Recent Advances in Coolsculpting – 2014

 

Coolsculpting is a noninvasive technique to permanently reduce unwanted fat.  It was FDA approved in 2009 for treatment of the flanks.  It has subsequently been FDA approved for abdominal fat and, as of April, 2014, has the indication for treating thighs.

Up until this point, all the handpieces required a suction to adhere to the area that was going to be treated.  There needed to be a roll of fat that could be “grabbed” by the suction or the area couldn’t be treated.  The development of the newest handpiece, the Coolsmooth, allowed for areas to be treated without the use of the suction, such as the thigh area.  It also enabled the person with smaller amounts of fat or tighter skin to be treated.  At the present time, each application of the Coolsmooth handpiece requires 2 hours but this will most likely be reduced to 1 hour in the future.

“Treatment to transformation” is a technique whereby multiple applications of the Coolsculpting machine are applied in either one or several sittings.  By overlapping areas treated or by treating some areas 2 or 3 times, results are now approaching what liposuction can achieve – without the downtime or risk associated.  The technique has been pioneered by Dr. Grant Stevens, from Marina del Ray, California.

Massaging immediately after removal of the handpiece has been shown to increase the fat loss in a recent study.  This has been done in our office for at least 4 years.

Although loose skin is a theoretical risk after losing fat underneath it, Dr. Stevens has shown that this is absolutely not the case.  He has seen skin contraction with his patients and has not seen cases of excess skin.

A recent study presented at ASLMS 2014 showed effectiveness in patients with gynecomastia.  Two treatments were required and most patients were satisfied with their results.

Future handpieces are being developed to work on the neck/chin area, ankles, and one specifically for breast tissue.  Cellulite reduction is also being studied and it looks promising.  Treatment for uneven results after liposuction seems to be greatly improved with Coolsculpting as well, and the new Coolsmooth handpiece will be a huge advance in this treatment.

 

Hyaluronidase – The “Magic Eraser” for Hyaluronic Acid (Juvederm, Restylane) Dermal Fillers

Hyaluronic Acid dermal fillers are the most popular fillers used worldwide.  In the United States, the commonly used HA fillers are:

  1. Juvederm Ultra and Ultra Plus
  2. Voluma
  3. Restylane
  4. Perlane
  5. Belotero

The beauty of HA fillers is that they are very well tolerated because hyaluronic acid is a component of skin, so it is a naturally occurring substance.  It’s a soft product, and will last anywhere from 4 months, to up to 2 years, depending on the brand used, and the location it is placed.

Another key attribute to the HA fillers popularity is that it can be completely dissolved with an enzyme called hyaluronidase.  It is manufactured from either bovine (cow) or ovine (sheep), so there is a remote possibility of having an allergic reaction to the commercially available products (Vitrase, Hydase, and Amphadase).  There seems to be a crossover with people that are allergic to bees for these animal derived products.  (Hylenex is a recombinant form of hyaluronidase that is the human form that is rarely used due to its expense.)

Hyaluronidase is useful for dissolving HA filler in the following instances:

  1. The filler was over done/”over filled” and it is not aesthetically pleasing
  2. There is prolonged swelling, particularly around the eye and most often with Juvederm
  3. An infection has occurred in the area of prior filler
  4. The filler is lumpy or has nodules and doesn’t respond to massage and time (especially lips)
  5. Rare possible allergic reaction to the HA filler
  6. When there is vascular compromise secondary to the HA filler injection which can be caused by external compression on a vessel or intraluminal (within the vessel) injection

My experience with hyaluronidase has been mostly with patients that have had Juvederm injected in the tear trough area from another facility.  I strongly recommend that Juvederm not be injected in this area because of the risk of prolonged edema.  The reason this happens more with Juvederm is speculated to be due to its ability to attract more water, and because it spreads more diffusely than the other fillers.

When injecting hyaluronidase, it is mixed with lidocaine by the physician, so it is a fairly comfortable procedure.  There are a couple limiting factors with the injection.  It is not as precise as the filler injection, so it can remove some of the filler that you wanted to stay along with the unwanted filler.  Also, dosing/how much to use, is not an exact science.  It may take more than one treatment to dissolve the HA filler.  The results can occur within minutes, but usually take about a day to fully appreciate.  Also, Juvederm tends to be the hardest to dissolve, and it thought that this is related to the way it is cross linked (manufacturing process).  I imagine that Voluma would be similar to Juvederm or maybe even harder to dissolve, but I don’t have any experience with it yet.

The bottom line is that you don’t have to live with HA filler that you are not happy with.  You can easily reverse lips that are lumpy or too big, swelling around the eye from filler, or dissolve an over correction or asymmetry with hyaluronidase.  An injection with hyaluronidase can get you back to where you used to be in about 24 hours.  Also, it’s nice to have a little piece of mind when getting injected with an HA filler that the process can be completely reversed with a small procedure.

Dr. Steve Weiner is a Facial Plastic Surgeon who “laid down his scalpel” in 2005 and concentrates solely on non invasive and minimally invasive cosmetic procedures at The Aesthetic Clinique.   His website is http://www.theclinique.net .  Call for a consultation:  850.622.1214

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Revance (RVNC) RT001 is Going to Improve Crows Feet and Sweating WITHOUT Needles

Revance Therapuetics, RVNC

Revance Therapuetics, RVNC

Revance RT001 is a topical treatment that is a neurotoxin or “neuromodulator”.  This means that it decreases the muscle activity, similar to Botox Cosmetic, Dysport, and Xeomin.  However, unlike the current FDA neuromodulators, Revance RT001 can penetrate through intact skin, whereas all the others require needle injections.  Although the Botox injections are fairly quick and cause minimal discomfort, it is the belief by the company, Revance (RVNC), that there are many people that are avoiding treatment because of the needles.  It has been reported that only 10% of the candidates for getting their crows feet treated are currently getting treated and that when offered a topical, the number of people getting treated will go up significantly.  Unfortunately, the only area that has shown promise on the face in their studies has been the crows feet.  The frown lines (glabella) treatment was not significantly improved with Revance RT001, and that’s most likely related to differences in the position of the muscles in this area (deep) when compared to the crows feet (superficial).

Revance topical treatment, RT001

Revance topical treatment, RT001

The treatment will be applied in the doctors office and will need to stay on the skin for approximately 20 minutes.  This will NOT be a home remedy.  Results might actually be better than the injections, for the crows feet, because the application will be more uniform to the area as opposed to the injections which are done in a sequential, interrupted manner.

Another use of Revance RT001 being researched is for excessive sweating, hyperhidrosis, in the underarm (axilla).  Treating this area with the injectable neurotoxins (Botox, Dysport) requires about 30 punctures on each side.  Clearly, Revance will be a huge step forward in comfort for patients being treated for this problem.  A growing trend has been using Botox to treat genital/pubic area sweat.  Needless to say, most people would prefer topicals in this area to several injections.  It doesn’t seem to be effective in the hands or feet at this time because the thickness of the dermis prevents proper absorption of the drug through the skin.  Research is also being done on its use for improving acne.

It looks like Revance RT001 will get FDA approval because of its great safety and efficacy in their current FDA trials.  When will it get approved?  Probably late 2014 or early 2015.  This will be a welcome relief to all the needle-phobes with prominent crows feet.

Dr. Weiner is a Facial Plastic Surgeon who laid down his scalpel in 2005 and concentrates solely on noninvasive and minimally invasive Cosmetic Procedures.  He is Johns Hopkins trained and Board Certified.

Website:  http://www.theclinique.net

YouTube:  http://www.youtube.com/user/StevenFWeinerFacial

Facebook:  https://www.facebook.com/TheAestheticClinique

Dermapen – Advanced Microneedling for Skin Tightening, Wrinkles, Acne Scars, Stretch Marks, and Improving Elasticity of Skin.

   

The Dermapen 3 is a motorized microneedling device that can produce over 1300 dermal penetrations per second.  The micro-injuries that are created cause an inflammatory response that ultimately causes collagen production.  The injury to the dermis is fractional, only a small percentage is affected, which has been shown to lead to faster healing and an improved risk profile when compared to treating the entire dermis.  There is no heat produced, as a laser would, so the risks of pigmentation issues is very low.  For maximal benefits, a series of about 6 are recommended.

Dermpen vs Dermal Roller The advantage of a Dermapen over a dermal roller is:

  1. The penetrations are perpendicular to the skin so there is no tearing of the skin.
  2. The perpendicular penetrations are linear and more precise than the roller that creates a wedge defect in the skin.
  3. Depth of penetration can be changed for the different areas of the face.
  4. The microneedles are much thinner than the dermal roller
  5. Many more penetrations are performed in a Dermapen treatment
  6. Able to treat areas where rolling is difficult or not possible – around the nose and eyes

What conditions can a Dermapen treat?

  1. Superficial skin laxity and wrinkles, especially around the eyes
  2. Enlarged pores.
  3. Scarring, particularly acne scars
  4. Stretch marks
  5. Thin skin related to sun damage or age
  6. Etched in superficial lines

What should I expect on the day of the Dermapen treatment?

  1. After pictures are taken, a dermaplane is performed – using a scalpel, the superficial layer of skin is removed including fine superficial hairs.
  2. A topical numbing cream will be placed on the skin for about 20 minutes
  3. The cream is wiped off and the face is cleaned thoroughly with hospital grade soap
  4. A hyaluronic acid lotion is placed on the skin which allows for easier movement of the Dermapen over the skin.
  5. IF THIS IS A “VAMPIRE FACIAL”, PRP (Platelet Rich Plasma) IS NOW PLACE ON THE SKIN INSTEAD OF THE HYALURONIC ACID.
  6. The Dermapen is then placed on the skin and each area is treated in at least 3 directions to get a thorough coverage.  The product or PRP placed on the skin is pushed into the deeper layers of the dermis by the Dermapen
  7. When finished with the Dermapen treatment (about 20-30 minutes), topical growth factors or collagen stimulators are placed on the treated skin.  Studies have shown that these topicals can penetrate 50x better immediately after the treatment.
  8. Your face will remain red or pink for 24-48 hours.  There is a skin care regime that will be tailor made for your skin, recommended by the aesthetician.

What are some other uses of the Dermapen?

  1. Prior to Levulan treatment for precancerous lesions, areas of concern can be treated with the Dermapen to allow for much better penetration of the Levulan.
  2. There might be some benefit when used in combination with the laser for tattoo removal.
  3. Chemical Peels will have better penetration and become more aggressive if Dermapen precedes placement of the peel.
  4. Stretch marks can be improved, particularly when topicals are used immediately afterwards.
  5. Although still experimental, there might be some benefit in treating areas of melasma followed by intensive topical therapy with hydroquinones and retin A.

Website:  http://www.theclinique.net

YouTube:  http://www.youtube.com/user/StevenFWeinerFacial

Facebook:  https://www.facebook.com/TheAestheticClinique

Hair and Eyebrow Restoration Completely NonSurgical using PRP and ACell

PRP was injected for hair regeneration, from Prime Journal article

PRP was injected for hair restoration, from Prime Journal article, one treatment

 

PRP was injected for alopecia areata.  From Prime journal.  One treatment

PRP was injected for alopecia areata. From Prime Journal, one treatment

PRP is “Platelet Rich Plasma”, a portion of whole blood that is separated from the red blood cells through centrifuging.  It should contain concentrations of platelets that are at least 4 times that of what is found in whole blood to get the maximum benefits.  Its use in medical conditions started in the 1990′s  mainly by Orthopedic Surgeons, Dentists, and Oral Surgeons, but has recently been expanded to the Cosmetic Surgery arena.

(Please note:  Not all PRP is the same!  Most PRP systems don’t get the concentration of the platelets above the 4x level needed to get the full benefits from PRP.  The system that has proven to have consistent 4-7x concentrations is the Magellan “TruPRP” system.  It cost much more that the other systems, but the results will be superior to all other PRP systems available on the market.  In a recent lecture that Dr. Weiner attended in Paris at IMCAS 2014, 13 different PRP machines were evaluated.  Some systems didn’t even result in platelets that had higher concentrations than whole blood!)

When an injury occurs in the body, platelets are the “first responders”.  Platelets have been found to contain the following growth factors and cytokines:

  • Platelet derived growth factors
  • Transforming growth factor beta
  • Fibroblast growth factor
  • Insulin-like growth factor 1
  • Insulin-like growth factor 2
  • Vascular endothelial growth factor
  • Epidermal growth factor
  • Interleukin 8
  • Keratinocyte growth factor
  • Connective tissue growth factor

PRP use in hair restoration began during hair transplantation 5-7 years ago.  Surgeons found that bathing the harvested hair follicles led to improvements in the “take” of the transplanted follicle as well as more hair growth, and denser hair growth.  Injecting PRP in the harvested area led to improved healing of the scar.  It was then discovered that when PRP was then injected into areas of hair loss without transplanting hair, that there was new hair growth.  Adding ACell (a derivative of porcine bladder) and Vitamin D3 and B complex gave even further improvements.  In a study published in “Prime” Journal, patients were found to have improvements in their hair growth from 12-63%, and notably, there was improvements in all the patients studied.  Growth seems to start at about 4 months, and starts to fade at about 11 months. Improvements are more dramatic in females than in males.

The mechanism proposed for the improvements seen is that the PRP leads to increased vascularization of the hair follicles, leading to a “waking up” of previously poorly perfused hair follicles.  The growth factors also stimulate the hair follicles to produce hair.  

Interesting findings have been thickening of hairs that have been growing but have miniturized (become thin).  It will not cause hair to grow in areas of scarring or in areas where there was never hair.  It’s also been found that new hair growth is sometimes pigmented in areas where hair had turned gray, representing a “youthful” follicle. 

Recommendations are for at least one treatment yearly for females, and 2 for males. Topicals such as Rogaine or Propecia should be continued.

The process starts by drawing blood, 60-120cc.  It is put in the Magellan processor to separate the PRP, which takes about 15 minutes per 60cc of blood.  During this time, the scalp in numbed up with both topical creams as well as injections.  When numb, the scalp in injected with the vitamin and mineral mixture as well as with the ACell solution.  The PRP injection in then performed.  The final process is using the Dermapen microneedling device to create very fine holes in the scalp.  A by product of the Magellan PRP system is “PPP” which is platelet poor plasma.  PPP has growth factors, but to a lesser degree than PRP.  This solution is spread on top of the scalp and will be left there overnight.  Washing the hair can be done the following morning.  Sometimes extra PPP will be given to the patient to apply to the scalp at home.  The total in office time is about an hour or an hour and 15 minutes.  A second treatment (for men) is scheduled at 2-3 months.

Dr. Weiner is a Facial Plastic Surgeon who laid down his scalpel in 2005 and concentrates solely on noninvasive and minimally invasive Cosmetic Procedures.  He is Johns Hopkins trained and Board Certified.

Website:  http://www.theclinique.net

YouTube:  http://www.youtube.com/user/StevenFWeinerFacial

Facebook:  https://www.facebook.com/TheAestheticClinique

PRP and it’s Uses in Cosmetic Procedures: Facial Rejuvenation and Hair Growth Restoration

PRP is “Platelet Rich Plasma”, a portion of whole blood that is separated from the blood through centrifuging.   It should contain concentrations of platelets that are at least 4 times that of what is found in ordinary blood to get the maximal benefits.  Its use in medical conditions started in the 1990′s mainly by Orthopedic Surgeons and Oral Surgeons but has recently been expanded to the Cosmetic Surgery arena.

(Not all PRP is the same!  Most PRP systems don’t get the concentration of the platelets above the 4x level needed to get the full benefits from PRP.  The system that has proven to have consistent 4-7x concentration is the Magellan “TruPRP” system.  It costs the most but the results will be superior to all other PRP systems available on the market.  In a recent lecture Dr. Weiner attending in Paris at IMCAS, 13 different PRP machines were evaluated.  Some systems didn’t even result in platelets which were higher concentrations than whole blood!)

When an injury occurs, platelets are the “first responders”.  Platelets have been found to contain the following growth factors and cytokines:

The end result of the combination of these growth factors is increasing the vascularity to the injured area, decreasing the inflamation, laying down new collagen, healing the injured tissue and generation of new tissue.

Studies have shown the benefits of these growth factors in multiple different areas of medicine:

  • Improved healing in orthopedic injuries
  • Faster and better integration of bone grafts
  • Improvements in healing of chronic wounds such as diabetic foot ulcers
  • Improved outcomes with hair transplants

About 3 years ago, Dr. Charles Runels, devised a new PRP procedure which he called, “The Vampire Facelift”, for facial rejuvenation.   The procedure involves injecting dermal fillers, Juvederm, and combining it with injections PRP into the face.  The theory is that the PRP will release all the above mentioned growth factors and cytokines and turn on “the healing process” in the aging face.  The benefits of the “Vampire Facelift” are:

  • Collagen stimulation
  • Neovascularization (new blood supply to the skin)
  • Collagen remodeling (for scars)
  • Dermal thickening
  • Stimulation of fat growth leading to volumization of areas where fat has been lost

PRP has been used in conjunction with hair transplants for at least the last 5-7 years.  Studies have shown that there is improved “take” of the grafts, faster growth of the transplanted follicles, as well as more plentiful hair growth.  The PRP is bathed over the follicles prior to their transplanting as well as injected into the recipient and donor site areas.  In the past few years, PRP with ACell (a membrane from pig bladder) has been injected into areas of hair loss WITHOUT TRANSPLANTS and results have been very promising.  In a study published in the peer reviewed journal “Prime”, hair growth was seen in ALL patients, and ranged from 12-63% improvement.  Women seem to have greater improvements than men for this treatment.  It is recommended that men get 2 treatments, about 2-4 months apart, but women only need one.  Once a year touch ups are needed.

The use of PRP is entering a new frontier in the area of cosmetic enhancements.  Its benefits continue to be discovered in different applications and areas.  It has no side effects because you are using one’s own tissue to heal and enhance your own body.  It also is in nearly limitless supply.  It seems only a matter of time when PRP will be mainstream for anti-aging treatments.

Dr. Weiner is a Facial Plastic Surgeon who laid down his scalpel in 2005 and concentrates solely on noninvasive and minimally invasive Cosmetic Procedures.  He is Johns Hopkins trained and Board Certified.

Website:  http://www.theclinique.net

YouTube:  http://www.youtube.com/user/StevenFWeinerFacial

Facebook:  https://www.facebook.com/TheAestheticClinique

VBeam (for Rosacea, Redness, Vessels) questions answered by Dr. Steve Weiner, Facial Plastic Surgeon

Q: Is it safe to use V-Beam laser on the face if Juvederm has been injected into the cheek area?

A: VBeam will not affect Juvederm or other fillers

There have been numerous studies showing no affect of lasers on any of the dermal fillers. The VBeam is actually a fairly superficial laser as well.

Q: Will the vbeam be a good recommendation for me?

A: Redness after acne eruption, VBeam is a perfect solution

The VBeam is made to improve redness. State of the art. It is also good to improve acne. So in your case you will get a double benefit: acne and redness improvement. There is minimal downtime, just some redness for a few hours. You will need 2-3 treatments

Q: Is the Vbeam Perfecta Laser Good to Get Rid of Red Marks Left from Acne? (photo)

A: VBeam is the go to laser for redness after acne

The VBeam is tried and true for this particular problem. It takes about 3 sessions to get the improvement but everyone is different. It also helps with ongoing acne. Steve Weiner, MD, Destin, Panama City Beach, FL

Q: Has Anyone Used the V Beam to Treat Redness from a Chemical Peel? I’m 20 Weeks Post Peel (40% TCA Done by a Plastic Surgeon).

A: VBeam will work for post peel, post laser resurfacing redness

The VBeam is very well suited for treating your condition.  Usually 2-3 are needed to decrease the redness.  It’s about a 10 minute procedure with no downtime, no topical, and nearly painless.

Q: How Many V Beam Treatments Needed for Broken/dilated Capillaries?

A: Vessels and Redness need 2-3 treatments with the VBeam

In general, 2-3 treatments with the VBeam can improve enlarged vessels and redness.  Over time, these can return.  Some people this is a year, some a few years.  There is no major side effects other than slight redness and maybe some swelling which lasts a couple hours, at most, overnight.

Q: Perfecta V Beam Okay for Asian Skin Type?

A: VBeam on Asian Skin is ok if skin is not too dark

There are studies treating Asians with the VBeam showing it’s safe and effective. It treats all vascular lesions such as hemangiomas, telangietasias, Portwine stains, rosacea, red scars, agiomas, and can treat acne.

Q: Will VBeam Treat White Stretch Marks?

A: VBeam for stretch marks works only in they are red

If the stretch marks are mature and white, the VBeam will not work.  Stretch marks are tough to treat and you can only expect mild but real improvement with the Fraxel Dual.  I don’t think using the CO2 laser on your skin type is a good idea but it is also used for stretch marks.  I don’t think pigmentation should be a problem it you treat with hydroquinones before and after.

Q: Can I V-Beam my Ears?

A: VBeam can be used on ears to treat small vessels (telangiectasias)

Yes, the VBeam is excellent for treatment of vessels on the ears.  The only place it doesn’t work well is on the legs because the pressure in these vessels is higher and the vessels are deeper.

Q: How Soon Can I Fly After Recieving a Vbeam Procedure?

A: Flying immediately after VBeam is perfectly ok

I have the VBeam Perfecta, the top of the line, latest version.  It’s algorithms are set so there is very little chance of bruising.  The most I see is usually only mild redness and occasional swelling.  Flying afterwards will not affect your outcome at all.

Q: Can V-beam Perfecta Effect Hair Growth After Treatment Like Cause Hair Loss on the Body Where It is Used

A: VBeam should not affect hair growth in area treated.

A VBeam may temporarily remove hair in the area treated but there is no long term hair removal by the VBeam.  It can vaporize the hair but not get deep enough to affect the hair follicle.

Q: V-beam Recovery, Is Delayed Pinkness Common?

A: Redness after VBeam is normal

After having a VBeam, it is not uncommon to have some redness which can last up to about a week.  You can have some bruising as well.  In general though, the redness is very mild, and the social downtime in minimal after having a VBeam.

Q: Will V Beam Help with Acne?

A: VBeam good for both acne and redness associated with it

The VBeam is a rather easily tolerated laser for treatment of redness associated with acne.  It also helps improve the acne.  It is usually done in a series of 3-4 treatments separated by about 3-4 weeks.  Of course, topical medications are needed to treat acne as well.

Q: Can V Beam Help Diffused Redness if IPL Didnt Help?

A: VBeam is better than the IPL for redness

The VBeam was specifically designed to take care of redness.  It’s actually safer than the IPL because it has DCD cooling which keeps the skin cooler than an IPL and because it is more specific for the redness than the IPL is.  As far as discomfort, the VBeam is extremely comfortable too.  It can take more than one treatment to get optimal results.

Q: Is V-Beam Good for Facial Erythema / Ruddy Complexion?

A: VBeam is great for Facial Erythema and Ruddy Complexion

The VBeam laser is the gold standard for treatment anything that is vascular or red.  It is great for treating generalized redness, enlarged vessels (telangiectasias), rosacea, hemangiomas, vascular lakes, poikiloderma, and port wine stains,  You must make sure that the ruddy complexion is not a cummulation of actinic keratosis, which would be best treat, in my opinion, with Levulan followed by activation with the VBeam.

Acne Scar questions answered by Dr. Steve Weiner, Facial Plastic Surgeon

All of these answers were done before the Infini was invented.  It might be the best option for acne scars currently.

See also this link – blog about Acne Scars.

Q: Looking for a laser to remove post acne marks! (Photo)

A: PIH from acne can be treated with topicals usually.

PIH is treated in most cases with a combination of Retin A and skin lightening agent such as hydroquinone or Lytera from SkinMedica.  This will also help prevent further acne.  I you are looking for laser treatment, consider the Fraxel Dual, which can resurface the skin, helping with acne scars and pigmentation.  Steve Weiner, MD, Facial Plastic Surgeon.

Q: What kind of treatment is suitable for these scars? plz help me i am totally confused

A: Fairly extensive acne scars can be helped with the Infini

Infini is a new RF device that uses microneedling with bipolar RF. It can go as deep as 3.5mm. There is no pigmentation risk as there are with lasers. You have to remember that it will take many procedures to improve (5-10) and it won’t get to look normal, just better. Other options are punching out the ice pick scars, Fraxel, subcision, CO2 laser.

Q: Please Help Me With My Acne/Severe Acne Scarring? (photo)

A: In a hispanic person, I believe that the Infini is best for acne scars

The Infini uses microneedling as well as radiofrequency.  I will not cause hyperpigmentation as lasers can in you skin type.  It would have to be done several times just like you would if you used the Fraxel laser.  It goes deeper than the laser as well.  It new to the US and we are lucky to be one of the first users of this device.  Steve Weiner, MD, Facial Plastic Surgery, Destin, Florida.

Q: How Much Improvement Can I Hope for with Acne Scars of This Severity? (photo)

A: Very severe acne scarring. Needs lasers, fillers, maybe Infini RF

You present with very severe acne scarring. Improvement of 30% is a fair estimate. Multiple modalities are needed including: lasers-ablative or non ablative, filler for volume, RF Infini, and maybe subcision. It’s going to be a long program. Infini looks promising because in can go 3.5mm deep, and is safe for all skin types. Steve Weiner, MD, Destin, Florida.

Q: Do I Have Deep Acne Scarring or Light/medium Pitted Scars? What Are the Best Treatments for This? (photo)

A: Acne scars can be treated many ways: lasers, peels, fillers, RF devices

It hard to say what’s the best for you.  There are a variety of options available, some more aggressive, some less.  One new option is the Infini RF device from Lutronic which I think would do well with your skin type.  Please see my blog which details several options.  Steve Weiner, MD, Destin, Florida

Q: What is the Best Laser Treatment for Acne Scars on the Cheeks?

A: In my opinion, the Fraxel Dual 1550nm laser is best for acne scars of cheek

I feel that the Fraxel Dual 1550 lasers offer great improvement in acne scars and has a long history of being used for this.  (Before the Dual, the Fraxel re:store was a 1550 laser as well).  Others will argue that a fractional CO2 laser is better, but there is more pain, more risk, and more downtime.  You can need 5-10 treatments, so don’t just stop at one.  Also, your skin will never return to normal, just better, 35-60% better I would say.  I’m looking at Lutronic’s Infini now as a possible treatment for acne scars.  It’s been used worldwide for this problem and just got FDA approval in the states in July.  This would be no downtime and no risk of hyperpigmentation in the darker skin individuals.  It uses RF with microneedling.  Please see my links for more information, Steve Weiner, MD, Facial Plastic Surgeon, Destin and Panama City, Florida.

Q: Can I Get Indented Acne Scars and Ruddiness Fixed? (photo)

A: Ruddy complexion is helped with VBeam and acne scars need various other treatments

Ruddy complexion is treated with the VBeam to decrease the redness. This is state of the art for this condition. Acne scars can be treated with:  Fraxel 1550, filler, Ulthera, Inifini, fractional CO2, micro needling, or dermabrasion. You must discuss these options with your doctor. Each has its benefits, downtime, and risks.

Q: Treatments for Raised Scars on Nose? (photo)

A: For minor scarring of the nose, fractional CO2 or Fraxel re:store are good options

Remember that you will always have scars, they will look better though.  To my eye, the scars look fairly minor and you might be expecting too much.  The full results of the CO2 aren’t completely appreciated at this time.  I can take up to 9 months.  Periodic Fraxel is a good no downtime approach as well that you might consider.

Q: How to Get Rid of Acne Marks and Fix Discoloration?

A: Treating acne scarring – many options, please see attached blog

Treating acne scars can be done various ways.  I have written a blog discussing the available treatments at my office:  VBeam, Fraxel Dual, peels, topicals, TCA cross, Ulthera.  It’s hard to say what is right for you.  Don’t expect your skin to “go back to normal” though.  Expect improvement.  Options not discussed but may work as well are:  subcision, microneedling.  Steve Weiner, MD, Panama City, Florida.

Q: What is the Permanent Treatment of Mild Acne Scars?

A: Once acne scars are treated, they shouldn’t come back if no acne occurs.

I just wrote a nice blog about treating acne scars.  Most people need the Fraxel 1550 to improve anything but very mild scars.  Plan on up to 10 treatments and expect improvement, not resolution of the scars.

Q: I Have a Red Acne Scar Above my Upper Lip. How Can I Get Rid of It? (photo)

A: Red acne scar above lip best treated with VBeam

It appears you have active acne with acne scars. You are a perfect candidate for using the VBeam. It will help both the scars and future acne breakout. It will be about 3-4 treatments. The VBeam is state of the art to improve redness.

Q: I Can’t Tell How Bad my Acne Scarring Is? (photo)

A: Redness from acne is treated well with the VBeam

You seem to have active acne with some healing areas.  The VBeam is a great treatment for this because it will treat both.  When things settle down and the redness is gone but there is scarring, the Fraxel dual can be used for that.

It’s hard to assess the scarring from the pics because of all the redness currently. I encourage you to get the VBeam now. I’ve had great success with it and it will help prevent further scarring.

Q: Best Way to Get Rid of Post Acne Red Marks? (photo)

A: Best way to get rid of red marks from acne is the VBeam

The VBeam is perfectly suited to take care of anything red on the face.  It’s great for this situation because it also helps with the acne.  So you help with the redness and with acne, all in one treatment.

Q: Indented Depressed Scars on Nose That Looks Like Very Large Pores? (photo)

A: Indented scars on nose respond well to TCA Cross

I have found a relatively inexpensive with little risk procedure for this – TCA Cross. It uses highly concentrated TCA (a peel chemical) to induce the body to produce collagen to “fill” these areas.  It takes about 4-6 treatments with very little downtime.  I would try this first.  It no results, try Fraxel 1550 laser.

Q: Acne Scar Removal (Dark Skinned Indian Male)? (photo)

A: Acne scarring in a dark skin person can be treated with Fraxel but at risk for hyperpigmentation

You have to set your expections that you could improve but resolve the scars.  Your skin will never be free of scarring.  Normally I would say about 40% improvement is what you can expect at best, but because in darker skin individuals, the Fraxel settings are more conservative, it would be less than that.  Most likely, there will be some hyperpigmentation, but that is almost always reversible, and it is helped with prevention: hydroquinones pre and post procedure and sun protection.  It takes a compliant patient with your skin condition for me to do this.  NOW WE WOULD USE THE INIFINI

Q: How Can I Get Rid of Acne Red Marks in Less then 6 Months?

A: Red marks from acne are best treated with the VBeam for fast improvement

The VBeam is a great laser to improve redness from acne/early scarring.  It is a fast and nearly painless procedure with little to no downtime.  It might require 2-3 treatments.  As a side benefit, it also helps with the acne.

Q: What is the Most Effective Way of Getting Rid of Red Marks from Pimples?

A: To get rid of redness from acne, use the VBeam – treats both acne and redness great

Many people have acne problems.  Even after the acne improves, there is residual redness.  Well the VBeam is perfect for this problem.  The VBeam is the gold standard for treating redness, and it does a pretty good job at controlling acne as well.  It’s a quick, safe, and almost painless laser.  You might need to be treated 2-3 times to get the redness to your satisfaction level.

Q: How to Treat This Old Indented Scar? (photo)

A: Treating a depressed scar needs to have filler placed underneath and maybe laser after that

The picture shows that the majority of the problem is that there is loss of tissue volume in the area of the scar.  I would first treat with a filler, either Restylane, Perlane, or Belotero.  If you don’t have the results you want after that, and the volume is corrected, Fraxel Dual would be helpfull to correct the superficial scar tissue.

Q: Will This Scar Possibly Improve or Heal? (photo)

A: Depressed acne scar needs a “lift” with a filler like Restylane or Scluptra

Stop using the home remedies, you are just wasting money.  It appears that the scar is depressed and you need some volume underneath it. Restylane is probably my first choice for this, but if desiring a longer fill, sculptra might work well too.  There still might be a superficial scar after the filler, and this could be treated with the Fraxel Dual, 1550 laser.  Don’t expect to completely resolve the scar, but it should look better.

Q: Acne Scarring-Silicone or Other Treatments? (photo)

A: Acne scarring Treatments

By the looks of your scarring, it seems to be fairly extensive.  I would recommend either fractional CO2 or Fraxel 1550.  Your skin unfortunately will never return to it original texture, but I have seen dramatic improvements with these lasers.  I will take multiple treatments.  I would not do silicone.  In the future, LaViv, might be a good option, the studies are being conducted now.  Stem cells might also help, but that is not investigated too well at the present time.

Q: Can Acne Scars Be Removed Completely?

A: Acne scars can be improved but not removed.

There are several methods to improved acne scars:  peels, laser resurfacing, punch excision, subcision, filler.  All of these are helpful but none will completely resolve the problem.  For people with extensive scarring, the only real viable option is the laser.  In my opinion, Fraxel re:pair or Fraxel Dual, are very good at improving scarring.

Q: Fraxel / TCA Treatments for Acne Scarring – Scheduling Question

A: Acne scarring requires multiple Fraxel Dual Treatments, less if doing Fraxel re:pair

I don’t think there is any data on the combo of TCA and Fraxel.  I’ve done it frrequently, but usually I do several TCA Cross treatments before the Fraxel.  If you are doing the Fraxel re:store or Dual, you will need much more than 2 treatments.  I would look at 4 or 5.  Fraxel re:pair probably 2 is adequate.  One of my biggest issues with patients is that they want to know up front how many treatments are needed.  This is very difficult to say and you have to be very flexible as to how many you will need.  Keep in mind that erasing acne scars is not going to happen.  They are going to look better, but not usually completely gone.

Q: Removing Hyperpigmentation Spots, Craters & Oversized Pores

A: Fraxel Dual would be good for Hispanic Skin with acne scars and enlarged pores

I feel that the Fraxel Dual is your best option for improving the acne scars and enlarged pores. I can’t be done until you are off Accutane for at least 6 months. The Fraxel treatment will also help your acne. Instead of Accutane, you could consider Levulan with Blu U activation. 2 or 3 or these can greatly improve your acne without the side effects or risks associated with Accutane.

Q: Best Laser Treatment for Acne Scars on Brown Skin?

A: Fraxel re:store Dual would be best for acne scars on Indian skin

I think that the Fraxel re:store Dual would be best for your skin type for acne scars. There are certain precautions that are needed. You need to use hydroquinone at least 4% for about 1 month prior. Sun exposure must be limited for 6 weeks prior and a couple months after.

Gentlewaves treatment has been shown in clinical papers to decrease hyperpigmentation risk. I would restart the hydroquinone about day 4 or 5 after treatment. I would avoid the highest settings on the laser and would not do treatments any closer than 6 weeks.

You can consider Retin A about 2 months prior to treatment and stopping 1 week prior. Restarting it about a week afterwards. Another option is the Fraxel re:pair. The result will probably be better, but you will need about 2, maybe 3 and there is wound care and downtime. Your risk of hyperpigmentation is greater with the re:pair, but almost always, this is temporary. Hope this helps.

Q: Best Options for Hypopigmented Acne Scar?

A: Hypopigmentation is tough to fix, but improves with Fraxel re:store or re:pair

Until fractional laser, there wasn’t any real good treatment for hypopigmentation. Nowadays, fractional lasers like the Fraxel re:store or Fraxel re:pair offer some hope. I have personal experience with the re:pair and the Lux 1540. Both have shown improvements in hypopigmented scars. Temper your expectations. It won’t be eliminated, just improved.

Q: What Exactly is Done During Punch Excision for Acne Scars?

A: Punch excision of icepick scars uses a circular scalpel

This technique uses the same instrument as a punch biopsy. You numb the skin with a small injection of lidocaine. You then twist a circular blade thru the area around the scar. The middle portion is then pulled up and cut out, leaving a small hole where the scar was. The hole is then closed with a suture. Multiple areas can be done, and there is no limit as to how many can be done. Occasionally, a small laser treatment after the area is healed is needed for the best results.

Q: Best Acne Scar Treatment for Asian Skin?

A: TCA Cross is good for acne scars

This technique involves placement of very concentrated TCA on the scars. There is minimal downtime. It needs to be repeated several times. There were initial studies done on Koreans with no adverse skin reactions so I feel it’s safe for you. After the wedding, the Fraxel re:pair is very good for acne scars. I have done several asian skin types without adverse reactions. You need to be on hydroquinones before and after the procedure.

Q: Nashville Acne Scar Treatment Doctor?

A: Dr. Brian Biesman

Dr. Biesman is past president of the ASLMS (American Society of Laser Medicine and Surgery). He is a wizard with lasers. He has tried them all, and is asked by the laser companies to trial the up and coming lasers. Without hesitation, please call him.

Radiesse Questions Answered by Dr. Steven F. Weiner, Facial Plastic Surgeon

Dr. Weiner performing Liquid Facelift with Radiesse and Belotero

Q: Restylane Vs Radiesse for Cheek Enhancement?

A: For cheek enhancement, Radiesse will last a little longer than Restylane

Radiesse is the highest G prime filler on the market.  This is a measure of lifting ability.  It will last anywhere from 12-18 mos in most people.  Restylane is a little softer with less swelling and slightly less G prime.  Both are good choices.  More important than the filler is the “filler” you choose.  The results depend on the injector for the most part.

Q: Is It Possible to Combine Radiesse and Joliderm?

A: Juvederm and Radiesse can be used in same area

If you get one filler like Radiesse and want to get more filler, it’s ok to use any filler on top of that filler. There is no interaction between the 2. If you’ve done Radiesse first, it has swelling which can persist for 4-5 days so wait for that to calm down before adding more. I typically wait about 10 days before I will inject more filler in someone.  In the video, you can see using Belotero and Radiesse in similar areas.  Steve Weiner, MD , Facial Plastic Surgeon, Destin, Florida.

Q: 5years Ago I Had Radiesse Filler Injected into my Lips. 4 Years Later my Lips Have Hard Bumps?

A: Radiesse is not a lip filler because you get long term nodules

Radiesse has been a problem for people who got their lips injected.  It creates the problem you describe, hard nodules in the lips.  These need to be excised to improve.  Radiesse is a great filler though, but not for the tear trough and lips.  See my liquid facelift video with Radiesse.  Steve Weiner, MD, Destin, Florida.

Q: I Have a Ridge After Radiesse!! What is It? and How Can I Make It Disappear? (photo)

A: Ridge after Radiesse in orbital rim area, try injecting saline with lidocaine to mechanically break up

I have some success with the very few episodes of Radiesse clumping by using a combination of Lidocaine and saline in the area. I vigorously move the needle in and out to try to break up the area. I has worked in all my cases. No other solutions other than cutting it out or camouflaging with another filler like Restylane. See my videos of using blunt cannulas with Radiesse in this area. Steve Weiner, MD, Destin and Panama City Beach, FL.

Q: Tear troughs to be injected with radiesse by occuloplastic surgeon?

A: Radiesse in tear troughs, not recommended.

Radiesse is a thick filler and will tend to show in the thin skin around the eye. It’s great for filling the cheek, but not the area which is close to the eye. It also has a tendency to clump. So for tear troughs, Restylane or Belotero are the fillers I use. Also, to minimize downtime and the chance of bruising, I suggest using blunt cannulas for this treatment. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Panama City, Florida.

Q: I got radiesse injections in my cheeks 6 days ago. Swelling progressively getting worse. What should I do? (photo)

A: The swelling you have after Radiesse is too much

You should see someone.  Swelling does occur after Radiesse, but not to the extent you have and usually subsides in 3-4 days.  Either it’s infected or you have an angioedema.  Either way, see someone ASAP.  My video shows a liquid facelift using Radiesse.  Steve Weiner, MD, Facial Plastics.

Q: Is It Possible to Combine Radiesse and Joliderm?

A: Juvederm and Radiesse can be used in same area

If you get one filler like Radiesse and want to get more filler, it’s ok to use any filler on top of that filler. There is no interaction between the 2. If you’ve done Radiesse first, it has swelling which can persist for 4-5 days so wait for that to calm down before adding more. I typically wait about 10 days before I will inject more filler in someone.  In the video, you can see using Belotero and Radiesse in similar areas.  Steve Weiner, MD , Facial Plastic Surgeon, Destin, Florida.

Q: Getting Radiesse a Month Before Engagement Pary in May, Will I Recover In Time?

A: Recovery from Radiesse should be very quick, especially if you have it injected with blunt cannulas

Radiesse has a characteristic swelling for a few days after injection.  There is nothing that can be done to combat that.  However to get the fastest recovery, use blunt cannulas so there is minimal bruising and less swelling.  You can see the video attached in which I injected about 8 syringes of Radiesse plus about 3 of Belotero (a liquid facelift) and then she left to go to work.  The only bruising she had was from the Belotero which was injected with a needle for the very superficial fine lip lines.  Steve Weiner, MD, Between Destin and Panama City Beach, Florida.

Q: Is 25 Years Old Too Young to Be Considering Radiesse Injections for Minor Nasolabial Folds? (photo)

A: Radiesse for a 25 year old nasolabial folds is quite alright

There really is no age limit as to when to get fillers.  If you have a concern about your nasolabial folds then try some fillers.  If you don’t like them, after about a year, you are back to where you started plus one year of aging.

Q: How to Get Rid of a Botelero (Fille) Ridge Lump?

A: Belotero is a hyaluronic acid so it can be dissolved with hyaluronidase

It would be unusual to have bumps from Belotero because its properties cause it to integrate with the skin and become rather smooth.  However, it you do have ridges, the first thing would be massaging the area.  If this weren’t to work, than hyaluronidase will work fine.  Lasers don’t dissolve filler.

Q: Will Radiesse Help Achieve Sculpted Cheek and Eliminate Slight Jowl?

A: Radiesse is an excellent choice to help lift cheek and fill pre-jowl sulcus

I like Radiesse for those purposes.  Radiesse has the highest G prime of all fillers which means it has the greatest lifting ability.  You will need at least 2, maybe 3 syringes to get the improvement.  See my video which goes over the liquid facelift which includes these areas with Radiesse.

Q: Is There a Way to Remove Lumpy Radiesse Be Removed from Tear Trough?

A: Radiesse in the tear trough – shouldn’t be done

The tear trough is very thin skin and you need a thin filler like Restylane or Belotero for that area.  Hopefully after 2 weeks it will not be noticeable.  It tends to swell for about 3 days so don’t be concerned at this point.  If it’s still a problem at 2 weeks, try some saline to break it up.  If that doesn’t work, it’s either time or surgical removal.  Watch my video for injecting all over the face with Radiesse and Belotero…so called liquid facelift.  Steve Weiner, MD, Destin, Florida.

Q: Do You Recommend Radiesse in One Cheek? (photo)

A: I’m 50:50 on this one. Right cheek looks too big, do you add to left to make symmetric?

I can see your problem from the pictures.  Do you overfill both sides to get symmetric?  If you wanted to see how it would look, I’d go with Perlane or Restylane, so it can be erased with hyaluronidase if you don’t like it.   Video shows cheek injection with Restylane.  Steve Weiner, MD Facial Plastic Surgeon, Destin, Florida

Q: Am I a Good Candidate for Chinn and Cheeekbone Enhancements with Radiesse? (photo)

A: Radiesse is great for chin and cheek enhancement

Radiesse is a very hardy filler, great for creating “pseudo implants” in the cheeks and chin area.  If cannulas are used, bruising and swelling should be minimized.  See my video which uses Radiesse all over the face.  Steve Weiner, MD, Facial Plastic Surgeon, Panama City Beach, Florida.

Q: Radiesse 1st Treatment Scheduled, Concerns & Questions

A: Questions when rushing for a Cosmetic Procedure discount.

When you see a 50% off discount for a cosmetic procedure, please evaluate the situation before rushing to get it done.  What are the qualifications of the Doctor?  Is the Doctor doing the procedure?  Have your friends seen this Doctor?  What are the Doctor’s reviews? What’s the Doctors experience with fillers and Radiesse.  Sometimes this is a perfectly legit way to try to expand one’s business but most of the time it’s a non Plastic or non Facial Plastic Surgeon or non Derm that is trying to undercut because he/she is trying to get into the business.  Blunt cannulas are the way to go with the Radiesse for less bruising, less swelling, and less discomfort.  There are no knock offs for Radiesse.  There is a little more swelling with Radiesse than the other fillers like Restylane or Perlane and it’s not reversable like the HA fillers..something to keep in mind.  See my video.  Steve Weiner, MD

Q: No Improvement After Initial Radiesse Injections?

A: Flat cheeks not improved with Radiesse…you just need more

Radiesse is a filler that you don’t want to do too much in one treatment in the upper cheeks.  Waiting a month for putting more in is appropriate.  I don’t think that the other fillers are any better than Radiesse for the cheeks so I would go with the game plan your PS has laid out.

Q: Does Radiesse Cause Serious Diseases Such As Cancer?

A: Radiesse is made of Calcium Hydroxylapatite which is a naturally occurring substance

Radiesse is made of Calcium Hydroxylapatite which is found in bone and joints.  It is great for volumizing, where there is large deficits, because it corrects about one and a half to one when compared to the HA fillers.  I does not cause any types of cancers.

Q: Complications from Radiesse Rec’d 6 Wks Ago?

A: Painful nodules soon after Radiesse injections – sounds like infection

You are not describing a normal reaction to Radiesse.  Your symptoms seem like there is an infection going on and should not be left untreated.  Unfortunately, Radiesse can’t be dissolved like HA fillers so you have to aggressive antibiotics.  It might need to be removed surgically if the infection can’t be cleared.  This is a very rare problem.  It is imperative that the physician use aseptic technique when adding lidocaine and during the injection as well as proper skin cleansing.

Q: Radiesse Injection Went Bad?

A: Problems after Radiesse injection – call you doctor ASAP

What you are describing is not normal after having Radiesse.  My patients have almost no swelling at day 4.  Having pus is very concerning.  Very rarely is there an infection after injections but obviously you have one.  Hopefully a fully trained physician performed you procedures and you can get help.  Could it be viral?-yes, herpes can be stimulated from the injection, but for anyone at risk for this, I put on preventative doses of Valtrex.  I have also seen agioedema after filler injections which this might be, but unlikely

Q: Lingering Numbness and Vision Problems After Radiesse?

A: Visual changes and numbness after Radiesse; you need an expert opinion

You sypmtoms are not normal.  I’d see an Ophthalmologist ASAP.  It sounds like the infraorbital nerve is bruised and possibly the vessels near it were injected.  This is not something that can wait.  All numbing from injection should be out of your system already.  If an Ophthalmologist clears you, I’d feel much better.

Q: I Want my Face to Look Fatter and Rounder. It’s Long and Skinny, What Can I Do?

A: A rounded face is more youthful than a long and narrow face. Sculptra is your best choice

You hit the nail on the head.  As we age your fat pads, bones, jaw, and muscles in the face all atrophy.  This creates a longer and skinnier face which ages us.  To recreate the more rounded appearance of a youthful face, fillers are the answer.  Sculptra is great for this because it is a long last volumizer, which can be injected in multiple areas such as the temples, preauricular area, upper and lower cheek, jawline, and marionette area.  I can’t be used too close to the eyes or mouth area because of nodule formation, and that is where an HA filler is good.  Can this all be done with Radiesse or Restylane?  Yes, but the expense would be much more than Sculptra, and the duration would be less.

Q: Radiesse on Actual Cheekbone? (photo)

A: Radiesse for volumizing face is a good choice

In answer to your question, it’s not uncommon to place radiesse deeply, even at the level of the cheek bone.  However, i think that the majority of your problem with volume is in the lower cheek area.  This area needs a little rounding out to give the face a more youthful appearance.  I just think you might need some more, you have moderate volume loss in your picture.  This area is just great to use the blunt cannulas for less bruising, downtime, and swelling.  A great alternative to Radiesse would be Sculptra for volumizing the entire face, including temples, lower cheeks, marionette area, and pre-auricular (in front of ear) area.  Dr. Weiner, Destin, Florida.

Q: Radiesse Injection Technique-internal (Through Mouth) Vs External?

A: Radiesse should not be injected through the mouth

When injecting through the mouth, you risk dragging oral bacteria along the needle and infecting the area where the filler is placed.  There is no advantage to this technique.  The absolute safest way to inject Radiesse in my opinion is using the blunt cannula technique.  There risk of bruising, swelling, and vascular injury is minimized and results are optimized.  Cleansing the skin with Hibiclens and alcohol will help prevent infection.

Q: Radiesse Was Injected into my Trough/cheek Area About Six Weeks Ago.

A: 2 reasons why correction of Radiesse has gone

Radiesse has typically more swelling than all the other fillers.  So after about 3 days, the initial correction will look less corrected.  Also, Radiesse is a combination of Calcium spheres and a liquid medium.  The liquid will gradually absorb over a 3 week period.  Collagen will take some time (maybe 4-6 weeks) to form.  So there is typically a loss of correction which then comes back somewhat when collagen is formed.

Q: Percentage of Patients That Had No Radiesse Side Effects?

A: Very little side effects can be expected with Radiesse, especially with blunt cannulas

The stories on this site showing side effects from Radiesse are quite frankly not related to the product but to the person injecting.  If not properly placed in a deep plane or too much is placed in a single area, you can have some issues.  But, with an experienced injector, you will be able to resume normal activity the following day.  I tell my filler patients to avoid exercise for the first day to minimize bruising.  Using the blunt cannula technique, bruising is almost nil.  You can expect slight firmness in the area injected for about 3 days, but usually this is not noticeable.  Do not have Radiesse injected too close to the eye, and I wouldn’t do it in the nose.

Q: Is It Ok to Have Radiesse Nose Injection 5 Months After Restylane Nose Injection? Fly Immediately After Radiesse Nose Injection?

A: Injections of filler in the nose, not as safe as once thought

There are more and more reports of complications coming from nasal injections with fillers of vascular compromise.  Prior nasal surgery puts you at particular risk.  After knowing that, and you still want to get it done, I would only recommend using an HA filler (Restylane, Juvederm, Perlane) because there is a way to dissolve these products if a problem arises.  Radiesse can not be dissolved and posses a problem if an issue happens.  There is no problem with “mixing” fillers by injection the same area as a prior injection.

Q: Can Improved Radiesse (2010) Be Used Under the Eyes?

A: Radiesse good for upper cheek but not superficial

I have been using Radiesse for years in the upper cheek, particularly medially without issues.  When you get into issues I believe is when you try to inject superficial near the eye.  If you keep the volumes small, stay near the bone, and not too high, it works very well.  By the way, the formulation for Radiesse is unchanged since it’s inception.

Q: Is There a Way to Speed Up Radiesse Absorption?

A: Radiesse has more swelling than other fillers for about 4 days

I warn my cllents about the swelling you get with Radiesse.  It’s different than the other fillers.  I have warned my clients about the “Joker” look (from Batman) after getting it around the mouth which always settles down.  It really helps to turn up the corners of the mouth.  It should get better.  There is nothing to dissolve Radiesse however.

Q: Possible to Remove Radiesse Lumps in Lips?

A: Radiesse is not a lip filler

Radiesse should not be used to fill lips. It will clump most of the time.  Usually these can be removed with small incisions overlying the bumps.

Q: Getting Radiesse from a Plastic Surgeon or a Gynecologist?

A: Radiesse is an unforgiving filler

Having longevity in a dermal filler is good and bad. Good, if the results are what you want; bad, if you have an issue. I would say that my patients are most satisfied with Radiesse when compared to the other fillers (a study done by Radiesse came out with similar results).

Having said that, if you are considering Radiesse, you need to have a very experienced injector. Unfortunately, there is no remover for Radiesse as there is for the HA fillers. You need surgery to remove Radiesse.

In conclusion, read Dr. Persky’s notes, and make an educated decision.

Q: Radiesse for Lip Wrinkles?

A: Best treatment is to resurface upper lip for lip wrinkles

For the optimal results for upper lip lines with a prolonged results, CO2 laser is what I recommend. The Fraxel re:pair is excellent for this. You can see an example in my pictures.

Just doing this area is very easy. No pain med, no sedation, topical and blocks will make you extremely comfortable. About 5 days of healing time are needed. Sometimes a second treatment will be needed.

Another option is fillers and Botox. I do inject Radiesse horizontally very lightly along the area above the lip which helps somewhat, but not in the lip or directly into the lip lines. HA’s can be injected into these lines, but sometimes can be seen. In the future, Evolence Breeze will be great for this.

Q: Best Method of Injection for Radiesse?

A: Very comfortable injections with Radiesse is easy

The physician numbs the face with topical anesthetic for about 20 minutes. He/She mixes the Radiesse with lidocaine. Apply ice to the face for about 15 seconds. You should have minimal discomfort. If that’s not the case. Dental blocks are not needed. In my opinion, the blocks have more discomfort than the injection, and people usually don’t like the numb feeling they get from it.

Q: Radiesse After Success with Juvederm?

A: I would stick with HA fillers for the tear trough

I think that HA’s are best for the tear trough area. Their longevity there should be about a year. Although Radiesse is shunned by many in this area, it can be done by a skilled injector without issues. By the way, my favorite for this area is Restylane. The key to this area is to inject conservatively.

Q: Feeling the Radiesse in Nasolabial Folds Normal?

A: Not normal after Radiesse, but not necessarily a bad thing

Radiesse typically will swell and feel firm for the first few days, and should not be able to be felt after about a week or 2. If you still feel it, it could be that there was too much placed in that area. Usually massaging the area can break this up. I would recommend that. Ultimately, it should get better on its own in about 9 – 12 months.

Q: Tips for Avoiding Radiesse Pain

A: Radiesse is not painful for my patients

I routinely add lidocaine to all my Radiesse injections. This significantly decreases my patient’s pain. Also, by applying Pliaglis, a new topical anesthetic, there is virtually no pain. Applying ice before also helps. The lidocaine added will give short term pain relief as well, while the patient is driving home. After it wears off, the painful time period has usually lapsed.

Q: Radiesse for Nasolabial Folds

A: Radiesse is great for nasolabial folds

I think that Radiesse is great for the nasolabial folds. It will give a long term correction of about 12-18 months. A couple things that are particular to Radiesse is that it:

  • Swells more than the other fillers, but this goes away after a couple days
  • Causes slightly more bruising because you have to use a large needle to inject it

I do add lidocaine to the syringe, so it is a fairly comfortable injection. I love Radiesse for the marionette lines. It seems to have more structural support than any other filler and is great to turn a downward corner of the mouth, upward. One syringe of Radiesse is 1.3cc’s.

Also, Radiesse corrects about 30% better than Restylane. So, you get about 50-60% more correction per syringe of Radiesse over Restylane. You also get more longevity. So overall, it is the most economical filler.

Radiesse is made of microscopic calcium particles and a gel. The gel will dissolve and leave the particles which cause collagen stimulation. The new collagen is what leads to it’s longevity. I sometimes will layer a thinner filler like Juvederm or Restylane on top of the Radiesse. I think of Radiesse as a foundation, and the other 2 as finishers

Fraxel Dual Questions Answered by Dr. Steven Weiner, Destin, Florida.

****Please note that these questions were answered before Infini was available.  It might be a better treatment option for certain conditions than Fraxel Dual or re:pair.****

Q: Fraxel – which type for rejuvenation for mature skin?? I had the Palomar 1540 with a 50-15 setting.

A: Don’t be confused with imitations, there is the Fraxel Dual restore and Fraxel repair

There are many physicians who buy less expensive lasers and sell them as being Fraxel. The only thing in common with the Fraxel and the others is that they are fractional, like the Palomar. In my opinion, Fraxel Dual restore is the gold standard for non ablative skin resurfacing. The Fraxel repair is ablative, with more downtime, more pain, and more risk.

Q: Fraxel and Resveratrol?

A: Resveratrol is an antioxidant and should not affect recovery from Fraxel

I’m a big fan of Resveratrol.  We sell the supplement, MegaResveratrol in our office.  It has many studies behind it showing multiple benefits.  It should not affect your recovery and may in fact speed the recovery from Fraxel.

Q: The Hyperpigmentation Post Fraxel Laser Treatment for Stretch Marks on Arms? (photo)

A: Hyperpigmentation after Fraxel for stretch marks is treated with hydroquinones

Hyperpigmentation after laser is more common in darker skin types and people with a lot of sun exposure.  I can be treated most often with hydroquinones 4%.  If not improving, adding Retin A +/- a steroid cream.  It almost always resolves.  A better, newer treatment for stretch marks, particularly darker skin types, is the Infini RF device.  I would try it, but not many docs have it presently.  Steve Weiner, MD, Facial Plastics, Destin, Fl

Q: Will Fraxel Laser Help White/mature Stretch Marks on Ethnic Skin? Stretch Marks Are on the Buttocks.

A: Fraxel will help mature stretch marks but don’t expect more than 30-40% improvement

Mature stretch marks are difficult to treat, particularly on an ethnic person because of the risks with laser of hyperpigmentation.  It will help, but to the degree you desire, I don’t know.  You will also need at least 5 treatments, maybe 10.  A new technology called the Infini by Lutronic might be promising for this and time will tell.  Steve Weiner, MD, Destin, Florida.

Q: Can Fraxel Be Used on a Scalp Laceration? (photo)

A: Fraxel 1550 is great to improve scars but using topicals first is probably a good idea for early wounds

The problem is that for the laser to work effectively, you must shave the area.  This might not be what you want.  In my opinion, use the Scar Recovery Gel from SkinMedica as well as Retin A, 0.05%, and the scar should heal up fairly well.  Save the Fraxel if it doesn’t heal to your satisfaction.  Another laser for early scars is the VBeam, but you also have to shave the area to be treated.

Q: CoolTouch, Thermage or Fraxel for Crows Feet?

A: Crows feet are best treated with Botox not laser.

Crows feet are produced with the active muscle contraction of the obicularis oculii. By relaxing with Botox this muscle doesn’t contract and the crow feet are less.  If you are opposed to Botox you might want to try Belotero for your crows feet.

Q: Fraxel to Restore Pigment to Skin Damaged by Cryotherapy?

A: Hypopigmentation from Cryotherapy can be improve with the Fraxel 1550 Laser

Hypopigmentation is a difficult problem to fix.  Having said that, the Fraxel has been shown to repigment areas which have lost pigment.  It won’t usually completely come back.  If cryotherapy was used for precancerous lesions, I prefer the Fraxel 1927 or Levulan because there is very little risk of hypopigmentation with these methods.  They will be more expensive but well worth it in my opinion.  Steve Weiner, MD, Destin, Florida, Facial Plastic Surgery.

Q: Does Fraxel Actually Work on White Stretch Marks?

A: Fraxel Dual works for mature white stretch marks but won’t resolve them

I have treated several people for this problem.  The best you can expect is about 40% improvement, and thats after about 4-5 treatments.  There really is no other treatments available for this problem other than excision.

Q: Can I Have Full Face Fraxel Laser After Having Had Facial Silicone Injections Several Years Ago?

A: After having silicon injections, even years prior, there is a risk of activating an inflammatory response w Fraxel or injections

Even though you’ve been doing relatively fine from the silicon, any invasive procedure might activate an inflammatory response or granuloma.  Having said that, I’ve haven’t encountered problems with people that have had silicon but it is a risk you need to be aware of and the physician should discuss with you.

Q: Will Fraxel Laser Make Active Acne Worse? Will It Cause a Flare Up if You Are in Remission?

A: Fraxel can temporarily make acne worse but in long run it makes it better

The Fraxel Dual can stimulate acne for the first couple weeks. Acne prone patients I put on minocin to help prevent having a flair. However, it reduces the sebaceous glands and thereby helps with acne in the long run.

Q: I Am Planning on Having 3-4 Fraxel Treatments Spaced One Month Apart. What is Your Recommendation Concerning Sun Exposure?

A: Sun exposure inbetween Fraxel treatments (as well as after) should be minimized.

You want to have as little direct sun exposure as possible when receiving any laser treatment.  I usually say 3 weeks before and after treatment at the very least.  Sun exposure will lead to rev’d up melanocytes which will lead to pigmentation issues.  It doesn’t mean staying indoors, it means wearing sunscreen, a hat, and avoiding intense sun exposure.  Heliocare can help reduce the tan and burn associated with sun exposure too as well as antioxidants such as those found in TNS Essential Serum from SkinMedica.

Q: Still Have Very Distinct Red Square Patches and Microdot Tracks on Cheeks 11 Days After Fraxel – Should I Be Worried? (photo)

A: You did not get the Fraxel Laser..There are docs using other lasers and saying it’s Fraxel

Fraxel uses a rolling tracking system and the laser comes out in lines, not squares. The Fraxel is an expensive laser and there is a fee you pay the company every time it is used.  It is the state of the art for laser resurfacing in my opinion.  Doctors buy less expensive lasers and say they are giving you Fraxel.   It looks to me like you have been overtreated for your skin type.  You should go back to your doctor and get evaluated and look at the machine which you were treated with.

Q: Fraxel Dual 1927 Vs 1550?

A: Difference between the Fraxel 1927 and 1550 wavelengths.

As you stated, the 1550 wavelength is a deeper penetrating laser and is more suited for scars, wrinkles, and some mild pigment improvement.  It is non ablative so there is no open wounds.  It will have more swelling than the 1927.  There is some peeling, but more with the 1927.  The 1927 is a “partially ablative” laser that is very superficial and used to help pigmentation and superficial fine lines.  Both laser wavelengths are approved for removing precancerous lesions (actinic keratosis).  In general, I use both lasers at the same sitting, unless someone is only concerned about pigmentation or AK’s (1927), or more concerned about scarring (1550).  My video show the 1927 laser.  Also, because the 1550 goes deeper, it is more painful during the procedure.

Q: Are These Setting of Fraxel Really High? 55 Energy, 6 Treatment Level, 8 Passes

A: The settings for the Fraxel 1550 you had are for moderate wrinkles, scars

The highest setting for the energy is 70 and you were at 55mj.  This is needed to improved deep wrinkles and scars.  The second number is related to how much of the skin is treated.  You were at the medium level for that.  So these are very safe parameters.  The passes really doesn’t matter in the end, it is basically how fast the procedure goes, but should be at least 6.  The more passes, the less treatment per pass, the more margin of error for the operator in unintended overlapping of the passes.

Q: Will Fraxel Dual Laser Treatment Damage Gore Tex Line Lift or Filler?

A: Fraxel Dual is safe for fillers and Goretex implant

The laser from the Fraxel Dual goes about 1.5-1.7mm deep at most.  Studies have shown that is does not affect fillers.  Goretex is placed much deeper than the depth the laser penetrates to as well.

Q: Not Peeling After Day 3.. is This Normal?

A: Not peeling yet after 3 days from Fraxel Dual is fine, it will!

You describe the correct sequence of events.  Your skin gets darker and the pigmentation looks more prominent after getting the Dual.  You should start peeling from 3-5 days after the procedure and it will usually start around the mouth and then work upward.  The cheeks might take the longest to completely peel.  When all is peeled, you skin will be smoother and less pigmented.  You must make sure the skin is moisturized before and during the peeling.

Q: Will Fraxel Restore Damage Hair Follicles at Level 9 and 75 Mj Setting?

A: Fraxel Dual or re:store laser will not damage hair follicles

Hair follicles are damaged by a laser that is attracted to melanin, the pigment in skin and hair.  The typical wavelengths of the hair removal lasers are lower (Diode – 800, Alexandrite 765) than the Fraxel Dual (1550 and 1927nm).  The Fraxel might singe the hair but won’t permanently affect the growth of the hair.

Q: Do You Need to Wear Eye Protection for Fraxel?

A: Eye protection for the patient during Fraxel should be done

Having said that, the Fraxel laser is not very dangerous to the eyes.  It has to do with it’s wavelength.  It’s attracted to water, so the most it would do is cause an injury to the conjunctiva or cornea.  It’s not attracted to the retina or iris where the lasers that are attracted to pigment (KTP, Pulsed Dye, Diode, Alexandrite) can cause visual lose or blindness. So, the Fraxel is relatively safe to the eye.  If you would have been injured to the eye with the Fraxel, it would present as pain immediately, and you would have irritation, swelling, pink/redness of the eye.  If this didn’t occur, you’re good, but would use eye protection next time.

Q: Telangiectasias Appearing Ater Fraxel?

A: Telangiectasias are easily treated with VBeam

Telangiectasias can occur after any procedure, including Fraxel, injections, or Radiofrequency devices.  The good news is that they are easily treated with a no downtime almost painless laser called the VBeam Perfecta.  You might require a couple sessions.

Q: Will Acne Scar Resurface if I Dont Do Fraxel Regularly?

A: The improvement from Fraxel Dual re:store for acne scars is permanent

After the edema settles down and you are about 3 months out from your Fraxel treatment for acne scars, the result you have should last a lifetime, IF you don’t create more scarring with further acne.  The question always asked of me is how many do I need.  That is difficult to answer, could be 5 or 10, depending on the degree of scarring, and how much you want it improved.  Also you can only expect improvement and not resolution of your scars.  Unfortunately, the skin will never look entirely normal, but better.

Q: Have Heard Different Answers About Fraxel Recovery Time During Consultations, Which is Correct?

A: Downtime after Fraxel Dual is variable

Downtime after a Fraxel Dual depends on the settings and the individual.  Obviously if your have more aggressive settings, you will have more swelling and downtime.  Also, different people have different degrees of swelling and redness.  Typically, after about 4 days, the peeling is done and there still is mild swelling.  The skin is intact.  Some of my patients go in public throughout their recovery, it depends on your comfort with the recovery process.  I would say it would be unusual for the downtime to be 2 weeks though.  You will have pinkness of the skin for several weeks, but I don’t consider this downtime.

Q: More Fraxel to Fix Fraxel Damage?

A: Try another physician

This doesn’t sound like normal care. I haven’t heard of treating with Fraxel and needling at the same time. Perhaps it was subcision, but still I would not do this at the same time. Also, only 7 weeks out, I would not treat with such a permanent filler. At this point, more fraxel or a pulse dye laser (V Beam) would probably be helpful.

Q: Side Effects of Too Many Fraxel Restore Treatments?

A: No issue with multiple Fraxel dual or re:store treatments

This very question came up at a recent meeting with all the best laser surgeons in the world at Mass General (Harvard). Dr. Rox Anderson, the inventor of fractional laser resurfacing said he saw no issues with multiple treatments.

He even stated that your incidence of skin cancer will be lower (not higher as some bloggers have stated) with the resurfacing.

Q: Fraxel Restore or Repair for General Improvement of my Skin?

A: For general skin resurfacing, both the Fraxel re:pair and Fraxel re:store Dual work well

I think that you have some scarring/textural irregularities on your face. I think the better result will probably be from the re:pair, perhaps even more than one. However, you have to be able to have downtime, do dressing changes, and have general redness for up to 8 weeks. If your lifestyle does not allow you to do this, the new Fraxel Dual is having great results for this problem with less downtime, but more treatments.

Q: Preventing PIH After Fraxel Restore or Repair

A: Using Hydroquinone a month prior and Gentlewaves helps prevent PIH from Fraxel

Starting hydroquinones 4% 1 month prior and restarting soon after the procedure will help prevent PIH from Fraxel. There is also a recent paper that suggests pre and post procedure Gentlewaves will decrease the risk of PIH as well. Avoiding the sun for 6 weeks prior to the procedure and good sunscreen also is important.

Q: Fraxel Restore Test Area for Dark Circles?

A: Dark circles around eyes is hard to treat

Please keep us updated about your results. Up to this point, dark circles have been hard to treat. Please moderate your expectations. Dermal fillers have seemed to be the most helpful, but smoothing out the shadows around the eyes from volume loss. I have a Dual and would love to add this application to my services if this works. The Dual is a very safe laser and test spotting is not a bad idea, but usually not needed.

Q: What is Fraxel Dual?

A: Fraxel Dual is 2 lasers in one treatment

Fraxel introduced the Dual about 1-2 months ago. I combines a 1927nm laser with an upgraded version of the 1550nm (re:store) laser. The 1927 laser is a superficial laser that is brand new to the aesthetics market. It is somewhat a blend of non ablative and ablative technology — referred by the company as “disruptive” to the skin. It removes pigment better than any laser I’ve encountered, in usually 2 treatments. It is relatively quick (10-12 minutes for the face) and fairly comfortable to have done. It will cause the skin to darken over the first 3 days and then peel. There is no wound care. Social downtime for about 3 days.

It is often combined with the 1550nm laser to give both a deep and a superficial treatment. When done with the 1550, there is slightly more swelling and redness. The 1550 has more discomfort. The Dual’s 1550 has been modified to be faster, more effective, and more comfortable (has integrated cooling) than the prior Fraxel re:store laser. Usually you will require 3 instead of 4 treatments with this laser as compared to the previous version. My experience with this laser has been very good. The satisfaction of my clients is high.

Q: Thermage Free with Fraxel, is It Worth It?

A: Thermage is a great addition to Fraxel re:pair or re:store

There have been recent clinical studies showing the benefit of doing both Fraxel laser treatment and the Thermage together. What happens is that you have tightening at both a superficial and and deeper layer of tissue leading to better results. The safety profile of the current Thermage CPT is extremely good and for the hour or so it takes to get the face treated, I would highly recommend doing the Thermage as well.

UPDATE:  We no longer do Thermage.  Ulthera is more precise and more consistent results.

Q: Treatment Spacing of 4 Days for Fraxel and Thermage?

A: Timing of Fraxel and Thermage

Thereare no restrictions regarding the timing of Thermage and Fraxel. They affect different areas of the skin. However, after having as many treatments as you describe, you probably have fully appreciated any benefits that you get from these treatments. If you want more improvement, I’d suggest the Fraxel re:pair.

Q: Should I Have Fraxel Re:pair or Active FX?

A: Recent study suggests better results from Fraxel Re:pair over the Active FX

In a paper recently presented at the American Society for Laser Medicine and Surgery, it showed both were effective, but the Fraxel Re:pair side had better tightening. It was a split face study, one side got the Fraxel Re:pair, the other the Active FX. The study was done by a group out of NY and NJ. It was a blinded study to the patients (they didn’t know which side was which laser). There were 10 patients.

Hope this helps!

Q: Fraxel Repair or Fraxel Restore for Loose Skin?

A: Fraxel re:pair more aggressive and more results than the Re:store

The Fraxel re:pair is a fractional CO2 laser. CO2 lasers are aggressive/ablative lasers that will give you the best results for skin tightening. They have been around for over 20 years. The recent resurgence of these lasers is the fractional technology which leads to less downtime, and less side effects.

The re:store is an Erbium laser that is non ablative. It typically will have less downtime, less results, and requires multiple treatments. When you add up all the downtime with the re:store (about 2 days with each treatment) it equals the downtime that a re:pair would have (about 1 week). My suggestion is to get the re:pair by an experienced physician for your best skin tightening results.

Q: Fraxel Repair Vs. Fraxel Restore

A: Fraxel re:store and re:pair are different

The Fraxel re:pair is a fractional CO2 laser and the re:store is a fractional erbium laser. The re:pair requires usually only one treatment (except for acne scars), whereas the re:store is usually a series of 4-6 treatments.

The re:pair will tighten the skin, the re:store will minimally tighten, even after 6 treatments. Wrinkle control is also far superior with the re:pair over the restore. The reason that the re:pair causes more wrinkle control and tightening is because it actually removes tissue, whereas the re:store thermally heats the tissue.

Also, CO2 lasers cause more thermal injury to the surrounding tissue, which leads to more collagen and better wrinkle control. The cost of 4 or more treatments with the Fraxel re:store is more than the cost of 1 Fraxel re:pair treatment. The Fraxel re:pair was introduced at the American Academy of Dermatology on January 31, 2008. The Fraxel re:store received FDA clearance July, 2004.

Q: Can Fraxel CO2 Be Used for Upper Arm Skin Wrinkles?

A: Use Thermage for tightening crepey skin

Fraxel has recently had FDA approval of a few new handpieces for the Re:pair laser. One of them is made to do body treatments as you are desiring. It will take a few months for those to be manufactured and in the hands of the physicians. The crepey skin can be improved but not redundant skin – this would have to be excised.

Answer updated 4/23/09:

I now feel that the best non surgical approach is Thermage. The new Fraxel handpiece hasn’t really turned out to be a revolutionary change.

I have recently added Thermage to my office. I have seen several clients who have had surgery that have been left with very large and long scars. Thermage seems to offer an alternative that has no real downside.

Q: Fraxel Re:pair Vs. Fraxel Re:store for Reducing Large Pores?

A: Both will work, but re:pair is overkill

I have seen improvements with the Fraxel re:pair for pore size which are dramatic, but if you don’t need all the other improvements (pigment, scarring, tightening, texture), then stick with something that is less expensive and less downtime like the re:store, Lux 1540, or IPL.

Steve Weiner, MD Facial Plastic Surgeon, Destin, Florida

Q: What is Fraxel Recovery Like?

A: Painless after Fraxel, swelling lasts under 5 days

Universally, nobody complains of pain after the procedure. Swelling is the worst on the second day after the procedure and gets better by day 5 or so. Seeing streaking is common and will go away. Redness lasts up to 3 months, but usually about 3 or 4 weeks.

Q: Fraxel Restore Vs. Fraxel Repair

A: Fraxel repair is the best laser for skin tightening and wrinkles

The Fraxel re:pair has fractional laser technology that made the CO2 laser much safer than completely ablative CO2 lasers. The company has seen none of the risks that the older CO2 had – hypopigmentation, scarring, and lines of demarcation. The CO2 laser has been long regarded as the gold standard for wrinkles and tightening, but with the previously mentioned risks happening in about 15 percent of patients, it fell out of favor.

Another benefit of the Fraxel re:pair is the depth of penetration, up to 1.6mm, much deeper than the prior CO2 lasers which went 0.3mm as well as the 2 competitive lasers – Mixto – 0.7mm, and the Deep Fx, which is 1mm. Deeper treatments mean better results.

The other Fraxel (re:store) is an erbium laser, and is considered non-ablative (does not remove tissue) whereas the re:pair causes ablation. Removing tissue will result in more wrinkle correction and tightening. The CO2 also causes some peripheral heat damage which also leads to more tightening. The erbium causes very little peripheral heating.

There is more downtime with the re:pair but it’s only one treatment. All my patients are extremely pleased with the re:pair, and I can’t say that about the re:store.

Follow

Get every new post delivered to your Inbox.

Join 9,403 other followers

%d bloggers like this: