Not All PRP is Actually PRP…Do The Math!

There is an increasing recognition of the power of PRP (Platelet Rich Plasma). Platelets contain a high concentration of growth factors and immune modulators which have been shown to improve wound healing, improve hair growth, and possibly rejuvenate skin and other areas of the body. The “Vampire Facial and Facelift” have become popular procedures in medspas and refers to applying PRP into the skin surface with microneedling devices (facial) or more deeply with injections (facelift). Wound care centers have great success at expediting healing in chronic would which have failed conventional therapy. Many orthopedic joint problems have been improved or resolved with PRP injections into the joint area. Cardiac surgeons have noted a significant drop in wound problems by using preventative treatments with PRP. Hair growth has been documented with PRP scalp injections and improvement in hair transplant results are found by bathing the follicles in PRP prior to implantation has been noted. Laser resurfacing has been shown to heal faster when PRP is applied immediately to the skin. It is clear, PRP has significant benefits for multiple medical ailments.

What’s even better news is that using PRP is extremely safe! Essentially what PRP consists of is using your own blood and isolating a concentrated portion of it, the platelets. This is where the lack of regulation can be abused. Since the FDA has considered PRP to be “minimal manipulation” of taking something out of the body and then placing it back, there is no FDA approval needed and oversight is minimal. The problem then becomes that there is tremendous variation is what one office considers PRP versus another office and concentrations of platelets can be all over the map.

Blood is essentially 2 components – Red blood cells (RBC) and plasma. In normal individuals, RBC’s make up about 40% of the blood (hemoglobin of 40). Plasma is serum and platelets, the other 60%. So in a 10 cc blood sample, about 5cc can be considered useful for making PRP. Through a process of centrifugation, the RBC’s can be removed, and the concentration of platelets can be increased. It has been shown by studies, that the “sweet spot” for PRP is a platelet concentration of 6X (1.5 milllion/ml) the normal value found in blood. Higher concentrations have been shown in some studies to actually be counter productive and lead to more inflammation, and lower concentrations have less improvements.

So, doing the math, if only a 10cc tube of blood is drawn, only about 1cc of useful PRP is obtainable if shooting for the 6X goal. A cc of PRP is 1/5 of a teaspoon…not much. Much higher volumes are needed to get an adequate amount of PRP to be useful (the author uses 60-120cc blood volumes). There was one study presented at the IMCAS conference in Paris over 2 years ago (which the author attended) which looked at the concentration of platelets using 14 different devices. In about half the devices, the platelets weren’t even concentrated more than what is found in normal blood. Only half the remaining were in the therapeutic “sweet spot” of 6X concentration.

Bottom Line: If only 10-20cc of blood are being drawn, then the final product is either not the ideal concentration of PRP (6X) or the volume of PRP is too small to be useful!

There is no doubt that there are clear benefits to PRP in the areas of wound healing, orthopedics, and hair restoration. However, with the lack of FDA oversight, many patients who think they are receiving therapeutic doses of PRP, are actually getting suboptimal doses or just plain plasma, which has little to no benefits. When seeking out PRP treatments, make sure that provider knows the concentration of platelets that his/her device is producing, and the math makes sense.

Cellfina: Improving Cellulite Dimples For Years

There have been hundreds of potions, lotions, and procedures claiming the end to cellulite. All have basically failed…until now. Finally, there is a way to cure those cellulite dimples on the buttocks and posterior/lateral thigh. The procedure is called Cellfina, and at the ASLMS in April, 2016, there was data presented showing 3 years of persistent improvements. One presenter suggested that the very early test subjects from 5 years ago had similarly persistent results.

Cellfina is done in the office using just local anesthesia. Start to finish, it takes about 1 1/4 hours, and patients are able to drive themselves home. There is very mild discomfort during the procedure (4/10) and is associated with the numbing of the areas to be treated. Afterwards, no pain medication is required, and some go back to work immediately afterwards. Most will take the remainder of the day off and head back to work the following day. Physical activity can resume after 1 or 2 days. Bruising is the most common side effect, but can be treated at the Aesthetic Clinique with the Excel V to cut down the duration to a couple days. There have been no long term side effects noted in any of the study patients.

The procedure starts with pictures and identification of the dimples that need treated. These are only able to be treated on the back part of the thighs and buttocks.  After marking the sites, the patient lays prone on the table and the areas are cleaned/prepped. The Cellfina suction plate is placed over the marked areas and controlled injection of tumescent anesthetia is placed. After about 15 minutes, the same suction apparatus is placed on the sites again, and a motorized reciprocating needle-like device is inserted. This device releases the fibrous bands which are pulling the skin down. By releasing the bands, the skin elevates and viola… gone dimple. This process is continued until all the areas marked are treated. Pads are placed on the treated areas because there may be some leaking of the tumescent fluid for the next day or so.

Results begin to appear within a few days. Results are stable after a couple months for years to come.

With years of research behind Cellfina, it appears that there is finally a long term solution for correcting the nagging dimples associated with cellulite. With minimal side effects and downtime, it seems likely to be a very popular procedure, given that over 85% of females over adolescence have some degree of cellulite.

The Top 5 Procedures for a Youthful Appearance

There is so much information available on the internet that is becomes extremely confusing to the average person as to what is the right thing for them to do. While genetics, race, and lifestyle play a role in how one ages, there are many universal features of the aging face which are inescapable. While it is common to be asked “should I do this or that”, the best results are always a combination of several different procedures.

  1. Wrinkles:  Botox/Dysport relax hyperdynamic muscles which cause wrinkles with movement. There’s a reason this is the most popular cosmetic procedure in the world. It is quick, extremely effective, very little downtime, minimally painful, and with a high satisfaction rate. Common areas treated are the “11’s” or frown lines, crows feet, and forehead lines. Duration of effect is about 3-4 months.  Early preventative treatment is effective in delaying lines which appear at rest (etched in lines).
  2. Loss of Volume: Volume loss is inevitable. The aging process in combination with sun exposure causes the face to lose fat, bone, muscle, and collagen. Starting at the age of about 32, a cc or 2 of volume is lost per year. It begins to become visible at about age 38-40. This is called the “tipping point” in women, about the time when fertility starts to drops off. Sun protection and darker skin types will delay this lost volume up to 10 or 15 years. Replacing lost volume is done with fillers. The most common fillers are made with Hyaluronic Acid (HA) which is a natural component of skin. Examples of HA fillers include Juvederm, Restylane, and Voluma. Longer lasting fillers are Sculptra and Bellafill.
  3. Pigmentation/Redness: Inevitably, skin gets exposed to the sun and “sun damage” occurs. The sun is responsible for destroying collagen in the skin, causing it to thin, and lose elasticity and hydration. Another effect is causing vascular fragility leading to visible vessels and redness. Melanin is produced as the body makes an effort to protect the skin resulting in “sun spots” or hyperpigmentation. Lasers are effective in treating these conditions near painlessly. For reds, VBeam or Excel V Lasers are the gold standards. Up to 3 treatments might be needed. For a few small patches of pigment, a Q Switched Laser or Excel V is used. For more diffuse patches of pigmentation, laser resurfacing (Fraxel) or IPL are good options.
  4. Skin Laxity/Sagging: The combination of gravity and loss of skin elasticity can result in the need for skin tightening. Surgery will give the most aggressive result for this. Alternative treatments with less downtime, less risks are Infini, Thermitight, or Ablative Lasers.
  5.  Fat Accumlation: Aging leads to changes in metabolism and fat storage. Patients develop fatty collections which become difficult to diminish despite aggressive workout routines and diets. There are now multiple noninvasive approaches to removing fat permanently with no downtime. Larger more diffuse areas require a technology called Vanquish ME. Smaller areas can be spot treated with either Coolsculpting, Sculpsure, Ultrashape, or Liposonix. In the submental area, fat can be reduced with an injection called Kybella, a new handpiece from Coolsculpting (CoolMini) or with Thermitight. Of course surgery including liposuction or tummy tuck has been the gold standard for decades and is the best option for those desiring the most aggressive approach.

Drum roll please….The top picks from the 5 categories (Dr. Weiner’s Choices):

Dysport, Sculptra, Excel V, Infini, Coolsculpting (CoolMini)

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.

Blog: https://stevenfweinermd.wordpress.com/

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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.

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