Dr. Dirk Lazarus
Plastic Surgeon

Tel: 021 424 1112
Fax: 021 424 1118

86 New Church St
Tamboerskloof
Cape Town, 8001
South Africa

I am frequently asked by patients for quick fixes for wrinkles and lines. This is especially so around this time of year when it is summer and patients want to look good with minimal or no downtime.

Sometimes I am asked specifically about fillers or botox. Patients may think that these products are interchangeable, but they are not. Each has its own specific indication which I want to outline in this newsletter.

Sometimes I am also sent email asking for advice, but especially with facial rejuvenation, it is much easier to give advice once I have seen the problem. Photographs are essential.

Botox, to my mind, is the best injectable we have. It has revolutionized some aspects of rejuvenation and can even allow sculpting of certain facial features. It is quick and simple to inject and has a safety profile better than paracetamol or aspirin. The procedure is performed in the rooms, is relatively painless and takes no longer than the regular consultation. But botox must be used correctly and for the right indications.

Botox is useful where there is muscle over-activity. Too much muscle action can cause lines: frown lines, horizontal forehead lines and crow's feet or laugh lines at the sides of the eyes are the commonest reasons for using botox. A very small and safe dose of botox can be given into the muscles causing these lines, weaken the muscles (not paralyze them!) and therefore reduce the repeated action of these muscles in causing the wrinkle. In time the wrinkle will fade and one's appearance will be enhanced.

Botox does not work immediately but takes about a week to reach full effect. Thereafter, the effect of the botox will start to fade after about 4-6 months and, if you choose, you can repeat the botox. Some patients do not want to start the botox because they know that it lasts 4-6 months and they feel that at the end of this period they will have to come for another injection. They do not want to commit to this. But this is not true and it is not necessary to have further injections unless you like the effect of the botox and want more (as most patients do). After a few injections the muscle atrophies (gets smaller and weaker like a leg that has been in a plaster cast) and you get out of the habit of frowning. I believe that one's need for botox ultimately diminishes in time.

Botox is safe. Although the botox toxin is very poisonous in large doses (many thousands of units), we only ever give relatively small doses for wrinkles - usually no more than 60 units. Babies with cerebral palsy and spasticity are treated with botox in doses of around ten times that! In addition, the botox given for wrinkles remains at the site of injection and only works locally on the muscle treated.

Nevertheless, there can be problems with botox. Some patients simply do not respond, either because the botox was inactive (it is very sensitive and does not like to be shaken or extremes of temperature, etc.,) or because they have antibodies from previous injections or because the muscle was missed. Non responders need a repeat injection.

About 10-15% patients experience a headache following botox. This is usually mild and responds to simple painkillers.

Some patients will bruise easily and might get a small bruise at the site of injection. This is not serious and will clear in a few days.

The most serious problem is a drooped eyelid. This is very very rare - I have never seen it - and is said to occur in 0.04% of injections. The drooped eyelid would be temporary and the eyelid would return to normal once the botox wears off. There are drops that one can use which will reverse the effect of the botox.

Botox can also modulate eyebrow shape and if used correctly can be used to lift the outer eyebrow which seems to be a more trendy look at the moment.

Fillers are used where wrinkles are present at rest. Whereas botox is good for a frown line that occurs when you frown or a laugh line that appears when you smile, a filler is useful once those lines have become etched into your face.

In addition to the botox lines discussed above, fillers can be used around the mouth in the naso-labial lines (from mouth to the nose), to fill the lips both upper and lower and for the marionette lines from the mouth down.

Like botox, fillers are simply injected in the rooms. They take no longer to do than a regular consultation. Most patients prefer a local anaesthetic block (like you would receive at the dentist), but some patients prefer to go without.

Following the injection there is usually some swelling which lasts about a day and there may be some bruising which will settle. Lumpiness is usually mild and settles after a couple of weeks.

The traditional filler used was collagen, but since collagen was derived from cattle, was associated with allergic reactions and the effect only lasted a few weeks, other fillers have become more popular. These include hyaluronic acid based fillers such as Restylane and Perlane. These are naturally occurring large biological molecules which work by drawing water into the area where they have been injected.

Fillers last between 9 and 18 months. They are quick, simple and safe and can be repeated at any time if desired.

Current costs and dosages for Botox and fillers are:

Botox to frown line: 20 units: R1000
Botox to horizontal forehead lines: 15 units: R750
Botox to crow's feet: 7.5 units per side: R750

Restylane 0.7ml: R2500
Perlane 0.7ml: R2500

Botox and fillers give me a simple, safe and quick way to help patients with certain wrinkles and lines. They are of course only useful in certain circumstances mentioned above. When there is ageing, droop, significant loss of volume and other features, then a facelift may be the better rejuvenating option.