Masks have become a mainstay fashion accessory for 2020, and likely into 2021. While they are an essential tool for keeping our communities healthy, many of us may feel tired of wearing them. Dr. Butterwick recently hosted a webinar to help us feel a bit better about mask wearing and the times we are living in. By focusing on beauty above the mask, we can still look and feel our best throughout this challenging season. 

What is beautiful?

Dr. Butterwick began her webinar by defining a beautiful upper face. The most aesthetically pleasing faces will have the following characteristics: 

  • Clear skin with a smooth texture and radiant tone
  • Minimal muscle movement – no dynamic wrinkles 
  • Volume and contours in the forehead, cheeks, and upper nose
  • No skin laxity or drooping of the brow over the upper eyelid
  • No bags or discoloration underneath the eyes
  • Ideal proportions with wider midface

Signs of Aging

Even when we have these features in our youth, the aging process can result in changes to the face long before we are ready. Dr. Butterwick says that even young people can start to get lines and dark under-eye circles since these developments can be genetic. The eyebrows can also begin to shorten and start to droop. Skin may become loose, and the face may look as if it’s caving inward and downward. These changes may convey emotions like grumpiness or sadness even when that is not how we feel. 

Causes of Aging 

Many of the superficial changes we begin to notice are caused by sun damage. Both UVA and UVB rays penetrate the skin, although UVA rays tend to go deeper. The exposure damages collagen, an essential protein in the dermal structure that gives skin its smooth, supple appearance. Most sun damage occurs during the first 18-20 years of life but won’t show until later. Early signs of sun damage include brown spots and facial wrinkles.  

Aging is a multi-level process that includes: 

  • Fat pad shrinkage (beginning in our 30s, we begin to lose a teaspoon of fat each year, leading to drooping upper eyelids, volume loss in the cheeks and forehead, and hollowing under the eyes)
  • Muscle atrophy or hypertrophy (begin tugging on the skin to create facial creases)
  • Bone loss and remodeling (eye sockets get bigger and bone gets smaller)

Rejuvenation and Enhancement of Beauty

While the aging process is inevitable, there are treatments that can reverse many of the effects. Dr. Butterwick explains the 4 R’s of skin rejuvenation in her webinar: 

  • Relax facial muscles 
  • Resurface sun damage
  • Refill to restore volume
  • Redrape to tighten skin 

botox wrinkle treatment in san diego, caRelax Facial Muscles with Botox

Wrinkles in the upper face are usually categorized as dynamic wrinkles because they form as a result of certain facial expressions. These lines typically appear across the forehead, between the eyebrows (glabellar lines), and in the outer corners of the eyes (crow’s feet). Dr. Butterwick and the other board-certified doctors at Cosmetic Laser Dermatology in San Diego, CA offer neuromodulators to reduce the appearance of these lines. 

Dr. Butterwick’s goal for most patients is to smooth the skin without creating a fake or frozen appearance. In most cases, she will leave some movement to maintain a natural look and expression. She can also use filler to treat any residual lines if the patient would like. She works with all the current neuromodulators on the market, including Botox, Dysport, Xeomin, and Jeuveau

Neuromodulators work by relaxing the muscles that lead to the formation of dynamic wrinkles. Some of the muscles targeted by this treatment are illustrated below. This treatment requires a tremendous amount of experience to ensure patients get the precise amount of neuromodulator, right where it’s needed. Results are temporary and typically last 3-4 months. Most patients get neuromodulator treatments three times a year to maintain their results. 

facial wrinkle treatment diagram in san diego, ca

Some patients may require more than one treatment to erase all the lines. With each treatment, the lines knit together a bit more and there is a smoothing effect of all lines after repeating your Botox Cosmetic treatment. Patients who start younger may prevent or delay lines from forming. We call this prejuvenation, as they look better now and actually prevent or at least slow down aging.

laser skin resurfacing in san diego, ca

Resurfacing for Sun Damage with Facial Lasers

When patients have discoloration, texture irregularities, fine lines, and early skin laxity, it is often due to sun damage. These symptoms can be treated with a resurfacing treatment customized to the precise concerns and severity of the damage. Dr. Butterwick explained that melasma, skin blotchiness, or hyperpigmentation is often in the upper third of the face and can be treated with intense pulsed light (IPL) therapy or the Clear + Brilliant laser. She often combines the two to produce optimal results. She can also combine Botox with IPL to produce a subtle brow lift while rejuvenating the skin. These treatments are quick “lunchtime” procedures and have no downtime.

Moderate damage requires different treatment modalities. Fraxel Dual is often the laser of choice for these patients. While it does require about four days of downtime, it can produce excellent results for tone, color, and texture. Photodynamic therapy is another choice for addressing sun-damaged skin with pre-cancerous lesions and broken blood vessels, producing much healthier skin, free of actinic damage. This treatment actually helps prevent skin cancer.

co2 laser resurfacing in san diego, caFractional CO2 is another resurfacing choice for more advanced signs of aging. This laser works on wrinkles, laxity, crepiness around the eyes, and a heavy upper lid. Recovery is a bit longer, requiring about a week to heal, but results are more dramatic than a light Fraxel in tightening and wrinkle reduction.

A fully ablative CO2 laser treatment is the preferred treatment for the most severe skin damage. This device can be effective not only for deep wrinkles and blotchiness, but also for skin tightening and treating laxity in the lower face that leads to jowl formation. Dr. Butterwick sometimes chooses to perform a lighter fractional CO2 treatment on the milder wrinkles and a more intense fully ablative CO2 laser on the deep wrinkles of the eye area or mouth area to produce the best result with the least downtime. Patients may need 7-10 days or more to heal and may be pink for up to one month or longer, but a single treatment can remove 10 years of sun damage. To learn more about laser resurfacing, visit

dermal filler treatment in san diego, ca

Restore Volume with Fillers

While the above treatments can be effective for some signs of damage, they are not efficient in treating volume loss that occurs during the aging process. Fillers are the best option for this concern and can be used to treat:

  • Wrinkles around the eyes or forehead
  • Tear troughs to treat dark circles and hollowing
  • Deep nasal root (bridge area) to improve curvature of upper nose
  • Volume restoration and definition of the cheekbone
  • Volume in the temples and forehead to frame the eyes, lift the brow, and enhance the facial contour

Dr. Butterwick often combines fillers with Botox to achieve results that last longer than using neuromodulators alone. 

Dr. Butterwick warns that filler treatments require a great deal of skill and experience to produce a natural result. For example, only certain fillers should be used in the tear troughs, since some can lead to more water retention and puffiness around the eyes. In some cases, Dr. Butterwick treats this area with two treatments, spaced one to two months apart to ensure the most natural result with minimal side effects. 

Redraping the Upper Face 

The redraping step in Dr. Butterwick’s rejuvenation process involves skin tightening treatments that smooth the skin, reduce fine lines, and lift the brow and eyelids. Treatment options for redraping include: 

  • Ultherapy – This treatment uses ultra focused ultrasound energy to tighten and lift the skin by increasing collagen levels and tightening deeper connective tissue. Ultherapy provides deeper tightening than other devices without required downtime. 
  • Thermage – This treatment is often Dr. Butterwick’s top choice for tightening the upper and lower eyelids. The device delivers radiofrequency energy deep into the skin to constrict tissue and promote collagen production. This can tighten saggy eyelids with no required downtime and is safe in all skin types. 
  • Silhouette InstaLift – This minimally-invasive procedure places sutures into the facial tissue, where they lift the midface and may create a refreshed, more youthful appearance. 
  • Plastic Surgery – Surgical procedures provide the most dramatic results, but also involve anesthesia, incisions, and downtime. While the doctors at Cosmetic Laser Dermatology do not perform surgery, they will let patients know if that is the best choice for them. However, the expertise and skill of our doctors ensures most patients can achieve excellent results to delay or even eliminate the need for surgery.

You may have read about pain from Ulthera or Thermage, but we have several options to feel comfortable during your treatment, including Pro-Nox, inhaled nitrous with oxygen that quickly leaves the body and allows you to drive home. 

Schedule Your Rejuvenation Treatment at our Medispa in San Diego Today

We are in unprecedented and challenging times today, but there are ways to ride out the pandemic positively. Dr. Butterwick encourages everyone to pursue even smaller cosmetic treatments to boost their appearance, self-confidence, and positive attitude. To learn more about any of these treatments, contact Cosmetic Laser Dermatology today to schedule your consultation at our skin care clinic in San Diego, CA.


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