David Owers, MD

Belotero, although new to the United States, has been used in Canada and Europe extensively.  In fact, like the Juvederm family of products, there are a wide variety of Belotero fillers.  Unfortunately, only Belotero Balance is offered in the United States. After studying the physical properties of a number of fillers, I have found that cohesivity is an important property that distinguishes the Belotero line.  Belotero Balance has been used in lips, fine lines, and delicate areas like tear troughs.  My experience with this product has been very positive, and when used correctly, will not cause any lumpiness.  I highly recommend it, and use it extensively in my practice.  

Xeomin, although newer to the United States, has been used in millions of people around the world.  Botox has had a longer history in the United States.  Essentially, Botox has an active core that is surrounded by extraneous proteins.  Xeomin, has a very similar active core, with far less extraneous protein content that Botox.  This would make the Xeomin product less reactive because it is in effect a more pure formulation.  The word toxic, in my opinion, does not apply here at all.  It would be interesting to note just what it is that has caused you to formulate an opinion that it is toxic and doesn't work well.  Further, with the millions of Botox treatments being performed in the United States, why are you not thinking that doctors aren't pushing Botox on the public?  What makes Xeomin any different?  I would be interested to know your answers.

Xeomin, although newer to the United States, and less popular than other neurotoxins, is actually very widely used in the rest of the world.  The active core molecule resembles that of Botox, athough unlike Botox, does not need the additional protein complexes surrounding it.  From a pure chemistry point of view, this is an over-simplification, but is practically rather accurate.  The onset of action and duration of treatment, as well as the dosing and placement, is officially the same between the two.  Some people will note that the Xeomin-effect starts earlier than Botox. Incidentally, the average duration to maximal effect of Botox is 10-14 days, not generally seven.  

Both products are quoted as lasting three-to four months.

The issues that you describe are experienced by many couples.  This is not to diminish the challenges that you have listed above.  It is only to say that even lesser life events can cause what you are experiencing.  ThermiVa can change both the physical appearance and functionality of the vaginal area.  The question that I cannot answer is whether the degree of physical change that you experience after the usual 3 initial treatments will address the sadness that you expressed.  Again, this is not to sound over-simplistic, but is merely to suggest that we must delineate between effecting a physical change and effecting the degree of wellness that addresses your entire situation.  Sometimes, the physical change can be the catalyst for healing this delicate situation.

There is a theory that one can develop antibodies with consistent Botox use.  The theory describes this phenomenon as occurring with too small a dose, and too frequent an interval, of treatment. I have not seen this clinically in my practice; but have seen the "Wow" effect diminish in certain individuals that use Botox as the only modality to address an issue.  Without knowing much about your lifestyle habits, I cannot speak specifically to you.  Perhaps something of what I say will resonate.  The rate at which an individual ages is genetically determined and influenced by environment and lifestyle choices.  For instance: appropriate "sun savvy" regimens; a valuation of loss of volume in the area; UV damage to the skin itself; and how the entire face appears and interacts as an expressive unit should all be considered.

Lastly, even if none of the aforementioned plays a role, the placement of the Botox needs to be altered by a few millimeters from time to time.  This can be challenging in that you do not want to stray too far from the placement to achieve your optimal effect - experienced hands come into play here.

There are various types of filler and it can be used in various locations of the face.  Based on your question, you are only referring to filler in the lips.  I am also assuming that you are using one of the more conventional fillers such as Hyleronic Acid.  As such, in my opinion, that is the preferred filler to use for the lips.  Other injectors may use different fillers and the effects may differ from what I am about to say here.  With the use of Hyleronic Acid, the local area will become hydro-phyllic (water attracting).  Further, the repeated use of Hyleronic Acid filler in the lips will have a mild-to-moderate collagen stimulus effect in the structures beneath the skin.  As this natural filler dissolves away, the production of your own collagen will create fullness that was not there prior to any filler use.

In addition, the water attracting quality of this particular filler remains to a small extent.  This also will add a plumpness to the area than without ever having received filler.  So, all of what I have described, generally occurs with repeated regular filler treatments and not usually just after one or two times.  The skin itself is not stretched.

LASER:  Light Amplification by Stimulated Emission of Radiation 

This is an extremely good question.  Unfortunately, the word laser is not a protected word.  It has a connotation of advanced technology that can be used to embellish services that are being offered to the consumer.  Laser is an acronym (see above) that indicates the electromagnetic process in physics that delivers the energy of treatment.  

Lasers are of a single wavelength on the electromagnetic spectrum.  They are not "jack of all trades," but are highly sophisticated machines that when used correctly act with precision in treating a specific condition.  

IPL stands for Intense Pulsed Light.  Quite simply, this is a glorified flashbulb.  While it is still very useful when appropriately applied, it is not a laser.  Because it is still a light-based energy device, they are often incorrectly described as lasers.  This is simply a marketing technique used by some, and misleads the public.  An intense puled light machine is less sophisticated than a laser in most cases, and therefore cheaper to purchase and more readily available to non-physicians.  

The service that is the most corrupt by the improper naming of an IPL device is "Laser Hair Removal."  Both an IPL and a true laser are offered in the hair removal service industry.  If your experience during a hair removal treatment feels like an intense snapping of a rubber band on your skin, this is not a laser;  it is an IPL device.  In my opinion, an IPL is not the best device for hair removal.  Not only are they unnecessarily uncomfortable compared to a laser, but they are not specific to hair, whereas a laser is.  

Intense pulsed light (IPL), has its place, but most be appropriately disclosed for what it is to the public, and appropriately sold for the proper job.

Once a fat cell is created by the body, it will not go away naturally.  The tendency of fat cells in humans is to remain full.  Due to various events in one's life (example pregnancy or lifestyle choices), fat can be stored in fat cells creating a situation where they are all full.  Once this happens, a signal goes out for the creation of more cells.  Unfortunately, in the human, there will never be a signal that will go out to destroy a fat cell.  So, the more you create, the more your shape will change and weight will increase.  

Liposuction is a surgical intervention that physically removes fat cells.  Once the fat cells are gone from an area, there is nothing left to fill.  

In your case, the events (example pregnancy), or possible lifestyle decisions that you have made, has triggered the filling of remaining fat cells to the point where they are full, and thus the need to create more fat cells, which, in turn, all strive to remain full.  The areas not subject to surgical liposuction, are the path of least resistance for this process to occur in you; hence your described experience in your fat and upper abdomen.  It is of note that one's lifestyle decisions could be of such extreme nature that even the liposuctioned areas would start to create new fat cells. However, this is not what you are experiencing.

SculpSure is a non-surgical means of physically disrupting and destroying fat cells.  Once this technology upsets the matrix of a fat cell, it can no longer act normally so it will not seek to be full. Indeed, your body's immune system will gradually remove these destroyed cells and eliminate them.  In my opinion, this method is far gentler to the body and is the preferred method over surgical modalities.

The muscles located in the forehead are grouped into two (2) important regions. So, in fact, your "forehead" is not actually your forehead.  The area located between the brows moves independently and differently than the areas located from mid-forehead upward to hairline.  It is difficult to say from you description whether the 20 units of Botox delivered was put in an advantageous position.  It is possible to effect a positive change depending on how your muscle movement is read, interpreted, and treated with 20 units, and also possible to deliver the same 20 units to create a heavy, motionless brow.  It appears as though what you are experiencing is a "dropped brow." The "indents" that I am seeing in your third picture can be some fluid accumulation known as edema.  Fortunately, nothing about Botox is permanent (the good effects, or the occasional bad effects), so this will more than likely resolve itself  over four to six weeks.  It may be necessary to consider a more favorable injection pattern the next time.  

So this question astutely recognizes that regions of the face "play together." The diagonal line that is created between the outer nostril, running to the corner of the mouth (nasal labial fold), can be influenced by the cheek.  Indeed, if the patterns of volume loss in one's cheek occurs just so, the resulting fall of the lower face can accentuate the nasal labial fold, among other things.  In this case, I would inject both areas.  Your pictures indicate the need to replenish volume in the cheeks and to soften the contour of the nasal labial fold.  The caveat here, though, is where n the cheek to inject (blush line versus apple), and where along the nasal labial fold to place the filler in order to soften the look.  In my opinion, it is not necessary to totally efface the nasal labial fold as this can look unnatural.  The decision on placing the filler in the cheek is best made live and in person, as static photos, though helpful, do not convey the dynamic needs of your face.