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Before delving into the myriad wrinkle solutions, it is important to understand why wrinkles form in the first place. For the most part, the decline of skin supporting collagen is to blame, and this is caused by two factors. First, our skin produces collagen over time. Second, eternal factors, like the sun, damage the existing collagen. When this happens, the support system that keeps skin plump and springy begins to falter, and as it weakens, fine lines and wrinkles become apparent.


                                       Collagen Helix Molecule Structure on

                                              Licensed image for

                                         Collagen Helix Molecule Structure


Collagen provides structure and is essential for healthy, plump skin. Over time our bodies naturally lose collagen and begin losing less of it. Once collagen levels become depleted, moisture levels diminish and elasticity is lost – the result is wrinkles, lines and loose skin. When it is young and elastic, the skin has support and literally wraps itself around the face. However, as we lose collagen, the skin thins.




Similar to collagen, elastin is the key for flexible, healthy, youthful skin. But with age, the amount of elastin that the body naturally produces begins to decrease. When there is less elastin present in the skin, it can droop and sag.



                           Drawing of Elastin Fiber and how it stretches and relaxes - Single elastin molecule is cross-linked

                      Copyright © 2005 - University of Florida PA Program - Summer Program - Pamphlet



Skin that has lost its elasticity cannot tighten itself around the underlying bone and muscle structure, causing drooping and sagging. The skin doesn’t progress in terms of elasticity, which is why some procedures, like a facelift, are not the best option for treating wrinkles, but are better for reshaping the face and restoring smooth contours.





Environmental factors including over-exposing your skin to the sun or UV light as in a tanning bed can cause the skin to lose collagen to break down and cause pre-mature aging. Other factors that contribute to the break down of collagen include pollution, smoke and the weather.


                               Image showing a cross section of younger skin or epidermis vs. older skin or epidermis.      

                                                                     2010 Copyright © ADAM, Inc. - Used with permission


Facial expressions also, unfortunately can cause collagen loss. It is nearly impossible not to smile, laugh, frown or squint your eyes – but with every facial impression made can contribute to the break down of collagen in your skin.

Collagen loss can contribute to the signs of aging on your face. The crow’s feet with the outer corner of the eyes and upper and lower eyelids show the signs with becoming saggy and baggy as collagen levels become depleted. Tear troughs (deep hollows under the eye sockets) can also form. Depleted collagen can also cause drooping brows. When the eyebrows droop, they can become hooded and fall over the eyelids. The nasolabial folds show the lack of collagen with becoming more pronounced, and fine lines increase. The lack of collagen, elastin, and volume will make jowls saggy with excess skin showing an unrefined contour. Lost collagen also leads to thin lip lines, along with losing volume with the lips thinning out.



                                    Image showing the difference between a line, wrinkle and a fold in the facial area

                      Illustration by Renée Gordon. Source: National Institute on Aging. Used with permission


Replacement fillers are designed to work by restoring lost volume or filling furrows. Studies have also shown that by stretching the skin or epidermis and creating an injury of sorts, these injectables may actually prompt a tiny bit of new collagen production.

In a “perfect world” the perfect dermal filler should be inexpensive, safe, painless to inject, hypoallergenic, and long lasting. We do have a variety of new and existing fillers on the market, but each one comes with their own pros and cons. Ultimately we all want to see the biggest improvement for the least amount of money with the best results. Also, these fillers should have consistent and predictable results, feel natural under the skin, take little time to inject, be ready-to-use, exert no downtime on the patient, and have a low risk of complications.

The aging “baby boomers” want a quick fix – so the pharmaceutical companies have complied with a variety of dermal fillers to fit any lifestyle. This area of dermal fillers and getting a lunch-time procedure, has been the fastest growing segment of the cosmetic surgery boom during this last decade.

Considerable advances in technology have given the cosmetic surgeon a selection of filler options. Still, no one filler can address every patient’s concern. Treatment should be tailored to the patient’s individual needs to achieve maximal benefit, minimize risk, and achieve the desired correction durability.



                                 Drawing showing dermal fillers before injection and after injection.  Dermal fillers soften wrinkles and scars.

                                       Copyright © 2010 - Dr. Sean Younai





  • The area to be injected will be cleansed, commonly with alcohol and a topical anesthetic cream, icing to the injection sites or a local anesthetic by direct injection (such as a dental block/nerve block) may be used for your comfort.

  • Once your treatment region in numbed, your doctor will make injections in several locations, placing the dermal filler where correction or volume enhancement is desired.

  • You doctor may massage or manipulate the area where the filler has been placed. Some physicians have a tiny vibrating tool to be used for the massaging. The treated area may be cleansed again.

  • You may be given ice or cold packs to place on the treated area to minimize swelling and bruising.

  • The entire treatment process may take 20 to 30 minutes or more.




                                             Key Injectable Locations

                                Photo showing Key Injectable Locations on the facial area.

                                 2010 Copyright ©




    Key Injectable Locations:

    • Smile Lines aka Nasolabial Folds:  The Nasolabial Folds run from the side of the nose down to the corner of the lips.  This area is also referred to as the "Prentices".  Sometimes these folds can wrap partially around the base of the mouth. Everyone has nasolabial folds however it is the depth of these folds that vary.  This feature can and does become more pronounced as we age. There are many reasons why the nasolabial fold becomes deeper and more pronounced with age. The most common reason is the slow migration of the cheek fat moving down lower on the face. People who have thin or aging skin tend to wrinkle more easily.  Sun-exposure and or expressions of smiling and laughing all contribute to the nasolabial area.

    • Marionette Lines:   Also known as "Oral Commissure".  These lines run from the corner of the lips down to the chin area.  These are vertical lines that run downward from the outer corners of the mouth along the outside of the chin.  Sometimes, these lines can look like an extension of the nasolabial folds.  These lines got its name because of their resemblance to the lines that appear in the face of marionette puppets or ventriloquists' dummies.

    • Vermilion Border:  This area is the border of the lips (the area that gives the lips definition.  Exposed margin of the upper or lower lip area. It extends from the junction of the lips to the surrounding facial skin on the exterior to the labial mucosa within the mouth.


    • Vertical Lip Lines:   These lines are caused from patients who smoke.  Tiny lines are noticeable above the vermilion border of the lips. Lip tissue is soft tissue - which adds fullness and definition to the lip area.  When lips lose definition and shape, the mouth area can look withered and drawn or misshapen. Lines of the lips are due to several factors which include loss of volume, loss of bony and dental structure, loss of elasticity and repetitive use.

    • Crows Feet:  These lines or wrinkles radiate outward from the corners of the eyes.  Caused by many factors normally responsible for the wrinkling of skin including sun exposure.  Not wearing sun-glasses contributes to these lines.  Repeated facial movements or expressions including laughing, smiling or squinting will make these lines more noticeable.

    • Tear Trough:  This area is located near the nose and the lower eyelid.  Loss of volume can create a hollow appearance under the eyes.  With filling the tear trough, the goal is to fill the hollows below the eye and to lift the cheek to provide a more natural contour between the two.  This will effectively reduce the appearance of the hollow out area.  Tear troughs respond well to fillers such as Restylane and Juvederm. Fat grafting can work extremely well and may be the most natural way to rejuvenate this area.


                                                 Photo showing "tear trough" area under the eye.

                                                 2010 Copyright ©

                                                               Tear Trough Area

    • Frown Lines aka Glabellar Line:  These deep creases form when the brow area is furrowed.  These frown lines also are a result of wrinkling the nose or making a face.  These lines are the result of facial muscles developing the habit of wrinkling over time, and they are by far some of the hardest types of aging to combat or repair.

    • Forehead Lines:  These lines run across the forehead area and can be categorized into three different areas: Mild - Moderate - Severe.  Most of these lines are considered expression lines which are hard to prevent. Forehead wrinkles are caused from repeated expressions of worry, concern and sometimes surprise. Over the years these wrinkles become fixed and deeper.

    • Facial Scars:  Sometimes scars that occur on the face have a tendency over time to become "drawn in" as the aging process begins. Fillers can help this area as well as other treatments including a scar revision.





    As with all facial or lip injections pain relief is a very common question. With the hyaluronic acid fillers, because they are delivered through a larger gauge needle, sometimes a sensitive patient will have to have a nerve block or a dental block.

    The dental blocks of course are more invasive than a topical cream, but are much better for pain relief. The block is performed by injecting 1 to 2 cc of local anesthetic right next to where a major nerve group comes out of the bones of your face.


                                                        Image showing a dental block before lip injections.

                                          Copyright © 2007 - - Used with permission


    The entire segment supplied by this nerve bundle then "falls asleep" for 1 to 4 hours. If the block is performed through the mouth using some numbing cream or spray at the injection site, it can be painless. There are relatively few nerve receptors inside the mouth, and those are very susceptible to the topical creams.





    EMLA Topical Cream is a local anesthetic which works by blocking the nerves from transmitting painful impulses to the brain.  It numbs the skin to pain from injections (dermal or lip fillers).

    EMLA Cream (lidocaine 2.5% and prilocaine 2.5%) is an emulsion in which the mixture of lidocaine and prilocaine is a ratio of 1:1 by weight.  It is packaged in 5 gram and 30 gram tubes.

    EMLA Topical Cream is available by prescription only. Your physician will either supply you with a tube or will write a prescription to pick up at the pharmacy for use before your dermal filler / lip augmentation or BOTOX appointment.


                                        EMLA Cream - Topical Numbing Cream with lidocaine and prilocaine.

                                                Photo courtesy of AstraZeneca - EMLA Cream


    EMLA Cream Indications:

    • EMLA is indicated as a topical anesthetic cosmetic procedures for dermal fillers.

    • normal intact skin for local analgesia and superficial minor surgery as pre-treatment for infiltration anesthesia.

    EMLA Cream should be used the following way:

    • Wash and dry the area to be treated. Apply a thick layer of cream to the affected skin - never rub EMLA into the skin.

    • EMLA Cream should not be used on broken or damaged skin.

    • Avoid getting EMLA Cream in the eyes, nose, or mouth.  If by accident it should get in the eye area, rinse with plenty of water. If swallowed, call your local poison control center.

    • Wash your hands after using EMLA Cream.

    • Apply EMLA Cream at least 20 minutes before the treatment.

    • The numbing effect will last approximately an hour after the procedure.





    After receiving injections with dermal fillers:

  • Make certain you have soft, flexible, cool compresses available for the first 24 hours after treatment.

  • It is important that you not exert yourself with exercise or any activity that can increase your blood pressure in the first 24 hours after treatment. This can increase the potential for swelling and bruising.

  • Have a good, rub-proof, sweat-proof non-irritating concealer or camouflage make-up available to touch up any discoloration after treatment.

  • Needle sticks may bleed a bit after treatment. You may apply an antibiotic ointment to the treated region.






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