■ Understanding the skin
The skin is the largest organ of the body. Proper knowledge of the skin’s structure helps practitioners understand how to maintain smoothness and suppleness and how dermal
fillers can work properly. There are three main layers of skin: epidermis, dermis, and subcutaneous tissue . Although they work together, each is responsible for particular functions. The top layer is the epidermis. It is the thinnest of the three layers and works as the main barrier to the body. This surface is subjected to daily exposure from the sun, weather, bacterial and viral infections, trauma, and the general stress of interacting with the environment. The epidermis contains melanin that defines skin color and sheds old keratin. It can become dry and scaly, and produce papules and macules or benign brown moles, red spots, or skin tags that patients seek to remedy whether by purchasing over-the-counter
products or consulting a healthcare practitioner for advice. The second layer is the dermis. Composed of blood vessels and nerves, it is mostly a sea of collagen, a durable protein that supports the epidermis.
Collagen gives skin a smooth, supple, and elastic feel depending on the health, age, and thickness of the layer. The term “collagen” is used loosely, as there are nearly a dozen types of collagen in the
dermal matrix, all working together to provide resilience and stability. The dermis is also the cornerstone of the cosmetic industry: manipulating the dermal layer is the key to younger-looking skin.
The final layer is the subcutaneous tissue, which stores fat. With age, however, its volume can decrease in the arms, legs, and face, while increasing in the abdomen in men, and in the thighs and buttocks in women.

■ Injection technique
Injections are generally made by five recognized methods:
straightforward 90-degree depot or bolus injections; serial punctures of multiple drops placed along the length of a wrinkle or fold; cross-hatching, which treats a frown line from opposing sides; linear threading, in which the full length of the needle is inserted and the filler injected while
pulling the needle backward so the filler is released; or fanning, which requires a single insertion while the filler is released by a pivot and swivel motion to the left and right. The NP should exercise a “treat, wait, and assess” approach to determine whether further injections are warranted.

Doctor working procedures and expertise

Results: Analysis of the same MRI slices verified by tissue
artefacts showed a statistically significant (all P < 0.0001)
average 18.6% reduction of adipose tissue thickness, 15.4%
increase in rectus abdominis muscle thickness, and 10.4%
reduction in rectus abdominus separation (diastasis recti)
as measured from the medial border ofthe muscle 2 months
post-treatment. More significant improvements were
observed in patients with BMI 18.5–24.9 (classified as
“normal”). MRI data from 6-month follow-up suggest the
changes can be preserved in longer term. Tape measurements showed on average 3.8 cm subumbilical circumference reduction. The weight of the subjects did not change
significantly (average 0.5 lb; P > 0.05). No adverse events
were reported.
Conclusions: MRI, considered as a highly precise
diagnostic method, revealed simultaneous muscle growth,
fat reduction and reduced abdominal separation at
2 months and at 6 months post treatments, unrelated
with dieting. Further research should investigate the exact
physiological processes which stand behind the tissue
changes observed in this study.

Introduction:

Botulinum toxin (Botox) is a drug made from a toxin produced by the bacterium
Clostridium botulinum. In large amounts, this toxin can cause botulism, an illness
that affects the nerves. Botox has been used since the 1970s in the field of
ophthalmology, and in the last 20 years, its use has expanded to various health
scopes, especially dermatology.1,2
Botox consists of 7 types of neurotoxins; however, only toxins A and B are used
clinically. Botox A is used for several disorders in the field of medicine, particularly
in dermatology, for cosmetic purposes.3 The first type of Botox introduced to the
market was onabotulinum toxin A. In 2002, it was recommended to be used as
a cosmetic treatment for glabellar frown lines by the Food and Drug Administration
(FDA).2,4,5 The second formulation of onabotulinum toxin A, which was produced
in France, obtained its license to be used for esthetic purposes from the European
Union in 2006 and was approved by the FDA in 2009.5,6 Botox type A has become
a term used by the society to describe all ingredients used in cosmetic treatments.7
A study in 1994 reported the effectiveness of Botox A for reducing the
appearance of facial wrinkles; since then, it has been used as a cosmetic
treatment.8 Botox injections can be used to treat glabellar frown lines, wrinkles

• around the lips (smoker’s lines) and marionette lines,
  platysmal bands in the neck, strabismus, blepharospasm,
  cervical dystonia, hyperhidrosis as well as synkinesis following facial surgery.1,2,9
  The objective of this article is providing a good literature review regarding Botox as a treatment for reducing
  facial wrinkles and also comparing it with other modalities
  such as fillers, skin peptide and facial muscle exercise. The
  main focuses are the mechanism of action, indication,
  contraindication, dosage, clinical effect, safety, side effect,
  and complication.

Doctor and expertise working the procedures