In this series, we explore cosmetic procedures that can help us look (and feel) refreshed as we get back to a near normal

Marcie UlmerThe pandemic has been full of challenges and while that toll is felt mentally, it can also manifest physically. Many of us have struggled to maintain our regular routines, while navigating the shifting circumstances influenced by public health guidelines. At this point, it seems like frown and worry lines have become permanent fixtures on our faces (and every single flaw seems to be amplified on Zoom).

But we know that when we look good, we do feel better. So we caught up with dermatologist, Dr. Marcie Ulmer from Vancouver’s Pacific Derm to discuss some popular anti-aging treatments and how to achieve the best results after this taxing year and a half.

Whether you're looking to improve fine lines, wrinkles or volume loss, there really is a solution to address every concern. If you’re interested in more smooth, relaxed skin, and a refresh, here’s everything you need to know about Botox and other neuromodulators…

BCL: What is Botox and what are the benefits?

Dr. Ulmer: Botox is one of the brand names of available neuromodulators and is one of the most popular non-surgical aesthetic treatments performed worldwide. As the focus of numerous clinical trials and continuous research over the past two decades, Botox has established an excellent safety record, accompanied by a high degree of patient satisfaction.

Neuromodulators are injected into the facial muscles, just below the skin. Although Botox can be utilized for a variety of aesthetic purposes, it is most commonly known for softening facial lines. By weakening signals sent from nerves to muscles, it reduces the strength of the muscle contraction which, in turn, minimizes wrinkling of the overlying skin.

In youth, facial lines only occur when the muscles are actively contracting but, as we age, some lines can become etched in by this repetitive action. Botox provides a non-invasive treatment for preventing increased depth of facial lines or helping to soften existing lines with virtually no downtime. This procedure itself is quite quick and most patients find it very comfortable.

The other neuromodulators available in Canada are Dysport, Nuceiva and Xeomin. These products share similar active properties and have each proven to be safe and very effective. Typically, product selection will depend on patient and injector preference.

Neuromodulator treatments provide incredibly high satisfaction rates, as shown through documented research and consistent patient feedback. Studies have shown neuromodulator treatments to be linked positively to enhanced self esteem and self confidence. I love it when my patients let me know that they feel more confident and refreshed following their treatment.

BCL: What specific areas can be treated to improve what? And where do you typically see the best results?

Dr. Ulmer: Botox is an ideal option for the reduction of frown lines on the forehead and between the eyebrows, resulting in a more relaxed and youthful appearance. Neuromodulators are also highly effective at minimizing crow’s feet around the eyes, smoothing a pebbly chin, relaxing bands in the neck and those “bunny lines” you see when you wrinkle your nose.

Besides smoothing wrinkles, Botox can also help lift the brow to open up the eye area and slightly lift the tip of the nose. Botox can minimize vertical wrinkles around the lips and the downward pull at the corners of the mouth, help reduce a gummy smile, and slim the appearance of the lower face.

When expertly injected Botox can help balance asymmetries (that many of us naturally have or those resulting from medical conditions) and subtly enhance certain specific facial features.crows feetCrow's feet before and after treatment

BCL: When will you see results from Botox and how long do they last?

Dr. Ulmer: Patients will begin to notice improvements a few days after their treatment and will see full results at the two-week mark. The improvements come on gradually with progressive rather than dramatic changes. Botox typically lasts from three to four months, but individual results may vary depending on dose and individual characteristics.

BCL: How obvious are the results from what you’ve observed and does everyone generally respond the same to Botox?

Dr. Ulmer: In my opinion, if a Botox treatment is performed properly, no one will ask you who you see for your Botox. It should look perfectly natural. My goal for my patients is that they look like themselves, but the best, most refreshed version of themselves. Doses are always individualized as everyone has different facial characteristics and there is definite variance in size of facial muscles. In general, larger and stronger facial muscles require a higher dose. For this reason, men generally require higher doses of Botox than women.

The response to Botox, and expected positive result from treatment, are very predictable, making it one of the most popular treatments we perform at Pacific Derm.

BCL: A lot of people fear looking like they’ve had “work done.” How do you ensure that your patients don’t end up with unnatural-looking results?

Dr. Ulmer: Patients often express a strong desire to look natural. It is my feeling that a natural appearance means a degree of facial movement and expressivity. For this reason, I prefer a light touch and a conservative approach. As my practice has evolved over time, I’ve found that many of my like-minded patients who desire natural appearing outcomes, tend to refer their friends, significant others and family members for consultation who, often like themselves, are seeking natural appearing improvements as well. It feels very harmonious to work towards a common goal with each of my patients and I feel privileged to be a part of their life journey, developing lasting and meaningful relationships along the way.

When assessing patients, we must fully assess the face at rest, and in animation. Dosing must be individualized to each patient as no two faces are exactly alike. A ‘cookie-cutter’ approach to treatment, treating every face the same, can lead to unnatural appearing outcomes.

Cosmetic treatments should complement an individual’s attributes. When treatments are performed by those without specific knowledge of facial anatomy and certified professional expertise, there is the risk that unnatural-looking results may occur.

It is our standard practice at Pacific Derm to have patients return to the clinic at least two weeks after their first neuromodulator treatment. This brief consultation allows patients to view their before and after photos with us and, most importantly, to ensure that both parties are happy with the outcome. Occasionally a few Botox units may be added at this follow up appointment to ensure, for example, that eyebrows are at the proper height or that just the right amount of expression is maintained.

Because the changes we see as we get older are multi-factorial, combination therapy, including Botox or other neuromodulators, often provides the most natural appearing results. In many cases my patients are most happy with small improvements performed regularly over time. This may mean, for some patients, Botox three to four times a year, with their annual filler treatment, and an annual Thermage. For someone else, it may mean regular Botox in addition to a treatment for their complexion such as IPL to remove sun-spots or a vascular laser to reduce redness caused by rosacea. For etched in wrinkles, soft tissue filler and laser used in combination with Botox will be most effective as Botox may help prevent deepening of lines but cannot remove lines that exist at rest.

Every face is unique and, as a result, every treatment plan that is put together after thoughtful consultation will reflect that individuality.

I think the most important way to ensure your treatments help you not only look your best but remain looking natural is to find an injector that you trust. You want your perspective on aging and beauty to feel aligned with their professional approach.botox forehead before and afterForehead before and after treatment

BCL: How should I prepare and care for Botox?

Dr. Ulmer: It’s best to arrive at your appointment without makeup on and to avoid alcohol and Ibuprofen a day or two before (and after) your treatment. This preparation will help reduce the small chance of bruising that could occur from the injections. For a few hours after the treatment, keep your head upright and avoid massaging the treatment area (in other words, this is not the best time to book a facial or face massage). For most people it is right back to life as usual immediately after treatment.

BCL: Who would you recommend this procedure to?

Dr. Ulmer: A comprehensive consultation helps me really understand my patients and what they are hoping to achieve. People come in for cosmetic consultation at various stages of life. Some patients come in to see me later in life, wanting to soften existing lines. Other patients come in at a younger age, with a more preventative goal in mind, as they begin to see the appearance of fine lines. There is no ‘right age’ to begin Botox because the motivation to initiate treatment will be different for everyone. The best starting point is a detailed discussion with your cosmetic specialist physician who will thoroughly assess your face during consultation and answer any questions you may have.

BCL: Are there any risks or serious side effects you’ve seen in your patients?

Dr. Ulmer: Botox is a very safe procedure that has been used in millions of individuals over the past near 20 years. Botox is a powerful molecule with a well-documented history of studied use across both cosmetic and medical applications.

Botox is not intended for use during pregnancy or in patients with certain neuromuscular disorders. The doses used for facial aesthetics are quite low in comparison to other applications. When precisely placed into the targeted facial muscles, side effects are exceedingly rare.

BCL: What is the cost (range)?

Dr. Ulmer: Some clinics charge a ‘by the unit’ (of neuromodulator) rate while others may present a determined cost based on the treatment area. Overall, cost will be influenced by how many areas of the face are being treated and will be guided by the strength of a patient’s facial muscles.jaw before and after BotoxMasseter muscle before and after treatment

BCL: From spas to dental offices, Botox is now being offered in many different businesses. How should one decide where to go?

Dr. Ulmer: You are correct that Botox is now offered in many different settings and by people with varying skill sets and levels of knowledge. It is always a good idea to do some research on the clinic you plan to attend for consultation. It’s important to ensure that you are happy with their level of knowledge and expertise. Asking about their experience and requesting to view before and after photos of their patients may help you decide if you will feel comfortable in their hands. Patients who attend Pacific Derm come because they are aware that we are all board certified dermatologists and having us treat them is within their comfort zone. Patients will choose clinics and providers based on their own preferences and goals I think.

BCL: Besides anti-aging, what other medical concerns can Botox treat

Dr. Ulmer: Neuromodulators have applications well beyond facial aesthetics and it is fascinating how the list of conditions has grown so rapidly. Botox is used to treat bruxism (unconsciously clenching/grinding your teeth) not only to slim the width of the lower face but to also minimize the force put on the teeth by the overdeveloped masseter muscles.

Anyone with migraines knows first-hand what a negative impact these debilitating headaches can have on quality of life. Botox is used, with success, to treat migraine headaches with facial and off-the-face injections.

Patients with excessive sweating (a medical condition known as hyperhidrosis) in the under-arm area/palms/soles often tell me that they experience significant social embarrassment because of this. Botox treatments in these patients can provide impactful improvements in their daily life. It is amazingly gratifying for me to hear that a patient can, following treatment, confidently wear any colour and style of clothing without the nagging worry of body odour, wet underarms or damp handshakes.sweatyspukkato

The list of applications for this powerhouse molecule extends across various other specialties and I suspect the list will only continue to grow. As someone actively involved in clinical research, I find this to be a very exciting time to be practicing medicine.

BCL: Do you do Botox yourself?

Dr. Ulmer: Regular neuromodulator treatments, including Botox, have been a part of my self-care routine over the past decade. Like my patients, I appreciate that it helps achieve a refreshed, natural appearance with predictability and no downtime.