With 20 years of experience, Dr Joseph Hkeik is one of Australia’s most trusted cosmetic physicians in the industry. He is dedicated to guaranteeing natural-looking results for his patients. Founder of All Saint Clinic, his clinics offer facials and peels, skin rejuvenations and injectables.
In this session of Mamamia's The Skin Summit, Mamamia's senior beauty writer, Erin Docherty, asked Dr Hkeik all your questions about anti-wrinkle injections.
How do anti-wrinkle injections actually work?
Dr Joseph Hkeik: Well, anti-wrinkle injections or a muscle relaxant, it's a product that we inject either under the surface of the skin or inside the muscle. And that muscle will relax in about seven days. And the result will last anything between three to four months after the procedure has been done. Because wrinkles occur because of movement on the face - what we call dynamic wrinkles. When you relax that muscle, these lines will disappear for that period of time.
Do anti-wrinkle injections work on the nerve or the muscle?
Dr Joseph Hkeik: It works on the muscle. When you found, for instance, you're seeing two types of muscle or three different small muscles on the forehead. And these muscles contract and as they contract that creates a wrinkle on the forehead. When you're in your 20s, sometimes, you don't get those wrinkles. But as you progress with life, and especially in Australia, we tend to get more dynamic wrinkles. So when you put anti-wrinkle injections in those muscles and those muscles are relaxed, the muscle cannot contract enough to create these wrinkles.
Who should get anti-wrinkle injections? Who is the ideal candidate for anti-wrinkle injections?
Dr Joseph Hkeik: This is a million-dollar question. But we need to make it simple. Anyone who's got concerns about facial wrinkles is probably the right candidate.
If we talk about the dynamic wrinkles in a forehead, horizontal forehead line, the frown line, crow's feet - when people smile, and they get wrinkles around the eyes and these wrinkles are bothering them, they are probably at the right time to get the procedure done. If they frown, and they get a wrinkle, or if they're getting what we call the 'static line' in the same area. I'm talking about if you start to get a wrinkle run in the centre of the forehead, or the one or the 11 even when you're not moving your forehead, you definitely are the right person to start to get anti-wrinkle injections if you're concerned about those wrinkles.
Who should not get anti-wrinkle injections? What would make you think that someone isn't quite right for anti-wrinkle injections?
Dr Joseph Hkeik: Well, often you see people come forward, and we see them here sometimes saying 'I'm here because I think anti-wrinkle injection is the fashion'. Even when they don't have wrinkles. These clients, we often talk to them about their skincare, other ways to prevent some damage, and other procedures that can actually help to make their skin healthier. But we'll talk them out of getting anti-wrinkle injection for that reason.
What are the things to consider before getting anti-wrinkle injections?
Dr Joseph Hkeik: I always say it's best to see a professional and I'll always say start by seeing a professional doctor that specialises in that field because when they understand really the suitability of each client, usually they're non-commercial. So, they're going to be very honest with you about if anti-wrinkle injections are right or not right for you. So, I'd say have a proper skin consultation. Let the doctor analyse your face, analyse your skin, and determine if solutions like skincare products or other procedures, like micro-needling or other alternatives can actually help your skin more. If we think that none of these procedures [are] gonna remove those wrinkles for you, and then anti-wrinkle injections will become the right procedure for you. And then we can talk about that as a solution.
I'm not a big fan of people who go into an anti-wrinkle injection party, and then everyone getting the procedure done whether or not they need it. I think this is not ethical, and I will not support it.
Are there areas of the face where you should not be getting anti-wrinkle injections?
Dr Joseph Hkeik: Let me start by saying that the common three areas that we treat with anti-wrinkle injection is obviously the glabella frown or the frown line between the eyebrow, the surprise horizontal line, the crow's feet - they're the three common areas that everyone, usually when they're starting to get wrinkled, they would like to have these areas treated.
There are other specialised areas on the face that we can also treat with anti-wrinkle injections. And that's basically the wrinkle on the nose, or we call them bunny lines. We can flip the lip with a tiny little bit of anti-wrinkle on the sides. We can drop the chin a little bit for the crease that happened just above the chin - between the lip and chin, you can put some product in there. I mean, in the right hands, you can use the anti-wrinkle injection in all these areas - there's nowhere on the face that you could not really treat safely if you know what you're doing. But for someone getting the procedure for the first time, and if the injector or the doctor treating the person is not experienced enough, of course they can get some issues with it. And, so if you're a beginner injector, I say, you're only focused on the upper face, you don't go to the lower face because it's more specialised, and it's more tricky. And there you're more likely to get side effects from anti-wrinkle injections.
What are the side effects of anti-wrinkle injections?
Dr Joseph Hkeik: Obviously, you can get side effects by having too much anti-wrinkle in the muscle or if you inject the wrong muscle.
And then this probably brings you back to the question you're talking about the areas, about maybe two centimetres above the lateral brow is a kind of danger zone if you put too much anti-wrinkle in because what it does, it drops your eyebrow. And then if you put an anti-wrinkle injection within two centimetres over the lateral brow, you can drop that brow and you can make someone look very sleepy and then the eyelid will start to swell. So, this is one of the side effects that people are often scared about. And hence why it's important to see an experienced injector.
The other reason where, sometimes, people get side effects from wrong placement or wrong amount of anti recommendation is when they start to inject around a lip. And that's become really quite fashionable. And I use that word fashionable, because I don't believe in fashion when it comes to facial aesthetics. If you need it, we do it, if you don't need it, we don't actually offer it.
So, when you put too much anti-wrinkle above the lip, you can drop the lip too much. And, people can have issues with sucking from a straw or kissing or, you know, just speaking some time or laughing. And I think that's sad because this is a specialised procedure, which should be done only by specialists in this field.
How long does it take to see the results of anti-wrinkle injections?
Dr Joseph Hkeik: Generally speaking, we say about seven days, but the change can occur between three days to two weeks after the injection of the product that varies between patient and patient or so it varies between the doses. So if you have a baby anti-wrinkle injection, it's going to take a little bit longer for the product to do the effect. If you use it in a bigger dose, you're probably going to get the result sooner.
Is it possible to overdo it with anti-wrinkle injections?
Dr Joseph Hkeik: I think all the studies have shown us that the anti-wrinkle injection lasts 12 weeks. So, you think that everyone will stick to that rule?
I would not encourage people to come in every four weeks. I've seen that sadly on social media at times where people say, 'I've just been four weeks since my last treatment and here I am doing it again,' and I think all it does is encourage the clients to become resistant to the treatment. And eventually, doesn't matter how much you use the product - you will not get any effects. So, that's detrimental rather than beneficial.
So, people should not really rush and get the treatment every four to six weeks or even every two months, they should really wait and wait the 12 weeks and come back. And wrinkle is not going to really kill anyone, it's not going to make anyone look ugly. I think it makes you look better. Sure. But it doesn't take away from your beauty. There are other things about the face that we need to also look after - skin, the shape, etc. So, let's not just focus on wrinkles.
Is there a certain age to wait before getting anti-wrinkle injections?
Dr Joseph Hkeik: I'd say in most cases, in your late 20s to early 30s is probably the right age to come and see someone about your lines or wrinkles. Sadly, in Australia, and I'm sure in the rest of the world, these procedures have become fashionable, amongst the very young (15 to 16), who I really don't think have any wrinkles.
Even in Australia, I think people at that age should not have any wrinkles if they take proper care of their skin. So, I'd say if they're in their mid to late 20s or early 30s and they haven't started [having] wrinkles, meaning wrinkles you can see all the time. It's probably the right time for some clients and depends on their job and lifestyle. If they started to get very strong dynamic wrinkles, meaning wrinkles when they move a muscle like smiling [or when] they get big crow's feet, and that is of concern to them.
I'm always a believer in natural beauty, so I don't endorse people getting everything on their face injected just because it's there. You don't want to risk losing your character in the process.
What is the right time to start getting anti-wrinkle injections?
Dr Joseph Hkeik: This is a question I've often been asked about many interviews that I've done over the years. If we think about preventing wrinkles and we need to think about really why wrinkles occur - and why wrinkles occur is because we lose elastin with collagen and volume in the skin. And often what causes that loss is driven by repetitive use of a muscle.
Let's just focus on the frown one more time. So, if you think of the frown, we moved the muscle too much in here ...I've got some anti-wrinkle in there right now. So far, we cannot demonstrate to you very well how it should really work. But I practice what I preach. And as we all do at the practice here.
So, when you repeatedly move that muscle, eventually you'll create a crease in the centre. So, if you're someone that uses that muscle a lot to concentrate, yes, a tiny amount of anti-wrinkle injection will help. But we cannot just focus on the anti-wrinkle injection as the hero product here, we need to think about what else is happening with that person, you know. Are they eating well? Are they taking the right supplement? Are they using the right skincare product? Are they losing too much volume? Is that because of weight loss or stress, etc? So, we need to think about all the causes that cause the wrinkle to occur and try to address them completely holistically and not just focus on one solution, because the anti-wrinkle injection, as good as it is and 99.9 per cent satisfaction rate like a quick Band-Aid solution, is not the answer to everything. We need to think about the bigger picture.
What are baby injectables all about?
Dr Joseph Hkeik: Look, I might have been a big culprit in starting this baby treatment, because from day one and 23 years ago that is, I always use small doses of the anti-wrinkle to treat people because one, my focus was on trying to make the eyes bigger rather than making them look frozen.
When you give the recommended doses of anti-wrinkle injection - that is recommended by the company - the result can be a frozen look. But, this is not how we do it here at All Saint, we see the anti-wrinkle injection to relax the muscle enough to be able to manipulate the shape of the brow and to lift the brow in the centre lifted on the outside, and just to actually give you a better, brighter look. You look rested, you look fresh, but you don't look frozen.
This is something that I've done for 23 years. And at the beginning, I was not popular because of it. But when people started to actually understand the philosophy behind All Saint and why we do what we do, all of a sudden that becomes more like a cult. So, people love this baby anti-wrinkle injection for that reason - because you don't want to look like you've had an anti-wrinkle injection. No one should look like they've had really any of these products on their face, you should look like you and "this is how I woke up this morning. And I've done nothing except for some skincare, and then in some instances, makeup, and then I'm ready to face the world".
What are the signs that the anti-wrinkle injections were a fail?
Dr Joseph Hkeik: Bad work is often because they've had either too much product injected or the product was injected in the wrong muscles on the face. So, just to give you an example, frozen faces - in my eyes, I think this is bad work. No one should really walk around with no ability to express themselves. How will you connect with your friends and family and your kids, if you have kids? How will you show emotions? If you cannot really express and show, upset or smile or show surprise, how would people understand what you're all about? So I think, to me, a frozen look is definitely a sign of bad work.
The second thing that often you notice is people that are too scared to inject the lateral part of the brow, and they skipped this area - so they miss this area. But, they end up with what we call the Jack Nicholson look where the eyebrow was going all the way up. And that to me is a visible sign that you've had anti-wrinkle injections. The key is not to miss it, but to actually know how much and where they put the product to keep the eyebrow looking the same, only slightly lifted. So, the centre and the outside open up your eyes. And these tricks that people need to learn if they're going to practice these procedures on the regular basis and keep people looking natural.
...And is it fixable?
Dr Joseph Hkeik: In some instances, yes it is. And other instances, if it's been put too much, and they fill in [a] bit heavy, we can inject the opposing muscle. So, because the other eye sits there in that position because of [the] balance of three muscles. And these three muscles push and pull in a different direction. So what we do as doctors, we try to manipulate the power of all these three muscles to place the eyebrow in a slightly different position that is more attractive to the eye. And so we can manipulate these muscles, if there's room, but if all muscles on the upper face are frozen, unfortunately, and sadly, we have to wait ''til the product wears off at three months time. And then after that time, we can start fresh.
What should you be looking for in a clinic or doctor to get anti-wrinkle injections from?
Dr Joseph Hkeik: Well, look, I think this is a very important question, obviously. What you firstly look for is a doctor that has already done it for many years or a clinic that's been doing these procedures for many years because one being the doctor, and if they especially belong to places like the Australasian College of Cosmetic Surgery or Australasian College of Plastic Surgery. So, you need to make sure that someone with qualifications running and not someone that just learnt it over one weekend and two hours because in Australia, sometimes, this is all it takes - is to attend one course of two hours and then voíla, you got a certificate in one hand and you got a needle on the other hand, and you're treating people. So, it's very to get into this industry and it is a glamorous industry. So, everyone wants to get into the industry whether or not you've got artistic skills, you want to do it.
So, look for a practice that's already been established for many years, and then make sure that you have a proper consultation. And I often say, take a friend with you. Don't hesitate to take a friend with you. Because sometimes you're just so emotionally involved in this process that you don't think straight about the procedures that have been recommended to you. If you have a friend who will more likely to pull you by the hand and say, 'Hey, stop, slow down or don't do it. Let's go home and think about it.' or 'Let's go and have a coffee, talk about it before you actually make a decision.'
You should not really make this decision on the run, or when you're rushing. And certainly, I would say, do your research - call the colleges both have cosmetic surgery and plastic surgery and ask the right questions, find out who's reputable. And they will give you two or three names and you can do your research. I say always don't do it because of a social media profile because that means nothing - really means nothing. No one checks the qualifications anymore, they check how many followers you have on social media. And as much as we all would like to have millions of followers on social media, it doesn't make you a better doctor, or worse doctor, if you have five followers, or you have five million followers.
What are the signs to look for in an anti-wrinkle injection clinic?
Dr Joseph Hkeik: Once you're in a clinic, one sign that I always advise people to look for is to check the receptionist behind the counter check the people that are looking after you see how they look. Do they look natural? Or do they look like they've had so much work done? Because if the people working in the environment have had so much work done that will give you an idea about the aesthetics of the practitioners - because if they think that this looks beautiful to someone having four or five millilitres in their lips, and you know, you can just see all the wrong signs about lip rejuvenation. Obviously, that tells you what kind of practitioner is doing the work.
I mean, I don't enjoy looking at it, but it doesn't mean it's wrong. Some people like that look, and I'm not going to really judge those people that want to get that look. But for me, I only endorse natural beauty. I just always say if you're looking for natural, subtle results, check the people in the practice and see how they look. If they scare you, you're not in the right place.
Are there treatments that could replace anti-wrinkle injections?
Dr Joseph Hkeik: To be honest, if you're concerned about the wrinkles on your face and then you want a good solution... There is nothing in the 23 years that I've worked here that can actually replace the anti-wrinkle injections. There's nothing that gives you that high level of satisfaction if it's done correctly with the right doses and replacement.
This is our duty as doctors to educate the clients that this is not the only solution. So, we cannot just resort to that we need to actually look at the reasons why they get a wrinkle in the first place. And like I mentioned before, try to address these things. So educating the clients about the skincare and certain ingredient we don't work with just the brand, we work with the ingredient at All Saint and always have done so. I just wanted to make people more intelligent about their choices, and not to make a decision based on a particular brand.
So, the ingredients in the skincare is very important. Challenging your skin through treatment at the practice level also is very important because we have so much technology that will promote collagen in your skin - elastin in your skin, this is the ingredient that is very important to keep your skin tight and lifted and firm. And so if we deny these clients, those modalities we are not being fair and honest about a fix in their wrinkles.
Now, just the anti-wrinkle - that's a quick fast solution. But what we need to do is start to work, and this is what I call preventative treatment is all these other things that we can offer them to make their skin healthier, firmer, brighter, clearer, and all those beautiful words that we can describe skin with that there are technologies for that.
What is the difference between anti-wrinkle injections and fillers?
Dr Joseph Hkeik: Okay, that's also a very important question because often clients do not actually understand the difference. And then you can give them filler and then they can assume [it] was anti-wrinkle and vice versa. So, as I mentioned before anti-wrinkle injection is a product - a very watery product that we inject to relax the muscles. So it's like you can use the word interchangeably with muscle relaxing. So this is what anti-wrinkles are, they relax the muscle.
While dermal fillers are made of gel solutions that have been put together in the laboratory to often mimic what we have in our skin. And the key filler that we use is 99.9 per cent of hyaluronic acid. Hyaluronic acid is a - this is a big word, a glycosaminoglycan that exists in our skin. And what it does is it actually locks in water, so it keeps our skin hydrated. But in the laboratory, we make it in a way like the one that your body makes every day, it can last between one year or two years or three years.
So, these gel we can place in the skin to create a different shape. We can plump up the cheek. I often use it in the nose to recreate a beautiful shape nose. You can [also] put it in the lips, this is a common error when people can see filler is in the lips. But you can do it in a discreet manner that no one should be able to tell that you've had these fillers. And then you also have the other types of filler which also stimulate collagen or we call them bio stimulators. So you can inject a filler to give you a shape, but at the same time, stimulate collagen and elastin in your skin, and then help to lift your face. So, you lose the heaviness from lower here and then lift the face in the right direction like you do a facelift. So the key differences is one adds volume, and then one relaxes the muscle.
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You can find Dr Joseph Hkeik on www.allsaintskin.com.au and on Instagram @allsaintclinic. You can also follow him on his Instagram account @drjosephhkeik.
Feature Image: Mamamia.