When assessing and treating a patients lips there are several subtle changes that can rejuvenate the mouth area without making the lips look “done”.  Although some patients want much fuller lips, a lot of us prefer subtle changes.

old lips

young lips

lip comparision

As we age our upper lip changes in several ways.  We tend to lose the definition along the vermillion border, the philtral ridge/columns (the vertical columns that start at the tip of the cupids bow and end below the nose) flatten and the space between the upper lip and nose elongates.  Subtle changes can be created with easy injection techniques, including defining the vermillion border, restoring the philtral columns and accentuating the cupids bow.  Restoring the philtral columns frequently make the lip lift slightly.  Filling these columns can return the contours that were likely once there.  Vertical lip lines can be softened as well.  Small amounts of filler can be placed within the lip itself to restore lost volume.  There are many fillers to choose from these days,  giving the patient and provider options, depending on the treatment plan.  Fillers vary in their hyaluronic acid %, viscosity, elasticity and cohesiveness.

When assessing and treating the lower lip there are several changes that can have a nice impact,  other than just looking fuller.  Again, the vermillion border can be defined and fine lines can be corrected.  The oral commissures, which tend to turn down as we age, can be turned back up with filler placement techniques.  Volume restoration can be completed to obtain the desired effect.

The ideal balance of upper lip to lower lip is 1/2 to 2/3’s.  This does vary individually and you and your provider can decide the best proportions for you.

In addition to fillers, small doses of Botox® or Dysport® can be utilized to relax muscles in this region of the face.  If a person tends to purse their lips  Botox® or Dysport® can be used in the muscle surrounding the mouth (the orbicularis oris) to minimize the pursing.  This injection technique also tends to roll the upper lip up and out slightly, making it appear slightly fuller.  Additionally, for a gummy smile,  an injection a little higher (closer to the nose) in the upper lip can relax the muscle that lifts the lip up.  This injection prevents as much gum tissue from being exposed with animation.

Another placement of Botox® or Dysport® that can help in the lower face and lip area is treating the depressor anguli oris ,(DAO) which, in some individuals, pulls down the sides of the mouth.  Very small doses are utilized in these muscles to help minimize the appearance of frowning.

As with all facial injections, make sure your provider has a thorough understanding of facial anatomy.   Ask if there is an “emergency kit” for injectables in the clinic.  (a kit containing an enzyme to dissolve filler, should it be required)

Do not worry that having injectables in the mouth area will leave you with unnaturally big lips. (which we have all seen) If you and your provider are on the same page, you can obtain a natural restoration of the volume and definition you once had.



There are a few stand-out products from 2016!

Alastin Restorative Skin

The Alastin Restorative Skin Complex® has become a part of my daily routine.  I have found an improvement in the texture and tone of my skin using this product regularly.  The skin around my eyes (especially under my eyes) has firmed and there are fewer fine lines.  This product has peptides that help your skin grow collagen and elastin.  Restorative Skin Complex has been written up in numerous publications and has been recommended by multiple dermatologists and plastic surgeons.   It is worth every penny.


Skinceuticals C E Ferulic rotates in and out of my regime, and has for years.  There is unequivocal evidence that this product, loaded with antioxidants, helps neutralize UV and free radicals.  Used with sunscreen, your protection is improved significantly.  90 % of visible premature aging is caused by environmental free radicals.  Sunscreen alone is not enough.  Adding an antioxidant such as C E Ferulic or Phloretin CF gives the skin significantly improved protection.


Elta MD® UV Daily Broad-Spectrum SPF 40 is always on my bathroom counter, in my purse and in my car.  With 9 % zinc oxide, the sun protection is superior to any chemical sunscreen.  The formula is not at all heavy, and with  hyaluronic acid , it is hydrating.   I love this sunscreen.


Skinceuticals Metacell Renewal B3 is also always in my rotation.  This product helps with hyperpigmentation and, with niacinamide, redness as well.  It has a smooth and hydrating feel without feeling heavy or greasy.  Great product.


Allergan Juvederm Voluma™ has become one of my favorite dermal fillers.  It is FDA approved for filling the midface, although I use if off-label in temples, tear troughs and lower face.  This filler is wonderful at restoring lost volume while looking very soft and natural.


And, as always, the tried and true merits of Botox® and Dysport® can not be disputed.   The preventative and corrective effects of both of these botulin products are proven in terms of efficacy and safety.  They are here to stay, and when in the right hands, can create a rested appearance.  We have all seen a “Botoxed” face, but that is not how it has to be.  There can be movement and expression  when the muscle activity is minimized rather than frozen.  A rested appearance is the ideal outcome.

Botox cropped


One more product I have enjoyed this year, and in previous years, The Vi Peel.  In a perfect scenario we would all have a peel every 3-4 months.  Peels help to lift damaged and dull skin, stimulates collagen, fades hyperpigmentation and clears stubborn breakouts.  I love my skin 10 days after the peel is applied.  The Vi Peel is strong enough to see a difference ,but not so strong that there are weeks of downtime.    Great glow!


All products and services mentioned are available here at TOC Medical Spa in Austin!

I hope your 2017 is off to a great start!  Here is to your health and happiness!


There are several programs offered by the aesthetic pharmaceutical companies that are meant to drive patients back in for additional treatments.  They are effective for the companies AND they save the patient money.

I think it is worth utilizing these programs if you are a consumer as it does save you $ on something you were probably going to do anyway.


Allergan, the makers of Juvederm®, Botox®, Kybella™, SkinMedica® products and Latisse®, has a program called Brilliant Distinctions®.  You accrue points by receiving treatments with your provider, purchasing skin care, and in the case of Latisse®, filling a prescription at your pharmacy.  You simply sign up at  When you receive an aesthetic treatment with an Allergan product remind your provider to issue you points at check out.  When purchasing SkinMedica® products also ask the person checking you out to issue points on your skin care purchases.   Check your account before your treatments to see how many points you have accrued and create a coupon.  The coupon are worth anywhere from $10-$80 depending on what you have accrued.  (I have seen patients have more than $80 in their banks)  Points do expire after 9 months so keep an eye on them.  Brilliant Distinctions® also has an on line mall where purchases from participating retailers can also create dollars in your account.  The list of retailers is extensive and includes many commonly shopped businesses.  Maybe your holiday shopping is going to pay for your next Botox® treatment!


Another program, from Galderma, the makers of Restylane® products, Sculptra® Aesthetic and Dysport®, is called Aspire.  Once again, you accrue points as you receive treatments.  Go to to sign up.  You are also able to accrue points in Aspire by taking monthly quizzes, participating in surveys and referring friends.  The Aspire program points last longer than Brilliant Distinctions® points,  although they do eventually expire.

Both programs have smart phone apps that make it that much easier to access and utilize.

If you are a fan of medical aesthetic treatments check these out.  It can only save you money!


facial changes 2

Our face experiences numerous structural changes over the years and having a general concept of these changes can help approach a customized aesthethic treatment plan.

Changes occur over time with the skin, fat, muscle and bone contributing to our facial changes, most notably, volume loss.

Over time our skin becomes thinner, drier and experiences a reduction in collagen.  The skin becomes less elastic and is likely to sag and wrinkle.  Sun damage contributes and causes skin discoloration as well.

fat 2

Additionally, our facial fat pads atrophy (break down) and shift under the skin leading to facial volume loss.  We tend to lose volume in the temples and mid face while gaining volume around the mouth, jaw and lower face.  The separation in the fat pads results in visible unevenness in our facial contours, where once it was a smooth with the apex at the lateral cheek.

bone 2

Bone loss over the years is another reason for the loss of volume.  Bone resorption over the years causes the overlying structures to loose support.

full face aging changes

The above diagram notes some of the commonly noted changes that individuals eventually seek treatment for.  There is not a one size fits all approach as we all experience age related facial changes differently.

Fillers such as HA’s, (hyaluronic acid) Sculptra® or Radiesse® can be used to return volume where it is lost.  Restoring volume in certain areas can have a nice impact on the contours, restoring a more refreshed appearance.  For instance, mid face.  Mid face volume does not only restore volume to the mid face but tends to have a lifting effect to all the tissues below.  Nasolabial folds, oral commissures and marionette lines all soften with mid face correction.

Some of the lines from repetitive muscle movement are best treated with Botox®, Dysport® or Xeomin®.  (such as the frown lines, crows feet or horizontal forehead lines)


Botox cropped

I hear this frequently from patients and thought it might be helpful to clarify.

Botox, Dysport and Xeomin all arrive to your providers office in  vials that are dry. (the botulin product is dry within the vial)  We all have to reconstitute the product with saline.  So, really, we all dilute the product.    Different providers have a variety of dilutions they prefer to work with.  Ultimately what the provider and patient should be concerned with is how many units are administered to an area.  A vial can be reconstituted with anywhere from 1ml to 4 ml or more.  The provider then determines what volume to pull from the vial to have the number of units they want to administer.

For instance, most patients receive 20-30 units to the glabella or frown.  If I am using my 1 cc dilution (which I use the most, just personal preference) and I want to administer 20 units I pull up 0.2 ml.  If I was using a 2.5 cc dilution (another commonly used dilution) I would pull up 0.5 ml for the same 20 unit dose. I can obtain the same degree of relaxation with either dilution.

So, if you find there is a variety of outcomes it is not the dilution that  creates different outcomes but the number of units placed in the muscle.

Hope this helps clarify what it means to dilute Botox. (or Dysport or Xeomin)

If you have a treatment that you love note how many units you received in the treated areas.  That is the key 🙂


CROPface-symmetry-e1441912227693 (2)

A “liquid facelift” is a non-surgical option for facial rejuvenation.  The objective is to restore lost volume, correct asymmetries, relax muscles that pull down and restore more youthful contours to the face.  Ideally the apex (or high point) of the face is the lateral  cheek below the lateral brow.   We tend to lose this volume as our facial muscles, fat pads and skeletal structures shrink and shift underneath the skin.

EVERY person has an individual plan of care with a unique set of concerns.  After discussing these concerns with your provider and hearing their expert opinion you can prioritize what areas to treat first and move forward from there based on your budget.   Frequently we recommend starting with the upper and mid-face as once these areas have received volume restoration the lower areas are improved as well.  For instance, I frequently have patients come in concerned with their nasolabial folds (from the nose to the mouth) or their oral commissures and  marionette lines. (from the side of the mouth down along the lateral chin) These areas can see marked improvement by building the volume loss in the cheeks and/or temples.  It is after filling temples and cheeks that we can fine tune the other areas.  The mid-face has become increasingly popular to fill as the benefits go beyond the cheek alone.

Treating muscles in the upper face with Botox or Dysport can also create lifting when the correct muscles are injected.  For instance, a brow lift can be achieved by relaxing the muscle that pulls down on the lateral brow .  At the same time muscles which help to lift our features (elevator muscles like the Frontalis muscle/forehead)  such as our brows need to be treated conservatively to avoid the brows and lids looking heavy.

We can also turn up the downturned corners of the mouth which can make us look unhappy or mad.  This can be done with a combination of filler and treating depressor muscles which pull down on the lateral mouth with Botox.

Definition along the jaw line and lifting can be acheaved with what  is called a Nefertiti lift.  We inject the platysmal muscle, which pulls down on the lower face along the mandible/jaw bone, with Botox.

As a provider I find restoring mid-face volume to be one of the most satisfying treatments.  Patients get a big bang for their buck with cheek augmentation with filler.  We gravitate towards Voluma (my favorite), Radiesse and Sculptra to achieve mid-face volume as these are longer lasting and produce more volume.  Fillers tend to last longer in the upper and mid-face as we tend not to have as much mobility in these areas as we do in the lower face.  Patients can maintain correction for up to two years in mid and upper face with filler whereas the lower face may need re-correction at 8-12 months.

Using these modalities to restore the appearance of the face is a great option with minimal downtime.  A patient can expect to re-touch the filler treatment every 8-12 months as needed.  Sometimes the touch ups are minimal and help the remaining filler to last longer. Botox touch ups are more frequent at 3-4 month intervals.   Rarely does a patient need to make as much of an investment at follow up appointments as they do at the original treatment.

Pain is minimal during the treatments as topical numbing is typically used and the products have Lidocaine mixed in.

Just in case you have ever wondered what a Liquid Lift was 🙂