bellafill Archives | The Aesthetic Clinique

Does Radiofrequency, RF Microneedling, or Lasers Affect Hyaluronic Acid Fillers?

While there are number of studies suggesting that lasers and RF do not affect fillers, a recent article by Dr. Weiss opened up the debate again. In his paper he stated that biopsies showed evidence of heating around the filler. It did not evaluated the changes in the filler volume over time. He concluded that the filler was at risk to be affected by the heat. Dr. Davin Lim’s recently published study contradicts Dr. Weiss, and showed with RFM, there was no affect on fillers (biopsy proved) at multiple different energy levels.

The heat from RF Microneedling reaches approximately 65-75 C for 100 msec to up to 3-4 seconds depending on the device and parameters used. This is the “hottest” version of RF delivery used in aesthetics. This compares to the sterilization process of the fillers at the (Galderma) manufacturing plant of 110-120 C for 15-20 minutes.

Lasers can heat the tissue to a higher level, up to 100 C, but again, it is for milliseconds at best.

Conclusion: There should be no concern regarding placement of HA fillers with RF Microneedling or lasers, at any level of the dermis or subcutanous planes on the same day. Furthermore, there will be no effect on previously placed HA filler. As a side note, PMMA has to be heated to 160 C to cause changes to it’s structure. While the exact temperature is unknown for calcium hydroxyapatite, it is significantly higher than HA, so it too is safe from RF and lasers.

2019 UPDATE: State-of-the-Art Acne Scar Treatments

Acne scarring has significant debilitating effects on one’s overall self-worth and confidence. Millions in the US are affected. There have been improvements in techniques and energy devices in past few years which have led to better outcomes for acne scar treatments.

Subcision – This is process of breaking up deeply tethered scar bands associated mainly with atrophic/rolling scars. Subcision has be performed for acne scars for decades and just using this procedure alone has proven to lead to significant acne scar improvements. Recently there have been a couple publications suggesting that cannula subcision had better outcomes, less downtime, and less discomfort than the traditional method of using a Nokor needle. A cannula has a blunt tip so it is also safer – less chance for cutting a nerve or blood vessel than the knife-like edge of the Nokor needle. In the study, both patients and the performing doctor rated the results better when using the cannula. Subcision is particularly important, in Dr. Weiner’s opinion, to be performed prior to any energy device for tethered scars. This is based on the fact that RF and laser will preferentially travel through collagen – which is high is water content – than fat or most other tissue. Scars are predominantly collagen, so it makes sense to cut the connection of the scar to the deeper tissue. Through personal communication with Dr. Davin Lim, biopsies he performed have shown scar band that reach the deeper fat pads from tethered acne scars. Transmission of the energy through the scar can theoretical lead to collagen contraction and deepening of the tethered scar. Sometimes fillers are placed at the time of the subcision to improve the volume loss associated with the scarring. Some hypothesize that putting a “spacer of filler” might improve results as well. Dilute lidocaine during the initial passes allows for this procedure to be well tolerated.

TCA CROSS – TCA (Trichloroacetic Acid) is a chemical peel used to improved acne scarring by placing minute quantities in the scar using a toothpick. CROSS stands for Chemical Reconstruction of Skin Scars. The most common use of this procedure is for ice pick and small boxcar scars. The process of causing a controlled chemical burn, allows for the body to heal from the deepest part of the scar towards the skin surface. This makes the scar smaller in diameter and shallower. Usually a series of 3-6 treatments are needed, with 3-4 weeks between treatments. There will be some mild scabbing for a few days which needs to be kept moistened for best results. Risk include widening of the scar or post inflammatory hyperpigmentation (PIH).

Radiofrequency Microneedling – This technology (RFM) has been available in the US for about 6 years and has revolutionized acne scar treatment. Using needles which are insulated, energy is delivered into the scar tissue directly and bypassing the epidermis, for the most part. The insulation protects the skin surface from heating so darker skin type individuals are at much less risk of PIH (post inflammatory hyperpigmentation) vs a laser treatment. The needles allow for deeper penetration than lasers as well. Overall, downtime is less than ablative lasers in most individuals (when insulated needles, proper technique, and appropriate settings are used). With acne scarring affecting darker skin types disproportionately, this is an excellent alternative to lasers. The Genius has recently been FDA approved and is now the “best of bread” RF microneedling device. There is now impedance feedback from the needles which allows for improved and exact energy delivery. The resistance in the tissues being treated is measured and this is important because throughout one’s face, there are differences, as well as between different individuals. Also, as tissue are heated or subcised, the resistance changes. Prior to Genius, there was no idea of how much energy was being delivered. There is now an accurate total energy for each pulse and a cumulative total. Other improvements include needle design-sharper, stronger motor, and feedback regarding quality of each pulse fired.

There is a myth that needs to be busted. Deeper does not mean better for acne scars.

The needles must stay within the scar for best results. If the needles go beneath the dermis, there is a risk for heating the fat and fat loss. Let it be known that the actual depth of the needles in most RFM devices is less than the settings, and becomes less accurate, the deeper the settings are. There is inherent resistance of the skin to penetration and many needles aren’t sharp enough or motors aren’t strong enough to get to the desired levels in the time required. This has also been addressed with the Genius and it’s depths are very accurate after extensive testing.

In addition, higher energy levels on any device which doesn’t monitor impedance, can actually result in very little energy delivered. Once the tissue is heating beyond a critical level, the resistance becomes so high that energy output cuts off. However, when higher energy levels are desired when using the Genius, the energy is adjusted to the increasing impedance and it is successfully delivered.

Fillers – Fillers are a very integral part of improving acne scars. They are extremely useful for the atrophic scars and the lipoatrophy associated with these scars. The aging process leads to dermal thinning and fat atrophy, which makes the acne scars appear worse, even if active acne has long been controlled. Fillers need to be injected deeply for correcting large areas of volume loss and superficially in minute quantities for focal defects. A hyaluronic acid filler will give about 12 months of improvement vs Bellafill which can give near permanent improvements. Bellafill does require a skin test to see if one has a allergy to the bovine collagen (0.5% chance) which needs 3-4 weeks to determine. There is some who feel fillers in areas of subcision will prevent re-adhesion of the scars. Most failures from other treatments are related to not recognizing the need to fillers to improve the acne scars.

Lasers – Erbium/CO2 ablative lasers still are beneficial for acne scars but have more downtime and risks vs RFM. Deeper skin imperfections are not improved with lasers and require fillers. These devices are best reserved for more superficial scars, mainly boxcar scars. Non ablative lasers are less affective but safer and in the author’s opinion give very minor results.

Microneedling – Also know as “Collagen Induction Therapy” CIT, has become popular in recent years. There are rollers available for home use and then there are medical grade devices which go to depths of 2mm or deeper and create thousands of penetrations per second. Rollers should be not be used at home for 2 reasons – questionable sterility at home and they tear tissue more than the in-office devices. Often these treatments are combined with topicals and PRP. It is highly recommended to not use any products on the skin which would normal not be injected. There have been many cases of infection and granulomas from these practices. Even when done in the office with PRP or amniotic membrane products, the efficacy of this procedure is minimal, and should be reserved for only mild acne scarring.

PRP/Amniotic membrane products – There is some date to support that better results and faster recovery with less side effects if PRP or amniotic membrane products are used during acne scar treatments. There is a movement more towards amniotic/placental products and away from PRP because there are more growth factors/healing properties in these vs PRP.

LLLT – There is a plethora of studies to suggest that using low level laser light (LLLT) is beneficial to results and healing times. The most researched device is Healite, and this should be performed immediately following all acne scar procedures which use energy devices. It calms the skin and improves circulation.

Acne scarring procedures are continuing to improve as technology and techniques evolve. One must understand that results require months to fully appreciate and multiple treatments (3-5 or more) are often needed to optimize results. Expectations need to discussed with providers/patients so that all are on the same page as to what one can achieve with treatments.

Dr. Weiner is an Acne Scar Center of Excellence designated by Bellafill and is a specialist on acne scars. He is a lecturer and trainer for Bellafill. He has become one of the leading authorities on Radiofrequency Microneedling and travels the globe lecturing on this technology. He performed the FDA trails for the Genius. He recently authored a chapter on RF Microneedling which soon will be published in the Facial Plastic Clinics of North America. He also wrote a recent chapter on Radiofrequency Safety and Complications which will be part of a book titled “Complications in Minimally Invasive Facial Rejuvenation: Avoidance and Management” by Paul Carniol, MD

Top 5 Procedures to Improve Your Jawline in 2019

It appears that 2019 is the “Year of the Jawline”. A strong jawline is interpreted as a characteristic of strength, beauty, virility, and power. In a study of S&P 500 CEO’s, 95% were considered to have a well defined jawline. With advances in aesthetic technology and techniques, achieving that perfect profile is becoming easier, with less downtime, costs, and risks. Here are the top 5 procedures to improve your jawline:

5) Neck Lift/Lower Face Lift: With incisions placed behind the ears, this surgery can be performed with just local anesthetic. Downtime is about a week or 2. For severe jowling and platysma bands, this will give the best results.

4) Ablative Laser (Erbium/CO2) or Renuvion(J Plasma): These procedures have significant wound care for a week or more. The skin is stimulated by the heat of the laser/plasma to contract and create collagen. Healing time can take weeks and redness can persist for months. Risks include infection, scarring, hyper and hypopigmentation. Procedure is limited to the face, and can’t achieve fat reduction.

3) FaceTite: A minimally invasive procedure whereby radiofrequency is placed below and on the skin surface. Requires tumescent anesthesia only for most patients. Procedure takes about an hour, more if liposuction is added. There is minimal bruising and swelling afterwards but requires a compression chin strap for a few weeks (constant for the first 48-72 hours). The RF energy causes deep collagen stimulation and contraction as well as dermal collagen remodeling. Jowls and submental fat can be attended to with RF and liposuction.

2) Genius/Infini: Radiofrequency is placed into the dermis (and subdermis for jowls/submental) using insulated microneedles. The downtime is 2-3 days but it requires 3 treatments. The procedure takes about 30-45 minutes. Most patients require just topical anesthetic with about 5-10% opting for Pronox (Nitrous Oxide – laughing gas). Results take 3 weeks to start to become apparent and 3 months for their full effect. It is the least downtime, least invasive of the top 5 procedures, outside of #1.

1) “reJAWvenation(TM)”: Using microcannulas, filler is placed along and below the jawline to enhance and restore the profile. Typical procedure time is 10 minutes or less and there is no downtime. The amount of syringes required varies, but can be anywhere from 1-6. Multiple sessions are required for the patients with severe jowling. While there is no actual removal of fat from the jowls or submental area, these areas appear improved due to the lifting by the filler as well as camouflaging the trouble areas.

It is left up to the individual as to what procedure is right for them. Lifestyle, degree of correction desired/needed, and finances all factor into one’s decision making. Dr. Weiner is world renown for his “reJAWvenation(TM)” procedure and is known as the reJAWvenator.

(Threads are notably absent because the author believes the expense, duration, and results, don’t warrant them to be a consideration for jawline improvement.)

Subcision of Acne Scars – Revisiting an Old Technique

Acne scarring is a significant psychologically debilitating disease affecting millions in the US, approximately 1% of the adult population in one study. Treatments for acne scars include:

Lasers
RF Microneedling
Fillers
TCA Cross
Subcision
Microneedling
PRP (Platelet Rich Plasma)
PDO Threads (?)

Most of these techniques are based on trying to make the disorganized collagen in the scar to be more organized and natural. Using carefully induced tissue trauma with heat or microneedles (mechanical), the body initiates a healing process to smooth the scars.

Acne scars will often affect tissues deeper than the dermis. Fibrosis/scarring can affect the subcutaneous tissues and fat and lead to tethering of scar to the deeper structures. Lipoatrophy (fat loss) can occur as the result of the inflammatory mediators released from the acneic process. When heating from lasers and RF is applied, it is preferentially conducted through the collagen because the water content of collagen is high. Heating collagen will lead to collagen remodeling but also collagen contraction. If the collagenous attachments to the deeper tissue are not cut (subcised), there is actually potential for worsening the appearance of the scars with these heating devices.

A recent paper suggested that using a cannula to subcise acne scars is better tolerated, with less adverse events, and judged to have better results by the patients. This is Dr. Weiner’s (and acne scar expert Dr. Davin Lim’s per personal communication) preferred method of subcision vs using a Nokor needle. By subcising, the energy flow to the deeper structures is severed and harm to fat is less as is the risk of pulling some scars deeper. Placement of filler (Restylane Defyne, Bellafill) is often done simultaneously with the subcision to help elevate the scars and prevent reattachment of the scars.

Subcision has been around for decades for acne scar treatment. It is now even more important when energy devices are used to maximize the benefits of these treatments. The use of cannulas for this procedure leads to more comfort, less risks, and better satisfaction.

The Aesthetic Clinique has been designated an Acne Scar Center of Excellence by Suneva (Bellafill) and is considered an acne scar expert.

**(Subcision is also useful for treating cellulite as there are fibrous attachments from the skin which cause the dimpling.)

How to Minimize Risks of Vascular Occlusion and Blindness During Filler Injections

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

Know the major vascular structures and their landmarks
Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
Use cannulas whenever feasible, preferably 25/23g or larger
Avoid boluses, small linear threads are safer
Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
Injection onto periosteum is safest but does not guarantee a vascular free injection
Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
Retrograde injections are safer than anterograde injections
Dermal injections should be relatively safe
Avoid deep injections in the lips. Stay superficial to the muscles
An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
Have on hand 6-8 vials of Hylenex
Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.

Proper Sterile Technique is Critical for Optimal Dermal Filler Results

In surgery, sterile technique is “the law”. Any break in sterility places the patient at risk for a potentially life threatening infection. It is the duty for the surgeon(s), scrub tech, and circulating nurse to self report or call out any suspected or potential contamination risk. Immediate actions are taken to remedy the situation and to limit the risk to patient.

Why should dermal fillers be treated as anything differently? They shouldn’t! Fillers are semipermanent or permanent implants, and they must be administered in aseptic technique. The majority of injectors are not trained as surgeons and therefore don’t fully comprehend what sterile technique entails. Granulomas, one of the more serious complications from fillers, have now been traced to biofilms. Biofilms are latent bacteria that somehow get activated and present as infection or granulomas, months to years after the initial injection. Most often biofilms are deposited in the tissues during the initial injection procedure. Clearing infections or granulomas takes weeks or months to clear and often entails antibiotics, steroids, 5 FU, and hyaluronidase (if a hyaluronic acid was used).

The following guidelines should serve as a reference for physicians and nurses to minimize infectious complications during dermal filler injections.

The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
Never inject someone with a current/ongoing infection. Even if the infection is not in the area of the dermal filler, bacteria can seed the filler from distant areas through the bloodstream (bactermia).
If a patient is in the process of getting dental work or even dental cleanings, hold off on injections until after the work has been completed. Bactermia is well documented during dental cleanings. It is recommended to wait at least 2 weeks after fillers to get dental cleanings. The areas of filler placement will initially have increased blood flow (hyperemia) so it is best to wait until this settles down.
Skin should be prepped for injection with chlorhexidine, with Hibiclens being the preferred form by the author. Although isopropyl alcohol (70%) is effective in killing bacteria and fungus, it is only effective for seconds and becomes ineffective as soon as it evaporates. Hibiclens kills germs on contact and will give persistent bactericidal effects for at least 6 hours, and up to 24 hours. It will bond with the skin even after washing to give continued killing effects. Isopropyl alcohol doesn’t give this lasting bactericidal effect, so anytime after the initial cleaning that an unsterile glove touches the skin, that area is now contaminated. (Hibiclens must be kept out of the eyes because it can burn the cornea). Technicare is also a great antiseptic but the author doesn’t have experience with it. Too many patients are allergic to Betadine for it to be used routinely.
Do not use tap water when applying Hibiclens or to clean the face after completion of the injections. There are several bacteria, fungi, as well as mycobacterium in water which can seep through the injection ports and cause infection.
If the filler is prepared by mixing lidocaine or saline, this must be done in a sterile fashion. The female/female connector used to connect the 2 syringes together must not be reused. It can only be used for the current patient and cannot be sterilized for use on other patients. The tops of all the solutions used must be wiped with an alcohol wipe. Routine use of blending fillers opens up more avenues for filler contamination and must be done with the strictest of sterile technique. If any of the solution vials becomes unsterile, all future filler patients using that vial will become infected.
Blunt tip cannulas can be used for multiple injection sites ON THE SAME PATIENT and are not intended to be used for multiple patients. When changing the cannulas between syringes, they should be recapped first. It is not sterile technique to lay the cannula on an unsterile tray or even a sterile drape when uncapped. After a syringe of filler is removed from its sterile packaging, the areas touched with the exam gloves become “contaminated”. Therefore, the sterile drape is not a sterile field anymore, once the syringes is placed on it. Best practice is to cap the syringe every time it is laid down.
Blunt cannulas are much longer than needles and must be kept sterile throughout their entire length. The cannula is contaminated if anywhere along its length it touches non sterilized skin, gloves, or hair.
It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
Unless the gauze used during the procedure is specifically labeled as sterile, it is not, and introduces another route of contamination. Gauze that comes in sealed pull away packs and labeled as sterile is best to use. The author will take unsterile gauze, place in autoclave packs, and place in the autoclave to obtain sterility.
Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
If ice or devices for vibration are used to control discomfort, these should be cleansed with Hibiclens prior to applying to the skin. In addition, the areas where these were applied should be “re-sterilized” prior to injections.
When the procedure is complete, sterile water or saline on sterile gauze should be used to clean the patient. Again, if tap water is used, this can seep through the injection ports and lead to infection. Also, when soaking the gauze, best practice is to pour the water/saline over the sink onto the sterile gauze so as to keep the remaining fluid in the container sterile. By tipping the water/saline onto gauze that is covering the top, there is risk of contamination going back into the container.
Make-up should not be applied to the skin until the morning. At this point, the injection ports have all healed and there is no risk of contamination.
Dental procedures, even cleanings, should be postponed for at least 2 weeks.

Although the details above are fairly lengthy, any break from any step will lead to a possible source of granuloma or infection in the future. Strict sterile technique will lead to better outcomes and happier patients,

Dr. Steven F. Weiner’s 6 year Experience with Blunt Cannulas for Dermal Fillers

The value of volume replacement in the aging face is now universally recognized as one of the most beneficial procedures to restore youthfulness. The combination of sun exposure, aging, and genetics leads to collagen, fat, muscle, and bone loss. Reinflating the cheeks, lips, and tear troughs are routinely done by physicians across the world on a daily basis. Most of these patients will have a week or more of downtime – swelling, bruising, discomfort – but that doesn’t have to be. Blunt cannulas can minimize most of these side effects associated with filler injections and has become standard practice for Dr. Weiner for the past 6 years.

The benefits of blunt cannlas are:

There is only one insertion point to treat multiple areas. This equates to less intrusions through the skin and therefore a more comfortable procedure.
The tip is rounded and blunted. This very fact accounts for less bruising/swelling. When a blood vessel is encountered with the end of the cannula, the vessel is more likely to be gently displaced rather than punctured.
There is increased safety. A phenomenon termed “vascular occlusion” occurs when a filler is injected into a blood vessel. The filler then blocks the blood flow and can lead to necrosis (death of skin) or even blindness. It is much less likely to occur with blunt cannulas, particularly larger cannulas (23 or 25 guage), because they don’t enter blood vessels as easy as needles do.
Allows treatment in areas otherwise not easily accessible. Due to the safety of the cannulas, there are now areas of the face which are more easily treated. The superficial temporal area, supraorbital, forehead, piriform, periocular and lower eyelid are now routinely treated with cannulas whereas with needles, these areas were very precarious to inject.
Downtime is minimize. As a result of all the benefits listed above, most patients have significantly less healing time and are much happier after receiving their filler treatments with blunt “safety” cannulas.

If blunt cannulas have so much benefits, why are only 5% of the providers using them for dermal fillers? The art of using cannulas is not an easy one. Patience is required because directing the tip to the exact spot it is needed is not always easy. Remember, when the tip encounters an obstruction (vessel, ligament, collagen), it will need to traverse around it and not pierce it (as needles would do). This can be frustrating and lead to longer and less satisfactory results for the inexperienced cannula injector.

Dr. Weiner is one of the leading authorities on cannula injections of dermal fillers and has used them for over 6 years for nearly all of his injections. The cannulas provide a safe, comfortable, minimal downtime technique for volumizing the aging face, even with multiple syringes being used simultaneously.

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.

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).
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.
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.
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.
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)

Bellafill is a Unique, Safe, Long Lasting Filler

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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 5^th 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.

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

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.