14 July 2020
As a follow up to my last post Is Botox Deadly? 5 Things You Need to Know About Botox Safety on the safety concerns surrounding Botox or Botulinum toxin; this post is about the alternative treatments to Botox/Botulinum toxin. Understandably, in light of an unfortunate piece of news in Singapore; there has been a lot of apprehension and second thoughts among patients who want to get Botox/Botulinum treatment. So allow me to break it down for you; a guide your alternatives to Botox/Botulinum treatment and what you can reasonably expect (or not) from these alternative treatments.
The alternatives to Botox or botulinum toxin will depend on the condition that is being treated. Broadly speaking in face and neck, Botox/botulinum toxin is used for treating:
Wrinkles are the expression lines on our forehead, glabella, periorbital (crows feet) and bunny lines when we laugh, smile, squint, frown or cringe. These lines appear because we use our muscles of facial expression to emote; and with habitual usage, the muscles develop these crevices. One of the factors that affect the severity of these wrinkles is how often we use these muscles- so if you were to frown more; your frown lines tend to appear earlier in life.
There are 2 types of wrinkles- dynamic wrinkles (wrinkles only with expression) and static wrinkles (wrinkles at rest).
Dynamic wrinkles are due to muscle contractions and can be treated with Botox/ botulinum toxin.
All wrinkles begin as dynamic wrinkles- this means that these wrinkles are only apparent when we use our muscles of facial expression to smile, laugh or frown. When our facial muscles are at rest and we do not display any facial expressions; these wrinkles are not seen.
Unfortunately, botulinum toxin is the only treatment for these dynamic wrinkles because botulinum toxin is able to target the muscles of facial expression to successfully treat dynamic wrinkles. All other treatments- be it Rejuran Healer, Skinboosters, Profhilo, chemical peels or high intensity focused ultrasound (HIFU) may improve the appearance of the wrinkles to a very small extent by promoting collagen formation in the skin but they do not target the muscles of facial expression.
Static wrinkles: The resting angry face explained
Static wrinkles are present when the face is rest. This is because the skin above the muscles have formed grooves due to prolonged and repeated muscle movements and collagen loss.
Just like wine, wrinkles evolve over time.
Dynamic wrinkles become deeper and involve larger areas of the face as we age if these wrinkles are not treated. Over time, dynamic wrinkles turn static. This means that even at rest, without using the muscles of facial expression; these wrinkles are seen, making you look older and possibly, angrier than you would think. Years of untreated dynamic wrinkles have caused the skin above the dynamic wrinkles to form grooves and so the wrinkles have turned static.
There are 2 issues that need to be addressed with static wrinkles-
1. The underlying dynamic wrinkle (muscle)
2. The overlying skin
As addressed earlier, the only modality of treatment for dynamic wrinkles is botulinum toxin.
Dermal fillers are a soft gel that is injected into the face to sculpt the face and soften lines.
Dermal fillers can help to smoothen the furrows of static wrinkles by literally filling these wrinkles. The overlying skin can also be treated with collagen building treatments to the skin such as fractional CO2 laser, Rejuran Healer, Profhilo, Skinboosters or chemical peels. These treatments induce collagen formation in the skin to resurface these grooves formed by the pull of the underlying muscles. However, the underlying muscle pulling the skin still needs to be treated with botulinum toxin otherwise the wrinkles will still be seen.
There are a few reasons why a face can look broad:
Masseter/jaw muscle hypertrophy and bruxism
As explained in my post A Guide to A Slimmer V Face: Jaw Reduction Botox and Chin Filler Review, the masseter muscles at the sides of our jaw control chewing and clenching of the jaw. Hypertrophic (enlarged) masseter muscles make the sides of the jaw can look enlarged. Bruxism (teeth grinding) is one common cause of jaw/ masseter muscles enlargement.
Mouth guards, mouth splints and medications for jaw slimming
An example of a mouth guard for bruxism
Although hypertrophic masseter muscles and bruxism are very commonly treated with botulinum toxin, these can also be treated with mouth guards or splints; or medications such as muscle relaxants. These can be obtained from a dentist or doctor in Singapore. Mouth guards and splints reduce teeth clenching and bruxism to slim down the msseter muscle and jaws.
If you would like an indepth review on bruxism or teeth clenching, please read my blogpost Bruxism: Causes, Symptoms and Treatments. The case study features my husband who also gets jaw botox from me.
Large or boxy mandible jaw bone structure
Types of mandibular resection surgery
Where the jaw bone is concerned, the only way to reshape the bone is- surgery ie. osteotomy. In South Korea, where the V shaped face silhouette is coveted, jaw reduction surgery is relatively popular. In Singapore, square jaw reduction surgery is performed by plastic surgeons. This is one instance where Botulinum toxin, HIFU, face threadlifts and other non-surgical treatments will not be useful as they do not address the bone structure.
Botulinum toxin/ Botox and the jaw bone
There are a few small studies that have shown that with repeated Botulinum toxin/botox injections to the masseter muscle; the mandible/jaw bone that is attached to the masseter undergoes remodelling over years to become slimmer- however, the caveat here is that these patients underwent sequential botulinum toxin injections to slim down their jaw muscles over consecutive years and the jaw slimming effect due to bone remodelling was small.
Facial massages and other ‘small face’ massages that face contouring
Talking about reshaping would not be complete without discussing another fad in Singapore- contouring facial massages that claim to slim down the jaw bone. Propelled by the appeal of promises of non-surgical bone contouring with instantaneous results; these massage parlours have grown in popularity.
These facial massages claim to ‘reshape the bone structure’ using ‘special bone massage techniques’ and ‘Golki therapy’ that supposedly increase blood circulation and calcium absorption to the bones and thereby alter bone density and bone shape. Besides sounding questionable; there is no scientific study or data to back up these claims. I performed an extensive literature review but there was nothing yielded. If miraculous bone massage techniques could enhance calcium absorption and remodel bones- by golly, we’ve found a cure for osteoporosis!
Meghan Markle’s go to facialist, Nichola Joss’s facial massage for face slimming
‘Small face treatments’ claim to enhance lymphatic drainage in the face. Hence, face swelling from ‘water retention’ due to sluggish lymphatic drainage is relieved and face becomes less puffy and lifted. Even her royal highness Meghan Markle is reported to be a fan of the buccal massage; which involves an unusual technique of massaging the face from inside the mouth.
The lymphatic drainage system of our face, head and neck
The lymphatic vessels drain excess fluids from tissues and body parts like the face, breast, arms..etc in the blood vessels. This is very important in maintaining fluid balance in the body- if the lymphatic drainage is blocked up for whatever reasons (e.g. surgery, radiation, tumors, infection…etc); the normal drainage of fluids from tissues and body parts becomes disrupted. Excess fluid then accumulates in these places and swelling then develops. This condition is called lymphedema.
Lymphedema can develop in the face; but this usually occur with cancers in the head and neck or after surgery and radiation. The lymphedema is usually very significant and painful; unlike the ‘water retention’ most of us may think that we may have (or your beautician may have you to believe that you might have). And lymphedema in the face almost never occurs spontaneously or with aging.
Manual lymphatic drainage is a specialised massage technique that helps with drainage lymphatics into the bloodstream. Numerous studies have shown that this specialised massage with reducing swelling due to fluid accumulation from blocked lymphatic vessels1,2,3. However, please note that there is a caveat. Lymphatic drainage/ massage is a very specialised massage technique that physiotherapists are trained to do so. If your beautician can simulate this technique you might be able to relieve your facial swelling or puffiness due to any lymphatic obstruction.
Jade rollers for face slimming
Jade rollers: making your instagram feed prettier.
Taking millennials by storm with their cotton candy pastel hues; it is not hard to see why these Instagrammable face jade rollers have also found a following. These hand held massaging tools claim to help with toning lax facial muscles and improve lymphatic drainage, thereby reducing face puffiness and swelling. So, scientifically speaking, jade rollers may work if you have facial swelling due to blocked lymphatic drainage and very likely, you’ll have to use your jade rollers in a very specific manner in order to enhance lymphatic drainage.
I wish I could find a study to support the use of these jade rollers; they are indeed so pretty and popular among my friends. That said, despite a lack of empirical evidence for me to advocate the use of jade rollers; anecdotally my friends can attest to some face slimming results of the jade roller. I’m not entirely convinced about the efficacy of jade rollers. However, if you believe in the face slimming properties of these jade or crystal rollers- go ahead. I will not discourage since they do no harm and are very affordable (and they do make great flatlay props).
The chin’s proportions and shape in relation to the face also affects the shape of the face. Briefly speaking, for ideal facial proportions, the lower one third of the face (namely the chin) should form one-third of the face length. A relatively short chin can make a face look broad of square shaped by truncating the length of the face.
Chin filler injected into the chin to create a V shaped face.
The only non surgical way to sculpt and enhance proportions of the chin is with dermal fillers injected into the chin. As explained in my post on chin fillers; dermal fillers can be injected into the chin to add volume, length and shape to the chin. Chin fillers work well to correct the chin projections and appearance of receding chins (retrognathia) and short chins (micrognathia).
One of the most common types of chin fillers used is hyaluronic acid fillers (e.g. Juvederm Voluma, Restylane Lyft, Boletero Intense…etc) because of their ability to add volume with a natural feel. Other types of chin fillers also include Calcium Hydroxyapatite (Radiesse).
Chin fillers are a soft gel. This allows the chin filler to be moulded to sculpt the chin. For patients looking for a sharper chin shape (‘V face’) or a more defined jawline; chin fillers are an ideal non-surgical treatment.
There are two methods of injecting chin fillers- the injection needle technique and cannula technique. In the picture above, I am demonstrating the needle technique. Both the needle and cannula techniques have their strengths when it comes to chin fillers; sometimes I use a combination of both methods for the chin filler.
What a difference a lip makes: Kylie Jenner’s lip evolution
Not to be confused with lip fillers; the botox lip flip is the buzzword on everyone’s lips now that Kylie Jenner has very famously removed her lip fillers. Unlike lip fillers which add volume to the lip to perfect your pout, the botox lip flip gently rolls up the lip corners to create the illusion of fuller, more voluminous lip.
What are the non-Botulinum toxin alternatives if you want a fuller lip?
Lip plumpers: topical lip fillers
If you are afraid of needles but want to pump up your pout; there is now a more elegant way to make your lips look thicker without the faux pas of overlining your lips. I know celebrities like Kylie Jenner overline their lips but it doesn’t make this horror any more forgivable.
Enter lip plumpers; a type of lip plumping gloss hat gives the impression of fuller lips when applied. These lip plumpers usually contain ingredients that increase blood flow to the lips; which temporarily causes the lips to temporarily swell up and look fuller. These ingredients may include menthol, pepper and ginger extracts and so these lip plumpers may have a slightly stingy and irritating feel to the lips. This means that one of the side effects of using these lip plumpers is a red and sore lip for some users who have sensitive lips. One study on lip plumpers containing ginger essential oil showed that increased blood flow (vasodilation) to the lips and protrusion of the lips for 30 minutes after application4.
Some of the ingredients used in lip plumpers like cinnamon and pepper can cause contact dermatitis and chapped lips. So if your lips feel irritated with the use of lip plumpers- you may have to avoid using lip plumpers with these ingredients in them.
The only lip plumper/ topical lip filler I have tried is Luscious Lips by Infracyte. Ayumi Hamasaki, J-pop’s empress, is known to be a fan of Luscious Lips. My lips were did not look fuller but the lip plumper was a decent lip gloss that kept my lips well moisturised. There are many other cosmetic brands like Dior and Too Faced that also carry their own lip plumpers.
There are also some lip plumper brands that also contain hyaluronic acid for adding volume to the lip. No surprises there, hyaluronic acid is a common features in skincare and dermal fillers. However, the results with these hyaluronic acid containing lip plumpers or lip glosses are subtle5. Nevertheless, hyaluronic acid is a very safe ingredient that does not cause irritation or dermatitis, so no harm having it in your lip gloss/ lipstick!
And no discussion of lip plumping will be complete without a word on lip fillers. Similar to chin fillers, dermal fillers are injected into the lip to add volume and sculpt the shape of the lip. Lip fillers are injected into the lips to fill the lip; but the botox lip lift is injected to the muscle surrounding the lips to roll up the lips. The advantage of lip fillers is that they are longer lasting than lip plumpers and can significantly improve the volume of the lips.
One of the non-surgical treatments that I do for lifting of sagging skin is face threadlifts. This is an example of one of the brands of threads that I use for the face threadlift- Silhouette Soft.
Lifting treatments for sagging skin in the face and neck deserves a post on its own because there is so much to share about this topic- HIFU, liquid facelift, face threadlifts…etc. Stay tuned for a blogpost in the works on non-invasive lifting treatments! But here’s a little teaser- my sharing on face threadlifts.REFERENCES 1. The Role of Lymphedema Management in Head and Neck Cancer. Smith et al. Curr Opin Otolaryngol Head Neck Surg. 2010 Jun; 18(3): 153–158. 2. Manual Lymphatic Drainage in Blood Circulation of Upper Limb With Lymphedema After Breast Cancer Surgery. Guerero et al. J Manipulative Physiol Ther. 2017 May;40(4):246-249 3. Manual lymphatic drainage for breast cancer-related lymphoedema. Shao and Zhong. Eur J Cancer Care (Engl). 2017 Sep;26(5). 4. How long does the volumizing effect of a Zingiber officinale-based lip plumper last? Mazzarello et al. Int J Cosmet Sci. 2017 Aug;39(4):373-378 5. Anti-aging and filling efficacy of six types hyaluronic acid based dermo-cosmetic treatment: double blind, randomized clinical trial of efficacy and safety. Nobile et al. J Cosmet Dermatol. 2014 Dec; 13(4): 277–287.