36 year old female: fraxel, botox or something else? (Photos)

Thank you for your question. You’re 36-years-old, and state in your question that approximately 3 years ago, your forehead went from relatively smooth to becoming thicker with deep lines. You also say throughout your 30s, you’ve been dealing with chronic breakouts, so you are open to solutions to help with your forehead lines and forehead skin, whether it’s injectables, laser or any other modality.

I can certainly offer you some guidance as I deal with this type of issue every day in our practice. A little background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years. I’ve administered drugs such as Botox™ for longer than that period of time, and use many different injectables as well as laser. I can give you some perspective on my approach when I meet patients like you in our practice.



When you seek opinions, you will get different opinions because there is more than one way to approach these issues. Every doctor comes from a perspective of experience, and others can be biased to whatever technology they currently employ. In our practice, we have everything, and as a cosmetic surgeon I don’t fall into a situation with a bias because we do everything from a skincare line, to injectables, to lasers, to surgery.



To help you understand the situation a little better, I’ll break down what I see in the photos - I see forehead lines and a lot of acne. The forehead lines are referred to as static lines which are always there regardless of movement. This is in contrast with dynamic lines that occur when a muscle is activated. The philosophy of dealing with forehead lines and to soften them in the long-term is using a drug like Botox™, Dysport, or Xeomin. These are called neurotoxins that relax the muscles in the forehead so the forehead does not crease the skin. When you raise your eyebrows, you are constantly creasing your skin.



Even if you don’t raise your eyebrows a lot, it is very common to see these lines form, which represent loss of collagen. Basically, loss of collagen happens in the supporting part of the skin called the dermis. The opportunity is doing something to help the dermis in a few ways. Number one is to manage the acne. Managing acne, especially for people in their 30s is adult acne. There can certainly be hormonal cause, but treating it from the skin, there are options such as topical medications, and more advanced, high tech options. In our practice, we have an Nd:YAG laser that we use to treat inflammation or inflammatory acne. We are able to shorten the lifespan of inflamed lesion acne and shrink the oil glands to reduce activity causing recurrent acne. Laser is not always the first line of treatment but it can be integrated with other treatments. Topicals, retinols and other acne-related topicals are always part of the treatment plan.



For other elements to stimulate collagen and the dermis, you have options such as platelet-rich plasma (PRP) which we use a lot in our practice. Platelet-rich plasma is derived from your own blood which is a concentration of the healing and growth factors needed for wound healing. Basically, you are stimulating the body to produce collagen by placing the platelet-rich plasma in the dermis, which results in the improvement in the appearance of lines.



In addition, there are also lasers that are non-ablative, meaning the top layer skin remains intact while the collagen in the skin is stimulated. Last but not least, you can do some type of laser or fractional laser to help further help the epidermis and stimulate and improve the overall skin quality. This type of procedure is like polishing and improving, which is one of the last things you do. It’s important to strategize don’t spend a lot and put yourself through more recovery than you need.



At this point, you need to meet with qualified, experienced doctors who can offer you a lot of different options, and can give you guidance for what is best for you. There is a lot to be said for a maintenance plan. As a surgeon, I used to be resistant to the idea of not fixing something once and for all, but as the technology and other things come in and improve, I have been able to help my patients maintain a certain look by employing things such as PRP, lasers, and injectables, and keep their skin looking good and healthy well into their 30s, 40s and beyond.



I hope that was helpful, I wish you the best of luck, and thank you for your question.



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Thank you for your question cf3555. Botox is a purified protein used to address wrinkles associated with facial expression such as the horizontal lines seen on the forehead when one raises the eyebrows. Treatments for acne include topical products such as retinoids, antibiotics (clindamycin), niacinamide, hydroxyl acids, and benzoyl peroxide. Oral medications include doxycycline. Treatments include microdermabrasion, chemical peels, and a variety of laser treatments. Please consult with a doctor for specific treatments. Good luck!