- 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.
Dermal fillers of becoming the fastest growing area of aesthetic enhancements. In general, the procedure of injecting the filler is safe, with very little downtime, and with visible results. However, there is a rare, but extremely significant potential risk, that patient’s, medical staff, and providers need to always be aware of: Vascular Occlusion or Vascular Compromise.
What is Vascular Occlusion or Vascular Compromise? This is caused when the dermal filler is either injected into an artery or around an artery to the point that the blood flow is reduced or completely stopped. The area of skin or other tissues that are supplied by the affected vessel will start to die without the necessary blood supply. Almost always, if this complication occurs, there will be an immediate blanching (paleness, tissue turns white) when the blood flow is interrupted, often in areas far away from the actual injection. Recognition is key to a favorable outcome. If this occurs, the injector must stop immediately and take measures to resolve the problem. Pain is usually associate with vascular occlusion. There have been cases reported that occurred 12-24 hours after being injected but almost always it occurs immediately.
If no treatment is initiated to improve the vascular flow, the skin will start to appear dusky, a bluish tint, with fine reticulations (lace like) to areas WELL BEYOND THE SITE OF INJECTION. This occurs within 24 hours. If still no therapy is done, the skin will start to die, turning black, and sometimes there is an associated infection. At this point, scarring will likely occur and surgery is often needed to remove dead tissue and/or to close the wound.
If there is a recognized vascular event, several steps should be initiated.
- Hyaluronidase, an enzyme that dissolves Hyaluronic Acid, should immediately be injected in the area, and into the vessel if possible. Some doctors advocate using hyaluronidase even if the filler is not an HA filler because it will dissolve the naturally occurring hyaluronic acid hopefully improving blood flow.
- Massaging the area will help mostly if the filler is externally pushing on the vessel. This might move the filler away from the vessel to re-establish flow.
- Blood thinners will allow the blood to flow thru a smaller vessel or to go around a blockage. Aspirin and possibly heparin are recommended by most physicians.
- Vasodilators such as nitroglycerin are also recommended by most physicians. There is a question as to whether this might allow the blockage to travel further down the vessel.
- For severely vasacular compromised tissue, hyperbaric oxygen treatments are beneficial.
Administering dermal fillers with blunt tip cannulas will minimize the chances of a vascular event. The fact that the ends of the cannulas are rounded, makes it very difficult to enter a vessel, particularly with the larger cannulas. To the author’s knowledge, there have been no reported events of vascular occlusion with cannulas larger than a 27g. There is still the possibility of causing external pressure on vessels, but this seems to be a low risk, and mainly associated with fillers that expand, like the HA fillers.
The areas prone to vascular events are areas of the face that are called “watershed areas”. These are areas where there is poor collateral blood supply. These areas are:
- Under the eye
- Nose and around the nasal ala (nostrils)
- Nasolabial folds
- Upper lip
The catastrophic complication of blindness from dermal fillers is also a form of vascular occlusion. This is when a bolus of dermal filler is injected into an artery in such a way that it travels back to the vessels supplying the retina. Not only does the injector have to be within an artery, but he/she has to exert a force of injection that overcomes the blood pressure (retrograde flow) in the vessel. This is an extremely rare occurrence but unfortunately is almost universally irreversible.
Prevention is key to avoiding a vascular event with dermal fillers. The safest fillers are the HA fillers which can readily be dissolved with hyaluronidase. Cannulas should be used in all high risk areas in the author’s opinion. If using needles, aspiration to see if the tip is within a vessel should be done before all injections in these areas. Careful counseling of patients and staff is needed to recognize a potential event early to get the best possible outcome.
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.
This coming year is an exciting one with a couple new FDA approvals expected. It’s also going to see several procedures fade away and new approaches with the “gold standards”.
- Kythera’s ATX-101 will be approved for reducing the double chin fat using only an injection. The procedure will need to be repeated 3-5 times in most people, but there will be no incisions and minimal risks. Side effects will be swelling and discomfort that will last maybe up to a week. Off label, it could be used for fat in the belly, love handles, or thighs.
- Longer acting dermal fillers for total facial volumization will catch on. Fillers such as Voluma, Sculptra, and Artefill can be used to add volume to the temples, cheeks, midface, jawline, and preauricular area. Even earlobes can use a little volume in most people. Very little side effects other than swelling and bruising are noted with these “Liquid Facelifts”, particularly when blunt cannulas are used. Results are instant with Voluma and Artefill, and gradual with the Sculptra. Duration of improvement is about 2 years with Voluma, 2-3 years or longer with Sculptra, and over 5 years (some doctors may say permanent) with the Artefill.
- Botox administration will be “lighter” to give a more natural look. No more frozen faces leaving people expressionless. Particularly in the forehead, less Botox using a “micro injection” technique, means more movement and less risk of dropping the brows. The downside to this lighter dosing is that its duration will be slightly less.
- A new topical neuromodulator, Revance’s RT001, will be FDA approved in 2014. Unfortunately, this won’t eliminate all the injections. It will be great for the crows feet area and possible for reducing underarm sweat though. It still will be administered in the doctor’s office (not for in home use).
- Tattoo removal will become easier with less trips to the doctors office. With new protocols like the R20 and R0, several treatments (up to 4) can be combined into one office visit. It looks like the side effects and risks are the same as doing only one treatment per visit. The Picosure laser seems to also lead to faster ink removal but it is still too expensive to be widely available.
- RF (radiofrequency) skin tightening will become even more popular, spurred on by microneedling devices which are more effective than transcutaneous ones. Being able to drive the RF energy to deeper levels both safely and reliably, as with the Infini, will lead to better and more predictable results. The other RF devices such as Thermage, Exilis, Pelleve and Tripolar will become less and less relevant as consumers are disappointed by their results.
- There will be even more interest in noninvasive fat removal. Lead by Coolsculpting, people will find that having no downtime, minimal risks, and getting real observable fat loss is better than getting liposuction. Certain areas such as outer thighs have been difficult to treat noninvasively but new attachments with Coolsculpting and/or new devices using high frequency ultrasound (HIFU) might be developed to treat all the areas that liposuction traditionally treats. RF fat reduction will also become more popular because they will be more effective than prior versions. Zerona will lose all relevance due to its lack of sustained results.
- Lip enhancements will be smaller and done using blunt cannulas. It seems like the trend for having your lips enter the room before you do is waning. People want to look like they have naturally beautiful lips and not obviously overdone lips. Using blunt cannulas enables one to have minimal downtime, minimal discomfort, and a naturally enhanced look.
- People will become more concerned with anti-aging procedures of the hands and chest. Volumization using Sculptra in the declotage and Radiesse in the hands will become popular. Skin tightening using the Infini RF device will help with the wrinkles. Spots can be improved with the Fraxel Dual or Q-switched laser.
- Tear trough injection will be the most popular area treated with dermal fillers. Blunt cannulas make this procedure both comfortable, safe, and quick. Restylane is the filler of choice for this area. By treating the tear trough and upper cheek, the nasolabial folds (smile lines) actually improve as well due to the lifting from above. Patients will have some swelling in most cases for a couple days which can be reduced by sleeping elevated. Bruising is minimal or none with the cannulas when compared to the needles which almost always has bruising lasting up to a week or more.
- Men will do more cosmetic procedures. The drivers for this will be the competitive jobs market and the “no downtime” procedures. Sometimes experience isn’t all that is needed to land a job. To compete with the younger job seekers, the more “experienced” men are seeking procedures that can improve their looks, yet not keep them out of the public for very long. Botox, fillers, Ulthera, and Coolsculpting will become even more popular for men.
- The number of people getting facelifts will continue to drop. With the improvements in skin tightening by Ulthera and full face volumization with dermal fillers, particularly collagen stimulators (Artefill and Sculptra) the aging face can be more naturally improved. There will be a trend for younger patients to start anti-aging treatments earlier leading to “more graceful” aging. People are not as willing to undergo the knife given the associated risks, downtime, and potential for undesirable results.
- Artefill, a permanent filler that stimulates collagen, will gradually replace fat grafting for the face. As an off the shelf solution, Artefill is much more attractive to the patient than undergoing 2 procedures for fat; fat harvesting and then grafting. Also, fat is not always predictable with its “take”, and there can be a need for more than one procedure. Fine tuning with fat is also somewhat difficult and is much easier with Artefill. The apprehension behind the permanent aspect of Artefill has not been borne out and more of the well known injectors are warming up to Artefill.
- Hydroquinones will gradually be replaced by other products to help with pigmentary problems. This trend started in Europe and South America. They have banned hydroquinones because of concerns over their potential carcinogenicity (even though there have been no known documented cancers from hydroquinones), ochronosis (pigmentation side effect that is very difficult to treat), and possible rebound hyperpigmentation. SkinMedica’s Lytera and Neocutis Perle will become acceptable replacements.
Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.
I stumbled across a very interesting article last night. It discussed how the naked mole rat had some very unique qualities. I has a very long life span for a rodent, up to 30 years vs. 3-4 years for most species, and it doesn’t get cancer!
After studying tissue cultures from the rat, they found that it had an unusually high level of Hyaluronic Acid (HA or HMW-HA) per Dr. Gorbunova and Dr. Seluanov, professors at the University of Rochester in New York. Apparently this is needed for the rat to burrow because the rat has no hair and it acts as a sort of “tissue lubricant”. To determine if this was the substance leading to the longevity and anti-cancer protection, they were able to genetically modify the rat so it didn’t produce high levels of HA. Sure enough, the rats started to be susceptible to cancerous tumors!
Is it possible that the Hyaluronic Acid fillers we are using to improve wrinkles and volumize the face (Restylane, Juvederm, Belotero) are having more benefit than making us look good? It is very possible. Human studies will be conducted soon. Get ahead of the curve and get some possible cancer prevention and look younger at the same time by visiting Dr. Weiner at the Aesthetic Clinique in Santa Rosa Beach, Florida for your dermal fillers.
Lip augmentation has received a lot of press over the past couple years and its been mostly bad. That’s because most physicians either overfill the lips or don’t understand what makes lips attractive and natural appearing. In addition, most patients equate lip augmentation to severe pain and several days of downtime with bruising and swelling. I would like to try to convince the public that you don’t have to fear the process of plumping up your lips and don’t have to have days of downtime where you either are hiding in you house or explaining to people that your significant other didn’t beat you.
Blunt cannulas have changed the game for lip augmentation. Through one entry port (which requires a small needle poke) on each side, you can have both upper and lower lips filled with little or no bruising. After applying topical numbing creams to the lips for about 10 minutes, the procedure is very well tolerated. The other advantage is that the swelling is minimized because the lips are minimally traumatized. Many patients go straight out to lunch or drinks or back to work without being self-conscious of people looking at them. On the contrary, traditional lip augmentation using needles requires 4-5 penetrations (each time causing discomfort and risking bruising) per quadrant (so you have to multiply by 4). The blunt cannulas push vessels out of the way with their rounded tips so bruising is minimized. Also, most of the pain is in the surface penetration and once under the surface, the blunt cannulas give less discomfort.
Dental blocks are performed by many of my colleagues. I’m critical of this technique because:
- Dental blocks are not comfortable
- Often times the block is incomplete so there is still discomfort during the lip injection.
- You often stay numb of a prolonged period of time with the associated drooling, etc.
- The lip anatomy can be distorted with the block making precise lip enhancement difficult.
Some doctors are critical of using cannulas for the lips because they say the control of placement of the filler is less than when using the needle. Admittedly, there is less precision for the novice, but over time, I’ve become very efficient at using cannulas and there is little difference as far as results. Sometimes, after filling the lips with the cannulas, I will go back into the already numb lip and place minute amounts of filler along the vermilion border or in the tubercles with the needle technique. This usually does not cause significant bruising or swelling.
A natural set of lips is about 33-40% upper lip and 60-66% lower lip. Often doctors will make the lips the same size or the upper lip bigger and this looks very abnormal. Sometimes when the doctor is trying to improve the upper lip lines, this problem occurs by accident. The best way to correct the upper lips lines is to place filler in the area between the lips and nasal area with the cannulas in a horizontal fashion. This usually doesn’t affect the ratio described above. There is loss of bone in the upper jaw as well as loss of fat, and this injection technique replaces those tissue losses and improves the lines. (For more the most severe lines, I will use Belotero into these lines but this is with a needle and does lead to bruising in most cases.) Also, the lip is not supposed to go all the way to the corners. It should gradually taper off on the sides. Those people who get there lips injected evenly all the way across end up with “sausage lips”. Another error is placing too much filler in someones lips. Small lips can only be enhanced to a certain degree before they appear awkward and you look like a “trout mouth”. People with extraordinarily small lips are gradually made larger in my office. Over successive fills, they are slightly larger than their previous treatment. That way you avoid the lips which get through the doorway before the body.
Procedures which should be avoided at all costs, in my opinion are: permanent filler/ implants in the lips or the Valentine lip lift. These lead to abnormal lip appearance, unnatural mobility/movement, long-term complications (firmness, bumps) and unhappy patients. Some patients are trying to avoid repeated injections due to discomfort and resort to these solutions. Don’t do it!! Cannulas offer a more comfortable injection, and overtime, there is collagen stimulation which lengthens the times between treatments. My long-term lip augmentation patients get filled every 9-12 months.
In summary, lip augmentation doesn’t have to prolonged downtime, be considered intensely painful, and look unnatural. Blunt cannulas in the right hands can make for a much more pleasant experience. It’s important to seek out a physician who knows the anatomy of aesthetically pleasing lips and what is needed to achieve those results. Although bruising can occur with cannulas, it usually is minimal or nonexistent, and you can continue your active social schedule after the procedure.
Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.
- “I’m considering a facelift so I don’t have to do all the maintenance with Botox and fillers.” A facelift will not substitute for Botox or loss of volume. You will still have wrinkles if you don’t do Botox or Dysport after a facelift. Also, loss of volume, a primary component of aging, is not corrected with a facelift. Just go back 20 years and remember how everyone with a facelift looked like a skeleton? Well, the concept of filling the face wasn’t understood at that time. So if you do have a volume deficit, additional procedures are needed at the time of the facelift (liposuction to harvest fat and then fat grafting).
- “I don’t want to start doing Botox because if I stop, the wrinkles are going to look even worse than if I didn’t do Botox.” This is false. When you stop doing Botox, the wrinkles which were corrected will reappear. Keep in mind that they might look worse because you are now older and/or you forgot how they looked before Botox.
- “Rather than get repeated injections in my lips, I would like a permanent solution.” There has never been a permanent filler or implant in the lips that has done well over time. Malformed lips, abnormal firmness, bumps, and repeated surgeries have resulted. The lips have too much movement and sensation to do well with implants. Over time, repeated injections will stimulate collagen and the need for filler will decrease. The HA fillers (Restylane, Belotero, Juvederm) are all completely reversible with an enzyme called hyaluronidase. They are also much easier to fine tune and customize than implants. Trying to remove old implants or permanent filler is nearly impossible to do without permanently misshaping the lips.
- “I can’t bother to use skin care products, I’ll just get the Fraxel to resurface my skin.” Without skin care after laser resurfacing, your results will be suboptimal and won’t last as long. Its very important to maintain results with skin care, and my preference is SkinMedica products.
- “Botox and filler parties seem like a great way to get treatments at a discount.” I highly recommend against getting these treatments at any location other than a doctor’s office. Often the lighting and positioning are suboptimal for the person administering the treatment. Also, emergency medications and equipment are usually not available. Often the injector is hard to get a hold of afterwards or is from far away, so post treatment care is difficult. Most importantly, in Florida, a physician’s license is registered to a specific location so almost always this means that the physician is not licensed in that location.
- “I’m afraid to get my lips injected because everyone looks like a duck that does it.” False. The amount injected into the lips can range from minimal to Angelina Jolie. It’s up to the skill of the injector as to control the size of the lips. I prefer using the blunt cannulas in the lips because the bruising and swelling are minimized. I consider everyone of my patients as a walking billboard for my work and I would never want anyone walking around with lips that look like Lisa Rinna.
- “I still have my frown lines, the Botox didn’t work.” With very severe frown lines, one treatment with Botox will not make them go away. Gradually over time with repeated regular treatments, you can expect better and better results. Etched in lines (lines that are present even after stretching the skin) are actually scars and won’t improve with Botox in general. Movement in the frown area is graded on a 1-4 scale. Botox will help you go down 1-2 grades in general. Also, wrinkles that are present at rest, particularly around the eyes, will not improve with Botox. Botox helps the wrinkles which appear with movement.
- “I’ve read horror stories on the internet about this procedure, it doesn’t seem safe.” The problem with the internet is that anyone can get on their soap box and discuss their poor (or perceived poor) outcomes. In general, a person is going to be much more likely to write about a unsatisfactory result than a very happy client. Rare side effects seem to be extremely frequent if you search the net. Satisfaction rates for a given procedure are usually much less on the internet than reality. Granted there is valuable information to be found on the net, but take everything with a “grain of salt”.
- “Sculptra patients seem to get a lot of nodules” Sculptra has been FDA approved for over 8 years. Indeed there were nodule problems in the beginning. However, several changes have been made to reduce this risk to an acceptable level. Deeper injections, massaging, greater dilution in the mixing of the Sculptra, mixing up the solution days or weeks before (rather than overnight) and not injecting close to the eyes and mouth have been implemented. Dr. Weiner has been using Sculptra for over a year and some of his happiest clients have had Sculptra.
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.