Common complaints I hear of when meeting patients for the first time, whether new to medical aesthetics or new to me, is issues with their anti wrinkle dose and "wearing off too quickly". So it bears repeating - anti wrinkle treatments work by paralysing the nerves that send signals to the muscles in your face to move, causing lines - eg frown lines, forehead and crows feet being the most common areas to treat. This effect may begin as early as 3-5 days and is complete by 2 weeks or 14 days when I normally like to review you to check the dose is right, you're happy with results and there is no unevenness or other fixes. After this, these nerves begin to regenerate as early as 6-8 weeks after treatment, when they begin to send signals to the muscles again, until at 3 months, movement is around 80% or more of movement before any treatment. Over time and regular treatment, or with a higher dose, this may stretch out to 4 months, but this is in effect how anti wrinkle treatments work. There is no -"on-off" switch, but a more gradual return to movement that will soften over time and repeated treatments. This is most common after the first 1-2 times you have anti wrinkle treatments, even if you had a standard dose, depending on how strong your muscle movement is before treatment and especially if you have lines visible at rest, usually indicating a stronger muscle. Occasionally, people believe this is dependent on the brand used, when it may have worn off quicker the first time with Brand D but worked longer with Brand X for eg. All else being equal, my experience has been that it is usually the fact that it is your first or second time having treatment rather than the brand (but it is good to keep it in mind). So some tips to keep in mind when seeking anti wrinkle treatments, especially if you are new to this. after your first treatment, it is common for some unevenness when it begins to kick in, until review at 2 weeks, and in 99% of cases this will settle by the time of review. we assess correct dose at 2 weeks, when the treatment is at peak effect if you are happy with the result. some movement the first few times, especially if you opt for a lower dose to "soften" lines rather than "freeze" lines, may return as 6-8 weeks and increase over time till re-treatment around 3 months lines present at rest, called static lines, are harder to fade and need regular treatment every 3 months with appropriate doses of the area to be treated until they fade, usually around a year; thereafter, they need ongoing maintenance to keep them from becoming worse again. unless we aim to freeze your face, it is usually not possible to completely prevent lines and wrinkles and it is important not to become hyper focused on chasing lines and wrinkles as opposed to an overall look of appearing refreshed, or rested, if that is your goal. as the result is dependent on the dose used, a goal of "no lines" usually will mean a higher dose is needed, and usually areas of the face next to the area to be treated will also need anti wrinkle injections as otherwise they will compensate for the frozen areas by becoming extra mobile (hyperdynamic) So as always, our advice at Skin Essentials, is to choose a provider whose face you like, including in animation, and to have a clear idea of what your goal is so you avoid disappointment. Realistic expectations and trust in your provider is the key on which longterm therapeutic relationships are built.    

Injectables! Despite the booming popularity of these office procedures, there are many people who are still new to the choices available, and who may enter their 30s, 40s and even their 50s, having never had a needle near their face. On these occasions, I like to allow for enough time to address concerns, answer questions and sometimes, manage unexpected anxiety that may rear its head as they get on the treatment bed. Some say to me “I was all psyched up, ready to go, when I booked and signed the consent form, but now I’m having second thoughts…” Why these second thoughts? At Skin Essentials, we mail out as many of the relevant forms to you prior to your appointment to fill out as possible, to maximise your allocated appointment time in clinic with your treating doctor. So common side effects we warn you about: bruising swelling temporary headache (with anti wrinkle injections) lumps and bumps (with fillers) asymmetry (fillers and anti wrinkle)   Additionally, we talk to you about rarer side effects and some medical emergencies, so it is no wonder some patients, on reading consent forms, begin to worry.  Informed consent is an important part of any consultation and not something to be simply rushed into. Equally, it helps you prepare to minimise the chances of adverse effects on the day. Having said that, how can you present to your appointment and have the best possible outcome? 1. No makeup means no makeup. Patients will often present with a full face of makeup, or “on my eyes since you’ll be treating my cheeks” etc. For anti wrinkle, it is less important than fillers, which are semi permanent implants, but an absolutely clean surface is vital to reduce risk of contamination of equipment and minimise risk of not only infection but also nodules down the track. This is non negotiable for me, not to mention makeup affects the quality of the pictures we take for our records and makeup removal especially of layers, can take up precious time in clinic. 2. Hair tied back or off the face Another big thing. Taking pictures before and after procedures is part of the process and hairstyles and hair in the face can affect results so it is imperative that hair is held off the face, and that you come with suitable hair bands and ties to do this, and during the procedure also. 3. Please avoid any supplements and medications as well as social drugs that may increase risk of bleeding Common culprits include Vit E, ginseng, fish oil, ginkgo biloba and some medications such as aspirin and ibuprofen. Also, alcohol. All of these will increase risk of bleeding and bruising. 4. Please plan to go home after the procedure and ice the area treated Patients often plan their treatments just prior to a lunch meeting, or a shopping date, and while with many minor procedures this is fine, if we are doing a fair bit in one go, it is safer to simply go home and to keep icing the area for best results and to minimise bruising risk. 5. Please don’t plan to exercise or get a facial or a massage immediately before or after your appointment Lying face down for a massage or having a facial may move freshly injected medication to an unwanted area, so these procedures are off limits at least for a day or two. 6. Please plan your injectables at least 2 weeks before any big events such as birthdays, weddings and more. Some of this is logistics - it takes anti wrinkle injections anywhere from 3-5 days to begin to kick in and to peak at 2 weeks. Fillers can take 2-4 weeks to settle and lumps, bumps and some asymmetry are common. Likewise, bruising is a common and well known side effect of all injectable treatments, so please plan these at least 2 weeks prior to any big events. 7. Please plan your appointment at least a week prior to any planned trips and flights away I like to have patients around for at least 2-3 days post treatments in the event that there is an unexpected and serious side effect. There are limited options to help if you are interstate, or worse, overseas. 8. Keep your mind open and your expectations realistic This is a big one. Please be guided by your clinician as to what is possible with your unique anatomy rather than insist on what you have seen on social media, complete with filters and photoshop. The face is a highly mobile area of the body, and subtle changes can make for big impact, but only if done well. Have an idea of what you’d like, but be willing to listen to your provider and take their advice on board if it is not possible (or out of your budget). What else would you add? What else would you wish to know if you were to consider injectables? 

Injectables are tricky to master, and anyone who tells you it’s easy, is often not telling the truth. With more experience, I’ve found that I see more and more variation in faces as to what can go wrong, go awry and even lead to unexpected results. Just like with Medicine, there is usually a Dunning-Kruger effect initially- when we are very new and know a little, we think we know a lot and it sometimes veers on arrogance. With actual experience and knowledge, we realise just how limited we are in our understanding, and how much can truly go wrong - not necessarily catastrophically wrong, but inconveniently, sometimes embarrassingly wrong, with areas such as the human face, which we use to emote and express and which is so important for non verbal communication.  This week I’ve had several patients new to some injectable treatments for them, with some glitches reaching out, concerned something has gone wrong, when it is all part and parcel of first time treatment. At Skin Essentials we reach out regularly after someone’s first treatment when things may go wrong, and as our patients feel more confident, we take a far more laidback, hands off approach as is appropriate, reserving advice and discussion for in person reviews. Nonetheless the enquiries this week have me thinking about the things that can potentially occur with anti wrinkle treatments, which are normal, no matter how much we prepare patients for them. So what are the commonest side effects that, while not life threatening or a medical emergency, nonetheless may cause someone to reach out for advice until it all settles?  1. Asymmetry. Among the commonest, asymmetry. Few of us are completely symmetrical, and sometimes the symmetry may be so mild as to not be apparent to us until we begin to undertake injectables. Then, perhaps as we begin to pay more attention to our own faces and the smallest of changes, or sometimes because anti wrinkle treatment may affect one side more than the other initially, even if the same dose was used; or surrounding muscles may pull on one side more than the other, asymmetry may be more obvious to us and to others also till it equalises.                                                      This is fairly common for first time treatment to a given part of the face - I often warn patients of this, and to leave well enough alone till 14 days because we cannot not do anything till then. 9 times out of 10 the asymmetry will settle in a few days, leading to evenness by the 14th day. Problem fixed!  Asymmetry is commonest in areas such as: Eyebrows when treating for frown lines Forehead lines when brows are raised, such as when treating forehead lines The degree of gum on show when treating for gummy smile In paired areas, especially when multiple muscles are involved such as with frowns and smiles, it is impossible to achieve complete symmetry (it is a rare person who's symmetrical anyway), but eyebrow asymmetry is usually easily fixed as are uneven forehead lines. We offer all new patients a complimentary review at 14 days to assess their first treatment in clinic and to address any concerns. This is much easier than emails to and fro, and allows me to standardise for photos taken in clinic if there are symmetry concerns for next time.  2. Heavy forehead/ brows In some patients, this may be an issue when the toxin is first kicking in. The forehead, which is the main elevator of the forehead, may feel heavy. When overdone, eyebrows may flatten and be hard to raise at all, giving women a mannish appearance. In severe cases, patients report not being able to raise their brows at all, and feeling like someone is pressing down on their forehead the whole time. This is different to patients who prefer a more arched appearance to their brows, and who have severe, visible forehead lines because of the regular unconscious raising of their eyebrows. With toxin to the forehead, they may still be able to raise the brows, and the forehead lines may smooth out due to treatment, but they may feel uncomfortable or dislike the effect treatment to this area has for them, unlike overtreatment of the forehead, which causes a flattening of the brows, inability to raise them and drooping of the eyebrow, causing eyelid skin to be pushed down as in the photo above (courtesy of Dr Joe Niamtu) If there is suitable movement retained, the dose is likely not excessive, but all toxin to the forehead will slightly flatten the brows such that if the effect is one that is distressing for the patient, they may prefer forehead lines over the unpleasant feeling/ loss of arch in their brows or prefer a smaller than ideal dose that softens lines without compromising the ability to raise brows (more). Ultimately that is a personal matter that only each patient can decide for themselves. Life is too short to be frustrated about non essential treatments.  Unlike dermal filler, toxin cannot be removed or dissolved and we must wait it out, a process which can begin as early as 6 weeks post treatment. Also unlike dermal filler, the beauty of anti wrinkle treatment is that if unhappy, it’ll resolve itself in time (indeed, nothing CAN be done), whereas when done well, patients want results to last forever, which leads to our next point. 3. Return of lines/ movement sooner than 3 months It is a misconception that faces treated with toxin will remain looking treated until the 3+ month mark when more treatment is needed. Toxin, once injected, depending on the brand used, begins to kick in as early as 3-5 days and peaks (ie has maximum efficacy) at 14 days post treatment which is the best time to assess for effect.  As early

Throughout Australia, anti-wrinkle injections have become a popular choice for people who want to look younger, feel more confident, and prevent the future appearance of wrinkles. Wrinkles occur for a variety of different reasons, including age, exposure to sunlight, and repeated facial expressions. Anti-wrinkle injections can help reduce the appearance of wrinkles and play an important role in younger, more vibrant looking skin. Let's take a look at how wrinkles occur. How Sunlight Causes Wrinkles By and far, exposure to sunlight is the biggest contributor to wrinkles. Ultraviolet light, a part of the visible spectrum, is the component of sunlight that causes wrinkles. Exposure to UV light plays a role in breaking down your skin's collagen and elastin fibers. These fibers lie deep in the dermis and contribute to your skin's strength and flexibility. When these fibers break down, your skin starts to lose its strength and flexibility and these can cause skin to sag and wrinkle prematurely. How Wrinkles Accrue Over Time As We Age Aging is a natural part of life. Some people start to notice that their first wrinkles can form as early as the age of 25. Wrinkles due to aging largely occur because of less sebum, making the skin more rough and dry, and a loss of hyaluronic acid in the skin. Hyaluronic acid is an essential compound for maintaining moisture in the skin. In our mid-twenties, the body's collagen starts to decrease by as much as 1% each year, which reduces the skin's ability to retain its organization, leading to wrinkles. How Facial Expressions Can Cause Wrinkles To Occur The various facial expressions that we use to express emotions can also lead to fine lines and wrinkles. The average person smiles twenty times each day, while extremely happy people smile as many as forty times each day. Every time a facial muscle is used, it forms a groove underneath the surface of the skin. As we age, the skin loses its dexterity and flexibility and these grooves become a permanent feature. How Anti-Wrinkle Injections Help With Wrinkles Anti-wrinkle injections are a viable way to deal with dynamic wrinkles (the ones that are caused by muscle movements in the face, like smiles) and dynamic wrinkles (ones that are caused by a loss of collagen over time). Anti-wrinkle injections and fillers can help restore the skin's ability to hydrate itself, lift the skin, smooth out lines and wrinkles and contribute to a fresher, younger, and invigorated appearance. Anti-Wrinkle Injections Support Healthier Skin Your skin is your body's largest organ. When it is healthy, you feel vibrant and more confident. But, the skin goes beyond how we look and feel. Healthy skin also contributes to overall health. When your skin is healthy, wrinkles are less of a possibility. There are also microbes on the skin called commensals. When your skin is healthy, these microbes can help boost your body's natural ability to fight off viruses and bacteria, leading to better health.