dermatology Archives | The Aesthetic Clinique

Coolsculpting Update 2017 – Faster, More Comfortable, Better Results

Coolsculpting’s original FDA approval was in 2009 and it was initially cleared to cool skin prior to dermal procedures. It was later in 2010 that the FDA approved Coolsculpting for fat reduction in the flanks (love handles). Over the next several years, the procedure has been approved for abdomen, thighs – both inner and outer with various sized handpieces to treat every body type.

What’s new is that there are 2 new indications for Coolsculpting treatment. The submental fat (double chin) can now be treated with the Cool Mini handpiece. Depending on the needs of the patient, one or two applications are needed. Treatment times are 45 minutes. There is no downtime as is customary with all Coolsculpting procedures. A 2nd treatment is needed in some patients who need larger corrections. Another exciting area of recently approved treatment is the underarm area. This is where the new Cool Petite handpiece is used. Loose skin is not going to improve but that annoying “bat wing” can be reduced with these treatments.

In 2016, there was a significant change to the handpieces used for treatment called the CoolAdvantage Handpieces. (Not all practices have upgraded to these, so patients must inquire). The difference is that these handpieces are more shallow – the amount of suction witl therefore be less. The cooling plate is continuous rather than just the sides. The area treated is now more uniformly cooled than with the prior handpieces. These changes result in:

More comfortable treatments
Treatment times of 35 minutes vs the usual 60 minutes
Faster onset of results – as little as 3 weeks
Less bruising and post procedure pain

Soon after Coolsculpting’s approval it had been noted that manual massage post treatment led to improved results. About a couple years ago it was found that using the Zimmer Z Wave in place of the massage yielded even better results. It was found that adding the Z Wave increased the treatment efficacy by 68-100%. The Z Wave uses Acoustic Pulsed Technology, which sends shock waves through the skin and fat. It is a painless 5-10 minute procedure. These shock waves further injure the fat cells leading to a better result. After the Coolsculpting treatment, there are fat cells which are killed, some unaffected, and some which are “on the fence” as to whether they will survive or die. The Z Wave pushes some of these “undecided” cells over the brink. Z Wave has also been shown to lead to less post procedure discomfort.

“If one is good, two is better”. In some practices, a second Coolsculpting machine has been purchased. This allows for “DualSculpting”, treating 2 areas simultaneously. Treatment times are then cut in half using this technique.

Comparing the DualSculpting to treatments 1 year ago, two areas can now be treated in about one quarter of the time when adding the benefits of the CoolAdvantage Handpieces.

The Aesthetic Clinique has been one of the pioneers in Coolsculpting treatments. Its first machine was obtained in 2009, being one of the first 25 in the country, even before the formal FDA approval for fat reduction. All the latest handpieces are available including the CoolAdvantage, Cool Mini, and Cool Petite. The Zimmer Z Wave is a complementary service added to all Coolsculpting treatments. A second machine has just been purchased, so DualSculpting is now available at The Aesthetic Clinique.

Recent advances have made Coolsculpting significantly faster, more comfortable, and more effective. It is a great noninvasive procedure for reducing unwanted fat without downtime.

The Top 5 Procedures for a Youthful Appearance

There is so much information available on the internet that is becomes extremely confusing to the average person as to what is the right thing for them to do. While genetics, race, and lifestyle play a role in how one ages, there are many universal features of the aging face which are inescapable. While it is common to be asked “should I do this or that”, the best results are always a combination of several different procedures.

Wrinkles: Botox/Dysport relax hyperdynamic muscles which cause wrinkles with movement. There’s a reason this is the most popular cosmetic procedure in the world. It is quick, extremely effective, very little downtime, minimally painful, and with a high satisfaction rate. Common areas treated are the “11’s” or frown lines, crows feet, and forehead lines. Duration of effect is about 3-4 months. Early preventative treatment is effective in delaying lines which appear at rest (etched in lines).
Loss of Volume: Volume loss is inevitable. The aging process in combination with sun exposure causes the face to lose fat, bone, muscle, and collagen. Starting at the age of about 32, a cc or 2 of volume is lost per year. It begins to become visible at about age 38-40. This is called the “tipping point” in women, about the time when fertility starts to drops off. Sun protection and darker skin types will delay this lost volume up to 10 or 15 years. Replacing lost volume is done with fillers. The most common fillers are made with Hyaluronic Acid (HA) which is a natural component of skin. Examples of HA fillers include Juvederm, Restylane, and Voluma. Longer lasting fillers are Sculptra and Bellafill.
Pigmentation/Redness: Inevitably, skin gets exposed to the sun and “sun damage” occurs. The sun is responsible for destroying collagen in the skin, causing it to thin, and lose elasticity and hydration. Another effect is causing vascular fragility leading to visible vessels and redness. Melanin is produced as the body makes an effort to protect the skin resulting in “sun spots” or hyperpigmentation. Lasers are effective in treating these conditions near painlessly. For reds, VBeam or Excel V Lasers are the gold standards. Up to 3 treatments might be needed. For a few small patches of pigment, a Q Switched Laser or Excel V is used. For more diffuse patches of pigmentation, laser resurfacing (Fraxel) or IPL are good options.
Skin Laxity/Sagging: The combination of gravity and loss of skin elasticity can result in the need for skin tightening. Surgery will give the most aggressive result for this. Alternative treatments with less downtime, less risks are Infini, Thermitight, or Ablative Lasers.
Fat Accumlation: Aging leads to changes in metabolism and fat storage. Patients develop fatty collections which become difficult to diminish despite aggressive workout routines and diets. There are now multiple noninvasive approaches to removing fat permanently with no downtime. Larger more diffuse areas require a technology called Vanquish ME. Smaller areas can be spot treated with either Coolsculpting, Sculpsure, Ultrashape, or Liposonix. In the submental area, fat can be reduced with an injection called Kybella, a new handpiece from Coolsculpting (CoolMini) or with Thermitight. Of course surgery including liposuction or tummy tuck has been the gold standard for decades and is the best option for those desiring the most aggressive approach.

Drum roll please….The top picks from the 5 categories (Dr. Weiner’s Choices):

Dysport, Sculptra, Excel V, Infini, Coolsculpting (CoolMini)

Smoking and Aesthetic Procedures Don’t Mix Well

Smoking is well known for its detrimental effects to one’s lungs and health. Lung cancer, heart disease, chronic lung disease, strokes are all sited to have much higher rates in those that smoke. It certainly is no leap of faith to imagine the harm smoking causes to the largest organ of the body, the skin.

There is one study which shows that moderate smokers (30 cigs/day) will show 14 more years of aging when they hit 70 then nonsmokers. They are more likely to have deeper crows feet and “smoker’s lines” above the lips. Telangiectasias, often called broken capillaries, are more common in smokers. The color and glow of the skin is changed. The circulation is decreased because the blood vessels are constricted (vasoconstriction), mainly due to nicotine, so the skin becomes dull, ashen, and loses it redness. Carbon monoxide levels become elevated in the blood stream, reducing the oxygen capacity of the blood. Hydration of the skin is reduced in smokers. Also, the vasoconstriction affects the hair by thinning it and causing premature graying.

Another study shows that smoker had about a 20% collagen reduction in response to a wound. Extracellular matrix turnover was also decrease. Smoking also depletes vital nutrients in the skin such as Vitamin B and Vitamin C (needed for collagen formation), and magnesium. Each cigarette generates million of free radicals, which causes an inflammatory response throughout the body.

Many of our aesthetic procedures rely on the body’s response to get optimal or for that matter, any outcome. A collagen response is needed in our collagen stimulating fillers such as Sculptra, Bellafill, and Radiesse. The longevity and volume afforded by these fillers is solely collagen related. These fillers should be reconsidered if they are planned to be used in a smoker.

A flap during surgery is when an area of skin is elevated from its normal position. This compromises the blood flow because part of the normal vasculature is cut. This is what occurs when performing a face lift, neck lift, rhinoplasty (nose job), blepharoplasty (eyelid surgery), tummy tuck (abdominoplasty), and breast surgery. A smokers outcome with these procedures is at significantly higher risk because of the vasoconstriction that nicotine causes. The flaps are at risk of necrosis (dying), prolonged edema, prolonged healing, scarring, need for reoperation and infection.

Laser resurfacing or RF (radiofrequency) procedures depend on the heat injury to cause an inflammatory response which ultimately leads to collagen stimulation and skin tightening. In a smoker, the blood supply in compromised to the skin so WOUND HEALING AND COLLAGEN FORMATION IS SIGNIFICANTLY IMPAIRED. Complications such as infection, prolonged healing, scarring, poor results are much higher with smokers. Most physicians will not perform ablative laser procedures on smokers because of these additional risks.

Many smokers say they will quit and use nicotine gum/patches or e-cigarettes. These solutions are just as detrimental as cigarettes to wound healing and collagen formation. There is still vascular constriction with these substitutes. Most surgeons require a window of at least 3 weeks prior to surgery and 4 weeks after to be smoke free. Some require urine testing for nicotine and its by products to document compliance.

Smoking and aesthetic procedures aren’t a good combination. It is counterproductive to smoke while striving to look younger. If one is really concerned about their looks, smoking cessation is absolutely necessary. It will save your appearance and save your life too!

Bellafill is a Unique, Safe, Long Lasting Filler

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Bellafill is a one of a kind dermal filler. What makes it unique is its longevity, composition, and FDA approved indications. Although FDA approved in 2006 for improving the nasolabial folds, there have been 2 recent studies that have expanding its indications. These are the use of Bellafill for acne scars and data which shows at least 5 years of correction from a Bellafill treatment. Both of these studies are ground breaking, with no other fillers able to make these claims.

Bellafill is a mixture of 20% PMMA (Poly Methyl Methacrylate) and 80% Bovine Collagen. PMMA has been used medically for over 50 years as an implant. The PMMA in Bellafill is uniform smooth spheres of 40 micron diameter. The spheres elicit an inflammatory response, which stimulates the body to create a collagen capsule around these spheres. The size of the spheres is important, because at 40 microns, the body is unable to phagocytize the PMMA (digest), leading to the prolonged longevity of the product. Being smooth, the inflammatory response is subdued, minimizing the uncontrolled inflammation found in granulomas. Prior to Bellafill injection, a dermal test is needed to see if the patient is allergic to the Bovine collagen and this takes 28 days to determine the results. The Bovine collagen in Bellafill provides a temporary correction for about 2-3 months, until the body’s own collagen is created.

Acne scarring causes significant psychosocial problems for millions of Americans. Isolation, depression, suicidal thoughts, and poor self-esteem are just some of the many issues these individuals suffer from. Bellafill is used to improve the appearance of the rolling type (scars that flatten when stretched) of acne scars. It is injected into the dermis, to elevate the scar. The results are immediate, but improvement is noted over the next 12 months. The FDA study showed that approximately 0.1cc was needed per scar, and most patients required 2 treatment sessions. There were no major complications noted and everyone was followed for 12 months. Satisfaction rated by the patients was over 90% at 12 months.

No filler on the market has published data showing persistent corrections at the 5 year mark. Bellafill studied 1008 patients for 5 years. Retention rate was 87%. Satisfaction rates at every year including the 5^th year was 80% or higher. The granuloma complication rate was 1.7%, which is comparable or better than all other fillers. With treatment, the granuloma rate was less than 1%. With corrections lasting at least 5 years, it is easy to see how Bellafill is actually a very economical filler as well.

Bellafill truly is unique amongst the dermal filler in regards to its longevity and use for acne scars. It is currently only available from a select group of physicians who have been trained by the company. Dr. Weiner is a physician trainer, lecturer, Key Opinion Leader (KOL) and on the physician advisory board for Bellafill. Dr. Weiner is actually a Bellafill patient as well, having been recently injected with 8 syringes of the product.

Comparing Infini to Ulthera and Why Infini’s Technology is Superior for Laxity, Wrinkles, and Acne Scars

When it comes to skin tightening and wrinkles, there has been an increasing trend for the consumers to choose the less invasive approaches and opting out of surgery. Although results aren’t as dramatic, nonsurgical treatments offer less downtime, less risk, and less cost. These treatments are great for the people who are not quite surgical candidates because of very mild signs of aging as well as those that just want to delaying the sagging before it is even apparent. Then there are those who really are surgical candidates but can’t afford the downtime or are concerned about the looks of some of their peers who have had face/neck lifts.

The most recognized name for noninvasive skin tightening currently is Ulthera (Ultherapy). This technology uses highly focused ultrasound to cause a thermal coagulation zone beneath the skin without affecting the surface. This technology is akin to the one used to break up kidney stones or gall stones with ultrasonic energy (lithotripsy). The coagulation zones elicit an inflammatory response leading to collagen stimulation and contraction. This results in tissue tightening and wrinkle improvement. Ulthera was brought to market in 2009, with Dr. Weiner being one of the first 20 adopters in the US. Dr. Weiner has had significant experience with this device and with all the changes in protocols.

In 2013, the Infini was FDA approved and introduced in the US. This was a novel technology for the US, but it had been used in Asia for at least 1.5 years prior. Infini uses radiofrequency attached to microneedles to cause similar thermal coagulation zones as the Ulthera, below the surface of the skin. Dr. Weiner is the largest user on the Infini in the US and now lectures and precepts other physicians in it use.

The similarities of the 2 technologies:

Both are fractional treatments (only treat a portion of tissue) which is safer and leads to faster healing.
Both can treat at multiple different levels. While Ulthera is restricted to 3 levels, it is not uncommon for Dr. Weiner to treat at up to 5 levels with the Infini.
Both have very little downtime – Ulthera has potential for bruising but otherwise no downtime. Infini has about 24-36 hours of redness and swelling. There are no activity or sun restrictions for either treatment.
All skin types can be treated with both technologies.
Both can be performed in the office with just topical – Patients who have had both technologies report that Ulthera had more discomfort in Dr. Weiner’s office.
Both can improve skin laxity, particularly in the jawline. It is Dr. Weiner’s opinion that this is primarily due to fat destruction by both technologies. Both can reach into this layer (the Infini only if desired, Ulthera almost always by default with the deeper transducers).
Both mechanisms of tightening are similar – create a controlled injury that leads to tissue contraction, tightening, collagen stimulation BUT the way the injury is produced is different.
Both can be safely off the face – neck, chest, extremities, under arms (hyperhidrosis)
Both are extremely safe technologies with very little side effects and don’t use lasers (so safer for the eyes).
Both have better results with multiple treatments. Although Ulthera states one treatment is needed, the experience Dr. Weiner had with the technology was that better outcomes were seen with multiple treatments.

Comparing the differences of Infini versus Ulthera:

Infini treatment of the face/upper neck lays down over 50,000 thermal coagulation zones VS Ulthera’s 16,000. It only makes sense that the more zones, the more results.
Infini depths can be adjusted from 0.25 mm to 3.5 mm in increments of 0.25 mm. Ulthera has 3 depths: 1.5, 3.0, 4.5 mm. Using the ultrasound of the Ulthera, Dr. Weiner was able to measure skin depths over the face and neck. There were no areas of skin thickness greater than 2.5 mm in the entire face and neck (except in very thick skinned males in the upper cheeks). Therefore, MOST OF THE TREATMENT FOR ULTHERA IS BELOW THE LEVEL OF EVEN THE DEEP DERMIS. Only the 1.5mm transducer causes coagulation in the dermis. This is not included in most protocols, or if it is, is only a minor component. Studies have shown that the area of greatest collagen formation is in the deep dermis. Infini is able to lay the coagulation zones all throughout the dermis, including the deep dermis because of its ability to change it’s depths. The Infini can even treat different areas of the face at different depths, which is important because the face has significant variability of thicknesses between the forehead, eyes, cheeks, lips, jawline, submental, and chin area. Depths below the dermis injure the subcutaneous tissue, which is mostly fat. Fat is what we want to preserve, not destroy, except along the jawline and submental area.
The treatment cost (consumable) of Ulthera for the physician is more than 10 times greater than for the Infini. The purchase price to the physician is also about 50% more for the Ulthera. The treatment time is also longer, sometimes up to 50% more for Ulthera. This all gets passed on to the patient resulting in Ulthera being about double the price of the Infini in most offices.
Although Ulthera touts that deeper penetration causes contraction of the SMAS, to Dr. Weiner’s knowledge, this has yet to proven histologically. The deeper penetration does lead to more discomfort as well as potential for fat destruction. The Infini targets the dermis, particularly the deep dermis, the area for maximal collagen creation.
Results seem to be more consistent with the Infini versus Ulthera. This seems to follow the science. More coagulation points in the correct zone of the dermis should lead to more collagen, more tightening.
Superficial fine lines can be treated with the Infini but not Ulthera. In certain cases with skin type 1-3, shallow treatments of less than 1 mm can be used to treat these wrinkles and etched in lines. Ulthera doesn’t have this capability.
Although there are some reports of Ulthera treating acne scars, Infini seems to be the best technology to treat these. It is probably the combination of the microneedles, RF energy, and adjustable depths that make it a superior technology to treat this difficult problem.

From about 2005 – 2009, Thermage was the most advanced noninvasive skin tighten device. This was replaced with Ulthera in 2009, which offered better, safer, and more predictable results because of precisely placed coagulation zones (albeit, maybe too deep). In 2013, Infini was introduce and it has been slow to catch on. However it is finally being adopted by the key thought leaders in the Aesthetic Industry. It will soon be recognized as the most efficacious noninvasive skin tightening technology on the market.

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State of the Art in Acne Scar Treatment – 2015

Dr. Weiner: Acne Scarring after 2 Infini treatments.

Acne affects 85% of people between the ages of 12 – 24. There are various types of acne that range from simple black/white heads, papules/pustules, to the cystic breakouts. It’s the cystic acne that leads to most of the scarring. Acne scarring can have a impact on one’s appearance leading to a significant emotional toll. Lack of self esteem, social withdrawal, negative self image, and depression have all been described by acne scarring sufferers. Acne scarring questions are one of the most frequently asked questions to the experts on Realself.com. It’s important for the medical community to address this problem for the overall well being of a significant segment of the population.

It might seem obvious, but in order to treat acne scarring, the active acne must be controlled. It’s the author’s opinion that acne can be controlled with topical medications combined with lasers. A newer treatment, recently popularized by Dr. Weiner, has been the use of Botox/Dysport for controlling the sebum production in the skin. Please see my blog for more details about acne treatments.

Fresh Acne Scarring Treatment

When acne scarring is still red, treatment is easier and results are better. The primary treatment for scars in this stage is vascular lasers. It has been found that early scar formation can be reversed using these lasers over several sessions. The author’s choice of lasers is the Spectra Q Switched Laser – Gold Handpiece. This offers a quick (5 minute) nearly painless treatment. It should be done 4-6 times in general. Other laser options are the Excel V or the VBeam. Some small smoldering areas of acne are treated simultaneously with these lasers as well.

Long Standing/Persistent Scarring Treatment

Longer standing scars are harder to treat than early red scars. Collagen has been laid down in an inappropriate, disorganized manner. Treatments are directed at breaking up this collagen and for it to reorganize in a more natural manner. There are a few ways this can be done:

Lasers: There are ablative (tissue is removed) and non ablative (tissue is heated) lasers. There is more downtime, more risk, and more results with the ablative lasers. Darker skin types are at risk for darkening of their pigmentation (hyperpigmentation)
Subcision: Using a needle or similar, the physician goes under the scars and cuts them from their deeper attachments. This process has been used for decades and has minimal risk and downtime. It’s the authors opinion that unless something is placed in the area where scarring was cut, the scar will reform between the “sticky edges” as it does in all other surgical wounds. Bellafill is a permanent filler that was recently FDA approved for acne scars. Dr. Weiner suggests placement of Bellafill in these subcised scars to keep the edges from tacking back down, and to fill lost volume in the rolling acne scars.
Microneedling Fractional (Controlled Depth) Radiofrequency: This technique uses RF energy to break up and reduce the scarring with coagulation. The healing process leads to a more organized collagen matrix. The best in class device for this category is the Infini from Lutronic. The insulated needles, variable depths, and fractional delivery make it extremely safe for all skin types with minimal downtime and risk.
Platelet Rich Plasma (PRP): PRP has been shown to improve healing times and results in many areas of orthopedics. As of yet, there are no studies that definitively say that PRP can help acne scarring but there are several case reports that it improves outcomes. It is probably an effective addition to laser or RF procedures when treating acne scars with no known detrimental side effects.

Dr. Weiner Recommendations for Mature/Long Standing Acne Scars:

The most effective energy based treatment for acne scars seems to be the Infini. Results from ablative lasers (CO2), and non ablative lasers (Fraxel 1550) don’t seem to match the Infini’s results in his clinical experience. Patient satisfaction is higher with Infini, with much less downtime and a safety profile, particular in darker skin types, unmatched by the lasers.

For persistent defects after 3 or more treatments with the Infini, subcision with Bellafill administration is then recommended. It typically will take about 2 treatments, 2 months apart, to get optimal results with this method. This is only practical on about 10 – 15 lesions at a single session.

PRP can improve healing times and may improve results.

Remember that acne scars “won’t go away” but will be improved with the treatments mentioned.

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Creating the Perfect Lips with Restylane Silk

Lips before treatment with Restylane Silk

Dr. Weiner Lip Enhancement, Restylane Silk

Lip Enhancement with Restylane Silk.

Enhancing lips has become a very popular cosmetic procedure. Most of the press has been negative because of the abundance of poorly performed injections, particularly on celebrities. Instead of improving ones looks, and sensuality, they become a turn off, negatively affecting one’s attractiveness if not done properly. A slew of new terms for these lips has arisen: “Fish Lips”, “Sausage Lips”, “Trout Mouth”. Patients go into the doctors office with aspirations of “Angelina Jolie” lips and leave with “Lisa Rinna’s” lips. Unfortunately, the bad outcomes of these celebrities and close friends, scares off a number of interested women, fearing they too will end up like Goldie Hahn from the “First Wife’s Club.”

Fortunately, with an experienced injector, and the newly approved filler Restylane Silk, cosmetically attractive lips are well within reach for most clients. Restylane Silk’s advantage lies with it small particle size. This enables the injector to more precisely place the filler, for better contouring, and with less chance of leaving lumps or bumps. Also, because it is superficially placed, there is less bruising and less discomfort during injections. It’s not just the filler though, it takes the skilled eye, technique, and knowledge of an experienced injector to get the lips just right.

Knowing the esthetically correct dimensions and landmarks of the face goes back to Leonardo Da Vinci, in the 1400’s. He recognized the golden ratio, phi, that equals 1.618. Throughout the face, he saw that relationships between spacing and dimensions of the face, and all were related to the pi ratio. In the lips, the golden ratio is found between the upper and lower lip, with the upper to lower lip ratio being 1:1.618. In African Americans, this can be close to 1:1 and Asians are somewhere in between. Several other aesthetically appealing features of the perfect lips are:

Prominent tubercles in the middle of the upper lip, and either side of the midline on the lower lip
A strong cupid’s bow and philtrum
Corners of mouth that are neutral or turn up slightly
Very little red lip visible on the lateral 1/3rd of the upper and lower lip
The length between the columella and space between the lips should be about 1/2 of the length from the space to the chin
The peak of the cupid’s bow is continuous with the philtrum
The upper lip should project more than the lower lip when visualize on a lateral view
A “Paris Curl”, lips curling up at their vermillion borders
Phi ratio: length between cupids peaks: length between corner of mouth and cupids peak

What goes wrong with lips that look obviously done or unattractive? The simple answer is that ratios and landmarks are ignored. Several common errors are: upper lips that are bigger than lower lips, lower lips that project more than the upper lip, tubercles (or other landmarks) that are obliterated, and no attention to the cupids bow. Also, enhancing lips to the “age appropriate size” is part of the art of an experienced injector. Selecting the appropriate filler is important too. Fillers other than Restylane Silk, are too thick to be added superficially in the lips without the risk of being noticeable or palpable. Silk can be injected just beneath the surface of the lip and not be perceptible. Fine tuning is much easier with this technique rather than the deeper injections that have more associated bleeding, bruising, and swelling.

The take home messages are that achieving desirable, sensuous lips requires a skilled injector with a keen awareness of natural ratios and landmarks. Using the newly approved FDA filler for lips, Restylane Silk, allows for greater control and results that can’t be achieved with the other, more viscous, hyaluronic acid fillers.

(In the older patient: It is very hard to restore lips to their youthful state when there is severe volume loss, multiple upper lip lines, and loss of the normal curvature of the lips. The lip muscle in a young lip forms a “J”, creating a natural curl in the lip. In some patients, this elongates into an “I” shape, making it difficult to create the natural shape with a filler injection without it appearing abnormal. In these patients, the author gradually enhances over several months and this seems to lead to better outcomes.)

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What is Vascular Occlusion or Vascular Compromise from Dermal Fillers?

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:

Glabella
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.

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

Juvederm is one of the most popular dermal fillers in the US. As with most fillers, it is only FDA approved for the nasolabial folds, but is used “off label” in other areas of the face. Although Juvederm is a very safe filler for use around the face, there are certain characteristics that make it the wrong choice for filling the “tear trough” and areas around the eye.

Like many of the popular FDA approved fillers, Juvederm is a hyaluronic acid (HA) filler. The other commonly used HA fillers are Restylane, Perlane, Voluma, and Belotero. One of the characteristics of HA fillers that extends their longevity is that they are hydrophilic. Hydrophilic means “water loving” which translates into the HA fillers absorbing up to 10 times their volume with water from the surrounding tissues. Although all the HA fillers have this characteristic, Juvederm is the MOST HYDROPHILIC of the dermal fillers mainly because it is has the highest concentration of HA. This is a disadvantage around the eye because it often results in PROLONGED EDEMA around the eye. All the HA fillers have been known to do this but it is particularly common with Juvederm. Dr. Weiner has seen this problem with people that have been injected with Juvederm in the tear trough even up to 3 years earlier. RealSelf.com is replete with stories and pictures of very unhappy patients with this Juvederm problem.

Another disadvantage of Juvederm in the eye area is related to its cohesivity. This is the ability of the product to bind to itself. Juvederm has low cohesivity, which means it tends to spread to the surrounding areas, causing a correction to areas beyond the injected area. This is fine for some areas, but in the tear trough, which is a very small area, doctors need precise control of the filler. The physician wants to know that when he places the filler in the tear trough, it will stay exactly there, and it doesn’t with Juvederm.

Fortunately, hyaluronidase is an antidote for HA fillers, and can be used for dissolving fillers with poor cosmetic results. For Juvederm, dissolving with hyaluronidase is harder and requires more treatments than the other HA fillers. Some believe this is related to the higher cross linking in Juvederm than other fillers. Nonetheless, Juvederm can be successfully reversed even in instances where the chronic edema has been present for several years.

Around the eye and tear trough area, the HA filler of choice should be Restylane. There are some physicians that are happy with Belotero and Restylane Silk. Another great option is Sculptra but only in very experienced hands. Remember too, that cannulas are a much safer option for the injection in this area, with less risk, less bruising, and less downtime.

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How Long Do Dermal Fillers Last…..It Depends!

It happens everyday. Patients ask how long they can count on their dermal filler lasting. The problem is, is that there is no quick and easy answer. There are a number of variables that factor into filler longevity, with the ultimate unknown being that there is no way that a physician can determine how one’s body is going to degrade a particular filler.

In the US, the majority of patients are injected with Hyaluronic Acid (HA) fillers. The commonly known HA fillers are: Juvederm Ultra, Juvederm Ultra Plus, Restylane, Perlane, Voluma, and Belotero. The differences between the HA fillers are their manufacturing process, and the concentration of the HA in the filler. The harder the HA is for the body to break down, the longer it will last. A larger particle of HA has less surface area then multiple smaller particles taking up the same space. Less surface area means there is less area for the cells to “chew up” the HA. In general, larger particles will last a little longer than smaller particles. Another factor in HA fillers is how tightly the particles are bound together. Cross-linking, adding bonds between molecules of HA, has been shown to significantly add longevity. All HA fillers are a combination of cross-linked and non cross-linked HA. Too much cross-linking leads to a filler that is very hard to inject, and has led to more complications (in a filler that is no longer on the market). Non cross-linked fillers last only 3-4 months and are hardly used anymore. One last variable in HA fillers is their ability to attract water, their hydrophylic properties. The more they attract water, the longer the HA filler gives a correction.

The fillers that are collagen stimulators, tend to lead to longer longevity. Fillers in this group are: Radiesse, Sculptra, and Bellafill. While studies have shown a very mild collagen response to the HA fillers, the visible volume correction with the HA fillers is the gel, not the collagen. With the collagen stimulators, the body responds to what is injected by creating an inflammatory response and lays down collagen. Until the particle is degraded by the body, collagen will continue to be produced. Radiesse is made of calcium hydroxylapatite, and is the shortest duration in this group. Artefill should be considered a permanent filler, because its component, Poly Methyl Methacrylate (PMMA), does not get broken down by the body. Sculptra has consistently given about 2-3 years duration in studies and in the authors experience.

The location in the face a filler is injected is one of the most important factors to determine longevity. Areas where there is more movement, there is faster breakdown. In order of increasing duration in the face, the order is (in the author’s experience):

Lips
Marionette
Nasolabial Folds
Tear Troughs
Cheeks
Temples

(Forehead, nose, earlobes are variable)

A couple more very important variables that should be mentioned. The more filler that is injected, the longer it will last. This applies to all the fillers. Also, filler doesn’t stop working all of a sudden. It takes months of gradual loss to notice a difference in volume. In fact, even when the patient believes there is no longer results, biopsies have proven that there is still filler present.

After all the above explanation, the author’s experience with the commonly used fillers is:

Lips: HA fillers give about 4 months, longer with recurrently injected lips.
Tear troughs: HA’s – about 9-12 months, Sculptra and Bellafill – years. Juvederm could last years and should never be injected in tear troughs.
Nasolabial: similar to tear troughs
Temples: HA’s – 12-18 months, Sculptra and Bellafill – years
Cheeks: HA’s – 18 months, perhaps 2 years with Voluma; Sculptra and Bellafill – years

Remember that individual results are unpredictable. These are generalizations and offer no guarantee as to how long a patient’s results will last. There are many variables that factor into longevity that are listed above, not to mention how each individual responds, degrades, a certain filler.

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

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

Website: http://www.theclinique.net

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

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