The discovery of botulinum toxin for aesthetic use

Botulinum toxin is a rather recent discovery. Ophthalmologists, among all medical specialists, were the firsts to discover the great effects of botulinum toxin on the muscles, particularly for the treatment around the eyes. The credit of the first observations on the reduction of glabellar wrinkles, after the various applications in ophthalmology, is due to the Carruthers, Jean and Alastair. In 1987, they observed and understood its potential: glabellar wrinkles disappeared if treated with botulinum toxin and it is precisely after these observations that its cosmetic use spread worldwide. Their first publication dates back to 1989, after which they became the major users and started teaching its use in the aesthetic field. Their publications still represent valuable lessons for aesthetic doctors all over the world.   The first company that understood the great future of this drug was Allergan who bought the rights in 1991. It bought lots of botulinum toxin to which he gave the name of Botox, a trade name that has become famous all over the world. Two years later, Porton Products launched a botulinum toxin called Dysport, used primarily in the neurological field and now distributed by Ipsen.

In Italy, the first toxin authorized for aesthetic use arrived only in 2004. It is again Allergan, with the trade name of Vistabex, that made the use of botulinum toxin possible. Then, Azzalure, distributed by Galderma, was approved in 2010, and last but least, Bocouture, distributed by Merz arrived in 2011. In 2021, however, the first liquid toxin became available on the market: Alluziance, distributed by Galderma. A toxin that does not need to be reconstituted and is ready to use. All toxins are stored in the refrigerator at 2 – 8 C ° except Bocouture which, if not yet reconstituted, has the advantage of being able to be stored at room temperature.

Botulinum toxin type a is the most used form in aesthetic medicine for face and neck treatments and for the treatment of hyperhidrosis. It causes the temporary block of muscle contraction, preventing the formation of wrinkles. The duration of the treatment can vary from 4 to 6 months and once injected, the effect is visible after 7/10 days.   Botulinum toxin is an extraordinarily effective, accessible and essentially risk-free product. Its qualities make it the main aesthetic drug for the prevention and treatment of wrinkles and is able to give the patient a less tired and more relaxed appearance.   If you are interested in the subject, we recommend reading the text edited by Prof. Alessio Redaelli. For more information, click here.

Poly-L-Actic Acid: face and body sculptor

Polylactic acid is a synthetic polymer of lactic acid produced through its polymerization, obtained from the fermentation processes generally carried out by the bacteria of Lactobacillus. It is widely used in aesthetic medicine in the form of fillers and suspension threads as an alternative to plastic surgery. Its success is to be found in its interesting properties. It is a synthetic, biodegradable, absorbable and immunologically inert polymer, whose task is to stimulate the production of collagen, a fundamental protein for skin tissues.

It is a valid alternative to facelift, used to successfully correct the imperfections of the face. It is used for the treatment of chin, marked dark circles, cheekbones, acne scars and to reduce the depth of facial folds and wrinkles, giving a more toned, compact, and smoother appearance to the skin.   Unlike other fillers, it is not injected directly into the wrinkle, but rather in the entire area. The purpose is not so much the filling, but the volumization and restructuring of the skin. A vigorous massage of the treated areas for the next 7/10 days is crucial to avoid small accumulations of product under the skin that are not visible, but palpable.   The peculiar characteristic of the polylactic acid is to increase the thickness of the dermis due to the formation of neo collagen. In other words, the microparticles of polylactic acid are covered with a collagen mousse produced by the patient himself which thickens the dermis and increases the subcutaneous tissue. This creates a light, medically controlled foreign body reaction which, as we have said, causes the formation of collagen. It is not a normal collagen, but it is rather a fibrotic collagen particularly useful in cases of atony. So, when it is reabsorbed, the collagen formed in the body will give a much longer lasting filling appearance.

Recently, the polylactic acid has been greatly requested for the filling and remodeling of the buttocks. The most used injection technique is certainly through cannula, which, unlike the needle, is much safer and allows a more homogeneous diffusion of the product itself. To avoid side effects, it is important to rely on expert and highly qualified aesthetic doctors. In the immediate post-treatment, it is possible to have redness in the treated area, bruising, edema, and hematomas which will be absorbed in a few days. The treatment is not recommended in the case of autoimmune diseases, neoplasms, diseases, or infections of the skin and, last but not least, avoid injecting it in case of pregnancy, breastfeeding and in subjects sensitive or allergic to this substance.

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Aesthetic treatment of the gummy smile

The gummy smile, or gingival smile, is described as the exposure of a large band of keratinized gum, more than 2 mm, during the full smile. Although the causes are multiple, the final result always consists of a high smile line that can be located several millimeters above the gumline of the upper teeth.  

The gingival smile is not a pathology, but a condition of disharmony of the smile. The more gum is shown, the more disharmonious the smile appears. For many people, this creates an embarrassment, and therefore many people tend to limit the movements of the mouth when they smile.

There is a solution to solve the problem. The treatment, as well as surgical, can be performed by injections of botulinum toxin, which acts on the muscle responsible for this phenomenon, reducing its activity. Botulinum toxin is a well-known drug, and as such it must be used by qualified medical personnel. If performed by specialized and experienced doctors, the procedure is particularly effective and painless. The gummy smile treatment lasts a few minutes and is now one of the most popular treatments in the field of aesthetic medicine. The procedure is performed on an outpatient basis, without the need for anesthesia.

The effects tend to gradually appear over 10/15 days and with extremely natural results. Most patients manage to solve the problem with one session, with no re-touch, even if the treatment must be repeated after about 6-7 months to maintain the results.

As our Scientific Director Prof. Alessio Redaelli says in his text1 dedicated to the topic: “The beauty of a face is given by the harmony of volumes, sizes, heights that characterize that particular face, inserted in that particular body and that evoke a feeling positive for an absolutely disinterested reason. Teeth, hair, and skin contribute to the harmony of the whole“.

If you are interested and want to know more about our hands-on workshop dedicated to the perioral area, click here.

1 Redaelli A. – Aesthetic medicine for the perioral area – basic principles and clinical practice (OEO Firenze 2014)

Hyaluronidase: an ally in Aesthetic!

Is it possible to cancel the effects of a treatment performed with hyaluronic acid in case you do not like the result? The answer to the question is: hyaluronidase.

The term hyaluronidase identifies a class of different enzymes, capable of degrading some components of the extracellular matrix, such as hyaluronic acid, chondroitin and chondroiditin sulfates.

Already used in the medical field since 1928 to facilitate the injection of vaccines and drugs, today it is widely used in aesthetic medicine. Considering its physiological degrading activity, this enzyme is currently one of the most used methods in Aesthetics for the correction of any ischemic events, due to the incorrect use of hyaluronic acid-based fillers, to rapidly reduce the development of an edema or for the treatment of cellulite in mesotherapy in combination with other medicine.

For problems related to the improper use of hyaluronic acid, the effect is immediate: the hyaluronidase acts instantly and eliminates itself by degrading the hyaluronic acid filler. In case of nodules, persisting even after some time, the injection of hyaluronidase in the affected area accelerates the degradation of hyaluronic acid until it is completely eliminated.

However, it is important to keep in mind that hyaluronidase is not an authorized drug for the correction of aesthetic problems: its use, in fact, is off – label. If the person is interested in eliminating the residues of hyaluronic acid, or if s/he is in danger of vascular compromise, s/he must be informed in advance of all its characteristics, methods of administration and complications, through a dedicated informed consent.

It can be purchased in pharmacies: there vials of 300, 600 or 900 units to be diluted, if it is in lyophilized form, or already diluted, to be stored in a cool, dry place away from direct light.

It is therefore important to rely on a competent doctor who will evaluate what to do and which products and quantities to use. All doctors in their office must always be well equipped.

If you are interested in the topic, find out more by clicking here.

Informed consent

The informed consent in medicine is the acceptance that the patient expresses a medical treatment, freely, and not mediated by anyone else, after being informed about the method of execution, the benefits, the side effects, and the reasonably foreseeable risks.

It is a real document with legal value (law L.219 / 17, article 1 paragraph 9), the purpose of which is to protect both the doctor and the patient from mistakes or misunderstandings: the Italian law provides that doctors and healthcare professionals can only treat a person if they agree and give their consent.

In the third paragraph of Law 219/17, the information that the doctor must provide are explicit: diagnosis, prognosis, benefits and risks of the diagnostic tests and treatments indicated, possible alternatives and the consequences of any refusal. The consent must always be acquired by the healthcare professional before carrying out any type of treatment.

A valid informed consent, therefore, must be personal, expressed directly by the subject; free, not conditioned by psychological pressures from other subjects; explicit, clearly requested and unambiguous; conscious, formed only after the patient has received all the information necessary to make a decision and specific, as in the case of particularly complex treatment, the patient’s acceptance must be directed towards these procedures, while a consent would have no legal value if completely generic.

A valid informed consent, therefore, must be personal, expressed directly by the subject; free, not conditioned by psychological pressures from other subjects; explicit, clearly requested and unambiguous; conscious, formed only after the patient has received all the information necessary to make a decision and specific, as in the case of particularly complex treatment, the patient’s acceptance must be directed towards these procedures, while a consent would have no legal value if completely generic.

For this reason, it is essential to reiterate the importance of the informed consent, not only from a medical point of view but also and above all from a legal point of view.

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Fillers and lips: a winning equation

Plump-looking lips are a universal expression of youth and sensuality: they are one of the focal points of the face, which, together with the eyes, makes each person unique. Lips and eyes are our main means of communication.

Lips, losing tone and volume mainly due to aging, are an anatomical area very suitable for this type of hyaluronic acid-based treatments.

Nowadays, in the perioral region, it is preferred to use resorbable fillers with hyaluronic acid, safe and very effective: it gives the lips a younger and more toned appearance, with redefined contours and a very natural effect that does not alter the nature of the person. This treatment is also very popular among teenagers, who undergo the treatment to obtain a sensual and natural look at the same time.

Lips are defined as perfect when they are symmetrical, are at least 10% of the lower third of the face and respect the proportion between the upper and lower lips of one third for the first and two thirds for the second. It is important that the lower lip is always fuller than the upper one to avoid an unnatural effect. In addition to the proportions, the external corners of the mouth must also be evaluated because it tends to be curved downwards with the aging, and the so-called cupid’s bow tends to lose its shape and become flattened and less sensual over time.

This treatment leads to possible side effects such as swelling of the treated area, which however tends to disappear in about 24/48 hours, or small hematomas that tend to reabsorb in a few days. The result is immediately visible even if appreciable in a couple of days, when the small trauma of the micro-lesions has passed.

Lip correction must always be natural and well proportioned, sometimes even a small improvement can lead to a pleasant and sensual effect.

If you are interested, do not miss the practical hands-on workshop dedicated to the lips. For more information click here.

The role of an assistant in Aesthetics

The assistant of an aesthetic doctor is a person who is able, not only to assist and support the doctor during the treatments, but also to assist the patient before and after the treatment. The role of the assistant is fundamental starting from the welcoming of the patient, being the first point of contact between the doctor and the patient.

The assistant has a key role in managing patients and appointments’ agenda. S/he must have a great experience in the medical field and has to be updated on the latest techniques, and on the products the doctor is more comfortable using in the office.

S/he welcomes patients, makes them sit in the waiting room and directs them to the specialist, and consequently has the task of putting patients at ease, entertaining them with patience and, if necessary, reassuring them with professionalism about the possible consequences of the treatment.

As of today, there are no specific training requirements to become a secretary and/or medical assistant, although a training course is recommended to approach the profession. These courses, however, are not yet nationally recognized as there is no academic study course leading to a degree. The training offer in Italy is wide. There are courses that provide both basic socio-health training, and skills in administration and accounting, secretariat, document archiving, communication, and computer course. They also allow to learn how to use management software and programs that are commonly used for appointments in a doctors’ offices. Then, there are courses aimed at training in Aesthetics which include hints of anatomy and physiology of the skin, illustrate the main treatments in aesthetic medicine and the materials available on the market, current regulations and, have a focus on the importance of communication.

It important to remember that the assistant must be an empathic person, able to get in tune with the patient, and have good communication and listening skills.

If you are interested in the topic, find out more about by clicking here.

Aesthetic dentistry: techniques and treatment of the perioral area

Now more than ever, aesthetic medicine increasingly involved another field: dentistry. In addition to the treatment of pathologies of the mid and lower third of the face, the aesthetics of these areas are also treated by the dentist himself to complete the treatment plans. Botulinum toxin A is used for the correction of gummy smile or bruxism, off-label treatments, and hyaluronic acid is used in the lower third of the face, mainly for lips and perioral tissues to restore the correct volumes and to reduce wrinkles. Since botulinum toxin A is one of the most powerful inhibitors of neuromuscular transmission, it is often used before an implant’s insertion to soften the muscles and to maximize the result.

Aesthetic dentistry, as we have already said, can only operate in the perioral area. One of the imperfections that patients are very fond of after a massive surgery is the decrease in the volume of the lips. In fact, the upper part tends to reduce the incisive and the maxillary exposure, while the lower lip tends to increase the exposure of the lower incisors. Wrinkles also appear due to the decreasing of volume in the chin and nasolabial folds, so the role of the dentist to restore the volumes with fillers is fundamental, thus giving that harmonious and fresh look to the patient’s face.

As our Scientific Director Prof. Alessio Redaelli says in his book1 dedicated to the topic: “The beauty of a face comes from the harmony of the volumes, measurements, heights characterizing that particular face, inserted on to that particular body and which evoke a positive sensation from an absolutely impartial reason. Teeth, hair and skin contribute to its overall harmony “.

If you are interested and want to know more about our hands-on workshop dedicated to the perioral area, click here.

1 Redaelli A. – Aesthetic medicine for the perioral area – basic principles and clinical practice (OEO Firenze 2014)

Medical devices: needle vs cannula

Usually dermal fillers are injected using needles, but in everyday practice there are several advantages to preferring the use of blunt tip cannulas.

In fact, cannulas have many advantages, including an important reduction in discomfort during treatment compared to needles, the ability to treat large areas and the complete absence of bruises in areas at risk, especially in the periorbital area and lips. On top of these advantages, there are faster recovery time and last but not least, a lower risk of vascular occlusion. The indications are represented both by the large volumetric areas of the face and the localized areas such as cheekbones, temporal area, rhinoplasty, lips and mandibular border. On the market there are various types of cannulas in terms of sizes, both in length and in diameter. The expert will choose the most suitable cannula according to the product used and the area to be treated.

However, many doctors prefer the needle because it allows greater precision and in fact it is used for countless techniques. It is great for lips and suitable for any other area of ​​the face, but it comes with some disadvantages. It can tear tissues and small blood vessels, and due to its short length, it does require repeated insertions which can cause bruising and pain during treatment and facilitate intravascular injection of the product. Disadvantages that are eliminated or reduced by using cannulas.  

The experience and knowledge of the expert is the key aspect for the best outcome of any treatment.

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Different approach among generations

Identifying the generations helps to better understand how to approach the patient and which treatments is best to obtain a result that is in line with the patient’s requests. Generations can be identified as:

  • Generation Boomers (1946 – 1965): it is the generation that has been most influenced by history, the one that has personally experienced the highest number of events with a considerable impact on society, economy, and politics.
  • Generation X (1966 – 1980): they are more educated than their parents, but they are also the first to suffer the consequences of the recession, with fewer job opportunities.
  • Generation Y or Millennial (1981 – 1995): they entered adult life in the first 15 years of the new millennium. They are the Euro and the European citizenship’s generation, but also the one that is paying the highest price for the economic and social consequences of the crisis.
  • Generation Z (1996 – 2015): the youngest, born and raised as true digital natives with access to the Internet and portable digital technology.

But how treatments differ from one to another among generations?

Generation Z is certainly the generation that has understood the importance of self-care. In fact, it is the generation that spends the most on personal care products and non-surgical treatments. They follow the trends proposed by social media and openly declare which treatments they have undergone. The most requested are lip fillers, facial biorevitalization and botulinum toxin in the glabellar area.

“Prevention is better than cure” is also the motto of the Millennials, the generation that invented selfies. The approach is to seek an attractive and eye-catching appearance, focusing mainly on combined treatments of fillers and botulinum toxin in the area around the eyes and increasing the volume of lips and cheekbones.

Generations X and the boomers generations, on the other hand, have a different approach to aesthetic medicine. Their goal is to maintain a natural look by working on restoring volumes. The tendency is not to share the treatments like the younger generations do with their friends, but to keep them confidential. They want to appear younger without distorting their appearance, and, in this case, treatments that include techniques combined with fillers and botulinum toxin throughout the face are the most suitable.

So, as always, the aesthetic doctor has a crucial role: understating the needs and wants of the patients, of all ages, and opt for the best treatment.

If you are interested and want to know more about our hands-on workshops, click here.