Artistic surgery remains entirely the undisputed standard of excellence for rejuvenation. However, overall national economics has many patients — who need to remain looking their best — curious about alternative options at this time. Therefore, I decided to write this letter to help guide you in explaining these non-surgical, almost immediate obtainable results.

As we have mentioned in a previous letter, we returned to the use of injectables a few years ago. The reasons are quite simple. Compared to earlier ones they are now safer, reversible, and non-animal derived (almost entirely eliminating allergies) and their longevity has increased. We have a much better understanding of how hyaluronic acid (HA) and BOTOX behave in live human beings. Some patients come to me and I have to make an effort, for their knowledge and comfort, to communicate to them the science of these substances, which is necessary for an informed decision on their part as well. "I trust you implicitly Dr. Ristow. If you say it is good that is sufficient for me." This is what I frequently hear from established patients.

Independent of this flattering attitude towards me and my integrity, I would like to, in an understandable and scientifically correct way, give you a look into these injectables such as hyaluronic acid (HA) and BOTOX: Why are they so popular, why they have advantages that you may consider for yourself, why they sometimes seem to last and sometimes seem to go away quickly, why re-treatment is important, and also the overall cost — another consideration that will affect your result. I do these injections personally, always.

Let's start — and this is intended to be a simple presentation dealing with a complex issue — with BOTOX, called amongst us physicians BTXA. (There are other types, BTXB, etcetera), but A is what we use. (I'm always referring to the manufactured U.S. product.) BOTOX is a complex, long, convoluted molecule which looks in a microscope like loose strands of fettuccini. It does not go through the vessels that protect the brain.

Safety: 28,000 (twenty eight thousand) units of BOTOX would be necessary to kill one out of two persons receiving this dose. We use 40 to 60 (forty to sixty) units in a woman and usually 60 (sixty) units (or less, but not more) in a man, so the margin of safety is very large. Why not more in one session? Because of the risk of our bodies making antibodies against BOTOX. If that occurs BOTOX will not work for a patient any longer, being destroyed by the antibodies in a very short time.

Repeating the maximum dose (especially in very muscular male or female faces) can be safely done after two weeks. This is indicated for those patients who received a full dose, but had only a partial response on the first treatment.

What about the cost? It depends strictly on the concentration used and the number of "zones" treated (see below). Concentration of BTXA varies among reputable physicians but, accepted is a maximum of 100 units of BTXA per 2 (two) cubic centimeters. Obviously, 100 units in 4 (four) cubic centimeters is almost half as expensive, but also half the concentration, and therefore more limited effectiveness. "A person may say; "But it is so much cheaper down where I live…etc., etc..." That is likely a diluted concentration.

So, keeping the objective clear: No. 1: The maximum dose of BTXA for a woman or a man is well known and it is not wise to exceed it in one session. No. 2: The cost (price) depends on the concentration and zone treated. This maximum concentration can be placed on one or divided among many "zones." Zone 1: Frown lines, angry lines; Zone 2: Forehead lines; Zone 3: Crows feet; Zone 4: Bunny lines (middle of the nose). DAO = Depressors of the corner of the mouth; Chin wrinkles; Turning up the upper lip ridge; Opening more the narrow eyes of Asians; Raising the side eyebrow. OBS: There are other locations that I use BTXA but the above mentioned are the main ones.

BOTOX (explained above) acts by paralyzing muscles. Hyaluronic acid (explained below) acts by volumizing the face.

What about hyaluronic acid (HA) and non animal stabilized ("cross linked") hyaluronic acid (NASHA)? In reality, these substances are sugars. Once injected into the human body, HA's would disappear in one or two days. Cross linking these sugar molecules (NASHA) gives them relative stability and longevity in the tissues. (We can follow their absorption in humans with MRIs.) All NASHAs have this intrinsic safety and that is, that they go away, are dissolved! Always. In the meantime, they give good correction to areas of deficient volume, like corners of the mouths, lips, nasolabial (NLF) folds. NASHAs are approved by the FDA for NLFs, but are off label for lips (meaning that long studies have not been presented to the FDA; however, the majority of specialists also use them for lips, etc.,) In our practice, Juvederm Ultra is what patients seem to prefer the most, although Restylane is also used. Scientific papers place the duration of the NASHAs up to six and nine months. Some seem to last longer. Possibly twelve months or more. The fact is that even a little amount of NASHA seem to retain, absorb, a lot of water, therefore giving a good long time correction.

Ideal Maintenance: (Keeping optimal results.) Touching up the sites appears to be best done at 4.5 months and 9 months after the original injection. There is some evidence that the body forms new collagen around NASHA injections which may explain the added longevity.

The question therefore "is it possible to maintain youth or a more vigorous look - even though shorter lasting - and perhaps later, do some more definitive work?" I believe sincerely the answer is "yes" and rests with these substances. It is obvious they cannot create results like the ones you see in our website www.brunnoristow.com but for sure they can make you look refreshed and less wrinkled; maybe just enough for us to feel attractive and be a competitive contender in the game of life.

I sincerely hope that this has helped you understand these complex issues and as a corollary make the proper decisions. Injectables are an effective way to gain some youth with almost no down time. Surgery can always be an option. We are at your entire disposition if you wish to pursue these non-surgical enhancements.