Intro to The 4th Cornerstone:
Although I am hopeful I have written my last blog on Coronaviruses, my guess is there will be (a lot ?) more to come this fall. Until then I get to return to topics that I hope are useful to my readers to keep them on the right path of health and wellness and an extended life and health span. After outlining some great stuff on nutrition and weight loss, as well as a blog on supplements and big pharma meds that should be in your arsenal for longevity, I opted for what many will consider an esoteric topic - aesthetics in general and Nueromodulators (Botox, Dysport, Jeuveau, Xeeomin) in specific. Why talk about looking pretty after a year of everyone worrying either about whether they will live or if so, will we have a normal economy to live in? Because I argue, that aesthetics, when incorporated into a healthy life routine will lead to a overall healthful life.
That may seem like a stretch - surely aesthetic procedures like Nueromodulators, fillers and laser treatments will make you LOOK younger, but can it actually play a role in health? Obviously my answer is yes because if you have ever been to our website we preach 4 cornerstones to Health and Wellness: Nutrition, Nutrients/Supplementation, Hormone Balance, and AESTHETICS. (Note: You may notice that exercise is missing - whereas those are the 4 cornerstones, Exercise is the floor or the foundation - we don’t execute that at Formula but we guide those to others who do that as specialists). The first 3 beg little argument, but Aesthetics as a cornerstone? Read on and see if you agree...
Nueromodulators And The Healthy User Effect:
If you haven’t read my blog from January of 2020, I encourage you to read it. It’s the basis of how I look at longevity and health span and perhaps the touchstone for me when someone says “why do X, it has never been scientifically proven to extend life/prevent cancer/prevent heart disease...” Long story short, science matters and when science proves something helps us for the long term we need to listen and add that arrow to our quiver. However studying the effects of specific sub topics like nutrition/foods/fasting/exercise are inherently problematic when using the gold standard of scientific study: The placebo controlled, double blinded, randomized controlled trial. That science is perfectly suited to study pharma drugs and how X drug can yield Y result, but it doesn’t answer the question, if a low carb diet will extend your life or will it prevent diabetes over two decades. In skipping to the conclusion, until science can give us more long term answers using other methodologies, we need to continually amass as many healthy user behaviors we can in every single day.By doing this not only will the sum total likely be more beneficial then not doing them, but you will be so active doing healthy behaviors (ie exercise, meditation) that due to lack of time you will be crowding out unhealthy behaviors (Netflix and a second bottle of wine). I propose that in the aggregate the sum of healthy user effects will lead to a healthier and longer life.
So in addition to things like, resistance and HIIT training, intermittent fasting and low carbohydrate diets, vitamin and herbal supplementation, drinking water, meditation and sauna, am I including getting Botox? Touching my touchstone I say YES.
Before I launch into the data I need to disclose a growing bias. When I started my wellness immersion 6 years ago I would have put the math on the “Formula” for wellness to be like 60% Nutrition, 20% exercise, 10% hormone and 5% supplements and 5% sleep. Although my current iteration of the “Formula” varies now by decade of life, I for sure see that I paid way too little attention to sleep and to mental health (particularly anxiety, stress, and depression). Those factors are huge and if they are out of balance, they are probably the 60% that need to be addressed. So any Healthy User Behavior that affects them, scores points in my formula.
The first piece of evidence in support of the Healthy User Effect (HUE) of Nueromodulators is an incredible study done at the University of Wisconsin 10 years ago. Subjects given Nueromodulators were assessed by reading either happy, neutral and sad or angry passages before and after Botox. Post-toxin, the study subjects took a significantly longer amount of time to read the sad/angry passages. The scientists showed that the neurolinguistic pathway between the eyes, the brain and the mouth was interrupted - by not being able to furrow the brow or frown, the brain had a harder time processing something as anger or sadness inducing - thus the patients where less angry and sad.
Not convinced? I admit, as a Northwestern University graduate I am always a little skeptical at intelligent things coming out of the Cheese-head state (tongue in cheek, U of Wisconsin is an awesome medical center), but what about a summary study from the truly prestigious University of California at San Diego. The folks at UCSD took a ten year summary of studies on Botox and Depression and showed that depression and depression related symptoms decreased between 40-88% in treated subjects. Woe. The most prescribe medication class in the world - Statins to lower cholesterol, reduce cholesterol on average of 24%, and they are heralded as game changers by nearly every cardiologist in the world. How about a drug that is 200-300% more effective? Is that an unfair comparison, well how about the efficacy of our modern crop of powerful big pharma anti-depressant medicines that target the brain neurotransmitter pathways. Their efficacy - between 40-60%. Pretty much the same. Now this is NOT a head to head comparison and this IS the perfect situation to do those placebo controlled, double blinded studies on. Still, the absolute reduction in this summary study was immense, but like most things when it comes to non-pharmacologic treating of mental health, the silence was deafening.
So we have a drug that can lower anxiety, stress and depression - and makes you a little younger looking in the process why do we all just choose to either do a toxin for beauty or say no, and don’t do it because it’s just cosmetic. Most Med-Spa marketing as well as overvolumized and frozen faced Kardashian and Instagram models probably don’t help those on the fence come over as the marketed goals are looking somewhere between a frozen Parkinson’s sufferer or Jessica Rabbit. We can, would and should be promoting the healthy user benefit and confidence inspiring age reduction and not the goal of looking like an instagram filter.
Lastly on the healthy user effect before we get to the “everything you wanted to know about Nueromodulator but were afraid to ask section” is the confidence boosting effect. Although certainly present in women, women have a historically higher adoption rate of Nueromodulator use then men (95% of industry sales) so it is more accepted already. Then men who my team or I do injections on universally come back and say you know what? People are asking me if I have been sleeping better or changed my hair or lost weight - all because of the toxin. The confidence boost can add to someone’s happiness or maybe even extra confidence.
OTHER NON-AESTHETIC USES FOR NUEROMODULATORS
Along with maybe helping with mental health there are other medical indications/uses for nueromodulators. The three we most commonly see at Formula Wellness are Migraines, Hyperhydrosis (Excessive Sweating) and Temporal-Mandibular Joint Dysfunction (“TMJ”). All 3 of these problems, although not life threatening, cause a tremendous amount of physical or emotional discomfort and can be relieved, temporarily by a modulator. With Hyperhydrosis the results are not only universally dramatic but quick as well. The downside is the amount of modulator you have to use is usually a full vial - at around $1000+, every 4-12 months (however its definitely cheaper if you are on our Aesthetic Membership where you get free units every month that can stack, or on our Aesthetic Elite Program where it is half price). For TMJ and Migraines, the underlying pathology is more complex such as multiple triggers for migraines and underlying damage to the joint in TMJ but usually there is a significant percentage reduction but the duration is the typical 3 months.
AESTHETIC USES FOR NUEROMODULATORS
The three most common areas both female and male patients ask us to inject are the glabella (“eleven” or angry lines between the eyes), the frontalis (forehead wrinkles) and the Obicularis Oculi (“Crows feet” eye wrinkles). All of these areas have a relatively quick onset of 2-5 days depending on which modulator (Jeaveau is quickest, followed by Dysport and then Botox) and maximum effect at around 2 weeks with 3-4 months duration. Complications are rare from glabella and Obicularis but their is an art to the frontalis/forehead injection to make sure the brow doesn’t “Spock” up the end of the brow or the brow overall does not fall and result in a more tired look. Although complications happen in even the best injector, these are relatively rare with good technique and can be treated with either additional modulator in a different location or just a little time.
Beyond the 3 most common areas there are great applications for fine tuning the rest of the face and neck. In the neck, the thin but powerful neck muscle called the platysmus progressively starts to bunch together in muscular bands. This can be seen when you look in the mirror and say “eeeeek”. These bands ultimately lead to more neck laxity and treating them can help preserve a younger, tighter neck.
The “lip flip” has more recently gotten popular which is a very small amount of modulator placed in a few spots at the border of the upper lip to increase the amount of red that shows, giving the illusion of a much fuller, more youthful lip. This $100 add on adds a much more subtle look then syringes of lip filler. The only complication is that for some people it is more difficult to drink out of a straw for the first few weeks. Because the muscle is used so often, it tends to wear off quicker in about 2 months.
Fixing other areas, like the downturned corners of the mouth, “the bunny nose”, or excessive nasal flaring are all quick low additional unit add ons for those that are troubled by these appearance.
CHOICE OF MODULATOR
There are 4 modulators currently in the US market: Botox, Dysport, Jeaveau, and Xeeomin. At Formula, we use the first 3 regularly. Xeeomin is not a bad product, we just don’t see where it does something the other 3 can not. With three products how do we or the patient choose which product to use?
First off the 4 chemically are virtually indistinguishable. They are all botulinum toxin, with a very small molecule attached to it. This small molecule allows it to be unique and patented but may also be responsible for subtle differences in activity between the four.
So this similar compound can have different effects. Prior experience (positive or negative), price, Onset/duration concerns as well as subtle differences in spread all play a role. It is on the daily I hear from a patient, “Botox doesn’t work on me” or “Dysport caused my eye to droop”. It is important to tease out whether it really was the toxin or was it the injector (or a dilute or bad vial) at another shop. It is a universal anecdote that a certain subset of people seem to get “immune” to the same toxin over and over again and do a little better by occasionally switching it up. Others seem to have no problem. So when we assess which toxin to use we eliminate if someone truly has had a “real” negative experience. If someone needs a quicker onset, Jeaveau tends to be SLIGHTLY quicker, and, as the new kid on the block looking for market share, is the cheapest. If someone has a broad area to hit and we can use a slight more “spread” of modulator, we choose Dysport as it is a little more broader in spread like a shotgun versus the more sniper rifle of Botox or Jeaveau. All and all, these FDA approved nueromodulators all work well and the subtle differences should be discussed between patient and provider at their consult to get the best individual result.
The two questions I hear a lot (although FAQ’s are an entire blog/web page) are Is it safe to start in my 20’s as a prevention? And Do I have to look frozen.
The first question touches on the progressive allure of aesthetics on Generation Z. The aesthetic industry is calling this trend “Pre-Juvination” and yes there is some evidence that if you can prevent the deep lines from forming in the first place there is a benefit. There is also a downside. Constant paralysis of muscles - the frontalis (forehead muscle) in particular can, like any underused muscle in the body, cause it to atrophy or permanently shrink/thin. It is of particular importance in this area because this muscle is what LIFTS the eyebrows up and not only aesthetically gives that youthful wide eyed look, but from a practical perspective helps you see better. For this reason I definitely recommend that younger patients go with a “non-frozen” look as well as space out the interval a little more between injections if its for Prejuvination.
Which then begs the answer to the second question, no, you don’t have to, and probably should not want to look completely frozen in the face. Whereas a furrowed brow and angry mouth at rest are not aesthetic and actually can make others act negatively unconsciously toward you, being able to express surprise, showing positive facial expressions can not only make you look prettier/more handsome but they can brighten someone else’s day. Like all things in medicine, “the poison is in the dose”. More toxin at each injection site is a more frozen look.
After Covid-19 and half a million deaths it can seem a little trite to talk about nueromodulators and aesthetics. But after a year of our faces either being completely hidden behind a computer screen or mostly hidden behind a mask, not only can it make you feel a little better about yourself when you take off that mask but it might ease some anxiety and depression along the way. Healthy user behaviors and their effects don’t have to be limited to hours of painstaking exercise, hunger induced fasting, and handfuls of supplements. If sitting in a chair for 15 minutes and coming out a few days later makes me look younger and has some health benefit, then sign me up.
As Always - Stay Well