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:
- Lowering of the eyelid and eyebrow
- Skin laxity in the periorbital and cheek area
- Changes to the overall 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:
- Slow injection of the filler which prevents retrograde flow of filler
- 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)
- Moving the end of the needle or cannula constantly to avoid a bolus injection within a vessel
- 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, 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:
- Pain is much less. There is no need for blocks with Infini and there is no pain afterwards.
- Swelling is also much less. Most Infini clients have no change to their social activities or workout regime.
- 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.
- There is no hair loss. One of the side effects of Miradry is hair loss. For a male patient, this isn’t always desirable.
- 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.
- 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.
- 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.
- Dr. Weiner is a physician trainer for injections techniques of: Sculptra, Restylane, Restylane Silk, Restylane Lyft, Bellafill, and Dysport.
- Dr. Weiner is a lecturer for Galderma (Restylane Family of Products, Sculptra, Dysport) and Suneva (Bellafill)
- Multiple techniques (cooling, vibration, small needles) are used during the injections to minimize the discomfort without the use of “dental blocks”
- Dr. Weiner is on the physician’s advisory board for Allergan (Botox, Juvederm, Voluma, Kybella)
- Dr. Weiner is a Key Opinion Leader (KOL) for Bellafill.
- Dr. Weiner is the only one that injects neuromodulators and fillers at The Aesthetic Clinique
- 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).
- 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.
- 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.
- Dr. Weiner has participated in 2 clinical trials for Juvederm.
- 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.
- 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.
- 3D photos are taken of all filler patients to show the volume improvements much more precisely than 2D photos.
- 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.
- Dr. Weiner is a Presidential Champion Level for Galderma, the highest volume level for their products: Restylane, Restylane Silk, Restylane Lyft, Sculptra, and Dysport.
- Dr. Weiner is a Platinum Plus Level for Allergan Products: Botox, Juvederm, and Voluma.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
Removing and reducing fat in Americans is a huge industry in the Aesthetics market. There are multiple ways to do this:
- Suction (traditional) Liposuction
- Laser Liposuction
- “Tickle” (vibration) Liposuction
- Water Liposuction
- Freezing the Fat (Coolsculpting)
- Heating the Fat (Vanquish, TruSculpt, Sculpsure, Ultrashape, Liposonix)
- 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.
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.
The concept of volume loss in the aging face is a relatively new realization by the aesthetic industry. Up until about 12-15 years ago, the dogma was correcting loose skin using primarily surgical approaches. Post surgical patients were very pleased parading around their newly tightened faces, free from wrinkles and sags, but prominently showing off their skeletonized features. There was no hiding the fact that something had been done, it wasn’t subtle, and it was obvious. Something didn’t jive with what the brain recognized as youthful or aesthetically pleasing. This dichotomy between what Plastic Surgeons and the brain thought was beautiful was due to the lack of understanding of the impact of volume loss on the aging face.
It is now widely documented that there is significant loss of volume in the face as one ages. Fat pads throughout the face become less prominent, and there is also bony resorption throughout the entire facial skeleton and jaw. Even if the skin didn’t stretch from gravity, there would be sagging related to loss of the structural support. A great analogy is in a youthful face, the dress (skin) and your body (facial structures) are the same size. An aging face wears the same dress, but the body is now a size or 2 smaller, so the dress doesn’t fit correctly.
How much volume loss occurs? Beginning at the age of 30, about 1-2 cc of loss occurs per year. However, it is so slow and subtle, and it isn’t until the late thirties or early forties that there is any noticeable changes. It seems to match the so called “tipping point” in women, just as they end their most “fertile” years. Doing the math, a person in their 50’s can have 20-30 cc’s of volume that needs replacing. Its up to the aesthetic physicians to combat this long standing evolutionary process, and keep women (and men) beautiful, well beyond their child bearing ages.
Fortunately dermal fillers can reverse the loss of volume that inevitably comes with aging foregoing the costs, downtime, and risks associated with surgery. The most recognized fillers, Restylane, Perlane, Juvederm, Voluma, are hyaluronic acid fillers. These all last about a year, with most of their longevity based on their ability to absorb water, hydrophillic characteristics. These are great fillers for small corrections around the eyes, lips, marionettes, and nasolabial folds. The cost/benefit ratio turns negative, once the number of syringes exceeds about 6. At this point, correction is still far from optimal, but the costs are significant. Also, in the author’s opinion, multiple syringes of HA filler give a “boggy” appearance to the correction, directly related to their hydrophillic nature.
The only filler that can correct large volume deficits in a cost effective manner is Sculptra.
Sculptra works by stimulating one’s own collagen to volumize the face “naturally”. Studies have shown Sculptra’s effect to last at least 2 years. The problem is, aging is always going to happen, so even after full correction with Sculptra, touch ups with one to two vials every 12 to 18 months are required. Not only does Sculptra produce a long lasting and natural result, it is a cost effective solution. When comparing Sculptra to an HA filler, one vial of Sculptra will volumize what approximately 4 (4 cc) syringes of an HA will do. The cost of Sculptra is usually about 1.5x the cost of a syringe of HA filler. It turns out that full volumization is usually about “1 vial per decade” with Sculptra. Sculptra should be considered the “workhorse” for replacing the structural loss of the face. Fine tuning, once the volume is replaced, is the job of the HA fillers.
Darker skin ethnicities are naturally better protected from the sun so the aging process is delayed (Skin aging is mostly related to sun exposure). These patients require less volume when compared to lighter skinned individuals. Also, severely sun damaged and unhealthy skin won’t respond quite as effectively in collagen production from Sculptra as the healthy, well protected skin, and will require more volume than the norm.
Although there is still a component of excess skin in the aging face, the primary cause of wrinkles and skin laxity is due to volume loss. Correcting volume deficits should be the primary focus of reversing the signs of aging. Of the fillers, Sculptra stands out from all the others in it’s ability to produce a long lasting, cost effective, and natural solution for large volume replacements.
Comparing Infini to Ulthera and Why Infini’s Technology is Superior for Laxity, Wrinkles, and Acne Scars
When it comes to skin tightening and wrinkles, there has been an increasing trend for the consumers to choose the less invasive approaches and opting out of surgery. Although results aren’t as dramatic, nonsurgical treatments offer less downtime, less risk, and less cost. These treatments are great for the people who are not quite surgical candidates because of very mild signs of aging as well as those that just want to delaying the sagging before it is even apparent. Then there are those who really are surgical candidates but can’t afford the downtime or are concerned about the looks of some of their peers who have had face/neck lifts.
The most recognized name for noninvasive skin tightening currently is Ulthera (Ultherapy). This technology uses highly focused ultrasound to cause a thermal coagulation zone beneath the skin without affecting the surface. This technology is akin to the one used to break up kidney stones or gall stones with ultrasonic energy (lithotripsy). The coagulation zones elicit an inflammatory response leading to collagen stimulation and contraction. This results in tissue tightening and wrinkle improvement. Ulthera was brought to market in 2009, with Dr. Weiner being one of the first 20 adopters in the US. Dr. Weiner has had significant experience with this device and with all the changes in protocols.
In 2013, the Infini was FDA approved and introduced in the US. This was a novel technology for the US, but it had been used in Asia for at least 1.5 years prior. Infini uses radiofrequency attached to microneedles to cause similar thermal coagulation zones as the Ulthera, below the surface of the skin. Dr. Weiner is the largest user on the Infini in the US and now lectures and precepts other physicians in it use.
The similarities of the 2 technologies:
- Both are fractional treatments (only treat a portion of tissue) which is safer and leads to faster healing.
- Both can treat at multiple different levels. While Ulthera is restricted to 3 levels, it is not uncommon for Dr. Weiner to treat at up to 5 levels with the Infini.
- Both have very little downtime – Ulthera has potential for bruising but otherwise no downtime. Infini has about 24-36 hours of redness and swelling. There are no activity or sun restrictions for either treatment.
- All skin types can be treated with both technologies.
- Both can be performed in the office with just topical – Patients who have had both technologies report that Ulthera had more discomfort in Dr. Weiner’s office.
- Both can improve skin laxity, particularly in the jawline. It is Dr. Weiner’s opinion that this is primarily due to fat destruction by both technologies. Both can reach into this layer (the Infini only if desired, Ulthera almost always by default with the deeper transducers).
- Both mechanisms of tightening are similar – create a controlled injury that leads to tissue contraction, tightening, collagen stimulation BUT the way the injury is produced is different.
- Both can be safely off the face – neck, chest, extremities, under arms (hyperhidrosis)
- Both are extremely safe technologies with very little side effects and don’t use lasers (so safer for the eyes).
- Both have better results with multiple treatments. Although Ulthera states one treatment is needed, the experience Dr. Weiner had with the technology was that better outcomes were seen with multiple treatments.
Comparing the differences of Infini versus Ulthera:
- Infini treatment of the face/upper neck lays down over 50,000 thermal coagulation zones VS Ulthera’s 16,000. It only makes sense that the more zones, the more results.
- Infini depths can be adjusted from 0.25 mm to 3.5 mm in increments of 0.25 mm. Ulthera has 3 depths: 1.5, 3.0, 4.5 mm. Using the ultrasound of the Ulthera, Dr. Weiner was able to measure skin depths over the face and neck. There were no areas of skin thickness greater than 2.5 mm in the entire face and neck (except in very thick skinned males in the upper cheeks). Therefore, MOST OF THE TREATMENT FOR ULTHERA IS BELOW THE LEVEL OF EVEN THE DEEP DERMIS. Only the 1.5mm transducer causes coagulation in the dermis. This is not included in most protocols, or if it is, is only a minor component. Studies have shown that the area of greatest collagen formation is in the deep dermis. Infini is able to lay the coagulation zones all throughout the dermis, including the deep dermis because of its ability to change it’s depths. The Infini can even treat different areas of the face at different depths, which is important because the face has significant variability of thicknesses between the forehead, eyes, cheeks, lips, jawline, submental, and chin area. Depths below the dermis injure the subcutaneous tissue, which is mostly fat. Fat is what we want to preserve, not destroy, except along the jawline and submental area.
- The treatment cost (consumable) of Ulthera for the physician is more than 10 times greater than for the Infini. The purchase price to the physician is also about 50% more for the Ulthera. The treatment time is also longer, sometimes up to 50% more for Ulthera. This all gets passed on to the patient resulting in Ulthera being about double the price of the Infini in most offices.
- Although Ulthera touts that deeper penetration causes contraction of the SMAS, to Dr. Weiner’s knowledge, this has yet to proven histologically. The deeper penetration does lead to more discomfort as well as potential for fat destruction. The Infini targets the dermis, particularly the deep dermis, the area for maximal collagen creation.
- Results seem to be more consistent with the Infini versus Ulthera. This seems to follow the science. More coagulation points in the correct zone of the dermis should lead to more collagen, more tightening.
- Superficial fine lines can be treated with the Infini but not Ulthera. In certain cases with skin type 1-3, shallow treatments of less than 1 mm can be used to treat these wrinkles and etched in lines. Ulthera doesn’t have this capability.
- Although there are some reports of Ulthera treating acne scars, Infini seems to be the best technology to treat these. It is probably the combination of the microneedles, RF energy, and adjustable depths that make it a superior technology to treat this difficult problem.
From about 2005 – 2009, Thermage was the most advanced noninvasive skin tighten device. This was replaced with Ulthera in 2009, which offered better, safer, and more predictable results because of precisely placed coagulation zones (albeit, maybe too deep). In 2013, Infini was introduce and it has been slow to catch on. However it is finally being adopted by the key thought leaders in the Aesthetic Industry. It will soon be recognized as the most efficacious noninvasive skin tightening technology on the market.
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:
- 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)
- 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.
- 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.
- 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.
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, phi, 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:
- Prominent tubercles in the middle of the upper lip, and either side of the midline on the lower lip
- A strong cupid’s bow and philtrum
- Corners of mouth that are neutral or turn up slightly
- Very little red lip visible on the lateral 1/3rd of the upper and lower lip
- The length between the columella and space between the lips should be about 1/2 of the length from the space to the chin
- The peak of the cupid’s bow is continuous with the philtrum
- The upper lip should project more than the lower lip when visualize on a lateral view
- A “Paris Curl”, lips curling up at their vermillion borders
- Phi 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.)
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.
- 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.
- 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.
- 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.
- 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.
- 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:
- Under the eye
- Nose and around the nasal ala (nostrils)
- Nasolabial folds
- 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.