Big lips and ‘chipmunk cheeks' - it never ceases to amaze Dr Anjali Mahto how many aesthetic practitioners, never mind patients, look odd from overusing injectables. If you're after subtle results, read her derm's guide to the latest treatments and finding a safe pair of hands

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Despite getting their skincare just right, some people still feel the signs of ageing are catching up. Others are intrigued to know what else is on offer beyond simply using creams (which are often heavily oversold and promise results that are simply not possible).

Visible signs of ageing can be improved with injectable treatments, most commonly Botulinum toxin injections (aka wrinkle relaxing injections) and dermal fillers. Essentially, wrinkle relaxing injections is for treating lines and wrinkles and fillers work for loss of volume. The two can work well together, provided you find an experienced practitioner. I have had both and have been pleased with the results and for me, it’s all about subtlety. Here’s what you need to know if you’re thinking of having injectables.

Botulinum toxin - AKA wrinkle relaxing treatments

I’m definitely seeing more people coming to me for wrinkle relaxing injections now compared to a few years ago. Botox is one of the trade names for the active drug botulinum toxin made by the company Allergan (there are other forms of botulinum toxin including Azzalure and Bocouture). Botox was in use by eye doctors from the 1980s to treat muscular disorders of the eye. It was noted that wrinkles around the eye were also disappearing following treatment and, by the end of the decade, wrinkle relaxing treatments for cosmetic use had been born.

Their most basic action is to block nerve transmission to muscles causing temporary weakness. Wrinkles and lines become smoother or disappear altogether. It will produce results that are simply not possible with creams. I’ve had it done a few times myself to treat very early frown lines (for which it’s super-effective) and from a patient perspective, I've found it quick and painless.

Dr Anjali Mahto

What wrinkle relaxing injections can treat

Forehead lines: These develop over time, often due to repeated eyebrow raising and can be visible from your twenties onwards. wrinkle relaxing injections injected into key sites in the forehead will soften these.

Frown lines: Frown lines, otherwise known as ‘number 11’, lines, are vertical creases that develop between the eyebrows. They occur due to repeated contraction of muscles. Often, wrinkle relaxing injections injected into three to five sites in the frown area will treat these lines.

Crow’s feet: these occur due to the effects of smiling over the years;  They become more prominent in your late 20s to early 30s and can also be effectively treated with wrinkle relaxing injections.

Other uses: wrinkle relaxing injections can help with ‘smoker’s lines’ around the mouth, jaw slimming and facial contouring, teeth grinding (bruxism) and excessive sweating (hyperhidrosis).

Preventative wrinkle relaxing treatments There is also an argument for using wrinkle relaxing injections in a preventative way. If injections are started before lines are present at rest, many people get out of the habit of frowning and permanent fixed lines may take longer to develop. It is important to go to an experienced practitioner who is able to show you other before and after photographs.

How long do wrinkle relaxing injections last? wrinkle relaxing injections do not work immediately and initial effects can be noted between 48-72 hours later. Maximal effects are reached at about ten days and effects last on average three to four months. The treatments need to be repeated regularly to maintain their effect.

Is it painful? The injections themselves are done with fine needles and are not usually painful. They can cause some minor discomfort at worst, but nearly everyone tolerates wrinkle relaxing injections well without any problems. It is, however, still a medical procedure and a proper consultation should take place first including a thorough medical history.

Side-effects of wrinkle relaxing treatments. These include bruising and swelling and a feeling of heaviness, but on rare occasions, problems with a droopy eyebrow can occur with forehead injections. These are not permanent and will wear off over time. wrinkle relaxing injections is actually a straightforward and very safe procedure in the right hands.

Keeping it subtle: Many people come to me worried they will look overdone and frozen, or concerned their partner will notice if they have treatment. Choose a reputable clinic with good reviews and avoid cut-price deals. Personally, I think it is all about subtle results, and all my patients have the option to come back and see me two weeks after their injections to make any small adjustments. It is far easier to add more in two weeks; you can’t take it out once it’s in!

Check out the British Cosmetic Dermatology Group for practitioners  or find a consultant plastic surgeon. In the US, choose a dermatologist or plastic surgeon who is ‘board-certified’; other parts of the world have similar accreditations.

Dermal fillers - the volumisers

As we age, collagen and elastin in the skin break down. At the same time, fat compartments lose volume and become thinner, particularly in the upper half of the face. The facial skeleton changes due to bone loss at strategic sites such as the mid- face and orbital bone around the eye. These factors combined result in skin sagging, prominent skin creases such as nose-to-mouth lines (nasolabial fold) and jowl formation. This volume loss cannot be addressed by wrinkle relaxing injections and requires dermal fillers to fill or plump out the areas that have effectively become deflated.

It is bad practice to treat individual areas in isolation (e.g. just the jowls); it is important to maintain balance and harmony in the whole face and so a complete facial aesthetic assessment should be carried out prior to any treatment.

What fillers can treat

Facial sagging, lines and loss of volume: Fillers have an excellent role in treating facial sagging, lines and even chin augmentation. I’ve had small volumes of strategically placed fillers to treat nose‑to‑mouth lines (nasolabial folds) which had become more noticeable around the age of 35; the lower half of my face had started to look slightly heavy and even a bit saggy. I was pleased with the results of the filler. While it may not be for everybody, I have no doubt I’ll have more in the future.

Lip augmentation: Hyaluronic acid fillers are used most commonly and when injected into the lips can enhance shape, structure or volume. The results typically last six months and need to be repeated for as long as one wants their effects. Lip fillers are not suitable for everyone and an assessment of facial shape needs to be made first otherwise there is a risk that the end result will look unnatural. Ageing of the lip results in a downturn of the mouth and lip definition is lost. Filler can be used around the mouth to correct this.

Hand rejuvenation: Volume loss in the hands as we get older gives them a sunken appearance, and bones, tendons and veins become more visible. Filler containing calcium hydroxylapatite is commonly injected into the backs of the hands. This is massaged and swelling can occur for a few days. The filler lasts about six months or so. This is a relatively safe area to inject, with few side effects.

The different types of dermal fillers. There are many on the market including products that contain hyaluronic acid (e.g. Juvederm, Restylane), calcium hydroxylapatite (Radiesse), polycaprolactone (Ellansé) and poly‑L‑lactic acid (Sculptra). The vast majority of fillers now used are the hyaluronic acid varieties. These have increased in popularity over the years because they are non-permanent but long-lasting, cause few allergies and can be reversible and dissolved if necessary.

Profhilo. This is a relatively new injectable treatment made of synthetic hyaluronic acid. It is not, however, a dermal filler. Its purpose is to improve the texture or hydration of the skin rather than correcting deep wrinkling, significant sagging or volume loss associated with facial ageing. Profhilo  can potentially help boost collagen and elastin production. As with any injectable treatment, there are risks such as bruising, swelling and infection. It can be a good treatment in the right patient when done by the right hands.

Before filler is injected, a medical consultation is necessary. Full facial assessment is vital to determine which areas require filling or volumising. A thorough medical history and details of any medications or supplements should be taken first.

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Are fillers painful and how long do they last? Numbing cream can be applied for 20 to 30 minutes before injecting or ice can be used for numbing directly before the injections are placed. Results usually last for six to 18 months depending on the product used.

Side effects and risks of dermal fillers. Side-effects include swelling, bleeding and bruising. Aspirin, ibuprofen and supplements such as vitamin E, fish oils, gingko biloba and ginseng should be discontinued as they can promote bleeding. Other potential problems include lumps, inflammation, filler migration to another site and infection.

Certain areas are considered ‘high-risk’ sites such as the forehead, under-eye area and nose. There have been rare reported cases of blindness, so it is absolutely vital that the person you choose to inject you has been trained to the highest level in facial anatomy. While the risks sound scary, in competent hands the procedure is safe.

The main problem with fillers is that their use is unregulated in the UK and consequently many in the industry feel they are a disaster waiting to happen. Unlike wrinkle relaxing injections, dermal fillers do not require a prescription, which means that anyone can theoretically buy and inject filler. It is all the more vital for the consumer to pick an experienced practitioner, in whose hands it is safe.

Keeping it subtle: It never ceases to amaze me how many aesthetic practitioners themselves look rather odd as a result of their own overuse of injectable treatments - think big lips and ‘chipmunk cheeks’. My personal feeling on this is that somewhere along the line, these individuals have lost their ‘aesthetic eye’ – that is, they are no longer able to perceive what is normal for a person’s face.

The purpose of these treatments should be to create natural results, not artificially enhanced or exaggerated features. I suspect that in many cases, this type of face is all such practitioners see on a daily basis, be it in their colleagues or their patients. This, in turn, may be driven by the pressures to appear ‘young’ that are prevalent in the industry but also sadly still and unnatural body images all over social media.

Finding expert hands. You need to be confident that you are being given the best advice on any injectable treatments available and sometimes the right answer is that it’s not the right treatment for you. Practitioners should be sensitive to this and give you an honest facial assessment. They should not automatically carry out a treatment just because they can. I certainly have no qualms about saying no if I feel an injectable treatment is inappropriate. This conviction has grown over the many years it has taken to become a consultant dermatologist (I am not afraid to admit that I’m now a much better doctor – and communicator - was ten years ago).

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Unfortunately, there are many practitioners who lack the experience and the confidence to say no. And even worse are the greedy and frankly unethical, types who coerce you into buying treatments for their own financial gain. You will be in safe hands with a properly accredited dermatologist or plastic surgeon who carries out these procedures.

They have the specialist understanding their extensive training provides, but also the experience and confidence to be forthright about what you need. And as they usually have mixed practices – treating everything ranging from potentially fatal cancer to anti-ageing treatments – they are better able to remain grounded in reality and maintain the ‘aesthetic eye’ essential in providing good results from injectable treatments.

Dr Anjali Mahto MBBCh BSc MRCP (Derm) is a UK-trained consultant dermatologist who has worked in both the NHS and private clinics. She began her career as a junior doctor before moving into dermatology after suffering acne for over a decade. Follow her on  Twitter  and  Instagram .

An edited extract from  The Skincare Bible - Your No-Nonsense Guide to Having Great Skin by Dr Anjali Mahto  published by Penguin Life £11.65 Buy your copy  here .