Harold L. Kent, MD (retired)

Botox will paralyze the orbicularis oris muscle near where it is injected. Our experience is that the effect is very subtle. We inject anywhere from 4 to 10 units above the pink part of the upper lip--usually about 1 cm medial to the lateral border of the lip and about 1 cm lateral to the philtrum column on each side. Generally this would be expected to let the upper lip turn outward slightly to give a fuller appearance. Small doses for this can make it difficult to whistle or use a straw to drink. A larger dose can mean that the patient needs to be careful when drinking from a cup or glass. With Botox, if the results aren't what you want, the effect will go away within a few months and you can try something else.

Exilis Ultra uses no needles, knives or injection. This is a totally non-invasive treatment that uses radiofrequency to tighten skin and destroy fat. A wand which channels radiofrequency current and ultrasound to the skin or fat (depending on the settings) can be used to destroy fat cells or tighten the skin. Exilis can be used to treat from "nose to toes" and it feels like a hot stone massage. This would be a good option for you.

My opinion is that your left eyebrow is slightly more arched in the outer third than the right eyebrow. There are times when we do Botox treatments and one or both eyebrows end up with an pronounced upward arch. This is sometimes referred to as a "Spock eye". We routinely treat this by injecting about one unit of Botox one centimeter above the highest point of the arch. This would be an quick and inexpensive thing to try. The results would last for two to three months.

You have had several procedures to tighten your facial skin. You could add Exilis Ultra to this in order to further tighten your skin in your lower face and neck. Exilis Ultra uses as combination of radiofrequency injury and ultrasound to cause a subclinical injury to your face. Your skin will respond to these treatments (usually 4 or 5) by producing more collagen and elastin which would be expected to tighten your skin further. Our practice is to treat the lower face and neck on one side then move to the other side of your body and repeat the procedure on both sides. This "dual treatment" at one session helps to produce better results. You can also use a SkinCeutical product called HA Intensifier. This has been proven to cause the skin to make more hyaluronic acid (something we all lose as we age) and we would expect this to help. The SkinCeutical products have been evaluated by doing pre and post treatment skin biopsies which prove that they have the intended effect.

Most surgeons would consider patients safe to return to full activities within 6 weeks of major surgery that has had no complications. This is because most post operative healing takes place within this time frame although complete healing will require about a year. You should be safe to start Coolsculpting at any time.

Botox is generally very effective for treating "frown lines", but needs to be done every two to three months as the Botox starts to wear off. Exilis Ultra from BTL can be used on the forehead areas and around the eyes to help with wrinkles and tighten skin. This device uses a combination of radiofrequency energy and ultrasound to cause a subclinical injury to the treated skin. The skin reacts by producing more collagen and elastin which are substances we lose as we age. In addition to this, treatment with Skinceutical products can be helpful, too. HA intensifier helps the skin to produce more hyaluronic acid (which we lose as we age) and anti-oxidants such as CE ferulic will help to slow down the aging process. Our office also offers chemical peels and facials which will help improve the appearance of your face.

We would recommend doing Exilis Ultra on your lower face and neck for the best results. For those patients who have a pocket of fat under the chin (you would need to be examined by someone familiar with this condition), Coolsculpting can help minimize the pocket of fat and improve the appearance of this area.

Squinting will bring out wrinkles which are referred to as "crow's feet" at the lateral borders of the eyes (also called lateral canthal lines). Botox will treat these areas very well by paralyzing a portion of the orbicularis oculi muscles. The lines adjacent to your nose may respond to Botox somewhat and are called "bunny lines"--treating the nasalis muscle may help with this area. For the area directly under your eyes, you have other options. A non-invasive option would be to treat this area with Exilis Ultra to help your face rebuild collagen and elastin (see our 75 + year old patient). Another option is to treat this area, called the "tear trough" with injected filler, but this area needs an experienced injector to treat it in order to produce a good outcome.

Your question was listed under "gastric balloon". This procedure is done endoscopically and the balloon is removed after 6 months and insurance doesn't pay for the balloon. Originally the balloon was meant to bridge the gap between patients who could diet and exercise and those who meet criteria for weight loss surgery (gastric bypass, sleeve gastrectomy, and lap banding). If your insurance coverage includes bariatric benefits, I would advise you to have weight loss surgery--especially if you have a co-morbid illness such as diabetes, hypertension, sleep apnea, etc. The current surgical procedures are permanent, but you will still need to observe a ketogenic type diet and exercise to optimize your outcome. Regular follow up with your surgeon is also essential to be successful. At your age a lap band would be a good choice because it is low risk, usually done on an outpatient basis, and is easily reversible.

Coolsculpting only affects and treats the subcutaneous fat which is held within the applicator during treatment. It would not be expected to affect deeper tissues. If you have had external beam radiation, it would be wise to consult with your urologist and radiation oncologist. Radiation can cause changes to blood vessels and decrease blood supply to various tissues. If you had radiation treatment of the lymph nodes near the aorta, then you need further evaluation from your treating physicians. If you have never had radiation for your cancer, or if the radiation was limited to your testicular area, then coolsculpting would not be expected to be a problem.