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Wish your toxin would last longer? Step number one: talk to your injector about your dose! All 4 current manufacturers of neurotoxin approved for use in the US agree that the duration of effect is directly related to dose delivered for the area of treatment. And while all products are measured in units, the “math” involved in the equivalency of a onabotulinumtoxinA (Botox) unit compared to an abobotulinumtoxinA (Dysport) unit can be tricky to explain. Add on top of the unit equivalency challenge the volume used to deliver the aid number of units may vary from injector to injector and even from area to area with the same injector. The math can be a mess! Bottom line, the number of units actually delivered per region is what is documented in the medical record, and what we use to measure our treatment on.

Certain muscle groups are stronger than others (think glabella and masseter)—the bulkier the muscle the more medicine that’s required to put it to sleep for a spell. Some muscles are thinner but cover large regions (think forehead or platysma)—they need enough product to spread throughout the region. And yet other muscle areas we do not ever want to overdo (think lip flip—overtreating that can keep you from enunciating your words, or controlling your spit—yikes!). Underdosing an area or treating with a small amount generally means it will not retain its relaxed effect as long as a larger dose would, but there may be good reason to do just that.

So, if you wish your toxin would last longer, the first thing is to evaluate whether or not you are receiving a dose sufficient for the muscle or the area. There are commonly accepted “usual” dosing for most areas, but every person is different, and dosing needs to be personalized. Consider too what product you are using, and what your expectations are. Movement is fine for most of us, we just don’t want to allow so much that the repetitive nature of the movement can contribute to etched in lines. And some wrinkles might be unloved but accepted because having the rainbow wrinkle above your brow is better than dropping your eyebrow and adding to upper eyelid hooding, eh?! Younger skin has healthy collagen and elastin stores, so wrinkles from movement may be better disguised than thinner, older, crepey skin.

Your injector has a complex job—they manage pharmacological, anatomical, technical skills all while using their artistic ability to finesse your treatment to match your goals, anatomy and dosing. Developing a good relationship with your injector is critical!

Updated: May 16, 2021

One question I am asked about frequently is “what can be done about the under-eye region?” Indeed, tear troughs are a thing! There are a few treatments we can do to enhance them, but they can also be a little fussy because the tissue is so thin and there are many things that contribute to the hollowing or enhance the shadowing of pigment, so let’s try to understand it first!

The tear trough is a region just under your lower eyelid, but above your cheek. The tissue in that area is approximately 1/9th the thickness as other parts of your face. And we all know by now that collagen stores start to decline somewhere between age 20 and 30, contributing to even more thinning. Yikes! But that’s not all, other changes are afoot as well. Our bones change with age. We think about this in things such as osteoporosis and fracture risk, but we don’t necessarily equate that to our facial bones, yet they resorb and remodel just the same. With maturity our jaw shrinks, our teeth recess and our eye sockets actually enlarge. This contributes to skin draping in places it didn’t when we were 16. Fat pads change and move as well, so our precious chubby cheeks flatten out and gravitational pull can even turn part of them into jowls. The cheek offers support for the ligaments of the tear trough, so you can imagine that as they deflate, under eye areas can become more of a focus as we pass by a mirror. And lastly, we should pay homage to the fat pads that reside under our eyes. When tissue is tight and the area is full, those precious fat pads provide a buffer between the skin and the structures below. But as we gain laxity and lose support, gravity can induce an unsightly bulge. For those with herniated fat pads, expectation of non-surgical maneuvers should be guarded at best.

So, in my lineup of recommendations first up is always a really yummy eye cream. Yes, I appreciate they can be a little pricy, but it’s a must-have, not a consider-this when it comes to treating the region. I personally prefer a rich cream over a gel, but I’m getting up there in maturity so need more hydration. I also like a brightening eye cream, but haven’t found one that’s quite rich enough, so I use a brightening cream in the day and a repair cream at night. Some ingredients you might find in an eye cream and like the sound of are hyaluronic acid (hydrator), caffeine (tightener), licorice root/tranexamic acid/vitamin c/niacinamide (brighteners) to name a few. Keep in mind this area requires more richness than your daily moisturizer likely gives—so if we want to fluff it up to keep the shadows away we need to treat it nicely.

Next recommendation for long term gain is collagen induction. Treatments such as medical microneedling can promote natural collagen growth can be a great idea to keep the bounce in our skin, including under the eye. Other more targeted treatments can include autologous injection. Most commonly a trained practitioner will take a sample of your own blood and spin it down drawing off the critical parts, but leaving most of the red cells. Since it is your own blood, there is low-to-no potential for allergic response. Re-introducing this nutrient rich fluid to the area of interest floods the tissue with as much growth factors, cytokines and other factors which can encourage your own body to thicken the tissue (but not thick like leather, just healthier). Think of it like fertilizing the lawn—the grass is already there, it just needs a little go-go juice to bring back the vibrancy! The advantage of this type of injection is that the growth factors are released slowly over several weeks rather than the dump-and-done approach of other options. Unfortunately the food and drug administration is pursuing this as a biologic treatment and so there may be more scrutiny in the near future on this--but stay posted. (There’s more that I could say, but this is a blog, not a novel!)

And of course, we have the option of placing filler in this zone as well. Looking at contour of the area I first look at the cheeks. When the cheeks start to flatten out, we lose the scaffolding that helps hold our tear trough ligaments and skin in place. So, treating the cheeks is absolutely a part of treating the under eye. Following mid-face, we can then look at volume loss in the tear trough. When placing filler in this space I prefer to do this very sparingly--because you wouldn't want to replace a cave for a pillow! I use hyaluronic acid filler in this area, and HA's job is to attract moisture, so picking the right product and placing the right amount is essential. And since we really can't tell how deep the cave is in the first place, it's better to place a small amount, let it settle, then repeat as necessary.

So, while there is plenty we can do for the region under the eye, matching the correct treatment to the patient’s deficit is trickier than offering only one-solution. My goal is always to enhance what you already have, bringing forward a fresher version of YOU!

Wondering about Kybella®?

Do you have stubborn unwanted fat under your chin? At your bra line or maybe heavy jowls? Kybella® may be part of your solution.

Kybella®is the brand name, deoxycholic acid the generic chemical tag. It works much like your own bile salts in breaking down fat by destroying the cell membrane that gives it life. Once that barrier is crystalized and destroyed, your lymphatic system has the opportunity to purge it. Bye-Bye Fat Cells! This destruction is felt to be permanent. Well, at least for those cells destroyed. It certainly does not take away the need for a healthy diet and exercise, but some of those genetically predisposed regions of fat (like the dreaded double chin) are simply hard to reduce with lifestyle changes alone—this is where chemical (Kybella®) or physical (liposuction) gets involved.

The upside is that the cell destruction is forever. The downside, it typically takes a series of treatments and can cause “socially significant” swelling for 2-20 days post injection. Fortunately, in the era of mask wearing, much of this can be disguised. I have also found that lymphatic drainage massage can speed the process of healing (less bullfrog days) for most of my patients. The injections are a bit uncomfortable, and I’ve been told it’s “achy” after, but totally manageable. Bruising and swelling are the most common side effects; but transient numbness and unusual nerve sensations can also occur though far less common.

Now I would be remiss to not let you know the only on-label (FDA approved) use is for the submentum (double chin). In the aesthetics industry it has also been used for jowls, bra line fat, that of the knee and lower buttock to reduce chubs off-label. So many clever scientifically driven providers out there! If you’d like to learn more, head over to or for Allergan’s intel.

Now don’t you feel wiser?!

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