Which Facial Areas Are Appropriate for Off-Label BOTOX®?

BOTOX® is a powerful microbial toxin that has a long history of use for both cosmetic and therapeutic applications. Since the early 2000s, when it was approved for glabellar lines, this breakthrough injection treatment has become the gold standard for diminishing hyperfunctional facial wrinkles. Basically, the injectable causes isolated muscles to relax, keeping wrinkles at bay. Specifically, when injected into particular facial muscles, it temporarily stops the activity that causes wrinkles to appear. It works by blocking the release of the neurotransmitter that initiates muscle contractions. Although Dr. Timothy Greco uses BOTOX® at his Bala Cynwyd practice for three FDA-approved applications (crow’s feet, glabellar lines, and forehead lines), experienced physicians like Dr. Greco also use their clinical judgment to inject it for other uses. Dr. Greco just published a chapter in a medical text as the lead author on the use of BOTOX® throughout the face and neck, Complications in the Minimally Invasive Facial Rejuvenation. Because the treatment is so versatile, physicians are constantly finding new applications for it.

The term “off-label” simply means that the medicine is used for a condition that has not been officially studied or approved for specific uses by the FDA. This is a perfectly safe and common way of using injectables. It’s up to the physician and patient’s discretion to determine whether the off-label use is the right choice in a given case.

BOTOX® is most often used off-label on the following areas:


Sometimes referred to as “Browtox,” the injectable can be used on the eyebrow area to lift and reshape brows, creating a brighter, fresher look.

Bunny Lines

The movements of facial muscles when you scrunch up your nose can cause diagonal wrinkles at the sides of the upper bridge, known as bunny lines. BOTOX® can smooth these out.

Gummy Smiles

BOTOX® relaxes certain overactive muscles so that the upper lip can unfurl, creating a more balanced smile that does not reveal as much gum show.

Lip Lines

Vertical lines around the mouth, which develop due to habitually pursed lips, can fade if the muscles are allowed to rest.

Marionette Lines

These are vertical lines that extend from the downturned corners of the mouth to the chin.

Dimpled Chin

A dimpled or “cobblestone” chin with an orange peel texture (peua d’orange) often occurs when the mentalis muscle is overactive, causing the skin to crease up because of the movement of the muscles below it. BOTOX® gives Philadelphia-area patients a youthful and refreshed-looking appearance by softening wrinkles and improving facial symmetry. Get more advice on this injectable and other cosmetic procedures available from Dr. Timothy Greco’s practice. Call us at (610) 664-8830 to learn more, or submit a contact form to request a consultation.

Facial Implants, Fillers, or BOTOX®: Which is the Better Choice for Addressing Facial Asymmetry?

Beauty treatments are often focused on enhancing the skin and individual features, but patients should remember that overall facial harmony is critically important. Faces that are symmetrical are usually deemed to be more attractive and beautiful. A perfectly symmetrical face would have identical sides that match if you were to draw a line down the center. Each side of the face is considered a sibling as opposed to an identical twin. While most faces appear to have a symmetric shape, we all have some mild asymmetry to our features—such as a slightly crooked nose, one eye that looks different from the other, or a misaligned chin. Genetics, aging, injury, and dental work are some of the common causes of asymmetry, but there are also several options for addressing it: Dr. Timothy Greco, a double board-certified facial plastic surgeon near Philadelphia, provides facial implants, fillers, and BOTOX® to correct irregularities and help patients achieve a more balanced appearance.

Facial Implants

If you’re looking for a long-term solution for asymmetry caused by your natural bone structure—such as a weak or recessed chin that you want to improve—implants might be something to consider. This is surgical procedure with lasting results. Implants are made from synthetic materials like silicone and plastic. Implants can be added to the cheeks and chin and further enhanced with autologous fat grafts for a fuller, more natural look.

Soft Tissue Fillers

Soft gel dermal fillers can improve contours that have changed over time. Having a youthful, v-shaped face with high, rounded cheekbones, a slim jawline, and defined chin is a common beauty goal.

Hyaluronic acid-based fillers like JUVÉDERM® Voluma improve facial structure by lifting and volumizing the cheeks, which also makes the jawline look sharper. JUVÉDERM® Ultra, another HA filler, plumps lips that are too small for the face due to genetics, aging, or both. Additionally, these fillers can be used to add volume to hollowed temples and to fix stretched earlobes. You can also straighten, refine, or thin the nose or elevate the nasal tip with fillers.


Neuromodulators relax active muscles in select areas of the face to make eyebrows more even, slim only one side of an enlarged jaw to match the other, or correct wrinkles in the forehead. Injectable treatment sessions are quick, with minimal side effects and recovery time—but keep in mind that the results are temporary. Fortunately, repeat maintenance treatments are possible.

Searching for a skilled facial plastic surgeon near Philadelphia? Talk to the office of Dr. Timothy Greco about our surgical and non-surgical options. Call (610) 664-8830 or request a free consultation.

How Do We Get Expression Wrinkles? A Guide to Skin’s Life Cycle

Millions of people each year choose a specific treatment to counteract facial wrinkles: BOTOX®. Patients in the Philadelphia area who come to Dr. Timothy Greco’s office have often heard about the popular injectable, but are still curious about how it works. To understand neuromodulators like BOTOX®, it’s important to first understand the overall structure of the skin and how it changes throughout a person’s life, and the effects of the muscles of facial expression on the overlying skin.

Cells on the outer surface of skin, the body’s largest organ, form a protective barrier against the external environment. The dead cells create a tough layer called the stratum corneum, which continuously flakes away. Shed cells are replaced approximately every four weeks by new cells produced in the deeper epidermal layers. The length of this skin cycle is influenced by age, as the process takes longer for someone in their 50s or 60s than it does for younger adults.

Older skin is more susceptible to wrinkles because of this slowing cell turnover, as well as the fact that the skin has been folded repeatedly into the same facial expressions for decades. Existing collagen is continually strained, even as it is being produced in smaller and smaller quantities in the skin.

Also, the dermis, which is the middle layer of skin that sits beneath the epidermis, thins over time as it loses the chemicals that nourish it. In a person’s youth, this layer has a strong structure made up of proteins called collagen and elastin, which hold it together and maintain its structure and elasticity. As these proteins diminish with age, the structure weakens and the skin grows increasingly inelastic.

Facial expressions are important for communicating subtle emotions or intention to other people. Think of smiles and raised eyebrows for happiness, a frown for sadness, wide eyes and an open mouth for surprise, furrowed brows and a scowl for anger, and any in-between variation you can think of. Studies have shown that humans are capable of up to 21 unique expressions. Unfortunately, as we go through life, our go-to expressions cause the associated muscles to pull on the skin in the same way over and over. This repetitive action coupled with dwindling collagen and elastin means the skin no longer springs back to its original position as easily. Thus, “dynamic wrinkles” are born.

BOTOX® works not by filling in these lines as fillers do, but by blocking the chemical messages that tell facial muscles to contract. When these muscles stay at rest, the surface remains smoother and appears refreshed.

Want to soften wrinkles with BOTOX®? Our team at Dr. Timothy Greco’s practice will discuss the treatment with you to determine whether it is a suitable choice. Dr. Greco has been injecting BOTOX® for more than 30 years and has instructed other physicians nationally and internationally on the aesthetic application of BOTOX®. We invite you to request a complimentary non-surgical or surgical consultation in the Philadelphia area to learn more about what we offer.

Comparing Four Cosmetic Neuromodulators

Winter is the season associated with colder weather, and—perhaps surprisingly—plastic surgery! Philadelphia’s Dr. Timothy Greco and his team often field questions from patients who are unsure of what to do for an aging face. More specifically, while facelifts handle lower-face contours, it may be more desirable to select a nonsurgical injectable to best meet needs higher on the face.

Many people believe that the later months of the year are ideal for cosmetic treatments, since the weather sends everyone indoors, where it’s easier to conceal cosmetic “tweaks” under heavier layers of clothing.

This past November, patients and practitioners around the country celebrated Allergan’s first ever National BOTOX® Day. Even as physicians around the country highlighted the effects and benefits of this powerful neuromodulator, it’s important to acknowledge three other highly effective alternatives to choose from. These are very similar (though there are some notable differences between them), and the choice largely depends on individual preference.

Originally only known for its medical applications for muscle spasms, BOTOX® is now the world’s most famous wrinkle-reducing injectable. The first, original product of its kind, BOTOX®, has given rise to a series of successors and competitors, including Dysport®, XEOMIN®, and, most recently, Jeuveau (Newtox). All of these injectables contain botulinum toxin type A as their key ingredient, used to minimize or prevent dynamic wrinkles by relaxing muscles. There are minor differences in how each of these products has been manufactured and how they are used in clinical settings.

Dysport® is very similar to BOTOX®, specifically designed for treating glabellar lines and approved by the FDA for that purpose. As opposed to its counterparts, XEOMIN®, the “naked injectable,” contains no accessory proteins. Its only ingredient is botulinum toxin type A. This purer variation is a popular alternative for those who have developed a resistance to other types of neuromodulators. However, the tradeoff may be that it takes a longer time to work compared to the other injectables.

Finally, unlike the other three options, Jeuveau was recently designed from the start to be used purely for aesthetic treatments. Dr. Greco also had a hand in its development with their manufacturer, Evolus, Inc.

Start planning your next procedure or treatment with the experienced team at Timothy M. Greco, MD, PC. To get in touch with double board-certified Dr. Timothy Greco and his staff, call (610) 664-8830 or schedule a consultation online.

Exploring the Causes and Types of Skin Aging

Are unwanted wrinkles and lines bringing you down? There are a wide variety of cosmetic solutions at your disposal, but it can be difficult knowing which one is most suitable for your specific needs. The range of possibilities is a common source of confusion, especially for those who may be new to the aesthetics industry.

One of the main things to know is that BOTOX® and fillers are not the same and are not used interchangeably. BOTOX® targets one form of skin aging, while dermal fillers address another. If you’re interested in getting started with wrinkle treatments or other forms of plastic surgery in the Philadelphia area, Dr. Timothy Greco, a double board-certified facial plastic surgeon, can explain the basics.

The cause of the wrinkles being treated will determine which treatments to pursue. There are two basic wrinkle groups: dynamic and static.

Dynamic wrinkles are related to muscle activity and are most visible when people make facial expressions. Picture forehead lines appearing when someone raises their eyebrows. Static wrinkles develop in the skin due to the effects of aging, sun exposure, gravity, other environmental factors, and lifestyle habits.

Within these two groups, wrinkles can be further classified into four subtypes: expression wrinkles, elastic wrinkles, compression wrinkles, and gravitational folds.

Expression wrinkles appear from repeated facial expressions, while elastic wrinkles are caused by excess sun exposure. Compression wrinkles come from pressure on the face as we sleep. Gravitational folds, such as severe creases like nasolabial folds and saggy skin, are formed due to the combined influence of time, gravity, and other damage.

To put it simply, if your wrinkles are caused by muscle action, your go-to would be a neuromodulator, while wrinkles associated with other types of damage are best addressed with other treatments, such as fillers.

BOTOX® is a neuromodulator, meaning it influences the activity of nerves. Once injected, it has a relaxing effect on wrinkle-causing facial muscles. Hyaluronic acid-based soft tissue fillers like JUVEDERM®, on the other hand, replenish essential volume in the skin to temporarily smooth our indentations. More severe aging may require a facelift or other surgery for complete rejuvenation.

Curious about the benefits of available skin treatments? Get more details on neuromodulators, fillers, skin rejuvenation, and more from Timothy M. Greco, MD, PC’s Philadelphia-based plastic surgery practice. Call today at (610) 664-8830 or submit a contact form to tell more about yourself.

BOTOX®, Fillers, or Blepharoplasty: Which is Better for Achieving Younger-Looking Eyes?

Many people are insecure about the eyelid droopiness, wrinkles, dark circles, and sunken eyes that tend to come with age. Baggy, hooded eye areas may make you look old before your time, or tired and angry even when you don’t feel that way. Cosmetic eyelid surgery, otherwise known by the medical term “blepharoplasty,” is one way of refreshing your face and taking years off of your appearance. In addition to blepharoplasty, Philadelphia’s Timothy M. Greco, MD, PC, provides other treatments for the eye area, such as BOTOX®, dermal fillers, and microneedling.

Is having big, bright doe eyes that “pop” one of your beauty goals? Wondering which procedure or treatment is right for you? Each patient has different needs, and the choice for each person will depend on the type of deficiency they’re hoping to correct, as well as their age, skin condition, and goals.

The thin, fragile skin around the eye areas is particularly vulnerable to stress, aging, and damage from smoking, sun exposure, or other factors. Makeup and topical products can help, but if you’re concerned about more moderate to severe symptoms of aging or skin damage, cosmetic treatments may be the more effective option.

In eyelid surgery, excess tissue is trimmed away, with the remaining tissue tightened to correct sagging, drooping eyelids. Additionally, the surgery can improve asymmetry and provide a lift for heavy eyelids. The procedure may be used on the lower and/or upper eyelids depending on what is needed.

When it comes to addressing eye-related wrinkles like crow’s feet, elevens, and forehead lines, BOTOX® is the gold standard. It works by relaxing wrinkle-revealing muscles. Hyaluronic acid-based JUVEDERM® filler adds subtle volume under the eyes for more youthful contours, while chemical peels and laser techniques work to reduce the severity of dark circles.

Another treatment for the eye area is microneedling. This is designed to improve overall skin quality from the inside out and can make a difference for dark patches, dryness, fine lines or wrinkles, and dullness. The treatment leads to skin that gradually grows clearer and develops a softer, more even texture. Although tiny needles puncture microscopic channels into the skin to spark collagen regeneration, microneedling is gentle enough for the thin skin around the eyes.

Want to learn more about blepharoplasty and other eye procedures available at the Philadelphia practice of  Timothy M. Greco, MD, PC? For questions, comments, or to request an appointment write a message or call (610) 664-8830.