underlying facial muscles. But not all facial wrinkles appear this way and their presence can be more difficult to explain. One influencing factor is that of your sleep position. Certain sleep positions can make more wrinkles appear and in often unusual locations. Sleeping on the side of your face pushed into the pillow can create vertical wrinkle lines in the forehead and the side of the face. When you count up the number of hours one sleeps over decades, it is not surprising that these pressure forces create creases or wrinkles. The best sleep position is the ‘mummy position’, flat on your back and with your face forward.

Wrinkles are a part of aging and there is no way to completely prevent many of them from happening. While topical creams and lotions once were the only players for wrinkle prevention and treatment, that has changed significantly over the past decade. Botox, injectable fillers and various energy-based device treatments (e.g., laser) have moved in to now play major roles in wrinkle treatment.

But those facial lines which develop are more complex than they appear. They are numerous causes of wrinkles which range from the movement of facial muscles to gravity and sun damage. This creates different types of facial wrinkles which are structurally different. Getting the best treatment results depends on matching the facial wrinkle type with the appropriate treatment.  Facial wrinkles and lines can be divided into four general types.

The most common facial wrinkles are known as dynamic expression lines. They have become well known because of Botox injections, which are used to specifically treat them. They are known by a variety of names such as smile lines, crow’s feet and the ‘11s’. They develop due to the repetitive movement of muscles of facial expression and the wrinkling of the skin appears perpendicular to the direction that the muscle moves. The most obvious example are horizontal forehead wrinkles which develop because of the movement of the vertically-oriented large forehead frontalis muscle which runs from the eyebrows to the back of the head. By weakening these expressive muscles with Botox injections, the lines become less evident with movement. This works well around the eyes because less movement is always good. Around the mouth, however, less movement can affect how one smiles so injections are done more carefully or not at all.

Elastic skin creases occur in areas that are exposed to skin folding and have high sun exposure, most frequently on the cheeks and at the base of the neck. They are not the result of muscle movement but occur in those areas where the skin frequently becomes ‘creased’. This could be the result of sleeping repetitively on the side of one’s face (e.g., vertical or oblique skin creases in the forehead) or other external force that sheers against the skin. The best prevention is to avoid activities that crease the skin and keep it well moisturized.

Gravitational folds are not really wrinkles per se but lines that form from the effects of falling skin. They are the result of skin sagging and falling. The most well known are the nasolabial folds and marionette lines. Nasolabial folds appear and deepen as the cheek tissue above them descends, pushing lower cheek tissues against the fixed and non-falling upper lip tissues. The same occurs as jowl and facial tissues fall downward against the fixed tissue of the chin, creating marionette lines. Gravitational folds are best treated by either lifting procedures  that pull the weight of the descending tissues upward and back (e.g., lower facelift, cheek lift) or by plumping the fold with an injectable filler material.

Atrophic wrinkles occur from thinning skin and loss of its elasticity. These are the fine smaller wrinkles that often appear between and around dynamic expression lines, elastic creases and facial folds. They create what is known as creapy skin and usually appear as one of the last wrinkle types to occur. Excessive sun exposure and smoking make huge contributions to their occurrence and are what creates the ‘prune-face’ appearance in those with a long-history of sun bathing and have developed a more leathery skin appearance. Exfoliative skin treatments such as laser resurfacing and chemical peels are very effective because these wrinkles are often very superficial and their appearance can be lessened by removing some of the outer skin thickness.     

Between topical skin products, Botox, fillers, lasers and surgery, a wide variety of skin wrinkle treatments exist. But these treatments must be applied to the wrinkle type in which they work the best to get good results. Most patients need three or more of these over time to lessen the inevitable appearance of facial wrinkling.

Dr. Barry Eppley

Indianapolis, Indiana

A weekdoes not go by that I do not find several patients that have confused Botox with injectable fillers in terms of what it can do for in-office facial wrinkle and line reduction. I have heard many patients say “Can you fill up my lips with Botox’ or ‘I need a filler between my eyes to stop me from frowning’. The confusion is that some patients believe that all that comes out of a needle is the same. While such confusion is understandable due to the relative newness of these treatments, that is a little like saying that a scalpel does all the same surgeries. Injectable materials are treatments which have different mechanisms of action, even if the end result is often times similar. (wrinkle reduction)

To clear up the confusion, I often explain to patients the difference between static wrinkles and dynamic wrinkles. Dynamic wrinkles are those wrinkles and lines that appear when your face is moving or expressing. When we were younger, the only lines and wrinkles we had were dynamic. Our face was otherwise wrinkle-free when we weren’t expressing ourselves. Static wrinkles are those facial lines that are evident even when our face is still. All dynamic wrinkles, with age, will eventually lead to static wrinkles.

These two types of wrinkles are what separates Botox and any of the injectable fillers. Botox is for dynamic wrinkling. It is a muscle-paralyzing or muscle weakening agent so it will soften the wrinkles and lines that occur from a dynamic facial movement, such as between the brows with frowning….or the crow’s feet from smiling. Injectable fillers are for static wrinkling. They soften lines and larger wrinkles by plumping them out so they look less evident at rest. In some cases, the combination of Botox and fillers are used when the line or wrinkle is very deep and weakening the muscle action will help perserve the longevity of the filler material but not being ‘beaten on’ by muscle movement. This is most common in the furrows between the eyebrows. (’11 sign’)

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Can Exercising Reduce Facial Wrinkles and LIft Sagging Skin ??

One methods that has been touted for over fifty years to reduce facial wrinkling and aging is exercising the facial muscles. One of the original books on this subject was entitled Lift Up Your Face from the 1950s, which I actually have a copy in my plastic surgery library. The concept continues to be espoused and written about today, now even expanding the exercise theme to include yoga facelifts, acupuncture facelifts and electric stimulation devices that promise to tighten the face through ‘muscle build-up’.

Having a good knowledge of the facial muscles and the facial aging processe, I still cannot understand how most of these approaches have any hope of being effective. Short of the platysma muscle of the neck (which I actually think can be tightened), the rest of the facial muscles are quite small and would have little impact on keeping the face uplifted as they are responsible for facial expression and not tissue suspension. The face ages as ligaments to the skin become lax, which subsequently allows skin and fat to sag (with the exception of the lips and chin) The facial muscles cannot prevent this problem, no matter how ‘tight’ one tries to make them. In fact, exercising (making extreme facial expressions) is likely to increase facial aging by making skin wrinkles worse.

For real prevention or improvement in facial aging, stick to the tried and true methods, Botox, injectable fillers, skin resurfacing, and eventually skin excisions and lifting procedures.

Dr Barry Eppley
www.eppleyplasticsurgery.com
www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Getting rid of those 11s!

Nothing makes yopu look more stressed or irritable than those vertical lines between the brows. Six different facial muscles converge in the area between the brows, and when making that classic scowl with straining or stress, creates two vertical lines in some patients, otherwise known as the 11s. If you frown enough, these 11s can become a permanent fixture of your face.

FDA-approved, specifically for this region, Botox injections can smooth these vertical lines so you can look stress-free for 4 to 6 months after treatment. In the event that these lines are still somewhat visible even after the muscles are relaxed, fillers such as Restylane, Juvaderm, or Radiesse can be used. They help fill in the indentations that left. This combination is particularly powerful at usually results in the best eradication of these lines. But not all patients will need both, however, If in doubt, do the Botox first, wait two weeks, and see if further line reduction is needed. The fillers can always be done later after the Botox.

Dr Barry Eppley
www.eppleyplasticsurgery.com
www.ologyspa.coom
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

A day does not go in my Indianapolis plastic surgery practice by that I find a patient that has confused Botox with an injectable filler in terms of what it can do for in-office facial rejuvenation procedures. I have heard patients say. “Fill my lips with Botox’ or ‘Use Restylane between my eyes to stop me from frowning’. Just because it is an injectable, doesn’t mean that what comes out of the end of the needle works the same.

To clear up the confusion, I often explain to patients the difference between static wrinkles and dynamic wrinkles. Dynamic wrinkles are those wrinkles and lines that appear when your face is moving or expressing. When we were younger, the only lines and wrinkles we had were dynamic. Our face was otherwise wrinkle-free when we weren’t expressing ourselves. Static wrinkles are those facial lines that are evident even when our face is still. All dynamic wrinkles, of course, eventually with age, lead to static wrinkles.

These two types of wrinkles are what separates Botox and any of the injectable fillers. Botox is for dynamic wrinkling. It is a muscle-paralyzing or muscle weakening agent so it will soften the wrinkle that occur from dynamic facial movement, such as between the brows with frowning. Injectable fillers are for static wrinkling. They soften lines and larger wrinkles by plumping them out so they look less evident at rest. In some cases, the combination of Botox and fillers are used when the line or wrinkle is very deep and weakening the muscle action will help perserve the longevity of the filler material but not being ‘beaten on’ by muscle movement. This is most common in the furrows between the eyebrows. (’11 sign’)

Dr Barry Eppley
www.eppleyplasticsurgery.com
www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis