State of the Art in Acne Scar Treatment – 2015

Dr. Weiner: Acne Scarring after 2 Infini treatments.

Dr. Weiner: Acne Scarring after 2 Infini treatments.

Acne affects 85% of people between the ages of 12 – 24.  There are various types of acne that range from simple black/white heads, papules/pustules, to the cystic breakouts.  It’s the cystic acne that leads to most of the scarring.  Acne scarring can have a impact on one’s appearance leading to a significant emotional toll.  Lack of self esteem, social withdrawal, negative self image, and depression have all been described by acne scarring sufferers. Acne scarring questions are one of the most frequently asked questions to the experts on Realself.com. It’s important for the medical community to address this problem for the overall well being of a significant segment of the population.

It might seem obvious, but in order to treat acne scarring, the active acne must be controlled.  It’s the author’s opinion that acne can be controlled with topical medications combined with lasers.  A newer treatment, recently popularized by Dr. Weiner, has been the use of Botox/Dysport for controlling the sebum production in the skin.  Please see my blog for more details about acne treatments.

Fresh Acne Scarring Treatment

When acne scarring is still red, treatment is easier and results are better.  The primary treatment for scars in this stage is vascular lasers.  It has been found that early scar formation can be reversed using these lasers over several sessions.  The author’s choice of lasers is the Spectra Q Switched Laser – Gold Handpiece.  This offers a quick (5 minute) nearly painless treatment.  It should be done 4-6 times in general.  Other laser options are the Excel V or the VBeam.  Some small smoldering areas of acne are treated simultaneously with these lasers as well.

Long Standing/Persistent Scarring Treatment

Longer standing scars are harder to treat than early red scars.  Collagen has been laid down in an inappropriate, disorganized manner.  Treatments are directed at breaking up this collagen and for it to reorganize in a more natural manner.  There are a few ways this can be done:

  1. Lasers: There are ablative (tissue is removed) and non ablative (tissue is heated) lasers.  There is more downtime, more risk, and more results with the ablative lasers.  Darker skin types are at risk for darkening of their pigmentation (hyperpigmentation)
  2. Subcision: Using a needle or similar, the physician goes under the scars and cuts them from their deeper attachments. This process has been used for decades and has minimal risk and downtime.  It’s the authors opinion that unless something is placed in the area where scarring was cut, the scar will reform between the “sticky edges” as it does in all other surgical wounds. Bellafill is a permanent filler that was recently FDA approved for acne scars.  Dr. Weiner suggests placement of Bellafill in these subcised scars to keep the edges from tacking back down, and to fill lost volume in the rolling acne scars.
  3. Microneedling Fractional (Controlled Depth) Radiofrequency: This technique uses RF energy to break up and reduce the scarring with coagulation.  The healing process leads to a more organized collagen matrix.  The best in class device for this category is the Infini from Lutronic.  The insulated needles, variable depths, and fractional delivery make it extremely safe for all skin types with minimal downtime and risk.
  4. Platelet Rich Plasma (PRP):  PRP has been shown to improve healing times and results in many areas of orthopedics.  As of yet, there are no studies that definitively say that PRP can help acne scarring but there are several case reports that it improves outcomes.  It is probably an effective addition to laser or RF procedures when treating acne scars with no known detrimental side effects.

Dr. Weiner Recommendations for Mature/Long Standing Acne Scars:

The most effective energy based treatment for acne scars seems to be the Infini. Results from ablative lasers (CO2), and non ablative lasers (Fraxel 1550) don’t seem to match the Infini’s results in his clinical experience.  Patient satisfaction is higher with Infini, with much less downtime and a safety profile, particular in darker skin types, unmatched by the lasers.

For persistent defects after 3 or more treatments with the Infini, subcision with Bellafill administration is then recommended.  It typically will take about 2 treatments, 2 months apart, to get optimal results with this method. This is only practical on about 10 – 15 lesions at a single session.

PRP can improve healing times and may improve results.

Remember that acne scars “won’t go away” but will be improved with the treatments mentioned.

Creating the Perfect Lips with Restylane Silk

Restylane Silk Dr. Weiner

Lips before treatment with Restylane Silk

Restylane Silk, Dr. Weiner

Dr. Weiner Lip Enhancement, Restylane Silk

Before Lip Enhancement

Lip Enhancement with Restylane Silk.

Lip Enhancement with Restylane Silk.

Enhancing lips has become a very popular cosmetic procedure.  Most of the press has been negative because of the abundance of poorly performed injections, particularly on celebrities.  Instead of improving ones looks, and sensuality, they become a turn off, negatively affecting one’s attractiveness if not done properly.  A slew of new terms for these lips has arisen:  “Fish Lips”, “Sausage Lips”, “Trout Mouth”.  Patients go into the doctors office with aspirations of “Angelina Jolie” lips and leave with “Lisa Rinna’s” lips.  Unfortunately, the bad outcomes of these celebrities and close friends, scares off a number of interested women, fearing they too will end up like Goldie Hahn from the “First Wife’s Club.”

Fortunately, with an experienced injector, and the newly approved filler Restylane Silk, cosmetically attractive lips are well within reach for most clients.  Restylane Silk’s advantage lies with it small particle size. This enables the injector to more precisely place the filler, for better contouring, and with less chance of leaving lumps or bumps.  Also, because it is superficially placed, there is less bruising and less discomfort during injections.  It’s not just the filler though, it takes the skilled eye, technique, and knowledge of an experienced injector to get the lips just right.

Knowing the esthetically correct dimensions and landmarks of the face goes back to Leonardo Da Vinci, in the 1400’s. He recognized the golden ratio, pi, that equals 1.618.  Throughout the face, he saw that relationships between spacing and dimensions of the face, and all were related to the pi ratio.  In the lips, the golden ratio is found between the upper and lower lip, with the upper to lower lip ratio being 1:1.618.  In African Americans, this can be close to 1:1 and Asians are somewhere in between.  Several other aesthetically appealing features of the perfect lips are:

  1. Prominent tubercles in the middle of the upper lip, and either side of the midline on the lower lip
  2. A strong cupid’s bow and philtrum
  3. Corners of mouth that are neutral or turn up slightly
  4. Very little red lip visible on the lateral 1/3rd of the upper and lower lip
  5. The length between the columella and space between the lips should be about 1/2 of the length from the space to the chin
  6. The peak of the cupid’s bow is continuous with the philtrum
  7. The upper lip should project more than the lower lip when visualize on a lateral view
  8. A “Paris Curl”, lips curling up at their vermillion borders
  9. Pi ratio: length between cupids peaks: length between corner of mouth and cupids peak

What goes wrong with lips that look obviously done or unattractive?  The simple answer is that ratios and landmarks are ignored. Several common errors are:  upper lips that are bigger than lower lips, lower lips that project more than the upper lip, tubercles (or other landmarks) that are obliterated, and no attention to the cupids bow.  Also, enhancing lips to the “age appropriate size” is part of the art of an experienced injector.  Selecting the appropriate filler is important too.  Fillers other than Restylane Silk, are too thick to be added superficially in the lips without the risk of being noticeable or palpable.  Silk can be injected just beneath the surface of the lip and not be perceptible. Fine tuning is much easier with this technique rather than the deeper injections that have more associated bleeding, bruising, and swelling.

The take home messages are that achieving desirable, sensuous lips requires a skilled injector with a keen awareness of natural ratios and landmarks. Using the newly approved FDA filler for lips, Restylane Silk, allows for greater control and results that can’t be achieved with the other, more viscous, hyaluronic acid fillers.

(In the older patient: It is very hard to restore lips to their youthful state when there is severe volume loss, multiple upper lip lines, and loss of the normal curvature of the lips.  The lip muscle in a young lip forms a “J”, creating a natural curl in the lip.  In some patients, this elongates into an “I” shape, making it difficult to create the natural shape with a filler injection without it appearing abnormal.  In these patients, the author gradually enhances over several months and this seems to lead to better outcomes.)

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

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

Website: http://www.theclinique.net

What is Vascular Occlusion or Vascular Compromise from Dermal Fillers?

Dermal fillers of becoming the fastest growing area of aesthetic enhancements.  In general, the procedure of injecting the filler is safe, with very little downtime, and with visible results. However, there is a rare, but extremely significant potential risk, that patient’s, medical staff, and providers need to always be aware of:  Vascular Occlusion or Vascular Compromise.

What is Vascular Occlusion or Vascular Compromise?  This is caused when the dermal filler is either injected into an artery or around an artery to the point that the blood flow is reduced or completely stopped.  The area of skin or other tissues that are supplied by the affected vessel will start to die without the necessary blood supply.  Almost always, if this complication occurs, there will be an immediate blanching (paleness, tissue turns white) when the blood flow is interrupted, often in areas far away from the actual injection.  Recognition is key to a favorable outcome.  If this occurs, the injector must stop immediately and take measures to resolve the problem.  Pain is usually associate with vascular occlusion.  There have been cases reported that occurred 12-24 hours after being injected but almost always it occurs immediately.

If no treatment is initiated to improve the vascular flow, the skin will start to appear dusky, a bluish tint, with fine reticulations (lace like) to areas WELL BEYOND THE SITE OF INJECTION. This occurs within 24 hours.  If still no therapy is done, the skin will start to die, turning black, and sometimes there is an associated infection.  At this point, scarring will likely occur and surgery is often needed to remove dead tissue and/or to close the wound.

If there is a recognized vascular event, several steps should be initiated.

  1. Hyaluronidase, an enzyme that dissolves Hyaluronic Acid, should immediately be injected in the area, and into the vessel if possible.  Some doctors advocate using hyaluronidase even if the filler is not an HA filler because it will dissolve the naturally occurring hyaluronic acid hopefully improving blood flow.
  2. Massaging the area will help mostly if the filler is externally pushing on the vessel.  This might move the filler away from the vessel to re-establish flow.
  3. Blood thinners will allow the blood to flow thru a smaller vessel or to go around a blockage.  Aspirin and possibly heparin are recommended by most physicians.
  4. Vasodilators such as nitroglycerin are also recommended by most physicians.  There is a question as to whether this might allow the blockage to travel further down the vessel.
  5. For severely vasacular compromised tissue, hyperbaric oxygen treatments are beneficial.

Administering dermal fillers with blunt tip cannulas will minimize the chances of a vascular event.  The fact that the ends of the cannulas are rounded, makes it very difficult to enter a vessel, particularly with the larger cannulas.  To the author’s knowledge, there have been no reported events of vascular occlusion with cannulas larger than a 27g.  There is still the possibility of causing external pressure on vessels, but this seems to be a low risk, and mainly associated with fillers that expand, like the HA fillers.

The areas prone to vascular events are areas of the face that are called “watershed areas”.  These are areas where there  is poor collateral blood supply.  These areas are:

  1. Glabella
  2. Under the eye
  3. Nose and around the nasal ala (nostrils)
  4. Nasolabial folds
  5. Upper lip

The catastrophic complication of blindness from dermal fillers is also a form of vascular occlusion.  This is when a bolus of dermal filler is injected into an artery in such a way that it travels back to the vessels supplying the retina. Not only does the injector have to be within an artery, but he/she has to exert a force of injection that overcomes the blood pressure (retrograde flow) in the vessel. This is an extremely rare occurrence but unfortunately is almost universally irreversible.

Prevention is key to avoiding a vascular event with dermal fillers.  The safest fillers are the HA fillers which can readily be dissolved with hyaluronidase.  Cannulas should be used in all high risk areas in the author’s opinion.  If using needles, aspiration to see if the tip is within a vessel should be done before all injections in these areas.  Careful counseling of patients and staff is needed to recognize a potential event early to get the best possible outcome.

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

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

Website: http://www.theclinique.net

Why Juvederm is NOT a good choice for the Tear Trough or Eye Area

Juvederm is one of the most popular dermal fillers in the US.  As with most fillers, it is only FDA approved for the nasolabial folds, but is used “off label” in other areas of the face.  Although Juvederm is a very safe filler for use around the face, there are certain characteristics that make it the wrong choice for filling the “tear trough” and areas around the eye.

Like many of the popular FDA approved fillers, Juvederm is a hyaluronic acid (HA) filler.  The other commonly used HA fillers are Restylane, Perlane, Voluma, and Belotero.  One of the characteristics of HA fillers that extends their longevity is that they are hydrophilic.  Hydrophilic means “water loving” which translates into the HA fillers absorbing up to 10 times their volume with water from the surrounding tissues.  Although all the HA fillers have this characteristic, Juvederm is the MOST HYDROPHILIC of the dermal fillers mainly because it is has the highest concentration of HA. This is a disadvantage around the eye because it often results in PROLONGED EDEMA around the eye.  All the HA fillers have been known to do this but it is particularly common with Juvederm.  Dr. Weiner has seen this problem with people that have been injected with Juvederm in the tear trough even up to 3 years earlier.  RealSelf.com is replete with stories and pictures of very unhappy patients with this Juvederm problem.

Another disadvantage of Juvederm in the eye area is related to its cohesivity.  This is the ability of the product to bind to itself.  Juvederm has low cohesivity, which means it tends to spread to the surrounding areas, causing a correction to areas beyond the injected area.  This is fine for some areas, but in the tear trough, which is a very small area, doctors need precise control of the filler.  The physician wants to know that when he places the filler in the tear trough, it will stay exactly there, and it doesn’t with Juvederm.

Fortunately, hyaluronidase is an antidote for HA fillers, and can be used for dissolving fillers with poor cosmetic results. For Juvederm, dissolving with hyaluronidase is harder and requires more treatments than the other HA fillers.  Some believe this is related to the higher cross linking in Juvederm than other fillers.  Nonetheless,  Juvederm can be successfully reversed even in instances where the chronic edema has been present for several years.

Around the eye and tear trough area, the HA filler of choice should be Restylane.  There are some physicians that are happy with Belotero and Restylane Silk.  Another great option is Sculptra but only in very experienced hands.  Remember too, that cannulas are a much safer option for the injection in this area, with less risk, less bruising, and less downtime.

Most Frequently Asked Questions about Infini, RF Skin Tightening from Lutronic

  1. What makes Infini different than other RF devices?  The long answer can be found at my blog post.  The short answer is:  fractional not bulk heating, needles are insulated, needle depths are variable, coagulation occurs for maximal collagen stimulation, and the epidermis is safely protected from the heat.  This allows for a very safe treatment for all skin types, that is also very effective.
  2. What long term complications have you (Dr. Weiner) seen?  With over 1000 treatments, I have seen no long term complications.  No skin atrophy, no unintended fat loss, no scarring, and no pigment changes.
  3. How long does a treatment take?  With an experienced provider, the face treatment takes about 45 minutes, and if the neck is included, add another 15 minutes.
  4. How long is recovery?  The initial redness subsides very rapidly in the first hour.  It takes about 24-36 hours to resolve, as does the swelling. Rarely, patients report extend redness for a few more days.
  5. What are the restrictions after the Infini?  Skin care must be only the prescribed creams.  No make up until the morning and care with touching the skin with unclean hands or towels.  There are no activity or sun restrictions!
  6. How many treatments are needed?  Good question.  It is variable.  To get maximum benefit, the general consensus is 3.  Some people might be happy with only one, but that is uncommon.  Younger patients wanting only preventative treatments can get one yearly. Acne scarring clients should consider at least 3, and might be more satisfied with 5 or 6.
  7. How does Infini affect fillers? If the fillers are injected deeply below the skin (sub Q, or deeper), such as is done by Dr. Weiner using the blunt cannulas, the fillers should not be affected.  Sculptra and Bellafill are not affected at any depth and are frequently done at the same time as the Infini by Dr. Weiner.  If the filler is placed in the dermis, they are at risk of being degraded.
  8. How long should I wait between treatments?  Consecutive treatments can be done as close as 3 or 4 weeks. If this is not possible because of your schedule, don’t worry, the final results are not affected.
  9. How painful is the Infini?  Most patients will rate the majority of the procedure a 3 or 4/10.  The areas which might be higher are over the bone, such as the forehead, cheeks, and jawline.  We have recently implemented changes in technique to make all but the forehead more comfortable.  The forehead can be excluded if desired.  All patients report no discomfort when the procedure is complete.
  10. Can the Infini be used on other parts of the body?  We routinely treat the neck and chest in conjunction with the face treatment.  Other areas we have treated are arm laxity, knee area, and scars from abdominal surgery.  Stretch marks have been treated but results are variable.  We have successfully treated hyperhidrosis with the Infini as well. Bottom line is that when appropriate depths and settings are used, the Infini can be used on all areas of the body.
  11. How many passes are performed on each area?  Each area is treated at least with 3 depths and 2 passes for each depth.  Some areas area treated at 4 or 5 depths.
  12. What patients would you exclude?  Very few patients wouldn’t be candidates.  Patients with pacemakers should not be treated.  If there is metal in an area of the face, the skin overlying this area can not be treated.  Patients on blood thinners can be treated but will get bruising.  We try to hold all thinners if it is possible prior to treatment.  Aspirin needs 12 days for it’s action to be completely reversed on the platelets.  Patients with severely sun damaged skin will theoretically respond less than a person with healthy skin.
  13. Why is Infini safe for darker skin patients?  The Infini is protective of the epidermis, where the pigment cells are, because it’s needles are insulated. Also, the depth can be adjusted so the heat from the RF stays in the dermis, below the most superficial layer.  Other devices are either not insulated, or try to push heat through the skin, potentially damaging the pigment cells.
  14. How does the Infini compare to lasers for treating acne scars?  The Infini is safer than a laser, with less downtime, and no risk to the eyes.  As stated above, the darker skin patients can be treated more safely with the Infini when compared to a laser because a laser will heat the upper layer of skin, the epidermis. Lasers have the risk of pigment changes (darker or lighter).  Results from Infini appear to as good, or even better, than lasers for acne scars.
  15. How long do results last?  This is a difficult question and will be different for each patient.  The collagen created will last at least 7 years.  However, the amount of collagen is variable, and depends on the overall skin health, patient’s health, smoking habits, age, tanning, sun exposure, and lifestyle.  It is usually recommended to have a “touch up” performed every 12-18 months.

Various Acne Treatments offered by Dr. Steven Weiner

For Restylane Silk…Size Matters…Smaller is Better

Before Lip Enhancement

Lip Enhancement with Restylane Silk.

Lip Enhancement with Restylane Silk.

Traumatic Lip before Restylane Silk Treatment

Traumatic Lip before Restylane Silk Treatment

One Day after Restylane Silk Treatment

One Day after Restylane Silk Treatment

Dr. Weiner performing Lip Enhancement with Restylane Silk

Dr. Weiner performing Lip Enhancement with Restylane Silk – Before

Immediately after Dr. Weiner injected Restylane Silk

Immediately after Dr. Weiner injected Restylane Silk

Restylane has become the number one trusted dermal filler in the world.  With over 20 million treatments worldwide, and numerous publish studies, Restylane’s safety and efficacy is well established.  It is composed of hyaluronic acid (HA), a naturally occurring substance that is found in skin and joints.  It’s duration of action is about 6-12 months, depending on the location it is placed.  (My other blog explains duration in more detail)  Crosslinking, a process that joins adjacent strands of the HA, is essential, because the breakdown of the HA would occur in weeks without it.

Restylane is composed of similarly sized HA particles, with a concentration of 100,000 per ml.  Perlane, a “cousin” of Restylane, is exactly the same as Restylane, except that it’s concentration is 10,000 particles per ml.  Both of these products have been on the US market for years, Restylane since 2005, and Perlane since 2007.  Restylane Silk, the newest US FDA approved filler, is composed of 500,000 HA particles per ml.

This means that the Restylane Silk HA particle is 1/5th the size of the regular Restylane HA particle, and that’s the reason behind it’s magic.

Although Restylane Silk was approved in the US in 2014, it has been used under the name Restylane Fine Lines for over 15 years in Canada.  There has been a huge experience in Canada using this product to improve superficial fine lines and in LIP ENHANCEMENT.  In the US, there are now only 2 FDA approved fillers for the lips, Restylane, and Restylane Silk.  Silk is also approved for the perioral area (area around the mouth).  It’s the author’s opinion that part of the problem lip enhancement has been disappointing to many patients is that US physicians didn’t have access to the proper filler.  Fish lips, sausage lips, uneven lips, overfilled lips have dissuaded many potential patients from ever trying lip enhancement.

The small particle size of Restylane Silk allows the skilled and experienced physician to add product in the very superficial aspect of the lip, in the submucosa.  This was impossible with other fillers without lumps being visible.  The product spreads in this plane, so only a couple points of injection are needed in each quadrant of the lip.  By being so superficial, and with only a couple injection points, the discomfort associated with the injection is markedly decreased.  In addition, by staying superficial, and not deep, the risk of a bruise is significantly less.  Very precise alloquots of Restylane Silk can be placed along the border of the lip (vermillion), cupids bow and peaks, in the tubercles, and corners of the mouth much easier than the larger particle HA fillers.

The addition of Restylane Silk to the aesthetic physician’s armamentarium fills a necessary niche that was missing in lip enhancement.  Patients can now anticipate less bruising, less discomfort, less lumps, with better and more natural results, thanks to the smaller particle size of Restylane Silk.

Move over VBeam, There’s a New Gold Standard for Treating Reds, Rosacea, and Vessels…The Excel V Laser

It was 1986 that the VBeam was originally FDA approved to treat red skin lesions.  That’s almost 30 years ago.  It’s been a good run, but it’s time to give up the number one spot to the Excel V laser.  There are several reasons that the VBeam is inferior to the Excel V which will be elaborated below.

The Excel V is actually 2 lasers, a 532 nm KTP laser and a 1064nm YAG laser.  (The Vbeam is a 595nm Pulsed Dye Laser).  With the 2 wavelengths, several more possible treatments are available that the VBeam cannot do.  Typically, the longer the wavelength, the deeper the laser is capable of going.  So basically, by the addition of the 1064 laser, spider veins, and deeper blue vessels of the face and legs can now be treated.

In clinical studies, the 532 wavelength has been shown to have a 5 times higher affinity for oxyhemoglobin than the 595 wavelength.  What that means is the Excel V’s laser is much better absorb by the red color (hemoglobin)
in the vessels being treated, resulting in more heat getting into the vessels, and thus, better outcomes.  Side by side studies of the 2 lasers confirm this.

Cooling is necessary to protect the skin with both lasers.  With the VBeam, a blast of cryogen is sprayed simultaneously with the laser pulse.  This technology is called DCD, Dynamic Cooling Device, and is not perfect.  If the laser is not held perpendicular to the skin, the cooled area might not correlate to the exact area of the laser pulse and therefore possible complications can result.  The Excel V has a sapphire cooling tip that allows for cooling of the exact area that is treated.  It also allows for pre, parallel, and post pulse cooling, leading to a safer and more comfortable treatment, with less risk to the skin.

Several user improvements make for a shorter, more time efficient treatment for both the physician and patient.  The warm up time for the VBeam can be 20 minutes, but for the Excel V, it is less than 1 minute.  Changes during the treatment with either spot size, power, or pulse duration, all require recalibration by the VBeam, but are pretty much done on the fly (Real Time Auto-calibration) with the Excel V.  Changes to spot size are frequently done during laser treatments, and with the VBeam, this requires removal and replacement of the handpiece compared to the Excel V which is just done by hitting a button on the computer interface.  There are much more spot sizes available with the Excel V vs the VBeam as well, allowing for more accurate treatments.

The following can be treated with the Excel V:

  • Telangiectasias
  • Angiomas
  • Rosacea
  • Generalized redness
  • Blue vessels around eye, forehead, temple
  • Port wine stains
  • Vascular lakes
  • Spider Veins
  • Reticular Veins
  • Scars
  • Skin tags
  • Bruising
  • Redness associated with acne
  • Activation of Levulan
  • Hair removal in small areas for all skin types (even type 5 and 6)
  • Benign pigmented lesions
  • Photofacial

The Excel V has now replaced the VBeam as the Gold Standard for treating all vascular lesions.  It’s safe, diverse (2 lasers), and gives more effective treatments, making it an easy choice for both patients and physicians.

How Long Do Dermal Fillers Last…..It Depends!

It happens everyday.  Patients ask how long they can count on their dermal filler lasting.  The problem is, is that there is no quick and easy answer.  There are a number of variables that factor into filler longevity, with the ultimate unknown being that there is no way that a physician can determine how one’s body is going to degrade a particular filler.

In the US, the majority of patients are injected with Hyaluronic Acid (HA) fillers.  The commonly known HA fillers are:  Juvederm Ultra, Juvederm Ultra Plus, Restylane, Perlane, Voluma, and Belotero.  The differences between the HA fillers are their manufacturing process, and the concentration of the HA in the filler.  The harder the HA is for the body to break down, the longer it will last.  A larger particle of HA has less surface area then multiple smaller particles taking up the same space.  Less surface area means there is less area for the cells to “chew up” the HA.  In general, larger particles will last a little longer than smaller particles.  Another factor in HA fillers is how tightly the particles are bound together.  Cross-linking, adding bonds between molecules of HA, has been shown to significantly add longevity.  All HA fillers are a combination of cross-linked and non cross-linked HA.  Too much cross-linking leads to a filler that is very hard to inject, and has led to more complications (in a filler that is no longer on the market).  Non cross-linked fillers last only 3-4 months and are hardly used anymore.  One last variable in HA fillers is their ability to attract water, their hydrophylic properties.  The more they attract water, the longer the HA filler gives a correction.

The fillers that are collagen stimulators, tend to lead to longer longevity.  Fillers in this group are:  Radiesse, Sculptra, and Artefill.  While studies have shown a very mild collagen response to the HA fillers, the visible volume correction with the HA fillers is the gel, not the collagen.  With the collagen stimulators, the body responds to what is injected by creating an inflammatory response and lays down collagen.  Until the particle is degraded by the body, collagen will continue to be produced.  Radiesse is made of calcium hydroxylapatite, and is the shortest duration in this group.  Artefill should be considered a permanent filler, because its component, Poly Methyl Methacrylate (PMMA), does not get broken down by the body.  Sculptra has consistently given about 2-3 years duration in studies and in the authors experience.

The location in the face a filler is injected is one of the most important factors to determine longevity. Areas where there is more movement, there is faster breakdown.  In order of increasing duration in the face, the order is (in the author’s experience):

  1. Lips
  2. Marionette
  3. Nasolabial Folds
  4. Tear Troughs
  5. Cheeks
  6. Temples

(Forehead, nose, earlobes are variable)

A couple more very important variables that should be mentioned.  The more filler that is injected, the longer it will last.  This applies to all the fillers.  Also, filler doesn’t stop working all of a sudden.  It takes months of gradual loss to notice a difference in volume.  In fact, even when the patient believes there is no longer results, biopsies have proven that there is still filler present.

After all the above explanation, the author’s experience with the commonly used fillers is:

  1. Lips:  HA fillers give about 4 months, longer with recurrently injected lips.
  2. Tear troughs:  HA’s – about 9-12 months, Sculptra and Artefill – years.  Juvederm could last years and should never be injected in tear troughs.
  3. Nasolabial:  similar to tear troughs
  4. Temples:  HA’s – 12-18 months, Sculptra and Artefill – years
  5. Cheeks:  HA’s – 18 months, perhaps 2 years with Voluma, Sculptra and Artefill – years

Remember that individual results are unpredictable.  These are generalizations and offer no guarantee as to how long a patient’s results will last.  There are many variables that factor into longevity that are listed above, not to mention how each individual responds, degrades, a certain filler.

Amazing Things That Can Be Done (By the Experts) With Dermal Fillers

This is the golden age for minimally invasive cosmetic procedures.  Who would have ever thought 15 years ago, that procedures done in the office in a matter of 20-30 minutes could result in demonstrable improvements in one’s appearance with results lasting, in some cases, a year or more?  Without the need for downtime, anesthesia, or significant costs, cosmetic procedures have flourished, with many people who never would consider enhancements, “dipping their toe” in these procedures.  The concept of “preventative maintenance” has spurred the younger generation to start earlier, with smaller, less dramatic, but noticeable procedures as well.

At the forefront of the wave of cosmetic enhancements are dermal fillers.  When Restylane was FDA approved in 2003, a revolution in the field was born.  Although the main focus was to improve the nasolabial folds, the “smile” lines, in its inception, the broad “off label” use of it, along with subsequent FDA approval of other fillers, treatments have spread to just about every area of the face.  There are now about a dozen dermal fillers on the market, with the majority of them based on hyaluronic acid, a naturally occurring substance that is found in skin and joints.  Hyaluronic acid fillers (Restylane, Perlane, Voluma, Juvederm, Belotero) provide a soft, very well tolerated fill, with an extremely safe profile.  There is also a level of security knowing that these fillers are generally completely reversible, using the widely available enzyme, hyaluronidase, that can dissolve hyaluronic acid, in minutes to hours.

Although less popular, it must be mentioned that there are other dermal fillers which are FDA approved, each with their own niche market.  Radiesse is composed of microspheres of calcium hydroxyapatite, and is known as a very robust filler, that has a very high G prime, a measure of it’s lifting ability.  Sculptra is composed of Poly L Lactic Acid (PLLA), also naturally occurring as a sugar in the body, and is known as a collagen stimulator.  Its use is for global, long lasting, volumization of the face.  The longest duration FDA approved filler is Artefill.  It is composed of microspheres of Poly Methyl Methacrylate (PMMA) which is a synthetic molecule.  Artefill is considered a permanent filler and works as a collagen stimulator, similar to Sculptra.

The understanding of the aging face has made great strides in the last decade.  It is now widely understood that loss of volume is the primary cause of the aging face.  Leading this volume loss is the shrinking of the multiple fat pads of face, primarily of the cheek and periorbital area.  This is why aging often begins to show around the eyes.  Gravity contributes to our aging problems and often manifests itself by the descending of these fat pads. Relegated to a less relevant problem than 15 years ago, is the aging related to excess skin.  Plastic Surgeons have tightened loose skin for decades during facelifts, often leaving people appearing skeletonized and hollow, but without wrinkles.  It is now understood that most of the redundant skin can be improve with proper volumization of the offending fat pads, and most facelifts incorporate this during surgery presently.  (In the author’s opinion, most of the patients undergoing the knife could have had their concerns addressed using a combination of fillers and skin tightening devices.)

The common manifestations of volume loss are:

  1. Temporal hollows
  2. Loss of cheek volume
  3. Tear trough deformity
  4. Excessive crows feet and forehead lines
  5. Low hanging eyebrows
  6. Hollowness of the eye (orbit)
  7. Jowls
  8. Poorly defined jawline
  9. Small lips
  10. Dropping of nasal tip
  11. Lip lines (smokers lines)
  12. Corners of mouth dropping causing sad look
  13. Saggy neck
  14. Elongation and narrowing of the face

All the above mentioned aging effects can be improved with dermal fillers.  Expertise is required to recognize exactly what areas need to be treated to replenished the lost volume, while still maintaining a natural appearance.  It’s been shown that the brain can recognize less than a 1mm change in brow position.  When corrections are not done properly, it is very easy for the brain to catch it.  Poor corrections of the lips probably stands out in most people’s memory, where they are either too full, out of proper proportion, or there was poor attention to landmarks.

Experienced dermal filler injectors are no longer “chasing lines”, the symptom of aging.  The goal is to lift and replenish lost volume by addressing the cause of the aging of the face.  Of note, even the neck’s problems can be improved by properly injecting the face.  Choosing a doctor that has experience in recognizing the areas affected by volume loss and has the knowledge and expertise to improve those areas is essential for optimal patient outcomes.

 

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