A corneal transplant is sight-saving surgery that allows a patient with eyesight compromised by cornea damage to have their vision restored, in some cases to 20/20. More than 44,000 corneal transplants are performed in the United States every year, making it one of the most common and successful procedures of its kind.
Advances have been made in technique and recovery, giving patients new hope in vision improvements.
New York Eye and Ear Infirmary of Mount Sinai (NYEE) is a leader in corneal transplants and, in recent years, has had great success with the latest technique called Descemet’s membrane endothelial keratoplasty (DMEK). By selectively replacing only the damaged portion of the cornea with ultra-fine donor tissue, surgeons are able to produce much better patient outcomes than other endothelial keratoplasty techniques.
Click here to make an appointment with Angie E. Wen, MD
In this Q&A, Angie E. Wen, MD, a cornea specialist at NYEE, explains why this procedure is becoming more popular.
“DMEK is the latest cutting-edge surgical technique, and at NYEE, patients get the best surgical and post-operative care, not only by our surgeons but the entire OR and post-op team,” she says.
What are the benefits of DMEK corneal transplant?
The DMEK technique is revolutionary. The technique offers a low rejection rate (1 percent), faster recovery, faster and more significant improvement in vision, and less reliance on long-term use of eye drops that can cause immunosuppressive side effects. Clear vision of many patients is restored in a few months.
What is the cornea and how does it get damaged?
The cornea is the clear outer layer of your eye that is directly in front of the iris (the colored part) and the pupil. It allows light to enter your eye. The cornea provides approximately 65 to 75 percent of the focusing power of the eye. It must remain clear for there to be good vision. If it is scarred or swollen, it may result in glare or blurry vision. Cornea damage may be caused by an infection, a medical condition that leads to a thinning cornea, such as keratoconus; chronic swelling following cataract surgery; or by Fuchs Dystrophy, a genetic disorder that causes swelling.
What happens during a DMEK corneal transplant?
During the DMEK procedure, the surgeon carefully strips out the damaged Descemet’s membrane and endothelium layer of the cornea and replaces it with donor tissue that has been thoroughly screened, processed, certified, and prepared by the eye bank. The surgeon replaces the damaged corneal layer with the new micro-thin tissue that, at 10 microns, is the thickness of a strand of hair. It is then secured with a gas bubble. The outpatient procedure typically lasts approximately 30-45 minutes. Although it is a highly effective procedure, it requires a steep learning curve for the surgeon to master who must work with tissue that is so thin and delicate. Consequently, only 30-40 percent of surgeons nationwide feel comfortable performing it.
Is anyone a candidate for DMEK?
Not all patients are candidates for DMEK, including those with complex anterior segment anatomy, a previous history of retinal detachment repair, or glaucoma surgeries. In these cases, a Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) may be a better option. Surgeons at New York Eye and Ear Infirmary are able to apply both the latest technologies of endothelial keratoplasties customized to patients’ individual anatomy and specific needs.
The changing seasons can bring on many changes in your health, including fatigue, seasonal depression, irritability, and colds. One of the more bothersome changes is seasonal hair loss. While it is normal to shed around 100 hairs a day, the loss of more hair can feel alarming.
However, seasonal hair loss shouldn’t be cause for alarm. In this Q&A, Brian Abittan, MD, Director of Skin and Hair Rejuvenation and Director of Hair Transplantation at the Kimberly and Eric J. Waldman Department of Dermatology at Mount Sinai, discusses seasonal hair loss and how to keep your hair healthy during changing weather conditions.
Brian Abittan, MD
What is seasonal hair loss? Is it a real thing?
Yes. Seasonal hair loss does appear to be a real thing. While we do not fully understand why it happens, there are multiple theories that have been suggested. One theory is that seasonal changes, possibly due to hormonal fluctuations or variation in nutrition, can cause a spike in the resting phase of hair growth, also known as the telogen phase. Shortly after, many of these hairs will shed. Additionally, seasonal stresses in patient’s lives may cause a hair shedding, called telogen effluvium.
How does seasonal hair loss differ from traditional hair loss?
Seasonal hair loss is different from other causes of hair loss. Patients can have medical hair loss disorders, like alopecia areata, which is a completely different form of hair loss. Also, patients can have a component of androgenetic alopecia, known as pattern hair loss, which generally develops over time. This, when accompanied with a seasonal hair loss or a telogen effluvium, can make the hair shedding appear to be worse. It is important to first identify the type of hair loss you are dealing with. Each specific type of hair loss can have a variety of unique treatments.
Schedule an appointment with one of the team at our Alopecia Center of Excellence: call 212-241-HAIR or email: alopecia@mountsinai.org
Is there a way to prevent temporary hair loss?
The best way to try to avoid seasonal hair loss is to maintain healthy, scalp and hair habits. Ensuring proper moisturizing during dryer months, using gentle grooming techniques, and maintaining a balanced nutrition are the most basic ways to help. If the seasonal hair loss becomes a consistent issue, more aggressive topical and oral medications can be considered as longer-term treatments.
Are there any lifestyle changes that help with retaining hair?
Balanced diets rich in vitamins, healthy lifestyle choices, and gentle hair practices are beneficial to hair health and growth.
Is vitamin D and biotin effective in helping to retain hair?
There is evidence that vitamin supplements, such as vitamin D and biotin, a water-soluble B vitamin, can be helpful in hair growth and maintaining healthy hair. Certainly, if someone has a vitamin deficiency, that can affect hair growth as well. More, in-depth studies are needed to fully understand the impact of vitamins on hair growth.
Food labels are supposed to help you understand what’s in your food, but deciphering endless lists of ingredients, nutrition facts, and marketing claims can often feel impossible—especially when you’re on the go.
Taylor Stein, RD
“Knowing how to read food labels is key to making good food choices,” says Taylor Stein, Associate Researcher and Registered Dietitian at The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai. “But keep in mind that food labels don’t tell you how the food will make you feel. You might eat a protein bar that says ‘20 grams of protein’ but still feel hungry afterward. This is important to consider, since foods that don’t fill you may trigger you to overeat later.”
In this Q&A, Ms. Stein explains why it’s so important to read the labels and offers seven tips to help you separate the good from the bad.
Check the Nutrition Facts
Most people only look at the marketing copy on the front of the product (for example, “25 percent less sugar,” “gluten-free,” or “fat free”). Marketing claims are often misleading. A bag of potato chips may claim to be 25 percent less fat, but compared to what? If the comparison is to potato chips in general, 25 percent is still a lot of fat. The Nutrition Facts on the back of the product gives you the actual breakdown of nutrition. People also often overlook the subsections under the Nutrition Facts—added sugar, saturated fat, carbohydrates, dietary fiber, etc., which are just as important as the totals. Fiber, for example, helps you feel full and is essential for gut, heart, and brain health.
Quick tips
Look at the Nutrition Facts and Ingredients on the back or side of the packaging, rather than the marketing labels on the front, which are often misleading.
The first ingredient is the primary ingredient. Generally, the more ingredients, the more processed the food is.
If the product does not look anything like the food that’s supposed to be in it, it’s likely highly processed (ultraprocessed). Ultraprocessed foods often contain many calories with little substance, which can lead to overeating.
Pay attention to the subsections under the Nutrition Facts—added sugar, saturated fat, carbohydrates, dietary fiber, etc.
To know how much sugar has been added to a product, divide the added grams of sugar by four. This gives you the exact number of teaspoons that were added.
Pay Attention to Serving Size
People often misunderstand “Serving Size” and “Percent Daily Value” on the Nutrition Facts panel. They think serving size is how much of a product they should eat. A serving size is simply the amount of nutrition that is in a specific amount of the product. If the number of calories is 100 and the serving size is one cup, then you are consuming 100 calories if you eat one cup. It does not mean that you should only eat one cup. The “Percent Daily Value” is based on a standardized 2,000-calorie diet or the recommended daily allowance of that nutrient, and is not representative of what you as an individual should consume.
Some Added Ingredients Are Good for You
Many people assume added ingredients are bad for them, but some products, such as cereals, are fortified with ingredients that are good for you. Unless you have a food allergy or intolerance, you don’t need to avoid any ingredients. The Food and Drug Administration regulates food, so anything truly hazardous is not sold. People may also not realize the ingredients list is ordered by weight. The first ingredient is the primary ingredient. As you go down the list, the amount of the ingredient gets smaller—the last ingredient is the smallest amount. If the first ingredient is sugar, that tells you the product is predominantly sugar.
Be Mindful of Foods Without Labels
Some people assume food products that don’t have labels, such as fresh vegetables and meat, are healthier than packaged foods. This is generally true of produce, whole grains, fish, and lean meats; however, red meats and certain cheeses, for example, may be high in saturated fat, and should be limited.
Processed foods are foods made from whole foods that have been broken down into their basic components (sugars, starches, fats, etc.) and reassembled to make packaged foods. There’s a spectrum of how processed a food could be—anywhere from not processed at all (whole foods, including those with minimal processing, such as frozen fruit) to foods that are extremely processed (ultraprocessed). These include chips, sodas, lunchmeats, ice cream, sweetened cereals, etc. One example is protein bars made from soybeans that have been turned into a powder. The manufacturer adds fats and sugars to make it tasty, which adds calories but not substance. The food is so processed that your body cannot tell when it should be full. For example, you can eat 500 calories of corn chips and not feel full, versus eating a whole corncob filled with fiber and water that satisfies you. For this reason, consuming too much ultraprocessed food can lead to chronic health conditions, such as obesity and diabetes.
How can you know how processed a product is? Look at the food—does it look like what is supposed to be in it? Applesauce has been ground down, but you can still tell it comes from apples. It’s processed, but not very. A bag of snacks claiming to be made from vegetables features images of carrots and onions, but the product does not look anything like vegetables—it’s actually made from potato flour and starch (with a little added carrot and onion flavoring).
Look at the Number of Ingredients
The number of ingredients, and the breakdown of ingredients, is another way to tell how processed a food is. Generally, the more ingredients, the more processed, though this is not always the case (trail mix, for example). Applesauce has a few ingredients, but it’s not been radically changed from its original form. In comparison, the bag of ultraprocessed “veggie” snacks contains a long list of ingredients.
Limit Your Sugar
The American Heart Association recommends no more than six teaspoons of added sugar per day for women and nine for men. We all know what a teaspoon looks like. But the Nutrition Facts panel lists ingredients by weight, in grams. In the Nutrition Facts panel, added sugar is listed separately under the total amount of sugar. An easy way to know how much sugar has been added is to divide the added sugar by four, which gives you the exact number of teaspoons. For example, if the added sugar is 12 grams per serving, divide that by four, which gives you three added teaspoons of sugar per serving.
“Before, I couldn’t travel too far and couldn’t go international. When I went to Washington D.C., I was limited by my ability to walk,” says Jose Eduardo Vazquez Bonano. “But right now, with spring coming up, I’ll be happy to do the inside loop of Prospect Park.”
Jose Eduardo Vazquez Bonano, 62, started having trouble walking a few years ago. “I noticed as I was getting older, my walking was starting to slow down,” he said. “I thought it might be age, or diabetic neuropathy, which I do have.”
But when the diagnosis started pointing to spinal issues, Mr. Bonano looked into several spine programs in New York City before settling on Divaldo Camara, MD, at the Spine Program at Mount Sinai Morningside. “I always do research before I take an important step, and when I saw his profile and read some of his history, I said, okay, this is a man I can trust.”
Now, he’s looking forward to long, leisurely walks.
“When I was younger, one of my hobbies that I loved was walking distance. But it got to the point that I couldn’t even walk half a block,” said Mr. Bonano. “But I’m recovering from my surgery very quickly. Right now, my goal is to walk the inside loop of Prospect Park, which is 3.5 kilometers. That’s what I’m looking forward to this spring.”
Divaldo Camara, MD, the Spine Program at Mount Sinai Morningside
Dr. Camara started seeing Mr. Bonano in January of 2023. He had severe back pain and pain running through his left leg. He also had a “foot drop” which means he had trouble lifting his left foot because of the nerve. Dr. Camara usually sees patients two or three times before recommending surgery unless it’s an emergency. They normally will first try physical therapy and other non-surgical treatments, but they weren’t working in his case. Doctors ordered imaging and saw evidence of degenerative disease on his MRI.
“By March, the compelling findings in his images led us to discuss surgery as the next best step in his case,” Dr. Camara said. “He had a severe sagittal and coronal imbalance which was compressing the nerve, which means the curvature of the spine was off both front to back and side to side.”
“I was hesitant about surgery,” said Mr. Bonano. “It took about a month to make sure this is the right thing for me. I talked with my partner and considered my age and my health condition. But I went for it. I said, at this point in my life, why not?”
Part of Mr. Bonano’s decision was based on discussing his goals with Dr. Camara. “I try to establish a relationship, understand the patient’s complaints and their goals for treatment,” said Dr. Camara. “When I asked Jose what things he’d like to do, he said that he would like to drive to Florida to see relatives. And that was one thing he couldn’t do in his current condition.”
Because of the severity of Mr. Bonano’s case, he needed two spinal surgeries, one from the front and one from the rear. The front surgery, an anterior lumbar interbody fusion, or ALIF, removed one of the damaged discs. The rear operation provided the corrective bracing.
“It was a complex surgery, but we were confident of a good outcome,” Dr. Camara said. “And the two surgeries allowed us to correct much more than we would have been able to otherwise.”
Mr. Bonano had the first surgery on a Monday and the second one on Thursday. He remained in the hospital between surgeries and was able to begin rehab in the hospital. He was in the hospital about a month.
“It’s an advantage when patients go to our rehab program,” said Dr. Camara, “because if there’s any concern about the patient’s improvement or wound healing, we can follow up easily.”
“The doctor did an excellent job. I recovered very fast,” said Mr. Bonano. “I’m not 100 percent back to normal, but so far, so good. Even the cut from the operation is just visible as a line. To see how well they did that was phenomenal.”
Now Mr. Bonano is looking forward to being able to walk and travel.
“Before, I couldn’t travel too far and couldn’t go international. When I went to Washington D.C.—there’s all the monuments to see and you’re always trying explore as much as possible—I was limited by my ability to walk. But right now, with spring coming up, I’ll be happy to do the inside loop of Prospect Park.”
Every year on March 26, people and organizations around the world band together in solidarity for Purple Day. They wear purple and host events to raise awareness about epilepsy, with the goal of ending its stigma. For Purple Day this year, we got together experts from the Mount Sinai Health System to explain what epilepsy is and answer other top questions people might have.
Is epilepsy contagious? “You cannot spread epilepsy from one person to the other,” says pediatric neurologist Natasha Acosta Diaz, MD, Assistant Professor of Neurology at the Icahn School of Medicine at Mount Sinai.
Epilepsy is not an infection. It is a neurological condition characterized by seizures caused by abnormal brain electrical activity, says Dr. Acosta Diaz.
Is epilepsy electroencephalogram (EEG) testing painful? In a standard EEG test, electrodes—small metal discs—are attached to the scalp with the help of a glue. The EEG test is not painful, says Anuradha Singh, MD, Director of the Epilepsy Monitoring Unit, and Professor of Neurology at Icahn Mount Sinai.
EEG tests study brain rhythms to look for any sign of irritability. A standard EEG test records these brain rhythms for 20 minutes to an hour, says Dr. Singh. “Sometimes you get a little glue left on your scalp but it’s not painful at all,” she adds.
Is epilepsy surgery dangerous? “The myths about the danger of epilepsy surgery come from the past, from about the last 100 years or so,” says neurosurgeon Fedor Panov, MD, Director of the Adult Epilepsy Surgery Program and Associate Professor of Neurosurgery at Icahn Mount Sinai. “What you currently find on the internet (about the dangers) unfortunately is not appropriate and it just perpetuates this myth that epilepsy surgery is dangerous,” he notes.
Epilepsy surgery has its risks and benefits. “Most certainly, the benefits outweigh the risks,” says Dr. Panov. As the epilepsy care team might phrase it to patients, the risk of going through a year with epileptic seizures far outweighs the risk of a surgical intervention to cure the epilepsy, he says.
Can epilepsy seizures be triggered by flashing lights? There is a type of epilepsy that can be triggered by flashing lights, called photosensitive epilepsy. “However, this is very rare,” says Dr. Acosta Diaz.
When testing a patient for epilepsy, flashing lights are used to see if they provoke a seizure, and if so, appropriate recommendations for care can be given, she adds.
Can people with epilepsy drive a car? “You can drive a car if you’re seizure-free,” says Dr. Singh. However, different states can have different rules and regulations. People with epilepsy will have to check with their state’s Department of Motor Vehicles, she notes.
What are some epilepsy surgical options?
Vagal nerve stimulator Involves placing a small wire around a nerve in the neck to decrease seizure activity. The wire is attached to a small battery inserted under the skin of the chest.
Stereotactic laser ablation Uses lasers to remove a part of the temporal lobe of the brain to help control seizures. The procedure is guided by magnetic resonance imaging (MRI), allowing for very precise cuts and removal.
Staged craniotomy A two-stage surgery that involves removal of part of the skull to expose the brain, followed by removal of the brain tissue that is causing the seizures. Removing the damaged part of the brain does not cause deficits, as other parts of the brain adapt and pick up function. The procedure improves the overall brain network because it allows the healthy areas to work without constant electrical interference from the seizure “hot spot.”
Responsive neurostimulation A device is implanted that automatically records and detects electrographic seizures, then rapidly delivers electrical stimulation to suppress seizure activity. It is the first device that the U.S. Food and Drug Administration has approved for use in the brain to listen, learn, and respond to seizures.
Can people with epilepsy have a job? “Absolutely,” says Dr. Panov. “It’s a myth to say you cannot work if you have seizures.” Epilepsy care teams are available to help patients be a part of their community, including having and holding jobs. The Americans with Disabilities Act prohibits discrimination against people with disabilities in several areas, including employment.
While it is not mandatory that people with epilepsy disclose their condition to employers or coworkers, it is recommended that someone at the workplace is aware, says Dr. Acosta Diaz. “Just in case you have a seizure, somebody can be with you or help you,” she says.
Can people with epilepsy have children? People with epilepsy can have happy, healthy children, says Dr. Singh. Women with epilepsy should work with their OB/GYN and epileptologist to ensure they’re on the safest drugs for the pregnancy, says Dr. Singh.
Can people with epilepsy stop taking medications when seizures stop? The goal of any Comprehensive Epilepsy Center is to get patients seizure-free, and ultimately off the medications, says Dr. Panov: “The idea is that you will come off your meds once the seizures stop.”
It is important, however, that patients do not stop taking medications without discussing with their specialists, says Dr. Singh. A lot of factors go into the consideration of stopping medications, including EEG results and MRI scans, so that process should be done in consultation with an epileptologist.
Can people with epilepsy swallow their tongue? “No way, there’s no way that you’re going to swallow your tongue,” says Dr. Acosta Diaz. During a seizure, the tongue can go to the side of the mouth and people can accidentally bite their tongue. To assist someone with a seizure, be calm and lay the person on the side, and definitely do not put anything in the mouth, such as a spoon, she says.
Does a ketogenic diet help people with epilepsy? It does, in certain cases, says Dr. Singh. A ketogenic diet is a high-fat, adequate-protein, and low-carbohydrate diet. It is more often used in pediatric epilepsy, especially for children in whom medications do not work well, says Dr. Acosta Diaz.
Ketosis, a state where the body derives its sources of energy from fat rather than glucose, is known to have anticonvulsant properties. However, it’s not easy for a person to enter into ketosis. That is why an epilepsy care team involves overseeing a patient’s metabolism and nutrition as well, notes Dr. Acosta Diaz. “It’s not something you can try by yourself at home. It’s not just doing a keto diet to lose weight,” she says.
Caring for people with epilepsy is a team effort. At the Mount Sinai Epilepsy Center, staff members across all levels of care work together to provide exceptional care. Here’s the Center at a glance:
Designated as a Level 4 medical facility by the National Association of Epilepsy Centers (NAEC), which is the highest recognition of care and expertise for people with epilepsy
Three inpatient Level 4 epilepsy centers at The Mount Sinai Hospital, Mount Sinai Kravis Children’s Hospital, and Mount Sinai West, and six outpatient locations in New York City and Long Island.
ABRET-certified labs
Five Mount Sinai sites have received American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET) Lab accreditation for achieving highest levels of quality and competence performing neurodiagnostic tests.
In 2023
The Mount Sinai Health System performed more than 13,000 electroencephalograms and completed 100 surgeries to reduce or eliminate seizures for adult and pediatric patients.
In addition to treating patients with epilepsy, the Mount Sinai Health System and Icahn Mount Sinai conduct research to push the frontiers of understanding the neurological conditions and what is possible with treatment. Here are some examples of what Mount Sinai is doing to further science in epilepsy.
Clinical trial: Epilepsy associated with Lennox-Gastaut syndrome
Lennox-Gastaut syndrome (LGS) is a severe form of epilepsy, with seizures beginning in early childhood. To treat seizures that have not been well controlled through conventional medication, researchers are using novel responsive neurostimulation (RNS) strategies. This is the first clinical trial using RNS for LGS.
The trial is supported by a five-year grant from the National Institutes of Health, and conducted in collaboration with five other centers in the United States.
Clinical trial: Efficacy of subanesthetic doses of IV ketamine for treatment-resistant epilepsy
Ketamine is an anesthetic that provides pain relief, and came into clinical use in the 1960s. In a hospital setting, ketamine is used intravenously at anesthetic doses to treat unrelenting seizures known as status epilepticus in comatose patients. Mount Sinai researchers are exploring using ketamine at subanesthetic doses in an outpatient setting for patients who have treatment-resistant epilepsy. With subanesthestic dose-ketamine recently approved by the FDA for treatment-resistant depression, researchers are optimistic about its safety, and are hopeful that this will provide relief for patients with hard-to-treat epilepsy as well.
Clinical trial: Phase 3 trial for a once-daily, oral treatment for those living with focal seizures (XTOLE2)
Focal seizures are when brain cells on one side of the brain malfunction, causing symptoms, and are considered the most common type—making up more than half of all seizures. Symptoms could include one or more of the following: motor, sensory, autonomic, or cognitive. While treatment can stop or reduce the frequency of the seizures, for some patients, current treatment options may be insufficient. Mount Sinai is participating in a Phase 3 study with Xenon Pharmaceuticals to explore the use of XEN1101, a potassium channel opener, along with the patient’s existing medication, for focal seizures. Clinical data from previous trials have shown up to around 50 percent reduction in focal seizures among participants who have received the drug.
Clinical trial: Phase 3 trial for Staccato® Alprazolam in participants 12 years and older with stereotypical prolonged seizures
Benzodiazepines are more commonly known for treating anxiety or panic disorders, but they can also be used to terminate most seizures in an inpatient setting. Approved therapies include a rectally-administered gel and intranasal formulations. However, there are no approved treatments for rapidly terminating an ongoing seizure in an outpatient setting. Mount Sinai is participating in a Phase 3 trial with pharmaceutical company UCB to study the effectiveness and safety of Staccato® Alprazolam, a breath-triggered device that delivers the benzodiazepine deep into the lung for rapid absorption and systemic exposure, with the goal of achieving rapid epileptic seizure termination (REST). In a previous clinical trial, in an inpatient setting, nearly 66 percent of participants who received the drug responded to the treatment, compared to 43 percent of participants who received a placebo. For participants who responded to the intervention, the Staccato® Alprazolam group saw seizure cessation in a median time of 30 seconds, compared to 60 seconds for those who had received a placebo. The Phase 3 trial tests the treatment in an outpatient setting.
Clinical trial: Electrographic seizure pattern modulation biomarkers in responsive neurostimulation for epilepsy
Although the therapeutic benefit of RNS is well established, predicting how well and when a patient might respond to the device is difficult. It may take several months for a patient to report a reliable change in seizure status, during which time the programming clinician has no objective guidance regarding whether or not to adjust settings. RNS devices can provide EEG recordings, offering an insight to seizure patterns, but there is little knowledge about how to use these recordings in individual patients. Thus, a critical need exists to develop methods for using a patient’s own data to predict when seizure reduction should be expected or to confirm objectively the presence and maintenance of a clinical response.
Icahn Mount Sinai researchers are working with Massachusetts General Hospital to apply machine learning, neurostatistics, and data science to improve the effectiveness of RNS, especially for children and adults who are not considered suitable surgical candidates.
The Laboratory for Human Neurophysiology seeks to understand how human cognition arises from the interaction of multiple brain areas and neurotransmitter systems, particularly in decision-making behavior. These research efforts involve studying prefrontal cortical and subcortical areas directly in the human brain by conducting intracranial electrophysiology recordings in patients undergoing neurosurgical treatment.
Ongoing research projects in the laboratory include investigating the neural basis of human decision-making under uncertainty using distributed intracranial EEG recordings in epilepsy patients, decoding overt subject behavior from preceding, distributed brain activity in reward-related brain regions, and studying reward and mood processing across multiple brain areas in epilepsy patients with and without comorbid depression. The lab is led by Ignacio Saez, PhD, Associate Professor of Neuroscience, Neurosurgery, and Neurology at Icahn Mount Sinai.
Botox® has been one of the most popular cosmetic treatments of the last 20 years.
For many, Botox and other brands of botulinum toxin injections have been a great way to maintain their youthful appearance. Botox injections work by blocking nerve signals to muscles. The injections prevent muscles from contracting for several months. While Botox injections are used to ease certain medical conditions, the results are not a cure and always temporary. These injections are also used to treat hyperhidrosis (sweating), overactive bladder, migraines, and neck spasms.
In this Q&A, Ahuva Cices, MD, Assistant Professor of Dermatology at the Icahn School of Medicine at Mount Sinai, discusses the ABCs of Botox and other brands, including how they work, how long they last and how to know if this is the right treatment for you.
How does Botox work?
Botox is a brand. It’s like saying Kleenex or Coca-Cola. It’s a type of neurotoxin or neuromodulator. This neurolmodulator comes from bacteria called Clostridium botulinum. We use the toxin that it makes to temporarily paralyze or control muscles.
The way that it works is that the neurotoxin prevents the nerve from activating the muscle by preventing the release of acetylcholine, which is a neurotransmitter that stimulates muscles to contract. It’s simply blocking the signaling that allows the muscle to contract. Other brands besides Botox are Dysport®, Xeomin®, Jeuveau®, and Daxxify®.
Patients will sometimes come in and ask me for Botox, but they don’t actually mean the brand Botox, they want a neurotoxin. It’s better to speak to your provider about which one would be best for you. Your doctor can determine the best treatment for by evaluating the individual patient, including the area to be treated and the patient’s goals.
What are the conditions you typically treat with Botox?
We use it for mostly for cosmetic purposes. The most common use is for the upper face, including the forehead, the glabellar area including the 11 lines between the eyebrows, and the lateral canthal lines, which are around your eyes.
Patients often say “I have these lines on my forehead” or “I look angry.” Those are some of the most common concerns. But there are many other cosmetic uses for neurotoxins. We use them in the mid face for areas like bunny lines; for correcting a “gummy” smile that shows more of your gum; and for a subtle lip enhancement with a lip flip. We can also prevent a downward turning of the mouth, which is common as we get older.
In addition, we can treat the neck. The platysmal bands can pull down on the neck, and we can get horizontal lines in the neck—we call this tech neck or necklace lines and they are becoming quite common from all the screen time. We can use neurotoxins for facial slimming by injecting the masseter muscles. We can also treat the masseters for bruxism for patients who grind their teeth or clench their teeth.
How long does Botox typically last?
In most people, these injections will last about three to four months. This can range from two to six months when patients will feel like it’s either started to wear off, fully worn off, or worn off enough to the point where they feel like another treatment is indicated.
The duration depends on the individual patient and product used. Different people have different metabolic rates of how fast their body metabolizes the injections or how it is degraded by the body. Different toxins also can last different lengths of time in different people. Over time, some people can develop antibodies to a specific toxin, and that one will not last as long or won’t be as effective. There are also certain areas where it will not last as long. For example: if you’re correcting those lip lines, because the lips are moving so much it tends to be metabolized quicker in that area. It’s possible that people who exercise a lot tend to metabolize faster as well.
Duration also depends on the product used, dose of neuromodulator, and the concentration. For example, Daxxify lasts closer to six months and higher doses of any neuromodulator will last longer.
How soon do patients see the results?
Everyone may react a bit differently, but there are some overall trends. Daxxify works fast. It usually kicks in within 24 hours. Dysport usually kicks in within one to three days after treatment. Jeuveau is also on the quicker side, usually two to three days. Botox is a little bit slower. It can kick in at three days, but often it takes a bit longer about five days. All of the neurotoxins should have their full effect two weeks after the treatment.
At what age do you recommend patients begin these treatments?
I generally do not do these treatments on patients under the age of 18. I think anyone over 18 can be eligible. What I tell my patients is that when you start seeing lines that are staying in the skin and lingering after you make an expression, that’s the optimal time to start.
Once the lines are already etched in the skin, we can’t promise that the toxin will erase those lines. We can soften and smooth them. Over time, they may fade. You want to catch it before those lines become etched in the skin permanently.
What are some of the potential side effects of these treatments?
Generally, these neurotoxins are very well tolerated. You can expect a little bit of discomfort with the injections. There could be a little bit of localized discomfort or temporary swelling. Bruising isn’t uncommon, but it’s not something that happens every time and it may happen just at one injection site. Some patients do develop a headache afterward, but it’s usually mild and does not last long.
Some patients may have brow heaviness, and this is more common for a first timer, but this usually would resolve within the first few weeks and occurs from over treatment. Also, improper preparation can cause an infection at the injection site. Improper technique can cause a symmetry drooping; temporarily paralyzing a muscle not intended for treatment, which can either lead to asymmetry. All of these side effects would be temporary, so it’s still very safe.
What makes someone a good candidate?
Neurotoxin treatment is great for everybody who is not pregnant or needle phobic. It’s obviously not necessary, but I think it is a wonderful treatment for most patients.
Can you stop treatments once you start?
Completely. The effects are temporary. There’s no evidence of long-term changes or atrophy. The biggest downside is that neurotoxin treatments can be very addictive because it looks so good. You may not want to stop. In fact, many patients will do it recurrently for a long time, stop when they get pregnant, and then pick it right back up after.
What other treatments are popular?
Upper face cosmetic treatments are by far the most popular. More patients are asking about other cosmetic uses. We’re using it a lot in the lower face and in the neck. These subtle changes can actually give you the cosmetic look without being an obvious change.
Many people may not know these treatments are very versatile. Neurotoxin is covered by some insurances for underarm hyperhidrosis. But we can also use neurotoxin on the scalp to reduce sweat and allow for extended time between washes.
A corneal transplant is sight-saving surgery that allows a patient with eyesight compromised by cornea damage to have their vision restored, in some cases to 20/20. More than 44,000 corneal transplants are performed in the United States every year, making it one of the most common and successful procedures of its kind.
