The most important thing about our health is not what our skin or face looks like—it's about keeping ourselves mentally and physically fit. You need to take care of your heart, your lungs and your brain. You need to keep your muscles toned and your joints healthy. You need to watch your diet, constantly strive to improve it and get exercise. And of course you need to get appropriate cancer screening—mammograms, colonoscopies and in some cases, ultrasound exams.

I've been a pilot for 29 years and owned a plane for many of those---with the birth of my son my priorities changed. Here's the point, though. As the plane and its parts aged I devoted ever more time and energy making sure that the mechanical things—the engine, the propeller, the radios and the wiring were in order. I could only budget so much money for flying but the priorities were all about keeping it mechanically sound. On those rare occasions when there was money left over I'd get it repainted or "touched up" so that it looked "youthful." The mechanicals were a "need" while the paint was a "want." I'd never fly a plane that looked nice but was mechanically unsound—and neither should you.

So let's understand that we all get older, there's no avoiding it, and that cosmetic enhancement is a "want" and not a "need" for our physical and mental well-being.

Healthy Attitudes About Aging and "Enhancement"

Many women in the United States regularly use products such as Botox and dermal fillers, which we'll discuss in this section. According to the American Society for Aesthetic Plastic Surgery (ASAPS) the number of Botox procedures in 1997 was just over 65,000 and by 2006 climbed to just under 3.2 Million! The number of dermal fillers procedures during that same period of time climbed from nearly 350,000 to almost 1.9 Million. Clearly more people are using these products.

There are good reasons and bad reasons for wanting to look good. Good reasons include, wanting to look good for "your self." It's not reasonable to think that these products will improve your love life or your marriage. They may help give you more self confidence—and that can be a good thing as long as your self-confidence doesn't rest entirely on an enhanced appearance. Remember that cosmetic enhancement can't reverse aging—it can only reverse some of the outward appearances of aging.

Some women insist that they'll fight the aging process kicking and screaming into their graves, spending enormous sums of money and time and exposing their selves to considerable risk. If that's your attitude about aging you might need a reality check about your life in general. You can't stop the aging process—all healthy people, at some point, need to accept aging as an inevitable part of life.

Anyone who considers any type of cosmetic procedure needs to balance the potential benefits, risks and costs. It's nice to look our best but not at the risk of our overall health, financial ruin and our children's college education.

Some women have very realistic expectations and motivations for cosmetic procedures. They may be aware that they have frown lines that make them look overly intense or intimidating. They want to soften their appearance or "erase" a few years as they're preparing for a job interview—especially in our present economy—or a social event.

So look at the big picture and remember to take care of all of you—not just your skin. Balance your life, eliminate stress to the extent possible, make a commitment to improve your nutrition and maintain an exercise regimen. If you smoke—stop it! If you drink too much get help. Do those things first. And then, if you have the desire and money left over to indulge yourself schedule a consult and determine if your "wants" are reasonable and achievable from a medical and financial perspective.

Botox and Dermal Fillers

Fifteen years ago, if you wanted to get rid of wrinkly, sagging skin, there was basically one way to do it—a surgical face-lift. But today a range of minimally invasive alternatives exist. Botox, as we'll discuss, can be used to reduce frown lines, "worry lines," crow's feet and even provide a "brow lift." Dermal fillers can be injected into those "nasolabial folds, marionette lines, thinning lips and furrows between the brows, taking years off the face--and all can be done during your lunch hour, with no invasive surgery and virtually no recovery time. In many cases the results can be so appealing that facelifts—an expensive and invasive intervention—can be avoided altogether. Frequently Botox and dermal fillers are used to compliment one another. This will make more sense as you learn about these products.

Botox--is it for you?

As you all know Botox is the most commonly used cosmetic procedure in the United States. When properly administered you can still smile and have other facial expressions---but without those lines between your brows. Botox diminishes those lines between your brows that result from muscle movement and the passage of time. It works by temporarily weakening those muscles so that they don't draw the skin together causing those deep furrows. Botox is also used to treat other areas of the face—though it's not FDA approved for those purposes. This includes forehead creases (d), skin bands on the neck and even the lines known as "crow's feet (areas g, h, i)." Properly injected Botox can also create a "brow lift" (area e)

There are other situations in which Botox is not a good option and these include wrinkles caused by sun-damaged skin or wrinkles around the mouth. Weakening the muscles around the mouth would be undesirable as you need them for talking and eating! The result you can expect from Botox depends on several factors including your skin type, its thickness and how well developed your facial muscles are.

What is Botox?

Botox is derived from a bacteria that is found in the soil—Clostridium Botulinum. There are seven different types named A through G. Botox is a therapeutic agent derived from Clostridium Botulinum type A, also known as Botulinum Toxin Type A.

What is Botox used for?

The FDA has approved Botox for cosmetic use—specifically to improve the look of fine lines and superficial wrinkles between the brows caused from every day facial expressions (See areas 'a' and 'b' above)—specifically furrowing. However, though not approved by the FDA, Botox is also very effective for wrinkles—and their prevention-- that result from smiling, frowning or squinting.

So, one could argue, Botox can be used to save your marriage—as long as you don't cuss your spouse—or help you win a hand at poker!

And there are other uses of Botox too. It's commonly used to control excessive sweating (hyperhydrosis) in such areas as the palms of the hands, soles of the feet and underarms. This too might save your marriage, or at least reduce your laundry bills.

How does Botox work?

Whenever a facial muscle (or any muscle) is activated a message is sent from your brain to your spinal cord and through a nerve that activates the muscle. The transmission of the electrical impulse from the nerve to your muscle is facilitated by the chemical acetylcholine. Botox works by blocking the nerve endings from releasing acetylcholine.

You can see from the drawing above that just beneath the facial skin is an intense array of muscles that produce and endless number of facial expressions—no doubt you're making some now! Botox is approved for the Procerus and Corrugator muscles but can be used for the ones in the forehead, in the outer corners near your eyes (crow's feet) as well as others.

What to expect at your first appointment

If you've never had a Botox treatment this will be an opportunity to learn some of the "BOTOX BASICS."

A. Expectations

It's important to review your expectations and determine if they're realistic. For instance, Botox will do little for nasolabial folds—the lines that develop between the corners of the mouth and your nose.

B. Risks

In general the use of BOTOX poses few risks. BOTOX may cause temporary headaches, bruising or temporary drooping of the eyelid. Rarely, it can cause temporary double vision. Obviously you will need to tell us about any medical condition you have. Certain antibiotics—Levaquin, Cipro or Clindamycin—shorten the therapeutic effect of BOTOX

so you may wish to complete your antibiotic treatment before receiving BOTOX injections.

C. Contraindications

BOTOX should not be used if you are pregnant, breastfeeding or are taking certain medications (aminoglycosides antibiotics).

D. How is it given? Is it painful?

Botox is given by fine needle injection. The number of injections will depend on the number of areas you wish to have treated. Most women say that the pain is minimal. We often apply a topical local anesthetic cream and wait 10-15 minutes to allow it to work. A typical treatment takes 10-15 minutes—again, depending on the number of areas you wish to have treated.

E. What can I expect afterwards?

There may be some temporary swelling and occasional bruising. The swelling typically lasts a few hours so you don't want to have this done just before an evening out on the town. After treatment you will see the effects of BOTOX within 1-3 days although the full effect may take 10-14 days. Some doctors ask their clients to frown or squint a lot so that the medication settles in. I generally instruct women to gently massage some of the areas—but how you do this is important. Don't massage the injection sites without specific instructions from me. It's important that you don't lie down or bend over for 4 hours after injection. I generally ask women to not exercise for 4 hours afterwards as well.

F. Things to avoid

Do not lie down or bend over for 4 hours after your treatment. Minimize your exposure to the sun and wear sunblock!

G. The two-week visit

If you're a first time patient you may wish to make a 2 week appointment so that we can evaluate how it worked for you. Obviously, if you're having any problems—bruising or eyelid drooping—you'll call us immediately. The 2-week visit is an opportunity to see how it worked and if you're satisfied. Occasionally, some "touching up" is necessary at the 2 week visit for optimum results.

H. How long does it last?

For most women BOTOX seems to last 3-4 months. The effects wear off gradually and you'll be the best judge of when to come in for your next appointment.

I. How much does it cost?

The cost varies with the number of areas that are treated. A complete price-list is available to you on request.

J. Is there anything else I should know?

Avoid aspirin and non-steroidal anti-inflammatory drugs (Ibuprofen, Advil, and Aleve) for at least one week prior to your planned treatment. This will reduce the possibility of bruising afterwards. Also, avoid Ginkgo and ginseng, Vitamin E, Fish Oil supplements and red wine for at least a few days prior to treatment—again to avoid bruising.

Dermal Fillers

As I noted above the use of injectable dermal fillers is one of the most popular facial rejuvenation procedures—about 1.9 million being performed in the U.S. annually.

As we age the underlying skin structures that keep it looking youthful and firm begin to break down. The causes are familiar—gravity, too much sun exposure, diet, smoking, genetic factors and the simple accumulation of years of squinting, frowning, smiling and other facial muscle movement. Over time we all develop lines, wrinkles and folds in the face.

Your skin consists of two layers known as the epidermis and the dermis. The epidermis is the skin's outer layer and protects us against the environment. The dermis, or innermost layer of the skin, is composed primarily of connective tissue and provides the skin with its support structure. Most facial wrinkles and deeper folds occur within the dermal layer of the skin. Facial fillers, also known as "dermal fillers" and "injectables" are temporary to long-lasting solutions administered through a few tiny injections to specific areas of the face. By re-establishing volume to the areas within the dermis and just beneath the dermis many skin folds and wrinkles can be softened and even be eliminated.

Dermal fillers can be used for reasons other than the softening of lines and wrinkles. Some women choose to use them to enhance their lips and even their cheekbones.

Perhaps nothing is more gratifying for a woman than having an immediate correction of deeply furrowed lines in the nasolabial folds, the corners of her mouth (marionette lines), or from pre-existing scars.

By definition, a dermal filler is a product that is injected or placed into the dermis. Patients are instructed to not manipulate the treated areas, because the product may shift. The best way to reduce swelling is to immediately apply a cool pack to the areas that were treated. In current practice, several dermal fillers are available for use in the United States. In the material below we'll review some of the more commonly used fillers and the areas for which we recommend them. We'll review 2 classes of dermal fillers—hyaluronic acid fillers (Juvéderm® and Restylane) and calcium hydroxylapatite (CaHa) microspheres (Radiesse).

Hyaluronic acid (HA) is complex sugar (polysaccharide) that is hydrophilic (attracts water molecules) and is found in all living cells. It attracts and binds more than 1000 times its weight in water which explains why it hydrates and adds volume to the skin. Juvéderm Ultra, Juvéderm Ultra Plus, Restylane and Perlane are all made of hyaluronic acid. The differences are among the long list of things you'll want to discuss with us before considering their use. Radiesse is both a dermal filler and a bioactivator. It contains 30% synthetic CaHa microspheres which supports the growth of new collagen in your skin.

Hyaluronic Acid (HA) Dermal Fillers (Juvéderm Ultra, Juvéderm Ultra Plus, Restylane and Perlane)

Please note that we do not endorse a given product. We have no financial arrangement with any company. The Juvéderm products are made by Allergan. Restylane and Perlane are made by Medicis-R and Radiesse is produced by BioForm Pharmaceuticals.

Hyaluronic acid is complex sugar substance that occurs naturally in your skin. Hyaluronic acid has been used for many years as an injection into arthritic joints to aid movement and also for wound repair. You cannot be allergic to hyaluronic acid.