What does it all really mean?
As a Holistic Esthetician who focuses on beauty from the inside out and healing through relaxation, I still advocate for Botox, fillers, and lasers. Even though my practice leans towards alternative methods for aging, Botox, fillers, and lasers can be beneficial, too. This article will discuss how these three Western Medicine methodologies work, what to expect, and whether they fit you.
Botox
Botulinum toxin does one thing, and one thing only; it paralyzes the muscle. When I worked as a Medical Esthetician, a mentor used the analogy of a snake temporarily paralyzing its prey. Botox works similarly by temporarily paralyzing facial muscles, thus preventing the creation of wrinkles. Therefore, Botox is a great preventative care tool. It is easier to prevent the breakdown of collagen than it is to reverse it. Once collagen is broken down, it is difficult to rebuild (i.e., wrinkles on your forehead).
Think of Botox like this: a truck is driving down a dirt road, and the crevices become deeper as it continues to drive down the road. Botulinum toxin serves as a temporary roadblock, preventing the truck from driving down the road and thus inhibiting the creation of deeper crevices (i.e., wrinkles).
The three most popular areas to receive Botox are the glabella, frontalis, and around the eyes (i.e., frown lines, forehead wrinkles, and crow’s feet). Even though these are the only FDA-approved areas to receive Botulinum toxin, injectors will treat other areas of the face including, but not limited to, the upper lip (lip flip), depressor muscles (frowny face), and masseter muscles (TMJ) (Satriyasa, 2019).
Botox is effective but also expensive. It is a common misconception that over time, the more Botox you receive, the less you will need. According to Satriyasa (2019), the effect of Botox will gradually resolve, resulting in reduced muscle paralysis over time. In my personal experience, I have found this to be true: the more Botox you get, the more you need. Therefore, proceed with caution.
Botulinum toxin is a potent neurotoxin that inhibits the release of acetylcholine to the neuromuscular junction, causing relaxation in the muscle (Satriyasa, 2019). There are many different types of neurotoxins: Botox, Dysport, Xeomin, and Jeuveau (Satriyasa, 2019). They only vary slightly from one another and achieve the same result: paralyzing the muscle. One may take effect slightly quicker than the other, but regardless of which neurotoxin is used, it is important to wait two weeks for the results to develop, and depending on your metabolism, results last anywhere from three to six months (Satriyasa, 2019).
Filler
As we age, the papillary dermis (superficial part of the dermis) that makes up the foundation of our skin loses hyaluronic acid, elastin fibers, and collagen structures (Bentkover, 2009). Most fillers are made of synthetic forms of collagen and hyaluronic acid (Bentkover, 2009). Because our bodies naturally create collagen and hyaluronic acid, the body easily adapts and accepts these synthetic substances when injected.
Like Botulinum toxin, there are many kinds of filler: Juvederm, Restylane, Belotero, RHA collection, etcetera (Bentkover, 2009). Fillers vary depending on the thickness and density of the molecular structure. For example, the filler injected into the lips is much softer than the filler injected into the cheekbones (Satriyasa, 2019). Fillers are most popularly injected in the cheekbones to lift the face, around the mouth to fill in deeper smile lines, and, of course, in the lips to enhance size. Fillers are best used to fill in areas where collagen has already broken down, where fine lines and deeper wrinkles have developed.
Not all injectors are created equal when it comes to filler; you want to ensure your injector is experienced and has a good aesthetic eye to prevent unrealistic patient expectations, under-correction, over-correction, and granule formation (Satriyasa, 2019).
Fillers are also very expensive and give subtle results. As a previous medical esthetician, I have found that more than one syringe of filler is needed to achieve the desired results. The pros and cons of fillers are that the results are subtle and go unnoticed. The “overfilled” look is actually very hard to achieve and takes a lot of filler. The expectation should be a slight lift and a beautiful, hydrated glow.
Lasers
While Botox and fillers work on muscular and dermal lower base levels, lasers work on the outer superficial layers of the skin: the epidermis (Hassouneh & Newman, 2013). There are many types of lasers, but we will focus on skin rejuvenation lasers. A good skincare practitioner will recommend some epidermal treatment in conjunction with Botox or filler because the epidermis serves as your canvas.
Regarding skincare, the number one way to reverse the signs of aging is to increase cell turnover. Young skin has a cell turnover rate of twenty-eight days (Hassouneh & Newman, 2013). This means a new layer of skin cells is generated every twenty-eight days, pushing up on the top layer of dead skin and sloughing it away (Hassouneh & Newman, 2013). As we age, the cell turnover cycle begins to slow down, and the dead skin does not slough off as easily as it used to. Moreover, this leads to multiple layers of dead skin lying on top of each other. This build-up slows down the creation of new skin cells altogether. Therefore, as we age, not only does dead skin begin to build on the surface of the skin, but the whole production system slows down, as well. This is why exfoliation is so important and why lasers are so effective. By manually removing the dead skin that has built up and taking off layers of skin, a rejuvenation signal is sent deeper into the base layers of the skin to stimulate new cell growth to replace the layers that have been removed (Hassouneh & Newman, 2013). Removing the top layer of dead skin reveals the fresh new skin underneath. This effectively decreases pore size, smoothing out fine lines and wrinkles, and removes some pigment (Hassouneh & Newman, 2013).
In summary, most medical rejuvenation aesthetic lasers, such as CO2, fractional lasers, and Erbium Yag, are meant to remove the top layer of skin to stimulate cell turnover, as previously described above (Hassouneh & Newman, 2013).
Lasers remove the top layers of dead skin. You can go as deep as a CO2 laser, Erbium Yag, and fractional lasers. However, all cell turnover increases through exfoliation (Hassouneh & Newman, 2013). From my experience as a Medical Esthetician, for deep lasers' cost and pain, similar results can be achieved through chemical peels, gentle lasers, or micro-needling. Furthermore, even with deeper laser treatments, you still need two - to - three sessions to see results. Very rarely is any procedure sufficient with one treatment. You must consistently do these treatments in a series to see results.
Micro-needling is a valuable alternative to more invasive procedures such as laser skin resurfacing (Alster, Graham, 2018). Microneedling works from the inside out, making small incisions through the epidermis into the dermis, stimulating collagen production at the source (Alster, Graham, 2018). The most common side effect is slight peeling of the face (Alster, Graham, 2018). Downtime is quite easy, with a little redness over the course of a few days. Microneedling is a technique that produces substantial clinical improvement (Alster, Graham, 2018).
Retinoids
Retinoids are the umbrella term for the derivative of vitamin A. Retinol, Retinaldehyde, and Tretinoin are all forms of retinoids varying in strength. For the skin to be able to use the vitamin A within each retinoid product, there must be a conversion. Retinols require a two-step conversion, retinaldehydes require a one-step conversion, and Tretinoin is immediately available. Due to the double conversion rate, Retinols can be found over the counter (OTC) in drug and beauty stores. Tretinoin is the most effective form of Vitamin A and is only available through the prescription of a doctor.
Tretinoin has three different percentages: .025% (the gentlest made for younger or sensitive skins), .05% (the middle ground, used for normal to mature skin types), and .1% (the most aggressive for acne or weathered skins). If you find that your skin is not tolerating the retinoid, well, it is ok to go down in strength. More is not always better. I recommend starting at a gentle percentage of .025%, getting accustomed to this strength for a few months, and titrating up. Remember, it is always important to wear a sunscreen at all times. I recommend a mineral sunscreen such as ColoreScience or EltaMD.
Retinoids are often mistaken for exfoliants because they cause peeling and irritation. However, retinoids are not exfoliants; they are antioxidants. Retinoids are a derivative of Vitamin A, which is meant to increase cell turnover. Dermatologists recommend retinoids as the number one skincare product to combat aging or acne (Gollnick, Dummler, 1997).
Using the analogy that retinoids are the gym for your skin - Retinoids strengthen the integrity and improve your skin because they increase cell turnover, aiding in producing new skin cells. Alas, like starting out at the gym, lifting weights, and exercising your muscles can cause your body to feel sore, as can retinoids. As you continue to go to the gym, your muscles get stronger. So, in theory, your skin will become more durable and accustomed to retinoid use (Gollnick, Dummler, 1997).
Peeling, redness, and sensitivity of retinoid use typically last about six weeks. When you first start using retinoids, your skin may feel irritated, sensitive, red, or peel (Gollnick, Dummler, 1997). Fortunately, these side effects will dissipate. As a result, your skin will start to adjust and see noticeable results of smoother and brighter skin as your cell turnover rate begins to speed up.
In conclusion, today, in my Holistic Aesthetic Esthetician Practice, I prefer to focus on the root causes of aging: cell turnover and decreased stress. This holistic approach seeks to support the various factors that promote aging-well; increasing the body’s ability to heal from within. However, after working within medical aesthetics, Botox, fillers, lasers, and retinoids are all safe and effective methods utilized for aging skin types.
References:
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Alster, Tina S. MD*; Graham, Paul M. DO†. Microneedling: A Review and Practical Guide. Dermatologic Surgery 44(3):p 397-404, March 2018. | DOI: 10.1097/DSS.0000000000001248
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Bentkover, Stuart. (2009). The Biology of Facial Fillers. 25(2): 073-085
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Gollnick, H. P., & Dümmler, U. (1997). Retinoids. Clinics in dermatology, 15(5), 799-810.
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Hassouneh B, Newman JP. Lasers, fillers, and neurotoxins: avoiding complications in the cosmetic facial practice. Facial Plastic Surgery Clinics of North America. 2013 Nov;21(4):585-598. DOI: 10.1016/j.fsc.2013.07.002. PMID: 24200377
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Satriyasa B. K. (2019). Botulinum toxin (Botox) A for reducing the appearance of facial wrinkles: a literature review of clinical use and pharmacological aspect. Clinical, cosmetic and investigational dermatology, 12, 223–228.