A common myth – or, perhaps, dream – is that botulinum toxin injections can fix just about anything that’s wrong with your face. This includes deep wrinkles, also referred to as static wrinkles. Dr Riekie Smit offers a deeper look into which types of wrinkles botulinum toxin can treat and which ones it cannot.
There is a vast array of terminology used for wrinkles – lines, folds, furrows, cracks, crepiness, and more. Then we’ve got various scales and classifications, such as the Glogau ageing scale, Fitzpatrick facial wrinkling classification, and the Lemperle scale. What’s clear is that many years of research have gone into understanding the differences between the types of wrinkles, with Dr Gottfried Lemperle addressing these differences at length in a publication published 23 years ago. Considering the studies he referenced on different treatments for wrinkles date back to 1977, it’s quite fascinating that there is still so much confusion surrounding this topic!
Image © SouthPointe Medical & Aesthetics
The terminology most used for wrinkles that are either treatable by botulinum toxin or not is “static” vs “dynamic” wrinkles.
Static wrinkles
Static wrinkles refer to superficial lines or cracks in the skin that exist with and without muscle movement or expression. These superficial lines are associated with textural changes on the skin surface caused by intrinsic and extrinsic ageing, as well as muscle movement or expressions. These static lines are superficial dermal creases and are mostly treated with skin treatments such as chemical peels, laser resurfacing, or intradermal injections, with a variety of pharmaceuticals focused on reversing dermal damage. Static wrinkles can occur over all the areas where dynamic wrinkles form due to repeated dynamic movement over the years, but they can also occur over areas not affected by muscle movement due to photo-ageing and intrinsic ageing changes in dermal collagen and elastin.
Dynamic wrinkles
Dynamic wrinkles are also referred to as mimetic wrinkles, or folds and furrows. They are the visible effects of deep dermal creasing caused by repeated facial movements or expressions, combined with the loss of dermal collagen and elastin. These lines are mostly perpendicular to the direction of the underlying facial muscle movement. The most common areas for dynamic wrinkles include forehead lines, frown lines, smile wrinkles (crow’s feet), upper lip wrinkles (smoker’s lines), nasolabial folds, or marionette folds (mouth corner folds).
Dynamic folds or wrinkles are treated with botulinum toxin to reduce the underlying muscle activity or by lifting the fold with tightening procedures.
A simple way to distinguish between static and dynamic wrinkles is to actually stretch the skin over the line or fold. If the line disappears when the skin is stretched, it’s most likely dynamic. If the line remains visible when the skin is stretched, it’s definitely a static wrinkle!
Images © Dr Riekie Smit
Images © Dr Riekie Smit
Static vs dynamic frown lines
The most concerning area where we often find difficult-to-treat static wrinkles is the frown area. With dynamic frown lines, botulinum toxin injections are sufficient to reduce the wrinkles. However, when it comes to static wrinkles and deep furrows, combination treatment is necessary. This happens when a patient waits too long before starting botulinum toxin for an overactive frown muscle. The continuous muscle movement starts damaging the dermal collagen, and a static fold forms in the skin.
Fillers are often used for deep folds, but the frown area is particularly dangerous for fillers since there are vital arteries located exactly where the injection is needed. These arteries not only supply the skin of the area, but they’re also connected to the arteries responsible for vision.
In other areas, such as mouth corners or even smile wrinkles, fillers are often used to manage the static wrinkles that remain after botulinum toxin injections. However, this is too risky for the frown lines.
The approach to deep or static frown lines still requires treatment with botulinum toxin to relax the muscle activity, but then additional treatments may be necessary to repair the collagen damage within the dermis.
Skin treatments that can help alleviate the existing line after botulinum toxin include:
- Fractional ablative lasers
- Medium-depth chemical peels
- Skin-revitalising injections (mesotherapy)
- Collagen-boosting threads
Collagen-boosting threads are among my favourite treatments to manage deep frown lines that persist even after botulinum toxin has relaxed the underlying muscles. They stimulate new collagen and volumise the fold, eliminating the risk of vascular occlusion, which may occur when using fillers in this area.
Images © Dr Riekie Smit
Images © Dr Riekie Smit
Now, let’s consider dynamic wrinkles. The patient pictured below has only dynamic wrinkles on their forehead, yet these can also be challenging to manage with just botulinum toxin. The muscle that raises the eyebrows (frontalis muscle) is the same one that causes forehead wrinkles. Relaxing this muscle with botulinum toxin reduces the forehead wrinkles, but it might result in heavier or lower brows. Consequently, the amount of botulinum toxin that can be used on this muscle is limited to a small quantity that will only mildly improve wrinkles without causing a brow drop. In these instances, when a patient complains about persisting wrinkles after botulinum toxin treatment, I prefer to use a very soft filler with a blunt cannula device.
Images © Dr Riekie Smit
In summary
Combination treatments are often the only way to actually eliminate wrinkles, lines, or folds because their formation is multifactorial. These different types of wrinkles occur due to a combination of muscle activity, skin thinning, photodamage, soft tissue sagging, and volume loss. Thus, different modalities are needed to manage both static and dynamic wrinkles. Starting preventative measures early will also help to reduce the number of dynamic wrinkles that become static wrinkles.
My advice is to schedule an in-depth consultation and evaluation with your aesthetic doctor to formulate the most suitable treatment plan that will help you not only look younger but also feel like the best possible version of yourself.
MBChB (UOFS). MSc Sports Medicine(Pret) Adv Dip Aesth Med (FPD).
Dr Smit has a private practice in Pretoria, South Africa, specialising in treating various aesthetic medical conditions. Dr Smit is the founder and ex-officio president of the Aesthetic and Anti-Ageing Medicine Society of South Africa(AAMSSA) and chairperson of the Aesthetic Medicine Congress of South Africa (AMCSA). Dr Smit is the course developer and current coordinator for the officially recognised Advanced Diploma in Aesthetic Medicine in South Africa at the FPD higher education institute. She is also a faculty member of the American Academy of Aesthetic Medicine, training doctors in Asia, Africa, Europe, the UK, Russia and the UAE. She is an international trainer and key opinion leader on aesthetic medical subjects and author of medical articles, journals and scientific publications. Her field of expertise includes skin rejuvenation, facial injectables (neuromodulators and fillers), thread lifting, chemical peels, mesotherapy, PRP, Lasers and LED. Dr Smit is a global KOL for various aesthetic medical and pharmaceutical companies in the industry.
- Dr Riekie Smithttps://www.aestheticappointment.co.za/author/dr-riekie-smit
- Dr Riekie Smithttps://www.aestheticappointment.co.za/author/dr-riekie-smit
- Dr Riekie Smithttps://www.aestheticappointment.co.za/author/dr-riekie-smit
