Skin Smart - Your Best Shot

By Jolene Edgar
Shape Magazine Feb 2021 (print)

A dose of confidence can take many forms—an I’m-speaking red lip or that good light on Zoom. But for injectable devotees, it commonly comes in a syringe. It’s true: Studies show that skin-smoothing neurotoxins and volumizing fillers can boost self-esteem. But this isn’t their only selling point. Injectables have been reimagined: “It used to be about treating lines and folds,” says Sarmela Sunder, M.D., a facial plastic surgeon in California. “Now we’re using Botox and fillers in a more artistic way to reshape the entire face.” Whether easing unhappy expressions or fine-tuning a profile, injectors prioritize facial harmony and personal identity for natural, customized results. Ahead, the ways doctors harness injectables to enhance our looks—and outlooks.

 

HOW WE USE BOTOX NOW
Botulinum toxins, like Botox Cosmetic and Xeomin, temporarily mute nerve signals to minimize muscle movement and its untoward effects on the skin—most famously wrinkles but also drooping, neck bands, and more. While doctors have been capitalizing on the crease-preventing capabilities of botulinum toxins for decades, they’ve more recently discovered that it “can not only relax muscles but reshape the whole face, restoring more youthful contours,” says Hema Sundaram, M.D., a dermatologist in Maryland.
This fresh perspective is encouraging injectors to venture beyond the limits of the upper face, where botulinum toxins have traditionally shined. “We now do full-face Botox, which may sound crazy, but I’ve found it’s the best way to make people look really good and natural,” says Papri Sarkar, M.D., a dermatologist in Boston. Moving south requires advanced skill and anatomical insight, she stresses, since “a lot of the muscles of the lower face overlap or are mere millimeters away from one another.” A miscalculation in dosing or placement can leave a smile awry for weeks. But if done right—oh, the rewards, especially around the mouth, where the “muscles become overactive with age,” Dr. Sundaram says, etching in lipstick lines, pulling down the corners of the smile, and engraving the chin with a pebbly texture. By lessening tension, a smidgen of a botulinum toxin can smooth cobblestone skin, turn out the lips to pert effect, and erase unintentional grimaces. (Sedating the chin in certain people can even change the contour of their lips so they look fuller, Dr. Sarkar says.) A series of pricks along the underside of the jowls can give a subtle lift by lessening the downward pull of the platysma muscle of the neck. A heftier dose in the chewing muscle, back by the ears, can slim a boxy jaw while relieving clenching and grinding. (Here, the botulinum toxin is weakening the muscle to shrink it slightly.) Injecting the ropy bands of the neck “can allow the skin to drape more smoothly and look less crepey,” says Annie Chiu, M.D., a dermatologist in California.
Treating areas that were once considered off-limits requires a special approach. New York dermatologist Ellen Marmur, M.D., a Shape Brain Trust member, calls her technique “texture tox,” explaining that “by injecting very superficially, you can actually improve the texture of the skin and keep your expressions.” These shallow injections target “the most actively mobile portion of the muscle without paralyzing the whole of it,” Dr. Sundaram says—and usually require less product, making these shots less expensive. This maneuver, she adds, “carries the bonus of improving the quality of the overlying skin, restoring radiance, making pores appear less prominent, and improving rosacea.”
With the impending arrival of a new neurotoxin, Revance’s DaxibotulinumtoxinA, we’ll soon be able to enjoy these benefits for longer; studies show effects lasting upward of seven months.

NEW WAYS TO GET YOUR FILL
It was common to see a derm just to have your cheeks plumped or smile lines filled. These days, doctors are dismissing that plan with the knowledge that treating features in isolation can give an odd or lopsided look over time. Injectors now prefer to take a 30,000-foot view of the face before injecting filler all over, starting with the framework—a strategy known as profile balancing. It’s not

as extreme or pricey as it sounds. “Perfecting the profile can be done with surprisingly small amounts of filler—even just a syringe or two—if distributed in the right places,” Dr. Sundaram says. These “power zones,” as she calls them, are pretty universal and include the nose, chin, temples, and jawline. Lips and cheeks may be tweaked for harmony, but less is more, since these areas can look overdone.
The chin and jawline, on the other hand, tend to wear filler well. The gel bolsters ill-defined contours—whether inherited or acquired with age—without turning them cartoonish. For folks confronting early jowls—the sagging that inevitably follows bone loss in this area—jawline injections can be especially transformative. “A lot of people who would have considered getting a face-lift may be able to push it off by filling the jawline and camouflaging jowls,” Dr. Sunder says. “It’s that effective.” (Filler cannot disguise severe sagging, however.) To create a sharper border between face and neck, Dr. Chiu says, “you have to rebuild the entire mandible—the chin, the notch in front of the jowl, the area behind it, and the angle of the jawline.” Sturdy structural fillers are made for the job—robust hyaluronic acid gels, like Juvéderm Voluma, and the calcium hydroxylapatite filler Radiesse. Hyaluronic acid offers the advantage of reversibility, melting away with a shot of enzyme if you’re not thrilled with the results.
The temples are less flashy than the jawline, but they hold an unexpected sway over our big-
picture appearance, gradually deflating to give the head a peanut-like silhouette. “A few years ago, this was something I had to point out to patients, but now there’s definitely more awareness of the peanut-head phenomenon,” Dr. Chiu says. The change is most glaring in women, whose faces are traditionally “made up of a confluence of soft, round convexities,” says Christian Subbio, M.D., a plastic surgeon in Philadelphia. “When you lose that in the temples, it can have a masculinizing effect.” But by reinflating the area, “we restore the softness of youth,” he says. Hyaluronic acid fillers, like the new RHA 4, can give a gentle lift to the temples. Sculptra, a liquid made of poly-L-lactic acid, can more gradually bring back fullness by sparking collagen growth over time.
The shape-shifting magic of filler is perhaps most evident in the nose. By hiding a bump or lifting a tip, filler can “help the nose blend in with the face,” Dr. Sunder says, shifting focus to other features. With proportions improved, the nose may even seem smaller—but in reality, filler can only make a nose bigger. “If someone’s nose is very wide or projected to begin with, they’re not a great candidate for this,” Dr. Subbio says. Liquid rhinoplasty can be a game changer for some, but the nose is a high-risk spot for filler (blocking a vessel here can cause skin loss or blindness).
Go to an experienced injector who uses only dissolvable hyaluronic acids, like Restylane Lyft, to subtly and safely sculpt your nose.

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