blunt-cannulas Archives | The Aesthetic Clinique

Cannulas Were Approved by the FDA for Restylane Silk….Finally!

On October 12, 2017, Galderma was notified by the FDA that Restylane Silk was approved to be administered using blunt microcannulas. Galderma deserves a huge “high 5” for stepping out of the box in recognizing the improved patient outcomes and safety benefits of cannulas. No other dermal filler in the US has been approved for use with cannulas, it is a “First for Fillers”. Galderma is researching other areas for cannula use and expect approval in 2018 for another 1 or 2 indications.

What’s the big deal with cannulas?

The traditional method to administer dermal fillers is using a needle. Unfortunately, there are many side effects and risks using needles. These include:

Bruising – sticking a needle into a highly vascular organ, skin, will lead to bruising a majority of the time. This is corroborated by the FDA studies for all the US approved fillers.
Pain – needles require multiple entry points to deposit the filler. Pain fibers are most prevalent in the dermis.
Vascular Occlusion Risk – when a blood vessel is cannulated with a needle and the filler is injected directly into the vessel, occlusion of the vessel occurs. The sequelae of such event can result in skin necrosis, eye injury, or even blindness.

Cannulas have a blunted, rounded tip which is less likely to injure blood vessels than a needle is. When the cannula brushes up against a vessel, it is deflected away, in distinction to a needle which will often pierce the vessel. When a vessel is traumatized, a bruise will occur.

To use cannulas, a small pilot hole using a needle is required. Unfortunately, completely eliminating needles is not possible. However, after that entry is performed, the cannula can be placed through the dermis and into the subcutaneous tissue or deeper fat compartments. The areas below the skin surface are generally less innervated and are more comfortable to place filler.

The most important quality of cannulas is their safety. By design, they are much less likely to result in placement of filler within the lumen of a blood vessel. The rounded tip eludes lumens of blood vessels whereas needles don’t offer that protection. Although vascular occlusion is possible with cannulas, it is much less likely when compared to the risks associated with needles.

Dr. Weiner has been an advocate of injecting dermal fillers with cannulas for the past 6 years, since 2012. He has become one of the most experienced cannula users in the US. He has been chosen by Galderma to use his cannula experience to “Train the Trainers” in the use of cannulas for Restylane Silk in the lips.

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,

Update – A Better Way (Than Sculptra) to Enhance Temples is Using Cannulas and Refyne

A couple years ago, I wrote a blog that stated deep injections along the periostium using Sculptra were the best way to enhance temples suffering from volume loss. I would like to update everyone to a newer technique I have perfected that gives better results.

Although the Sculptra temple injections are safe and long lasting, there were deficiencies:

Multiple treatments were required – 3 or more
Results take weeks or months to occur
Final results still showed volume loss in the temporal fusion line and supraorbital area
Significant volumes of Sculptra were required
Needle injections inherently lead to more bruising than cannulas

The temporal fossae is a very large space and when Sculptra is injected in this area, there is tremendous spread of the product due to its watery consistency. In addition, the deep temporal fascia is a thick and unyielding tissue plane that resists lateral movement from filler placed deeply.

My current preference for volumizing the temples uses large (23g) cannulas and a diluted HA (Refyne) dermal filler. I use large cannulas because they are safer than the smaller cannulas and needles for preventing vascular occlusion. I have found that the larger cannulas navigate the numerous veins in the temples well with minimal discomfort. My entry point is the zygomatic arch, about 1 cm posterior to the brow. The plane of injection is between the superficial temporal fascia and the deep temporal fascia. This is the exact area where the temporal fat pad is situated and where fat loss occurs. Surrounding areas such as the superior orbital rim, supraorbital area, forehead, and hairline can all be injected from the temporal approach. By diluting the Restylane Refyne with 1cc of saline and 1cc of lidocaine 1%, the thinner product is able to distribute very evenly throughout the plane of injection. Refyne’s high tissue integration and low swelling properties makes this the optimal filler for this area. I have found that a total of 1-2 syringes of the filler is needed to achieve correction in most patients. Massaging at the time of injection and periodically afterwards by the patient will give the smoothest results. A follow up in 3 weeks is typically made to make final touch ups if needed.

Techniques must constantly be re-evaluated and refined to achieve the optimal and safest results for our 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 Most “Botched” Cosmetic Procedures Dr. Steven Weiner Is Asked on Realself.com

Realself.com is a public forum for asking questions about cosmetic procedures which patients have had or are thinking of undergoing to the website’s participating physicians. The website allows doctors of the following specialties to respond:

Plastic Surgeons
Facial Plastic Surgeons
Dermatologists
Oculoplastic Surgeons

Unfortunately, experience and credentials are not always fully evaluated by the public, and undesired outcomes, often with long term repercussions, can result. Sometimes with only a few weekend courses under their belt, Internists, Family Practitioners, Dentists, ER Physicians or OBGyns hang up a shingle Aesthetic Procedures. An article by Tom Seery, CEO of Realself.com, points out that consumer satisfaction rates are about 30-35% higher when a specialist is performing Botox or Dermal Fillers vs. “all providers”.

Now for the most Botched Cosmetic Procedures:

1. By far, the #1 most botched procedure is tear trough injection with fillers. Complaints range from lumps, prolonged swelling, worsening of appearance, pain, prolonged bruising, vascular injury, numbness, and firm nodules. The skin around the eye is very thin, and there is very little room for error in this procedure. Dr. Weiner is a firm believer that this injection should be performed using blunt cannulas with Restylane. There is less swelling, bruising, and significantly less vascular risk with cannulas. Lesson: Leave this injections to “the pros” for better outcomes and safety.

2. Botox being botched is a close 2nd. Common problems are eyebrow or eyelid droop, uneven smile, ineffectiveness, bruising or swelling, or “Dr. Spock” look. Sometimes a touch up can improve these results, but often one has to wait for the Botox to wear off. This can be 3-4 months. So that deal on Botox that is supposed to improve ones looks becomes a nightmare where one looks abnormal and/or worse. Lesson: Botox deals aren’t usually worth it.

3. Laser hair removal resulting in burns is fairly commonly asked about on Realself. If the laser operator is not using the appropriate laser or settings for one’s skin type, permanent pigmentation problems can result. Fortunately, most superficial burns will reverse over the course of several months. In several states, rules for operating a laser are very lax, allowing techs without significant training to use the laser. Florida is one of the strictest in the country. The operator can only be a nurse practitioner, physicians assistant, doctor, or specially trained electrologist. Lesson: Get the most qualified person to operate the laser, preferably a physician with years of laser experience. Dr. Weiner has over 25 years of laser experience.

4. Lip augmentation with dermal fillers is another highly botched procedure. The most common lip problem is uneveness and lumpiness. These are a direct result of poor technique by the injector. Hyaluronidase to dissolve the filler is usually required, and then you are back to where you started (so 2 procedures to get back to square one). Bruising, swelling, and prolonged downtime is seen when lips are injected using needles in combination with injector inexperience. Dr. Weiner is a huge fan of using blunt cannulas for the lips to minimize the recovery time and bruising. Overfilled, and unnatural lips are also a problem, mainly due to lack of knowledge of the natural anatomy of lips by the provider. Lips should have a ratio of about 40% upper to 60% lower. When the upper lip is larger, or the natural landmarks (tubercle, cupids bow, shape) are not preserved, the lips become obviously “done” and unattractive. The sausage lip is when the lips appear tube like (like a sausage link) which is another common error by the inexperienced injector. Lesson: Lips are another area with several intricacies that require an experienced injector. Cannulas limit bruising, swelling, and downtime so you can enjoy your lips without interrupting your social life.

The take home message is that all providers are not equal. Please do the homework, look at reviews, ask friends, and ask the facility “Who is actually doing my procedure?”. In general, specialty trained physicians will give better outcomes with higher satisfaction rates.

Juvederm Questions Answered by Facial Plastic Surgeon, Dr. Steve Weiner

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Q: Is there any other option than Hyaluronidase to immediately reverse botched Juverderm injections to the lip?

A: Hyaluronidase is the easiest solution for improving botched lip injections with Juvederm

There really is no other great alternative to hyaluronidase. It my hands, it quickly, sometimes within minutes, dissolves the HA fillers like Juvederm, Restylane, and Belotero. I add it with lidocaine and use cannulas so it fairly well tolerated. Steve Weiner, MD, Facial Plastic Surgeon.

Q: Juverderm filler put in my top lip & a tiny bit in my bottom lip 3 days ago, caused uneven lumps and white patches. (photos)

A: Anyone who injects Juvederm or other fillers SHOULD HAVE HYALURONIDASE, don’t go to them if they don’t

There are rare emergencies when injecting filler which require using hyaluronidase. If there is a vascular occlusion, hyaluronidase needs to be available immediately. It is expensive and has a short shelf life so people that don’t have it are trying to decrease their costs. I would never go to someone that didn’t have hyaluronidase because no one wants to take care of someone else’s complications. So, for your problem, it looks like alot of correction/swelling for less than 1/2cc. I’m not sure what was injected. I wouldn’t inject anymore. Probably too early to decide if you want to remove it. Hyaluronidase doesn’t swell much at all and usually improves the problem within hours. Watch the video on the easy way to get your lips done, with cannulas. Steve Weiner, MD, Facial Plastic Surgeon.

Q: Had juvaderm injected into cheeks two months ago. Swelling under the eyes What other steps can I take? (Photo)

A: Juvederm leaving swelling around the eyes is seen often

When injecting around the eyes, blunt cannula technique and RESTYLANE should be used. Juvederm is too hydrophilic and moves too much for this area. Your only choice now is hyaluronidase but that doesn’t always work well with Juvederm and might need repeated treatments.

Q: Is it possible for Juvederm to not settle or is my injector just trying to cover up for bad work? (photo)

A: Upper lip lines is a difficult area to treat. Filler will help but laser, Infini, dermabrasion can be better

Upper lip lines are hard to treat! The easiest solution is using filler, but its not perfect and lasts for about 4-6 months. Belotero seems to be the best filler for the lip lines, if you inject them directly. Filling the vermillion border with filler helps and so does filling above the lip with a cannula horizontally. I think the most recent treatment, using the Infini, seems to be very promising, with very little downtime and risk. I’ve abandoned injecting Juvederm superficially because it becomes noticeable and the only filler I will inject superficially for the lines is Belotero.

Q: My Juvederm Lip Augmentation Lump Won’t Go Away! Its been 9 months?

A: Bump in lip after Juvederm can be dissolved with hyaluronidase

Sometimes it takes more than one injection to dissolve the bump with hyaluronidase. Just go back for another injection. One reason that it’s still there is possibly he/she didn’t want to dissolve all the Juvederm and was being cautious. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Is it too late now to get the enzyme injected to remove Juvederm?

A: Never too late to use hyaluronidase for undesirable Juvederm results

If you are not happy 18 months after having Juvederm, you can try using hyaluronidase to dissolve it. There is very little downside to this other than it not working for you.

Q: Is it Ok to have laser teeth whitening a few days after juvederm injections?

A: Laser teeth whitening is fine after Juvederm but….

I don’t recommend dental cleaning or drilling after fillers for a few weeks if possible. There are bacteria which get in the blood stream during those procedures which can infect the filler.

Q: Will Juvederm XC work for my hollow eyes?

A: Filling eye hollows should be with blunt cannulas and Restylane

Blunt cannulas have significantly improved the filling in this area. Much less downtime-swelling/bruising, and removes the risk almost entirely of intravascular injection and blindness. Juvederm is not my choice because of issues with prolonged swelling/edema. Restylane has less affinity for water and therefore less edema. Look throughout realself and you will find people with the edema problem and it is almost always Juvederm. Most important is finding an experienced injector to avoid complications and get a great result. I do this at least 5 times a day. Steve Weiner, Facial Plastic Surgeon, Destin, Panama City, Fl

Q: Will Fleet phospho-soda oral solution affect my Juvederm because of potential dehydration?

A: Using a laxative should not affect the Juvederm

I understand your concern because part of the substance and longevity of Juvederm is related to its hydrophilic nature. It absorbs water to keep its integrity. However, the small amount of dehydration which might occur with the laxative shouldn’t affect the Juvederm and if it did, drinking water will reflate it. Steve Weiner, MD, Destin, Panama City Beach, Florida.

Q: Just Had Juvederm and Belotero Need Help?

A: IMO only inject around the eye with blunt cannulas, safer and much less bruising

There are many vessels around the eye and injecting with a needle IMO is not the way to fill the tear trough. Bruising is almost a sure thing with a needle and much less with cannulas. Also, entering a vessels is very difficult and near impossible with a large cannula. Please see my videos and blog. Juvederm is not preferred either, Restylane or Belotero is. Steve Weiner, MD, Destin and Panama City Beach, FL.

Q: Can Juvederm That’s Been Injected into the Nasolabial Folds Be Surgically Removed?

A: To remove Juvederm that is causing a problem, use hyaluronidase, not surgery

Hyaluronidase is a very safe and effective treatment to dissolve HA fillers like Juvederm, Restylane, Perlane, and Belotero. Usually it works within minutes to hours. Sometimes a 2nd treatment is needed. To remove surgically, there are risks of scarring, infection, nerve injury and need for more surgery which makes it a long second choice for your problem. Steve Weiner, MD, Destin and Panama City Beach, FL.

Q: Im a 22 Y.o Girl Who Had Juvederm Ultra 4 Injected into my Upper Lip 2 Days Ago and They Are Swollen? (photo)

A: Swelling after Juvederm in the Lips

Depending on the technique, swelling can last up to a week. I would recommend that you wait and see the final result before you decide if you want correction or dissolving with hyaluronidase. I almost always use blunt cannulas for my lip enhancements because the swelling is minimized. Steve Weiner, MD, Destin, Florida

Q: Had jevederm injected in my tear drop area and on my cheek bone to give little more filler? (photo)

A: Juvederm is not the preferred filler for tear trough area

It seems to me that you need to try another physician. The right eye problem is related to Juvederm being injected there, not “a fat pocket”. Unfortunately, several people on Realself have had this experience with Juvederm in this area. Its a chronic edema, which doesn’t seem to improve all the way with hyaluronidase. See my videos on injecting with cannulas in this area. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Can Filler Injections Cause Blurry Vision?

A: Blurred vision needs an Ophthalmology evaluation

It doesn’t seem like the visual changes are related to the filler…but it is remotely possible. You need to get an evaluation by an Ophthalmologist (an MD). Dissolving the filler won’t help at this point. Most likely there is something else going on that is coinciding with the filler injection. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Are These Broken Capillaries an Obstacle in Getting Filler to Fix the Nasolabial Folds? (photo)

A: Dilated vessels around nose are no problem for filler (Juvederm)

The enlarged vessels around the nose pose no problem whatsoever for using filler in the nasolabial folds. You might consider treating these very easily with the VBeam laser, 1-2 treatments will significantly improve them. Steve Weiner, MD, Destin, Florida

Q: Hi, Im a Male and Would Like to Get Filler in my Temples and in an Area with Beard Growth. Could Dermal Fillers Cause Hairloss?

A: Dermal fillers for the temple and jawline will not cause hair loss

You don’t have to worry about using dermal fillers for these areas regarding hair loss. It doesn’t happen with fillers. Steve Weiner, MD Destin, Florida.

Q: Is It Normal to Get Bumps After Ultra Juvederm? and How Long Do They Last?

A: Lumps after Juvederm can occur to a small degree in lips, but not usually elsewhere.

Juvederm is a very soft filler and lumps are unusual but sometimes occur in the lips. With a little massage, these usually go down but occasionally need some hyaluronidase to smooth out. Steve Weiner, MD, Panama City Beach, Florida.

Q: I Had a Restylane Injection for my Upper Lip Yesterday! Very Swallow and Pumpy? (photo)

A: Very swollen after Restylane in lips..should improve but not sure if it will look much better

It appears that too much was inject for your lip enhancement. I think it should improve, but to the extent that it looks normal is questionable. The upper lip is now much larger than the lower and this is not the right ratio. Normal ratio is 40% upper, 60% lower lip. To minimize swelling in the future, I suggest blunt cannulas for your lip restylane injections, see video. You might need hyaluronidase to undue the poor correction. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Are There Any Solutions Besides Vitrase That Might Speed Up the Breakdown of Juvederm Ultra Plus? Thank You.

A: Hyaluronidase will dissolve Juvederm as fast as anything

There is nothing other than hyaluronidase to breakdown the Juvederrm. With that amount of filler, you might need more than one injection. However, you might consider another doctors opinion. You actually might do better with more filler.

Q: Uneven Lips After Juvederm. Embarassing! What Can I Do? (photo)

A: Uneven lips after enhancement with Juvederm gets better usually after a few days

Often there is asymmetric swelling after the lips have been injected. This can be due to bruising on one side or just slightly more trauma from the placement. It will usually get better. If still asymmetric after a week, it can be corrected with more filler or erased with hyaluronidase. It’s too early after 1 day to do anything. Using blunt cannulas is way to go with lip enhancement: safer, less bruising, faster recovery. Steve Weiner, MD, Destin, Florida.

Q: Necrosis from Dermal Fillers in Tear Troughs?

A: Tear trough injection with dermal fillers is extremely safe w blunt cannulas

The tear trough has vessels which can be injured with injection with fillers. Blunt cannulas don’t have a sharp end to them so its very difficult to enter a vessel, particularly with cannulas that are 27g or larger. Eye injury would be the risk in this area so you need to go to a qualified physician for this injection. Most of the problems I read on realself are related to poorly performed tear trough injections. Necrosis happens when filler either enters a vessel or compresses it. Yes, the glabella, nose, and piriform aperature are the most common areas but it can happen anywhere, including lips. An experienced physician can also recognize these problem early and avoid any long term issues most of the time.

Q: More Than 1 Syringe of Juvederm for Undereyes? (photo)

A: In my opinion, Juvederm is not the right choice for use under the eye

The problem with Juvederm is that it is very hydrophilic (loves water) and this can lead to prolonged swelling in this area. It can happen immediately or several weeks later. Restylane is a much better choice for this area. I don’t see much change in the pictures either. Often, the upper cheek has to be injected at the same time as the tear trough because it too has lost volume and is part of the reason for the loss of volume around the eye. It seems like 4 syringes in someone as young as you is a bit much as well. Make sure blunt cannulas are used as well, see video. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Fl.

Q: Is It Possible to Mess Up Juvederm After It’s Been Injected?

A: “Messing up” Juvederm after it was injected is unlikely

Rubbing you eyes 6 days after treatment is unlikely to change the filler. For the first 24-48 hours, I believe it is possible to affect the fillers and recommend not to rub or massage the area.

Q: Could Juvederm Injected Inside Mouth into Upper Cheek Area Migrate Behind the Eye & Cause Excessive Puffy Lid and Sore Eyeball?

A: I don’t think that transoral injection of Juvederm is a good idea

Injecting filler through the mouth invites all the bacteria in the mouth to possibly infect the filler. I am fastidious with my sterile technique to try to avoid bacteria with hospital grade cleansers. Addressing your problem in particular, you should see your physician immediately and/or an eye specialist – Ophthalmologist to see what is causing this problem. It’s possible that the injection was behind the orbital septum, thus leading to this swelling, which is not normal. I would see a doctor which uses blunt cannulas around the eye in the future. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Fl.

Q: How Much Downtime for Injectable Fillers in the Laugh Lines and Possibly Under the Eyes (Sunken in Eye Sockets)?

A: Downtime for filler in laugh lines and around the eyes could be near zero if blunt cannulas are used.

I use to tell patients that they needed to plan their fillers about a week ahead of a big event. I no longer have that stipulation now that blunt cannulas have changed the game. There is minimal or no bruising with the cannulas. There might be some swelling, but this is more due to the characteristic of the filler absorbing water than the actual injection. Please see my videos and blog. Steve Weiner, MD, Facial Plastic Surgeon, between Destin and Panama City Beach, Florida.

Q: DMSO for Bruising from Filler Injections?

A: VBeam is the best treatment for post Juvederm bruising, not DMSO

A very short painless couple passes with the VBeam is a great way to rapidly resolve a bruise after dermal fillers. It take a minute or 2 and will make the bruise go away in about 2 days. It must be done within 2 days of the procedure. By the way, blunt microcannulas reduce the chance of bruising significantly.

Q: Fillers for AIDS Patients?

A: Nice replacement for chin implant in AIDS patient is Radiesse

Radiesse is a good filler to augment the chin. It can really act just like an implant. The only thing that must be diligently followed is sterile technique in an AIDS patient. I am with all my fillers but I’ve seen some docs who are a little lax in this department.

Q: Cosmetic Fillers in Cheeks Yesterday, Surgeon Massage Area Really Hard to Spread it Out Evenly?

A: Hard lump under eye day after Juvederm is probably a bruise

Juvederm is a very soft filler. I’m not sure why the doctor massaged so hard in that area but its likely he created the bruise. It can take up to two weeks to resolve. If it still is hard there it might be the filler and at that time you can try hyaluronidase. I would always use blunt cannulas in this area to decrease bruising. Also I prefer Restylane over Juvederm for this area. Better lifting ability of Restylane. Steve Weiner, MD, Facial Plastic Surgeon, Panama City, Florida

Q: Are You Guys Just After Our Money? (photo)

A: Juvederm is never refrigerated. It can be stored after opening for 9 months safely.

There is a study which was done (I think it was on Restylane) which shows that there is no increased risk of infection if the unused portion of it was stored for 9 months and then used. It might be good longer, but the study only was based on storing for 9 months. Some docs will charge for the 2nd injection, I don’t.

Q: I Had Juvederm Injected into my Lips and Have a Large Bump on my Top Lip. You Can SEE THE PRODUCT Under the Bump. (photo)

A: Bumps after Juvederm in lips can be resolved with hyaluronidase

Bumps in lips after lip augmentation can occur with even the best injector after Juvederm. This is a very easy problem to fix with just a small injection with hyaluronidase. It usually will improve before you leave the office. See video on using a blunt cannula for the lips. I prefer this way to inject the lips so there is less swelling, less bruising, and less nodularity.

Q: Will the Lumps in my Lips Caused by Juvederm Ever Go Away? (photo)

A: Wow, significant lumps after Juvederm in lips. Use hyaluronidase to dissolve.

I would immediately use hyaluronidase to dissolve this issue. I don’t know why you waited so long. I also would choose a different injector.

Q: Got Under Eye Filler 2 Yrs Ago at Least and I Am Still Wearing Dark Shades and Feel Ashamed of my Swollen Look? (photo)

A: I disagree with the others. The Juvederm can still be there after 2 years in the eye area.

The swelling you have is very similar to the multiple people on RealSelf.com who have had problems with Juvederm when injected around the eye/tear trough area. The Juvederm is very hydrophilic and absorbs water leading to prolonged swelling. I would try hyaluronidase to dissolve it. It might take several injections to get it better. I would only go to a surgeon after exhausting these efforts. Restylane is my preferred filler for this area. See video using Restylane and blunt cannulas. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: I Had Juvederm a Year Back. Now I Have Pillow Like Bags on the Left Cheek. Cheek Seems Falling?

A: Juvederm is not the ideal choice for filler under the eye..prolonged swelling is possible

There are several patients on RealSelf that have similar complaints/problems with Juvederm when used for tear troughs. It is a very hydrophilic product (loves to absorb water) which leads to the edema around the eye. It can be dissolved with hyaluronidase, but it sometimes won’t make the problem go away immediately. It will get better! My choice for filler is Restylane using BLUNT CANNULAS around the eye. Less risk, less swelling, less bruising. Steve Weiner, MD, Destin, Florida.

Q: Lumpy Upper Lips After Juvederm, What Are My Options? (photo)

A: Lumpy lips after Juvederm can be fixed easily with hyaluronidase

Its my experience that after nine days if a lump is present it will persist. Injecting a little hyaluronidase mixed with lidocaine can correct the problem, sometimes before you leave the office. I find Juvederm has a propensity to do that and Reatylane does it less.

Q: 2 Syringes Jowl Area Barely Noticeable? (photo)

A: Sometimes jowls can’t be changed much with just fillers

If your “jowling” is moderate or severe, there is not much hope for fillers correcting this. Early or minimal jowling can be helped by placing volume behind and above the jowls, and in the prejowl sulcus with Radiesse, Perlane, or Restylane. Otherwise, you would require surgical correction (facelift) to improve the jowls.

Q: Fillers in Cheeks and Side of Face to Help Decrease Smile Lines?

A: Often lines around the mouth area are due to loss of volume

If you lose volume in the cheek area, this will sage around the mouth and produce wrinkles. So it’s not unreasonable to try to attack the loss of volume in the cheek, buccal area, and preauricular area to help around the mouth. I can’t tell you if this is the right thing to do your situation. You might need a little bit around the mouth as well. My choice for volume is not Juvederm, it’s either Radiesse, Perlane or Restylane. Voluma will be coming and might be a good alternative too.

Q: What Can I Do About my Hollow-set Under Eyes and Wrinkles at 24? (photo)

A: For the hollows under you eyes, Restylane or Belotero with Blunt Cannulas will help

You have soft tissue loss around the eyes. The upper cheek and tear trough need to be filled to give you a more youthful appearance. IMO, this is best done using blunt cannulas because of the reduced risks or bruising and vascular injury. Top choice for this area is Restylane, otherwise use Belotero. This is a quick procedure and there can be some minimal swelling over the next couple days.

Q: Depressed over juvederm lip injections?

A: Juvederm lip injections, 2 days out, not happy – I would wait another week

Because of swelling and possible bruising, the lips take about a week or little longer to “settle out”. You will most likely improve over that time. I can always be dissolved with hyaluronidase after waiting for all the swelling to go down. Hyaluronidase takes minutes to hours to dissolve the juvederm…it works very quickly. Good luck.

Q: Juvederm and Possible Headaches?

A: Headache after Juvederm in nasolabial folds is probably unrelated.

Listening to your story, I can’t see a connection between the Juvederm and the headache. I would see a physician to see if you have other reasons for a headache. There are probably over 100 reasons for a headache and I just don’t think that Juvederm is the reason in this case

Q: Possible Bad Reaction to Numbing Cream After Topical Application for Juvederm Injections? (photo)

A: No smell and taste is related to septoplasty not Juvederm

The most likely reason for having poor taste and smell is due to disruption of the cribiform plate or swelling from the septoplasty. All lidocaine from injection would be worn off after a few hours.

Q: Juvedurm in Tear Troughs Caused Permanent Bruise/dark Circle Under One Eye? (photo)

A: Blue around eye after Juvederm is 1 of 2 things

First off, I would never use Juvederm around the eyes. Your picture is hard to decide between Tyndall effect and residual hemosiderin. I would try hyaluronidase first. If no improvement, a pulsed dye laser would help remove the pigment, like the VBeam. You will need corneal shields to protect the iris and retina.

Q: Dermal Filler and Tetracycline?

A: Getting filler done when sick is not a good idea

Fillers such as Restylane, Juvederm, Radiesse, and Perlane are foreign bodies place into the lower skin. If there is an infection in the body, it might get trapped in the filler and cause a localized infection. So if you are on an antibiotic and fairly sick, you should not get injected with filler. Also, having extensive dental work after filler should be held off as long as possible because there is bacteria in blood stream with the dental work. There are many reports of filler getting infected from a dental infection as well. If you are on a chronic antibiotic for acne, there is no problem getting injected while you are on it.

Q: Advice/Treatment Options for Sunken Cheeks/Marionette Lines? (photo)

A: Volumization is needed to improve sunken cheeks and marionette lines

Volume, volume, volume is needed to improve you issue. You must go to a surgeon familiar with fillers and not just the cheapest or closest place to you. I would put more in the cheek area, buccal area, marionette jawline and fill the face out somewhat. Just attacking the marionette or nasolabial will look funny and won’t completely improve your problem.

Q: Compatibility Juvederm/Restylane?

A: There are no issues with compatibility of Juvederm and Restylane

Both products, Juvederm and Restylane can be used in the same area, without any worries. I don’t combine these 2 fillers much, but I do often use a deeper filler like Radiesse and combine it with Belotero or Restylane/Juvederm often. The only caution about combining fillers is when there is long standing silicon filler in place. If that’s the case, using filler, even in areas not close to the original injection can cause a granulomatous reaction, and it’s not recommended, or at the very least, let the patient know of the risks.

Q: Juvederm Yesterday for Wrinkles and Thinning Upper Lip. Bruised but Worry About Duck Lip? (photo)

A: Bruising and swelling after Juvederm to lips

After getting lips enhanced with Juvederm, all people will have swelling and some will have bruising. I’ve decreased the downtime with using blunt cannulas for most of my injections, with some needle injections along the borders if needed. There is less pain, less bruising, and less swelling when using cannulas. Swelling usually will go down after cannulas in 1-2 days. If you are left with the dreaded “duck lips”, it can easily be treated with hyaluronidase when all the swelling is better. The VBeam is useful for decreasing the time the bruise takes to resolve. Please see my website for more details and my video.

Q: How Long Will It Take to Heal from Hemosiderin Staining Resulting from Juvederm Injection to the Under Eye Area? (photo)

A: Bruising when getting under eye filler can be avoided with blunt cannulas

I’m sorry you were so bruised after fillers for the tear troughs. This can almost be avoided 100% with using blunt cannulas. The hemosiderin can be improved with a laser, but it’s not easy in that area because of the proximity to the eye. I would wait longer and see if the body can get rid of it. The number one problem I get asked about on Realself is filler around the eye. I would like to recommend that anyone who wants this area corrected go to someone that uses cannulas and has done a ton of these. It is very routine in our office, probably 5 per day.

Q: Juvederm Removal with Hyaluronidase Injections?

A: Hyaluronidase breaks down HA fillers, not collagen

Hyaluronidase will not affect collagen. The body does have some natural hyaluronic acid but that will be replenished by the body after hyaluronidase. Some docs routinely use it when injecting local anesthetic because it makes the area of numbing larger. Bottom line is that the filler (Juvederm, Restylane, Perlane, Belotero, Prevelle) is mostly affected by hyaluronidase and it should dissolved rather quickly, minutes to hours.

Q: More Juvederm on One Side? (photo)

A: Assymetry after Juvederm in Nasolabial Folds

It’s not uncommon for our natural nasolabial folds to not be symmetric. The sides of our face are sisters, not twins. Sometimes, putting more in one side can help balance this difference, but it doesn’t always work because expressions, boney structures, and soft tissue might be different preventing things from being exactly the same. Immediately afterward getting treated, sometimes there is assymetric swelling, but this usually resolves after a week. I would ask to add more to the left side, but I don’t think that you will get it exactly the same of both sides. It appears to me that when you smile, you are stronger on the left side, thus making the fold appear deeper.

Q: 19 Yo Juvederm in Tear Troughs? (photo)

A: Although you are only 19, I do think that your tear troughs need a filler, my choice is Restylane

Your case is fairly common, but not in your age group. I would treat your tear troughs with Restylane using the blunt cannulas to minimize swelling and bruising. I do not recommend Juvederm in this area. No surgery is recommended. See my video 🙂

Q: Tyndall Effect After Juvederm? How Long Will This Last or is It Something

A: Tyndall effect from Juvederm in tear trough needs to have hyaluronidase to correct

If the problem has been present for 2.5 years, it’s not going to go away on it’s own. Hyaluronidase will dissolve the remaining Juvederm and should improve the problem. I do not recommend Juvederm in this area. I also see more problems here on Realself with fillers around the eyes more than any other site of injection. It is key to get someone that is experienced in this area, and I always use blunt cannulas in this area to minimize bruising and swelling. One other thing that this could be is hemosiderin, which is a residual form bruising in this area. If it is hemosiderin, it is more difficult to treat, and topicals might improve it

Q: I Had 0.8ml of Juvederm Injection for my Laugh Lines and After 8 Hrs I Had Sex with my Husband?

A: Having Sex after Juvederm; ‘Instant results”, never thought about it in that sense

Juvederm and other fillers are very popular because the “cosmetic results” are seen immediately. Having sex right after treatment will not affect the results at all. You propably just need more Juvederm.

Q: How to Treat Eye Swelling After Juvaderm Injections?

A: Swelling after having Juvederm in the tear troughs happens too much and should be avoided.

Why do a diagnostic procedure if you aren’t going to change what you do? Regardless if the ultrasound can show if there is or isn’t Juvederm in the area, my suggestion is to treat with hyaluronidase. There are too many complaints with Juvederm on this site so I have given up using it around the eyes and tear troughs. Restylane is a much better choice. Probably Belotero is good too, but haven’t had enough experience with it yet..

Q: Had Juvederm Injected in Upper Lip and Verticle Lines, Duck Looking. Should I Get It Removed? (photo)

A: Your Juvederm injection was not done correctly and needs to be dissolved with hyaluronidase

A natural ratio of the upper lip to lower lip is between 1:1 to 1:2, most people think 1:1.5 is about right. In any event, your upper lip is now bigger than your lower lip instead of being smaller. Also, it was unevenly injected, so there is more on your left side. I think I would put some Juvederm in you lower lip and dissolve some of the upper lip Juvederm, particularly on the left side with hyaluronidase. See my video on blunt cannulas for lip enhancement.

Q: Non-surgical Rhinoplasty Redness Nightmare! Allergic Reaction?

A: Extreme redness after injection with a dermal filler in the nose is cause for concern

The concept of fixing small defects in the nose with filler sounds like a nice and easy solution. However, there are risks associated with it. It sounds like what has happened is the vascular supply of the nose has been compromised. If not recognized early, you have potential for skin necrosis (loss). Hyaluronidase, heat, massage, needs to be done in these cases. I have stopped doing the “5 minute nose job” because of more and more reports of this happening. The reason it happens is because the filler either goes into the vessels supplying the nose or compresses it. This can happen anywhere on the face and is one of the reasons that blunt cannulas are safer. Blunt cannulas can not enter a vessels so that eliminates the most common etiology of this problem.

Q: Can a Primary Care Doctor – Internal Medicine, Inject Juvederm Fillers and Botox Cosmetic?

A: As reimbursement from insurance and medicare get less, more doctors will be injecting dermal fillers and Botox

Although legally, any MD, DO, Dentist, Nurse Practitioner, PA (with supervision), can inject Botox and Juvederm, it doesn’t mean that they are properly trained, or that you will get a good results. In life in general, you “get what you pay for”. Same is true with these treatments. If this is your face, which you wear 24/7, why chance the results with someone that went to a weekend or 2 training session or who does this on the side of his regular practice to make some “extra money”. Go to someone that does this full time, who trained for years on the anatomy of the face. More importantly, although rare, complications can occur, and at that point, you wished you’d gone to that Plastic Surgeon or Facial Plastic Surgeon. As an aside, “Botox parties” are usually not a good idea either. The facility is not properly equipted for emergencies, and the lighting and patient chair are suboptimal.

Q: Juvederm for Acne Scars Left Skin with Bumpy Appearance – is This Common?

A: My experience with dermal filler for acne scars is that it doesn’t work well

Because scars are firmer tissue with adhesions, injecting filler into the scars does not “lift” them to the level of the surrounding skin. I find, like you, that if you inject below the scar that you end up with a scar which looks like a volcano, elevated, but with an indent in the middle. Lasers such as the Fraxel Dual, are much better for acne scarring.

Q: How Long Does It Take for Swelling to Go Away from Juvederm/Botox?

A: Swelling from Juvederm and Botox should subside in about 48 hours

Swelling from the Juvederm and Botox treatment is mostly related to water being absorbed by the Juvederm. I can also be related to tissue trauma caused by the injections. To get the least tissue trauma, blunt cannulas are preferred. Bruising can also cause swelling. In general, without any significant bruising, swelling will be better after about 48 hours. The lips may take a little longer. Sleeping with your head elevated helps with reducing swelling. I tell my patients after they leave to expect to have swelling then to have a diminished result of about 10-15% from what it looks like just after I’m done.

Q: How Can I Prevent Bruising from Restylane or Juvederm?

A: To reduce bruising with Restylane or Juvederm, use blunt cannulas and avoid blood thinners

I have greatly reduced my incidence of bruising with the use of blunt cannulas for my dermal fillers. Although I will inject clients who are on blood thinners for medical reasons (coumadin and plavix), I recommend clients stay off any non-essential supplements and advil, aspirin, for their procedure. If a bruise occurs, the VBeam can be used to significantly reduce the duration of the bruise (see my pics in the VBeam section) and it is painless and given as a complimentary service if one occurs. I also tell clients to avoid strenuous activity on the day of the procedure.

Q: Extreme Swelling After Juvederm- Is This Normal? I’m Very Worried. (photo)

A: Severe Swelling after Juvederm

This could be a few different issues, but the extreme swelling you have is probably angioedema. This will respond to steroids usually. The cause for this is not always known, but often related to someone that is taking an ACE inhibitor for their blood pressure. Other things that can cause this is a hematoma, rare allergic reaction, or too much filler placed.

Q: Juvederm Lips

A: Juvederm is great for lip enhancement

Juvederm gives great lip enhancement. It has minimal swelling and feels very soft. Using blunt cannulas, the injection is very comfortable and leaves very little bruising.

Q: Juvederm Bruising

A: Bruising from Juvederm is much better using blunt cannulas

I know that I might sound repetitive with my answers on Realself, but using blunt cannulas has greatly reduced bruising for my clients, even in lip injections. I find no difference with the degree of bruising with Restylane or Juvederm In general, the more experienced the person injecting, the less bruising you will have.

Q: Real Pain with Juvederm Injections Around Mouth. Can This Be Avoided?

A: Blunt cannulas are the way to go for Juvederm around the mouth!

Using this new innovative technique, you can get your Juvederm around the mouth with very minimal discomfort. I just use topical and have very comfortable clients. Even injecting the lips is relatively easy with blunt cannulas. Bruising is also significantly reduced or eliminated with blunt cannulas. I now inject exclusively with this technique and have been for the past 4 months. It’s the way to go!!!

Q: How Precisely Can Juvederm Be Injected? Volume ONLY at Place of Injection?

A: Juvederm will diffuse slightly so correction is not precise

Juvederm tends to spread a little from the area of injection. This is good in some areas and not in others. To answer your question, the correction, which also involves water absorption, will not be exactly where you place it, but close.

Q: Juvederm Ultra Plus for Indented Smile Lines?

A: Juvederm Ultra Plus is a great choice for smile lines

I think the physician was spot on. Nasolabial lines are very well corrected with Juvederm Ultra Plus. It should give about 1 year in duration, but you might not want for the correction to completely go away. So about 9 months later or so, a touch up might be needed.

Q: Juvederm for Undereye Troughs with a History Severe Scarring?

A: Around the eyes, I use Restylane for a filler and have seen no issues with scarring

I agree with the others that scarring does not appear to be an issue with injectables around the eye. The most important factor is the experience of the filler. This is the area where most of the issues I’ve seen on Realself have stemmed from. I also almost always use Restylane around the eyes.

Q: Does Juvederm Help Lines in Eye Corners?

A: Injecting the corner of the eyes is great for Juvederm

There always seems to be a slight loss of fullness in this area. Injecting a filler in this area, a small amount, leads to a great enhancement around the eyes.

Q: Juvederm with a Dental Block Cause More Swelling?

A: Juvederm can be injected very comfortably without dental block

Juvederm, particulary the new XC version which contains factory added lidocaine can be injected rather painlessly with just topical and no dental block. I feel the dental block adds more pain and can lead to swelling which makes the correction harder to do (don’t know what is caused by the block and what was there before). I ask my patients to apply ice for about 1-2 hours, but to be careful because you will be numb and don’t want to create a problem by freezing the skin.

Q: Downtime for Juvederm on Nasolabial Folds?

A: Typically, no downtime after getting Juvederm

In most cases, you can resume your normal activities after Juvederm except I don’t recommend stenuous physical activity until the next day. Swelling and redness is usually very mild or minimal after the injection. Most of the time there is very little bruising. Occasionally, you can have a bruise which is hard to cover with make-up. Evolence will give less bruising and swelling than Juvederm, if that is a concern.

Q: Lower Lip Asymmetry and Lumps After Juvederm

A: One other thing to consider

There is a condition call Angioedema. This is fairly uncommon, but does occur. It is abnormal swelling as the result of trauma (the injection). It can happen to anyone, but most cases occur in people that take ACE inhibitors (a type of blood pressure medication).

If it is angioedema, steroids and antihistamines will help. It can occur again with subsequent injections, so you must alert your physician if you choose another physician. Steroids can help, even if it is not angioedema. Most likely, I agree with Dr Beraka, that it’s a hematoma. I just wanted you to know all possibilities.

Q: Juvederm Bruising on Nasolabial Fold

A: Sounds like Tyndall Effect after Juvederm

If Juvederm is injected too superficial, it can cause a bluish hue to the skin. If nicking the skin doesn’t do the trick, injecting Wydase can dissolve the Juvederm and you can start over. My experience has shown that scars don’t always get a lot better with filler, but some do.

Q: Risks of Using a Stored Syringe of Juvederm?

A: The risk is very small but is a possible infection

Studies have shown that Restylane can store for 9 months without leading to any increased risk of infection.

However, these were stored in a physician’s office, and the needle was replaced with a clean needle before storage. I don’t ever let my patients take home a portion of an unused syringe of filler.

I would not inject any syringe in which I was not sure of it’s origin and storage. Just my opinion and my controlling my risks.

Q: Can Juvederm Add Volume to Sunken Cheeks?

A: I prefer Radiesse or Perlane for cheek augmentation

I agree with all the other responses. I would just add that my choice is Radiesse or Perlane in this area, but Juvederm is fine as well. There are 2 camps with Sculptra: Docs who use it and ones who don’t. I’m in the camp of not using Sculptra, but that doesn’t mean it shouldn’t be used.

Steve Weiner, MD Facial Plastic Surgeon Destin, Florida

Q: If my Doctor Saves my Leftover Juvederm Vial, Do I Have to Pay for my Next Injection?

A: It varies

My policy is to not charge for the remainder of the syringe to be injected. I also charge a flat fee per syringe, no matter what area it is placed. I think that is something that needs to be discussed up front. Please keep in mind that I feel it is most important to pick the right physician rather than shop for the lowest price. The physician you choose is hopefully someone your friends have seen, had a good experience with, and is well qualified to do the procedures. (I personally teach the injections to other physicians for Evolence and Juvederm.)

Q: Juvederm Gone in a Week?

A: Juvederm probably not gone, but correction is hard to see

You’re probably saying, if I can’t see it, then it really doesn’t matter if it is there or not. My first question is how many syringes were used. You mention a lot of areas to correct. I would use at least 3 or 4 syringes for this. Any less than this, you will be spreading the filler out too thinly. If someone comes to me and says I want all those areas and can only afford 1 or 2 syringes, I typically will ask which area is most important and fully correct it. The filler is probably not gone, but the changes are so minimal that they are hard to see.

There are people who rapidly metabolize HA. Usually this doesn’t occur in a week though. For those people, Radiesse is a good solution, except for the lips.

One other point, I prefer Restylane around the eyes because to me, Juvederm spreads more and the corrections are often less noticeable.

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.

[youtube=http://www.youtube.com/watch?v=XERvczwIOOg]

[youtube=http://www.youtube.com/watch?v=wd9r3Tw43YU]

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