Radha Mikkilineni, MD

Botox is very effective when used for dynamic wrinkles.  When it fails to work, it is usually because not enough was used or the botox was expired or stored incorrectly.  Very rarely there are patients who develop resistance to botox if they have been using it for a very long time.  In this case it is best to use an alternative such as Dysport.

If you have wrinkles present at rest and these lines are due to muscle movement (typically between the brows or horizontal forehead lines), these can be improved significantly by botox.  They may not disappear completely if they are present at rest.  In addition to botox, a small amount of filler can be used to minimize, even further, the presence of lines at rest.  I have found many of my patients to be very satisified with botox alone since they still have a great result and appear more relaxed. 

There is no age limit to botox use.  I don't treat patients who have a history of neuromuscular disorders such as myasthenia gravis or other neurologic conditions or allergies to any components of botox.  Clinical history is always important to obtain, particularly a history of prior procedures (face lift for instance) since the musculature that is injected may be in different positions.  In addition, older patients may have wrinkles due to skin laxity, rather than muscle movement and these wrinkles are less likely to be improved by botox.  Finally, lower doses may be used in older patients due to weaker muscles and there are nuances to injection sites in older patients, so that I typically do not inject extensively in the forehead as there is a higher chance of a brow ptosis (inability to raise eyebrows).

Botox does wonders for crows feet as well as for undereye wrinkles that are caused by excessive movement of the muscles.  That being said, if someone has a lot of loose skin under the eyes and crepiness (loss of elasticity, etc), then I typically never treat infra-orbitally and very conservatively (low units) will treat the lateral lines.  Sagging of the lower lids is an issue whenever there is skin laxity and needs to be addressed as a potential problem prior to injecting this area.  I will often perform a clinical test to determine if there is a lot of lid lag (and therefore too much loss of elasticity) before injecting this area.

Botox is very effective for wrinkles on the upper part of the face, forehead, frown lines (between the brows) and crow's feet.  These lines are due to repeated muscular movement and are known as dynamic wrinkles.  The lower face wrinkles, such as the marionnette lines (lines radiating from the lateral corners of the mouth towards the chin) are better treated with fillers to replace volume.  Occasionally, a tiny amount of botox can be used in the depressor angularis oris (DOA muscle), a lip depressor, to relax marionnette lines and create an uplifting effect on the mouth corners.  This is better done in combination with a filler.

The best treatment for skin rejuvenation varies depending upon an individual's skin type, age, ethnicity, sun exposure, and overall health.  I am a major proponent of a healthy lifestyle:  diet high in fruits, vegetables, nuts, legumes and fish, 8-10 hours of sleep, limiting alcohol intake other than the occasional glass of red wine, and regular excersize.  Next step for all skin types is sun protection including daily sunscreen, sun hats and sunglasses....and avoiding sunburns! 

Moving on to reversing signs of damage, I would recommend first and foremost using a daily topical vitamin A product such as tretinoin  (by prescription) or retinol (over the counter).  If these cannot be tolerated, then anti-oxidant topical creams such as vitamin C, E, co-enzyme Q, coffeeberry, or green tree extracts can be used.  Regular exfoliation with topical AHA/BHAproducts (glycolic acids, fruit acids, salicylic acids) either  as leave on products or peels are extremely helpful to use at least 1-2 times weekly.  Maintaining skin hydration using topical moisturizing creams is also beneficial.  Older, delicate and drier skin may require thicker moisturizers and younger, acne prone skin may require oil free moisturizers or serums.

It is never too late to start a skin care regimen.  After years of neglect, it may be helpful to first undergo a series of medical grade peels, supplemented with photofacials as necessary. 

Deep folds and dynamic wrinkles and fine wrinkles are best treated by combinations of fillers, botox and resurfacing laser procedures. 

We charge 250 to 500 per treatment.  A spot treatment is 250 and full face is 500.  2-4 treatment sessions are necessary and depends on the goals of the patient.  Greater number and intensity of treatment is required for more sun damaged patients or for individuals with moderate to severe rosacea/red blood vessels.

Downtime from IPL treatments are minimal.  Typically shortly after the procedure the patient will appear flushed, may have a bit of puffiness and brown spots appear darker.  It is possible to use sunscreen and cover up with makeup, immediately following the procedure.  In addition, a patient may even return to work after a treatment.  Over the course of the next few weeks (about 2) the dark spots will raise and there will be a "coffee ground" appearance to these areas and eventually slough away.  Gentle cleansers and moisturizers with sunscreens are the mainstay of topicals that can be used during this time.  I recommend avoiding the use of products containing AHA's and retinoids for one week prior and three weeks following an IPL treatment.  Occasionally, when patient's with darker skin types are treated, they may develop post-inflammatory hyperpigmentation.  This is reversible and can be managed with prescriptions lightening creams.  In my patients with darker skin tones, I prescribe lightening agents one week prior and for one month post treatment.

Dear Alisha,

I would be very cautious about the use of total fx in Asian skin types.  It can be done  with excellent results but it is critical to have the procedure performed by a physician experienced in the use of this laser in Asian skin.  The parameters need to be adjusted to skin type and lower energies as well as more treatments may be necessary.  In general, skin hyperpigmentation (or darkening) following treatment is expected and is reversible. 

Sincerely,

Dr. Mikkilineni