PDO Threads – The Latest Minimal Invasive Lifting Procedure

Thread lifting is not a new concept. It was first developed in 1999 by Dr. Sulamanidze in Russia. APTOS Threads (a non absorbable suture made of polypropylene) were used for lifting and tightening skin without surgery. Contour threads of similar make up were introduced in the US in the early 2000’s. There were problems with these procedures. Placement was fairly complicated, requiring deep fixation points with hooks on the suture. The downtime was several days, skin redundancy was frequent, and sutures extruded or needed to be removed. Complications rates were very high and by 2007, the Contour threads were taken off the market. Thread lifting was not ready for “prime time” at this point.

After heading “back to the drawing board”, a simpler, less invasive, less risk thread was developed, PDO Threads. PDO (also known as PDS) sutures have over 30 years of safety use in Cardiothoracic, Plastic, OB Gyn, and Trauma surgical procedures. This material (polydioxanon) is highly flexible, elastic, strong, and absorbable. It is hydrophobic (does not absorb water) so swelling is kept to a minimum. Gradually over 4-6 months, the suture is degraded by the body’s immune system and replaced with collagen. Patients with immune system diseases, on immunosuppressants, or smokers are not good candidates for threads.

The placement of these PDO sutures is done with minimal discomfort (somewhat similar to filler placed with a cannula). They are placed just underneath the surface of the skin and don’t require the deep fixation that the prior threads needed. Downtime is minimal, with only possible bruising holding you back from social events. The risks and complications have been significantly reduced as well. It is extremely rare that a thread needs to be removed because they are much smaller (therefore less noticeable) than prior threads and because they can be dissolved with using heat (most often RF energy). The ability for the threads to dissolve over time increases the comfort level of all involved in PDO Threads. Results can last from 12-18 months, depending on the area treated (lip area is maximum 4-6 months). Only about 30% of the full result is seen immediately. It takes about 3-4 months to see the final result as the body reacts to the thread.

There are 4 design variants of the PDO Threads:

  1. Smooth threads: these are used in areas where collagen stimulation (dermal thickening) is needed. Often they are placed in a cross-hatched pattern. They are commonly placed in areas of superficial wrinkles or crepey skin. Common areas used are: cheeks, neck, marionette lines, glabella, temples, forehead, lip lines, lips.
  2. Twisted threads: these are smooth threads which are coiled. They give more collagen production than the smooth. These are used mainly in the nasolabial folds and marionette areas.
  3. Single Barbed threads: these threads have barb on them (cut with a laser) to lift and tighten sagging skin. Once they are placed, the physician runs his hand over the thread to engage the barbs to help pull the skin up or back. The ideal areas for these threads are the mid/lower face, jowls, and upper neck. Keep in mind these can be used anywhere on the body and some physicians are using these in the knee area, chest, and breast area. Think of these threads as “creating a collagenous tendon” as the body breaks the PDO down and replaces it with collagen.
  4. Double Barbed threads: similar to the single barbs but they have 2 sets of barbs going in opposite directions. They are placed slightly differently and require an exit point as well. Once the suture is in position and engaged, both ends are cut at the level just below the skin. These are used in similar areas as the single barbed threads when cheek fullness is desired or additional lifting is needed.

PDO threads aren’t for everyone. Severe skin laxity won’t be improved with these. It is important that patients are volumized to their fullest prior to or during the procedure. It is vitally important that patients and physicians have realistic expectations for threads. The results won’t be comparable to surgery but will offer improvements which might push surgery out for a few years. The great thing about the threads is that more can be added down the road to maintain or get additional correction.

Dr. Weiner is a physician trainer for PDO Treads (Nova Threads) and was one of the earliest adopters of this new procedure in the US.

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ThermiVa Rejuvenates the “Va”

It’s okay to talk about these things now. Women are discussing this subject at bars and parties. Restoring and enhancing the vaginal area is now popular, the “in” thing. The industry has gotten onboard with no less than 6 devices that have entered the market in the last 12 months for treating this area cosmetically. A colleague has called 2016, “The Year of the Vagina”. The only one that is different is ThermiVa and here’s why.

  • ThermiVa is completely non invasive with no healing required
  • There is no downtime – physical and even sexual activity can resume immediately
  • ThermiVa can tighten vaginal laxity
  • ThermiVa can improve “leaky bladders”
  • ThermiVa can enhance the appearance of the labia
  • ThemiVa improves lubrication associated with atrophy
  • There is no topical or blocks needed for pain
  • Improve sexual gratification, orgasmic function

ThermiVa works by gently heating the tissues up to the desired preset temperature using radiofrequency (RF). The heat causes release of factors with result in increased vascularity to the area, increased collagen production, and tissue tightening. The temperature is not too hot, but tolerable, and has been described as similar to heat from a hot stone massage. There is immediate tightening that patients recognize as well as an improved cosmetic appearance. Full results take about 3 months to fully appreciate.

It is recommended to have 3 treatments spaced about 1 month apart. Results should last about 12 months and touch ups will keep the results up at that time. There are essentially no risks or major side effects. Treatment times are about 30-40 minutes and regular activities can begin immediately afterwards.

There are several anecdotal stories of the partners of women who received the ThermiVa enjoying the results as much as the patient. It’s a procedure both will benefit from.

It is no longer taboo to discuss female sexuality or functional problems in the vaginal area. ThermiVa allows for a quick, no downtime procedure that addresses several areas for which improvement is desired. Please call our office to discuss further, 850.622.1214.

 

 

 

Smoking and Aesthetic Procedures Don’t Mix Well

Smoking is well known for its detrimental effects to one’s lungs and health. Lung cancer, heart disease, chronic lung disease, strokes are all sited to have much higher rates in those that smoke. It certainly is no leap of faith to imagine the harm smoking causes to the largest organ of the body, the skin.

There is one study which shows that moderate smokers (30 cigs/day) will show 14 more years of aging when they hit 70 then nonsmokers. They are more likely to have deeper crows feet and “smoker’s lines” above the lips. Telangiectasias, often called broken capillaries, are more common in smokers. The color and glow of the skin is changed. The circulation is decreased because the blood vessels are constricted (vasoconstriction), mainly due to nicotine, so the skin becomes dull, ashen, and loses it redness. Carbon monoxide levels become elevated in the blood stream, reducing the oxygen capacity of the blood. Hydration of the skin is reduced in smokers. Also, the vasoconstriction affects the hair by thinning it and causing premature graying.

Another study shows that smoker had about a 20% collagen reduction in response to a wound. Extracellular matrix turnover was also decrease. Smoking also depletes vital nutrients in the skin such as Vitamin B and Vitamin C (needed for collagen formation), and magnesium. Each cigarette generates million of free radicals, which causes an inflammatory response throughout the body.

Many of our aesthetic procedures rely on the body’s response to get optimal or for that matter, any outcome. A collagen response is needed in our collagen stimulating fillers such as Sculptra, Bellafill, and Radiesse. The longevity and volume afforded by these fillers is solely collagen related. These fillers should be reconsidered if they are planned to be used in a smoker.

A flap during surgery is when an area of skin is elevated from its normal position. This compromises the blood flow because part of the normal vasculature  is cut. This is what occurs when performing a face lift, neck lift, rhinoplasty (nose job), blepharoplasty (eyelid surgery), tummy tuck (abdominoplasty), and breast surgery. A smokers outcome with these procedures is at significantly higher risk because of the vasoconstriction that nicotine causes. The flaps are at risk of necrosis (dying), prolonged edema, prolonged healing, scarring, need for reoperation and infection.

Laser resurfacing or RF (radiofrequency) procedures depend on the heat injury to cause an inflammatory response which ultimately leads to collagen stimulation and skin tightening. In a smoker, the blood supply in compromised to the skin so WOUND HEALING AND COLLAGEN FORMATION IS SIGNIFICANTLY IMPAIRED. Complications such as infection, prolonged healing, scarring, poor results are much higher with smokers. Most physicians will not perform ablative laser procedures on smokers because of these additional risks.

Many smokers say they will quit and use nicotine gum/patches or e-cigarettes. These solutions are just as detrimental as cigarettes to wound healing and collagen formation. There is still vascular constriction with these substitutes. Most surgeons require a window of at least 3 weeks prior to surgery and 4 weeks after to be smoke free. Some require urine testing for nicotine and its by products to document compliance.

Smoking and aesthetic procedures aren’t a good combination. It is counterproductive to smoke while striving to look younger. If one is really concerned about their looks, smoking cessation is absolutely necessary. It will save your appearance and save your life too!

Vanquish ME Vs Coolsculpting for Fat Reduction

Coolsculpting ushered in the era of non invasive fat reduction in 2009. Who would ever have believed that a one hour procedure could remove fat permanently, without incisions? Coolsculpting can produce reliable fat loss of approximately 20-25% with no downtime and minimal risk. It is clearly the market leader with over 2 million treatments. For a long time, Coolsculpting stood without competition, but over the past couple years, formidable competition has been developed. The differences between Coolsculpting and Vanquish ME will be elaborated below. (Dr. Weiner has experience with both technologies, adopting the Coolsculpting in 2009 and the Vanquish in 2014.)

Research has found that a fat cell’s survival is sensitive to both heat and cold. Coolsculpting takes advantage of cooling the fat tissue to a temperature that is safe for all other structures such as nerves, muscles, and skin. After the Coolsculpting treatment, the fat cells gradually die in a process called apoptosis over the next 6-8 weeks. Subsequent treatments in the same areas yield even better results.

Vanquish ME uses radiofrequency technology to heat up the fat tissue to a point where the fat cells undergo apoptosis as well. The more treatments an individual has, the better the outcomes will be.

From a cursory perspective, it appears that these technologies are interchangeable, but that is definitely not the case. These are where they differ:

One of the major differences between these 2 technologies is that Coolsculpting requires pinchable fat that can be suctioned into the handpiece. This is a major downside to this technology because patients that have fat that can’t be drawn into the handpiece, can’t be treated. On the other hand, Vanquish ME can treat all patients. This includes the moderate to severe obese patient, who is not a candidate for the Coolsculpting. It can also treat the very fit patient who has just a small bit of fat that doesn’t go away with exercise but is not enough to place in a Coolsculpting handpiece.

The treatment area of Vanquish ME is significantly larger than with a Coolsculpting application. This is important because there have been cases of Coolsculpting treatments leading to demarcations between the treated areas. Correction of this problem is difficult, and might require liposuction. This has not been found to occur with Vanquish ME due to the large treatment areas, multiple sessions, and feathering that occurs on the edges of the area treated.

Coolsculpting has been advocated for patients with BMI’s (body mass index) below 30. This limits the procedure to those patients which are mildly overweight. On the other hand, Vanquish ME can be performed on all body types. The problem with treating the higher BMI patient’s with Coolsculpting is that they are at higher risk to have the indentations and demarcations then the lower BMI patients.

Radiofrequency has long been used to help tighten skin. The heat causes collagen stimulation and remodeling. An advantage of the Vanquish ME over Coolsculpting is it’s ability to cause some skin contraction.

Potential side effects of Coolsculpting have been shown to be numbness, bruising, prolonged pain, and paradoxical fat enlargement. The potential side effects from Vanquish has only been superficial skin burns, but that risk has been minimized with changes in the administration of the treatments.

The areas treatable with the technologies are:

  1. Abdomen and Flanks:  Coolsculpting needs at least 4 different applications to treat abdomen and flanks (4 hours). This can be performed in one treatment with the Vanquish ME, but will require 4-6 visits (about 4-5 hours).
  2. Inner and Outer Thighs: Coolsculpting 2 different applications each leg vs Vanquish ME’s one each leg but 4-6 treatments
  3. Chin, Gynecomastia, Bra Fat: Only treatable with Coolsculpting
  4. Arms (“batwings”): Treatable with both technologies

Zimmer’s Z Wave has been shown to increase the fat destruction after use of both the Vanquish ME and Coolsculpting. Studies have shown an average increase of about 68% fat loss (up to 100%) when the Z Wave is used. The Z Wave is a painless 5 minute procedure that is performed at the conclusion of the treatment. Technically, the Z Wave is described as “Radial Pulse Therapy (RPT)”, which causes a shock wave to go thru the fat. It pushes fat cells that are “undecided” as to whether they are going to survive the fat destroying treatment over the edge, leading to a more effective treatment.

Both Vanquish ME and Coolsculpting have proven technologies that treat unwanted fat permanently using noninvasive techniques. Coolsculpting can be used to treat some areas that Vanquish can not. Coolsculpting has more side effects, albeit usually minor. The clear winner for the larger patient is the Vanquish ME for its ability to treat larger surface areas without the risk of lines of demarcation or indentations. Patients with loose skin will be better served with the Vanquish ME.

 

Bellafill is a Unique, Safe, Long Lasting Filler

Bellafill is a one of a kind dermal filler. What makes it unique is its longevity, composition, and FDA approved indications. Although FDA approved in 2006 for improving the nasolabial folds, there have been 2 recent studies that have expanding its indications.  These are the use of Bellafill for acne scars and data which shows at least 5 years of correction from a Bellafill treatment. Both of these studies are ground breaking, with no other fillers able to make these claims.

Bellafill is a mixture of 20% PMMA (Poly Methyl Methacrylate) and 80% Bovine Collagen. PMMA has been used medically for over 50 years as an implant. The PMMA in Bellafill is uniform smooth spheres of 40 micron diameter. The spheres elicit an inflammatory response, which stimulates the body to create a collagen capsule around these spheres. The size of the spheres is important, because at 40 microns, the body is unable to phagocytize the PMMA (digest), leading to the prolonged longevity of the product. Being smooth, the inflammatory response is subdued, minimizing the uncontrolled inflammation found in granulomas.  Prior to Bellafill injection, a dermal test is needed to see if the patient is allergic to the Bovine collagen and this takes 28 days to determine the results.  The Bovine collagen in Bellafill provides a temporary correction for about 2-3 months, until the body’s own collagen is created.

Acne scarring causes significant psychosocial problems for millions of Americans. Isolation, depression, suicidal thoughts, and poor self-esteem are just some of the many issues these individuals suffer from.  Bellafill is used to improve the appearance of the rolling type (scars that flatten when stretched) of acne scars. It is injected into the dermis, to elevate the scar. The results are immediate, but improvement is noted over the next 12 months. The FDA study showed that approximately 0.1cc was needed per scar, and most patients required 2 treatment sessions. There were no major complications noted and everyone was followed for 12 months.  Satisfaction rated by the patients was over 90% at 12 months.

No filler on the market has published data showing persistent corrections at the 5 year mark. Bellafill studied 1008 patients for 5 years. Retention rate was 87%. Satisfaction rates at every year including the 5th year was 80% or higher. The granuloma complication rate was 1.7%, which is comparable or better than all other fillers. With treatment, the granuloma rate was less than 1%. With corrections lasting at least 5 years, it is easy to see how Bellafill is actually a very economical filler as well.

Bellafill truly is unique amongst the dermal filler in regards to its longevity and use for acne scars. It is currently only available from a select group of physicians who have been trained by the company. Dr. Weiner is a physician trainer, lecturer, Key Opinion Leader (KOL) and on the physician advisory board for Bellafill. Dr. Weiner is actually a Bellafill patient as well, having been recently injected with 8 syringes of the product.

 

 

Filling The Temples Should Be Done With Sculptra…Period.

Temporal volume loss is part of the natural aging process of the face. It is the result primarily of fat pad atrophy, but loss of bone, soft tissue, and muscle also contribute. Losing volume in the temples leads to:

  1. Lowering of the eyelid and eyebrow
  2. Skin laxity in the periorbital and cheek area
  3. Changes to the overall shape of the face
Aging temples changes shape of face

         Temporal volume loss changes the shape of the face

Probably the most significant of the above changes is #3. A youthful face is “upside down egg” or “heart” shaped. The upper face is rounded, with the widest part being the upper cheeks. The center of beauty is the eyes, and the youthful face emphasizes this. With the temple wasting associating with the aging face, the overall shape turns more square, and the lower face becomes dominant. Filling the temporal defect can help to re-establish the upper face dominance that is the hallmark of youth and beauty.

There are basically 2 ways to fill the temples. Filler can be placed deep to the temporalis muscle, at the level of the periostium of the bone in the temporal fossa. This type of correction will lift the muscle, fat, and soft tissue “en mass” for a very even appearance. Needles are needed for this technique because the temporal fascia is difficult to pierce with cannulas. This is the preferred method of the author. The second method is placement of the filler just below the dermis, in the subcutaneous tissue. Imperfections caused by uneven placement of the filler will be more visible because the tissue in this area is very thin. Bruising is more likely as well because there are multiple veins in this area. Using blunt cannulas helps to mitigate bruising but not eliminate it.

Risks associated with temporal fillers are similar to placement in all other areas: bleeding, bruising, infection, unevenness, unsatisfactory result, need for more filler, vascular compromise including necrosis AND BLINDNESS.  Fortunately, blindness is an extremely rare complication of fillers with somewhere between 100 and 200 cases reported in the literature. The most common “filler” sighted for this complication is fat, but it has occurred with all the fillers. It is the duty of the injecting physician to take all precautions to minimize this catastrophic risk. The etiology of blindness is occlusion of the retinal artery by filler that is obstructing its blood flow. Filler makes it to this area because there are natural occurring anastomoses between the external (face) and the internal carotid (ophthalmic) systems. Techniques to minimize blindness are:

  1. Slow injection of the filler which prevents retrograde flow of filler
  2. Use of large cannulas or needles which makes entry into vessels more difficult. (Using cannulas has been shown to be significantly safer than needles because their blunt tip is less likely to result in an intravascular injection)
  3. Moving the end of the needle or cannula constantly to avoid a bolus injection within a vessel
  4. Aspiration prior to injection to see if there is a flash of blood, indicating a intravascular location

Sculptra is ideally suited for correcting the temple defects. When placed at the level of the periostium (the author’s preferred method), it creates a very long lasting correction (at least 2-3 years) formed by collagen and neo-osteogenesis. More importantly, it is the only filler in which aspiration can be relied upon to produce a flash. Sculptra is nearly the consistency of water and will flash with a red reflux of blood if intravascular. The viscosity of all the other fillers makes this technique an unreliable indicator for testing where the tip of the needle is. That makes Sculptra much safer for use in this area.

For improving temporal volume loss, Sculptra will produce a long acting and natural appearing correction with a safety profile that is superior to all other fillers on the US market.

Hyperhidrosis of Face, Body, and Axilla can be Treated Permanently using The Infini

Hyperhidrosis, excessive sweating, affects about 3% of the US population, which is about 10 million people. There are many areas affected by this disease, with the most common being the axilla, or underarm. Less common areas are: Face, body, hands, and feet. There are significant psychosocial implications of hyperhidrosis which can lead to isolation, depression, and lost job opportunities.

Measures recommended to try prior to initiating more aggressive measures are: Prescription grade antiperspirants, ionophoresis, or oral anticholinergic drugs. The downside to these measures are they are effective for only the lesser forms, and are temporary in nature. Botox is highly effective, but it’s duration is about 6 months and it is fairly costly, $1200-1500 per treatment.

More permanent measures include surgery, Miradry, and the newest treatment, Infini. There are 2 types of surgery available. The easier of the 2 is going into the axilla with either a laser or liposuction, after it is fully anesthetized, and destroying the sweat glands with heat or removing them. The other type of surgery enters the chest cavity and is called endoscopic thoracic sympathectomy (ETS). These 2 procedures are fairly invasive and have several risks. The Miradry, is a microwave device that is attached to the underarm after it has been injected with lidocaine. The treatment then consists of heating the area for several minutes which ultimately causes destruction of the sweat glands. It is usually repeated a second time. Result are long lasting and fairly consistent. Typical costs for Miradry are $3000 for the 2 sessions. One other consideration is that (except for Botox) these treatments are only effective for axillary hyperhidrosis.

Infini brings a whole new prospective to the hyperhidrosis treatment paradigm. Infini can treat all areas of hyperhidrosis (except for the hands and feet with current protocols) with minimal risk. The heat from the Infini – High Intensity Focused Radiofrequency (HIFR) is placed at the level of the sweat glands. These glands reside at the deep dermal layer or upper subcutaneous level. Using just topical anesthesia, the procedure can be performed with minimal discomfort in about 15 minutes for both axilla. There is no downtime or activity restrictions. It can be performed in all skin types. Areas of the face and body can be treated safely as well. The destruction of the sweat glands (apocrine and eccrine glands) is nonspecific, so there is not total erradication of the sweat. It is estimated by clients that they get 50 – 75% improvement in their sweat in one treatment. Results will be permanent because once the glands are destroyed, they don’t grow back. Most people are happy after only one treatment, but for further improvements, 2 or 3 total treatments can be performed. Results are seen in a few as 7 days.

The advantages of Infini over Miradry are:

  1. Pain is much less. There is no need for blocks with Infini and there is no pain afterwards.
  2. Swelling is also much less. Most Infini clients have no change to their social activities or workout regime.
  3. Cost is less. The cost for Infini treatment for a permanent solution is about the same as one treatment with Botox (6 months duration). Miradry is usually $3000 for 2 treatments. The Aesthetic Clinique charges $500 per treatment.
  4. There is no hair loss. One of the side effects of Miradry is hair loss. For a male patient, this isn’t always desirable.
  5. Infini can be used in areas which the Miradry can’t be applied. Body and facial hyperhidrosis can easily treated with the Infini but not the Miradry.

To summize, for a low cost, low risk, well tolerated permanent treatment for hyperhidrosis, the Infini seems to be the obvious choice for those who can’t be controlled with topical or oral medications.

What Differentiates Dr. Weiner from the Majority of Other Filler and Botox/Dysport Providers

  1. Dr. Weiner is Board Certified in Facial Plastic Surgery and is an expert on the anatomy of the face. He trained, and was a faculty member, at the number one rated Otolaryngology/Head and Neck Surgery Department in the country at The Johns Hopkins Hospital.
  2. He started injecting Botox in 1994. His initial uses for Botox were for spasms of the vocal cords and neck, as well as excessive muscle tension, particularly in the TMJ area. Even prior to FDA approval for cosmetic use, Dr. Weiner was using Botox for improving wrinkles around the crows feet and forehead in the late 90’s.
  3. Dr. Weiner is a physician trainer for injections techniques of: Sculptra, Restylane, Restylane Silk, Restylane Lyft, Bellafill, and Dysport.
  4. Dr. Weiner is a lecturer for Galderma (Restylane Family of Products, Sculptra, Dysport) and Suneva (Bellafill)
  5. Multiple techniques (cooling, vibration, small needles) are used during the injections to minimize the discomfort without the use of “dental blocks”
  6. Dr. Weiner is on the physician’s advisory board for Allergan (Botox, Juvederm, Voluma, Kybella)
  7. Dr. Weiner is a Key Opinion Leader (KOL) for Bellafill.
  8. Dr. Weiner is the only one that injects neuromodulators and fillers at The Aesthetic Clinique
  9. Dr. Weiner has experience with all the FDA approved neuromodulators (Botox, Dysport, Xeomin, Myobloc) and fillers (Restylane, Restylane Silk, Restylane Lyft, Juvederm, Voluma, Radiesse, Bellafill, Sculptra, Belotero, Prevelle Silk, Evolence (off market), and Cosmoderm (off market).
  10. Dr. Weiner uses exclusively blunt tipped cannulas for his filler injections (except Restylane Silk in lips) since 2012. Cannulas are much safer and lead to less bruising, less discomfort, less complications, and less downtime. Less than 5% of providers use cannulas.
  11. Fillers, neuromodulators, and lasers are all Dr. Weiner does at the Aesthetic Clinique for the past 10 years. He is completely focused on Aesthetic Medicine.
  12. Dr. Weiner has participated in 2 clinical trials for Juvederm.
  13. If there is bruising after treatment, Dr. Weiner offers complimentary laser treatment with the Excel V. This is a couple minute procedure that decreases the duration of bruising from up to 2 weeks, down to 1 or 2 days.
  14. All patients are photographed with TouchMD, which allows for patients to see their own before and after photos either online or on a phone app.
  15. 3D photos are taken of all filler patients to show the volume improvements much more precisely than 2D photos.
  16. There is an extensive library of videos on Dr. Weiner’s YouTube channel that shows his techniques so patients can learn what to expect during their visit. Gain confidence and trust even before the actual visit.
  17. Dr. Weiner is a Presidential Champion Level for Galderma, the highest volume level for their products: Restylane, Restylane Silk, Restylane Lyft, Sculptra, and Dysport.
  18. Dr. Weiner is a Platinum Plus Level for Allergan Products: Botox, Juvederm, and Voluma.

Commonly Asked Questions About Lip Filler Problems

  1. My lips are swollen, lumpy, and a little uneven, when will they get better? This is the most commonly asked question on Realself.com. The lips take about 7-10 days to settle down after getting filled. Restylane Silk will swell the most of all the fillers. Juvederm, and Restylane are the most commonly used fillers and the swelling and lumps will all even out gradually over the first week. Sometimes there is asymmetrical swelling, and that usually evens out too. Elevating the head of bed will help lessen the swelling. Unless there is bruising, ice will not change the swelling, nor will antihistamines. The swelling is most often related to the HA filler absorbing water from the surrounding tissues. On an extremely rare occasion, the lips and surround tissues swell abnormally, and this is called angioedema. This most often occurs in people that take a blood pressure medicine that is in the “ACE inhibitor” family. If this occurs, immediate attention is needed by your doctor or the emergency room.
  2. I’m very bruised, when will it go away? Bruising is related to technique, not the filler itself. Bruising can take up to 10 days to go away. Early bruising can be treated with a laser (VBeam or Excel V) to decrease the duration to 2 or 3 days. It is best to stop all supplements, anti inflammatories, fish oils, vitamin E, or all other medications that can thin the blood a few days before injections if possible. Aspirin takes 12 days to get out of the system. Cannulas help minimize bruising as does careful technique, but bruising isn’t always avoidable. Arnica will help bruising too.
  3. My upper lip is very full, is this normal, I look like a fish or duck? There is an art to filling the lips. The upper lip should be smaller than the lower lip by the golden ratio of phi, 1:1.6. If the doctor does not abide by normal anatomic ratios, the lips look done and abnormal. It does not happen to most people and is unrelated to the product injected. It is poor technique by the injector. In ethnic people, sometimes a 1:1 ratio does look normal, but never when the upper lip is larger. Click here to learn about perfect lip anatomy.
  4. Can the corners of mouth be turned up, I always look sad? The corners of the mouth can be lifted with properly placed filler. Also, an injection with a neuromodulator such as Botox or Dysport can be injected into the depressor angularis oris, DAO, to relax the muscle pulling the corners down. Often, support is also needed in the above the upper lip in the triangle of volume loss near the corner. Also, injection into the corner (commisure) is needed.
  5. I’m not happy with my lips after injection, what can I do? First thing is to discuss with your injector. After waiting the 10 days, lips that still have bumps, look odd, or are uneven, can be dissolved with hyaluronidase. This is not a precise procedure, so fine tuning is not possible. Most often, one treatment is needed but sometimes 2 are needed. Sometimes a little filler can be added to make things more symmetric. Asymmetries are very frequently noticed after injections by patients, but after careful review of photos, were present before the procedure too.
  6. I have severe pain, days after the injection. Pain should not be present after about a day or 2 from the procedure. This needs to be discussed with your injector. Concerns would be possible injection, or herpetic outbreak.  Severe overfilling can cause this too.
  7. What can be done for my upper lip lines, “smokers lines”? Upper lip lines, “smokers lines”, are some of the hardest wrinkles to treat. This occurs even in non smokers and is mostly a volume related problem. Best treatments include filler placed horizontally in the white lip or ergotrid (with cannulas), a fine bead of filler along the vermilion border, and a small amount in the lip body. Adding Botox in small amount help too. Don’t expect elimination, just improvement. Longer term solutions are laser resurfacing with ablative lasers, Infini, or dermabrasion.

What Everyone Is Missing About Neothetics (NEOT) Lipo 102 Drug Candidate…Potential Blockbuster Status

Lipo 202 for abdomenal fat reduction with injections.

Lipo 202 for abdominal fat reduction with injections.

Removing and reducing fat in Americans is a huge industry in the Aesthetics market. There are multiple ways to do this:

  1. Suction (traditional) Liposuction
  2. Laser Liposuction
  3. “Tickle” (vibration) Liposuction
  4. Water Liposuction
  5. Freezing the Fat (Coolsculpting)
  6. Heating the Fat (Vanquish, TruSculpt, Sculpsure, Ultrashape, Liposonix)
  7. Chemically with Injections (Kythera’s Kybella, Neothetics 102, 202)

There are positives and negatives to all the above methods. Some are more aggressive but have more downtime and risk. Pain is a limiting factor for wide acceptance with others. Devices tend to cost the physician $80,000 and up, which keeps costs high to patients. The public demands little to no downtime with reasonable costs.

Kybella’s FDA approval recently has opened up a new way to remove fat…using just injections. Kybella drug, deoxycholic acid, is a bile salt. It is normally excreted by the liver to aid in the breakdown of fat that is ingested. It has been shown to be effective in reducing the double chin fat through a series of injections. Most people will require between 2-4 treatments. The fat cell that is affected is permanently killed. That doesn’t mean your chin will stay the same after you are done with treatment. Residual fat cells will enlarge, if there is an overall weight gain due to eating habits, exercise change, or other systemic disease. There are already trials going on to use Kybella for other areas and it is just a matter of time that it will be approved for the excessive abdominal fat. It seems like a great way to remove fat…but there is one catch. There is swelling and discomfort for a few days at least. Most will overlook this minor point, but it is just this issue that makes room for Neothetic’s Lipo 102 to become a blockbuster. Neothetics doesn’t cause the fat cell to lyse (burst open) and therefore leads to significantly less inflammation and swelling.

Neothetics is researching Lipo 202 for abdominal fat reduction and Lipo 102 for fat reduction in the eye area for Graves disease patients (off label use for treating cosmetic unsightly fat bulges around the eye is obviously their intention). Neothetic’s Lipo 102 and 202 are both made with salmeterol xinafoate. Salmeterol is an asthma drug, a beta adrenergic agonist. In layman’s term, this drug acts like adrenaline (epinephrine). Fluticasone is a strong steroid and helps reduce swelling and is added to Lipo 102. The way Lipo 102 and 202 work on fat is that the salmeterol mimics exercise of the fat cell, by increasing the metabolism of the cell. Glycerol and fatty acids are expelled from the fat cell because it percieves (it is tricked into believing) that the body needs these energy sources. This will result in shrinkage of the fat cell. Just as with Kybella, multiple treatments are needed.

NEOT, Neothetics, Lipo 202 causes fat cell shrinkage

NEOT, Neothetics, Lipo 202 causes fat cell shrinkage

Neothetics NEOT Lipo 202 causes reduction of abdominal circumference

Neothetics NEOT Lipo 202 causes reduction of abdominal circumference

One of the big questions is: “How long do results last with Lipo 102 or 202?”. This question is being researched in a follow up study to the phase II study on abdominal fat using Lipo 202. Although a concern to investors, whether or not the results are long standing or not is almost irrelevant in the authors opinion. For a procedure that is 5 minutes from start to finish, with very little downtime, it’s perfectly acceptable to require touch ups months after treatment. This is the norm for Botox, dermal fillers, laser procedures, and skin tightening procedures.

The hidden gem with Neothetics is Lipo 102. There is currently no easy way to treat fat around the eye without surgery. Lasers have been tried and were abandoned because of numerous complications. If there were a way to reduce bulging fat around the eye with injections, it would be a HUGE drug. Kybella has too much swelling to be considered for this area. The eye cannot tolerate post septal swelling (within the orbit) without risk to visual loss. It is conceivable that the procedure would be similar to getting Botox around the eye, but in a slightly different area, with little to no downtime. Again, the need for touch ups would be perfectly acceptable to most patients as long as pain, risk, and downtime are minimal.

Neothetics’ Lipo 202 for treating abdominal fat in less than 5 minutes with injections seems like a great story. However, Lipo 102 has an even greater potential and without competitors for treating the bulging eye fat. With the recent acquisition of Kythera by Allergan, the other 2 large players in the aesthetics industry, Galderma and Merz, may want to have a competitor to Kybella. A fat busting injectable seems to fit in well with the offerings of either company, but it’s the authors opinion that Merz will eventually be the buyer of Neothetics later this year. With Kythera being bought by Allergan for $2 Billion, and Neothetics $146 Million Market Cap, with $70 Million in cash, it makes the buy out all more likely. In addition, there were several insider buys at the IPO price of 14 when NEOT went public late last year. There have been no insiders selling after the IPO despite the stock’s dip to just under 6 a few weeks ago. Since the purchase of KYTH by Allergan, the stock has moved up to 10.73 on large volume.

Disclosure: Dr. Weiner is a share holder of Neothetics (NEOT) and was a shareholder of Allergan (AGN) and Kythera (KYTH). At the time of posting this blog, NEOT had closed at 10.73.

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