Belotero Archives | The Aesthetic Clinique

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.

Blog: http://stevenfweinermd.wordpress.com/

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

Website: http://www.theclinique.net

Facebook: http://www.facebook.com/TheAestheticClinique/

Hyaluronidase – The “Magic Eraser” for Hyaluronic Acid (Juvederm, Restylane, Voluma) Dermal Fillers

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Hyaluronic Acid dermal fillers are the most popular fillers used worldwide. In the United States, the commonly used HA fillers are:

Juvederm Ultra and Ultra Plus
Voluma
Restylane
Restylane Lyft (Perlane)
Restylane Silk
Belotero

The beauty of HA fillers is that they are very well tolerated because hyaluronic acid is a component of skin, so it is a naturally occurring substance. It’s a soft product, and will last anywhere from 4 months, to up to 2 years, depending on the brand used, and the location it is placed.

Another key attribute to the HA fillers popularity is that it can be completely dissolved with an enzyme called hyaluronidase. It is manufactured from either bovine (cow) or ovine (sheep), so there is a remote possibility of having an allergic reaction to the commercially available products (Vitrase, Hydase, and Amphadase). There seems to be a crossover with people that are allergic to bees for these animal derived products. Hylenex is a recombinant form of hyaluronidase that is the human form that is the preferred form of Dr. Weiner for there are no allergies, yet it is a bit more expensive.

Hyaluronidase is useful for dissolving HA filler in the following instances:

The filler was over done/”over filled” and it is not aesthetically pleasing
There is prolonged swelling, particularly around the eye and most often with Juvederm
An infection has occurred in the area of prior filler
The filler is lumpy or has nodules and doesn’t respond to massage and time (especially lips)
Rare possible allergic reaction to the HA filler
When there is vascular compromise secondary to the HA filler injection which can be caused by external compression on a vessel or intraluminal (within the vessel) injection

My experience with hyaluronidase has been mostly with patients that have had Juvederm injected in the tear trough area from another facility. I strongly recommend that Juvederm not be injected in this area because of the risk of prolonged edema. The reason this happens more with Juvederm is speculated to be due to its ability to attract more water, higher concentration of HA in the product, and because it spreads more diffusely than the other fillers.

When injecting emergently for vascular compromise, at least 200 units (more is better) should be injected in and around the original site of injection of the HA. It has been shown that extravascular hyaluronidase is able to traverse the vessel wall to make it intraluminal, useful knowledge for the cases where the HA is within the vessel. (Blindness needs emergent Ophthalmology evaluation and might require arteriogram for placement of hyaluronidase. Even with such extraordinary measures, blindness is almost always permanent.)

When injecting hyaluronidase, it is mixed with lidocaine by the physician, so it is a fairly comfortable procedure. There are a couple limiting factors with the injection. It is not as precise as the filler injection, so it can remove some of the filler that you wanted to stay along with the unwanted filler. Also, dosing/how much to use, is not an exact science. It may take more than one treatment to dissolve the HA filler. The results can occur within minutes, but usually take about a day to fully appreciate. Also, Juvederm and Voluma tend to be the hardest to dissolve, and it is thought that this is related to the way it is cross linked (manufacturing process).

The bottom line is that you don’t have to live with HA filler that you are not happy with. You can easily reverse lips that are lumpy or too big, swelling around the eye from filler, or dissolve an over correction or asymmetry with hyaluronidase. An injection with hyaluronidase can get you back to where you used to be in about 24 hours. Also, it’s nice to have a little piece of mind when getting injected with an HA filler that the process can be completely reversed with a small procedure.

Dr. Steve Weiner is a Facial Plastic Surgeon who “laid down his scalpel” in 2005 and concentrates solely on non invasive and minimally invasive cosmetic procedures at The Aesthetic Clinique. His website is http://www.theclinique.net . Call for a consultation: 850.622.1214

Blog: http://stevenfweinermd.wordpress.com/

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

Voluma is the latest filler to be FDA approved – What makes it different? Dr Steve Weiner explains

Front view before and after 12 syringes of Voluma: cheeks, temples, marionette lines, and preauricular area.

45 degree view after 12 syringes of Voluma injected.

45 degree view before and after 12 syringes of Voluma: cheeks, temples, marionette lines, and preauricular area.

Voluma, 12 syringes injected, 90 degree photo

After 12 syringes of Volume, 90 degree view. Injected cheeks, temples, marionette lines and preauricular area.

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Juvederm Voluma was approved by the FDA today for treatment of age related volume loss in the cheek area. This is the first filler to be approved for this purpose. Its main component is Hyaluronic acid which is also found in Juvederm Ultra, Restylane, Perlane, and Belotero, all FDA approved fillers. Juvederm Voluma is a thicker, more viscous version of Juvederm Ultra which gives it more “substance”. The technical term for this property is called “G prime”. The higher the G prime, the better ability for the filler to lift and support skin and surround structures. Compared with Juvederm Ultra, Juvederm Voluma has about 10 times (10X) the G prime. A comparison graph is shown below (from Going With the Flow: An Overview of Soft Tissue Filler Rheology and Its Potential Clinical Applications, Part II by Hema Sundaram, MD, FAAD):

As seen in the chart, Radiesse, Perlane, and Restylane have higher G primes than Juvederm Voluma. Although these others are not approved for volume loss of the cheek, they are all used commonly “off label” for this application.

Being very thick/viscous, Voluma will need to be injected with large bore needles or blunt cannulas. It is mixed with lidocaine (numbing medication) from the factory, so the procedure is very well tolerated. It’s longevity is longer than most fillers, lasting up to 2 years in their clinical trials. At 2 years, 76% of patients were still satisfied with their Voluma results. (It was 90% at 6 months). Also, at 2 years, the average patient’s perception was that they looked 3 years younger since the Voluma treatment. (It was perceived as 5 years after 6 months).

Obviously, the volume needed for correction varies from patient to patient, depending on their degree of volume loss. During the clinical trials, the average volume needed for correction was just over 6cc. Some patients needed up to 13 syringes.

An advantage of Voluma over Radiesse, Artefill, or Sculptra is that Voluma can be “erased” or dissolved with an easily obtained enzyme called hyaluronidase. Although it is seldom used, it can give patients the piece of mind that their results don’t have to last for a year if they aren’t happy with it.

Initially, Voluma is being released to a select number of physicians who are very experienced injectors. These physicians will then become trainers for the other physicians with less experience. Dr. Weiner has been chosen as one of these initial users of Voluma, and it should be available at his office in November.

Dr. Weiner is Facial Plastic Surgeon who laid down his scalpel in 2005 and now concentrates on minimally and noninvasive cosmetic procedures. His website is http://www.theclinique.net His YouTube is: http://www.youtube.com/user/StevenFWeinerFacial

Did you know…..Interesting things to do at the Aesthetic Clinique

This blog entry is filled with random facts and procedures that many people don’t know are available at The Aesthetic Clinique.

Aging of the hands can be improved with filling the back of the hand with Radiesse and getting rid of the age spots with the VBeam or Fraxel Dual. Filler in this area is practically pain-free.
Chronic, recalcitrant acne can be treated with near Accutane results using Levulan. Two or three treatments are needed. The results can improve the acne 80% or more for a year or longer.
The temples are a common area of fat loss as we age and can be filled with filler in a few minutes with Sculptra, Radiesse, or Restylane.
Belotero is a new filler that can be injected more superficially than other fillers and is great for those fine lines around the mouth and cheek area.
Blunt cannulas for dermal fillers significantly decreases the discomfort and bruising that normal needles injections cause. We’ve been using cannulas since early 2011.
Those enlarged vessels around the nose and those small red spots on the body (cherry angiomas) can be treated quickly and with very little discomfort with our VBeam.
Ulthera, our non-invasive skin tightening device which uses ultrasound, has recently been approved for the entire neck. It has already been used by us for years on the face. Studies are ongoing for the chest as well as for reducing sweat in the underarms.
Sculptra is now being used to improve the loose, thin skin and wrinkles of the chest.
Facial slimming can be done with Botox for those people who have enlarged masseter muscles.
To improve healing in a surgical or traumatic scar, we are treating with the VBeam when the stitches are removed or the skin is healed.
Precancers on the face can be treated with the Fraxel Dual or Levulan without the need for surgery.
Sculptra not only improves the volume loss of the face, but also improves the skin quality by thickening it.
The duration of bruising after a procedure can be shortened to just a few days when treated with the VBeam a day or two later.
We have a chemical peel which can be done on the eyelids with very little downtime. We also have peels for the body.
With our new Coolcurve handpiece for Coolsculpting, we are now able to treat smaller areas, including inner thigh, male breast tissue (gynecomastia), banana rolls, or very small love handles.
We have a new freezing device from Europe that can take off benign skin lesions, tags, and warts almost painlessly.

For more information, please visit our website: www.theclinique.net

Blunt Tipped Micro Cannulas are “the bomb” for dermal fillers – Dr. Steve Weiner

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About 2 years ago, I had one of those “AHA” moments when I saw a physician from France demonstrate the use of blunt cannulas for injecting dermal fillers. Since then, I have hardly used the traditional needle method for fillers and my patients love it. I have become one of the strongest advocates of this technique, and it has revolutionized my thoughts about fillers.

Blunt cannulas have a rounded tip and are very flexible. The advantages are:

The bruising and swelling post procedure are dramatically reduced. So you don’t have the social downtime after having your lips done (which can be up to 2 weeks). Blood vessels bounce off the tip and are not injured as easily with the cannulas.
Procedural discomfort is much improved in most areas.
With only 2 entrance “pokes”, I can enhance the lips, vs. at least 10 pokes using needles.
Overall time of procedures are significantly reduced. Because I’m not using topical anesthesia in most cases, the total time to have your smile lines injected can be only a few minutes. Under eye injections are the same. In and out of the office more quickly and then go to lunch.
The risk of a vascular catastrophe is almost eliminated because you can’t enter a vessel with a blunt cannula. You can still compress a vessel, but this is a much easier problem to deal with than an intravascular injection. So BLUNT CANNULAS ARE A MUCH SAFER WAY TO INJECT DERMAL FILLERS.
I can inject the upper lip lines, lips, nasolabial folds, marrionette lines, and lower cheek, all through the same entrance site.
Tear trough injections can be done deep to the muscle to avoid the filler from showing (“Tindel Effect”)
I can use the cannulas for all fillers except Sculptra.

My YouTube videos with blunt cannulas: http://www.youtube.com/user/StevenFWeinerFacial?feature=guide

The only area which I might use a needle to inject filler now is along the vermilion border of the lips and for superficial fine lines or scars.

When choosing a physician for filler, technique makes a world of difference…ask my patients.

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

Hyaluronidase – The “Magic Eraser” for Hyaluronic Acid (Juvederm, Restylane, Voluma) Dermal Fillers

Voluma is the latest filler to be FDA approved – What makes it different? Dr Steve Weiner explains

Did you know…..Interesting things to do at the Aesthetic Clinique

Blunt Tipped Micro Cannulas are “the bomb” for dermal fillers – Dr. Steve Weiner

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