dr weiner Archives | The Aesthetic Clinique

What is Myomodulation?

The aging process leads to hyperactivity of the muscles of the face. This movement leads to increased wrinkles and loss of the smooth, youthful appearance of the skin. In the upper face, neuromodulators such as Dysport and Botox, do a great job at relaxing this hyperactivity. What’s trending with aesthetic providers is dampening the muscle movement but not complete relaxation, leading to a more natural expression without “freezing” the patient.

Unfortunately, the neuromodulators can’t be administered throughout the entire face. In the lower face, low doses of neuromodulators are safe for the lips, chin, gummy smile, and DAO (AKA RBF) muscles for the most part. Inhibiting the lower face too much leads to changes with expression and smiling. What can be done to control the muscles in this area? Filler!

(Side note: Hyperactivity of the lower face has been described by Dr. Weiner in gum chewers in a previous blog. It leads to accelerated aging in the lower face and should be discouraged by aesthetic providers.)

An interesting study by Dr. Nowell Solish supports this concept. Using a rather large and sophisticated machine, Dr. Solish was able to determine muscle strain in the lower face during facial expressions. He compared patients in their 50’s to ones in their 30’s. As expected, the older patients had more muscle strain than the younger patients. He then injected the older population with Restylane Refyne and Defyne, 3-4cc in the perioral area. These fillers have XPresHAn technology and have flexibility – stretch capabilities. After the injections, the older patients were restudied for muscle strain. The findings: The muscle strain of the 2 groups (older vs younger) were basically the same. The filler was able to reduce the muscle strain about 15 – 20 years!

What’s the explanation? Dr. de Maio has coined the term myomodulation. His theory is that filler placed around hyperactive muscle leads to stretching and relaxation of the muscle. While this is plausible, there is probably a better way to describe this phenomenon.

Dr. Weiner’s theory: Think of an Aston Martin that has a top speed of 230 mph or more. However, in the US, to conform to the laws and regulations, governors are placed on the car to keep its top speed at 180 (This is purely hypothetical and used for illustrative purposes only). Dr. Weiner feels the fillers Refyne/Defyne limit the full range of movement of the hyperactive muscle, akin to a governor on the muscle. Why these fillers work so well at doing this is because they can stretch and recoil (akin to a tether), leading to some, but not excessive muscle movement. Other fillers would work but with a different and less natural mechanism. Think of the non-flexible fillers as acting as a wall, and not as a governor or tether.

With the new XPresHAn fillers, Refyne and Defyne, we now have a new treatment modality for the lower face which is highly effective. Myomodulation is real, exactly what is the underlying mechanism is still debatable.

Introducing the Concept of “Age Freezing”

The nonsurgical aesthetic industry has finally hit an important milestone. Using a combination of techniques, cosmetic physicians are now able to halt, and even reverse, the age-related changes which occur to one’s face. In the past, technologies would allow for turning back time for a few years but eventually, the inevitable and undeniable signs of aging would occur. As lasers, radiofrequency (RF), filler and neuromodulator techniques have improved, the aging face is a thing of the past. The concept of “age freezing”, keeping ones looks for a decade or more, is not merely a dream, but reality. More importantly, this all can be done without surgery!

Not everyone is a candidate for “Age Freezing” unfortunately. The stipulations are:

Must be a nonsmoker – There are several significant skin and health issues associated with smoker which can’t be overcome. Many procedures require healing and collagen stimulation which are inhibited by smoking.
Free of chronic debilitating disease – There are tolls long term diseases take on the body which lead to premature aging, cellular changes.
Stable weight – As Katherine Deneuve once stated, at the age of 40, you must decide between your ass or your face. If you lose too much weight, fat is lost from your face. In most instances, this can be overcome but not always. However, in patients with significant weight gains, there can be some difficulties maintaining the same look one had in the years prior.
Alcohol consumption in moderation – Alcohol can take a toll on the body in the long run when taken in excess. 1-2 drinks per day is the recommended maximum intake that the author recommends.
Healthy lifestyle and diet – Although this topic overlaps some of the previously mentioned necessities, a good exercise regime is also required. The benefits of exercise on weight, hormones, circulation all benefit the facial appearance. Obviously, a well-rounded diet full of antioxidants, vitamins, and nutrients is beneficial too. There is research to support telomere lengthening with these measures as well.

The requisite procedures for “Age Freezing” are:

Neurotoxins on a regular basis. Relaxing the hyperdynamic muscles of the face with either Dysport or Botox needs to be performed at least 3 times per year. The regularity is needed to keep the muscles weak and prohibiting them from regaining strength.
Dermal Fillers for lost volume. Fillers are the epicenter of the whole “Age Freezing” concept. Beginning in the mid 30’s, at least a cc of volume is lost per year. This is the result of fat, bone, and muscle loss. Replacing and keeping up with this process is tantamount to looking young. Large volumes are best replaced with using Sculptra, a collagen stimulating filler. It is best to recreate the foundation with Sculptra. Superficial fine tuning is best performed with a hyaluronic acid filler, such as Restylane. New techniques using blunt cannulas permitted safer, less downtime procedures. A comprehensive understanding of the aging process has enlightened our specialty as to what needs to be corrected for accomplishing age reversal.
Skin Tightening to reverse gravity. The constant downward pull due to gravity leads to skin laxity, above and beyond what is attributable to volume loss. Devices that heat up the dermis will stimulate collagen and tissue contraction. Devices vary in their ability to tighten, often with a tradeoff of more downtime/discomfort/risk for more results. Ablative lasers, CO2 and Erbium, will give the most tightening for lasers. Radiofrequency can also be used, with the microneedling RF, such as Infini, giving the best results. A new procedure called JPlasma, looks like it may have promise in significant tightening, but does have about 14 days of downtime and a month of redness.
Skin Resurfacing to improve pigmentation, fine lines, and thicken the dermis. The aging process, primarily due to sun exposure, causes skin to thin with loss of collagen and elastin. Dyspigmentation, pigmentation problems, occurs as well. Renewing the surface of the skin can be accomplished using lasers, such as the Fraxel Dual, or chemical peels. Microneedling can thicken the skin by producing small injuries in the dermis with very little downtime or risks. There may be benefit to adding PRP, platelet rich plasma, to the skin, but the jury is still out.
Skin Care is essential to achieve the optimal results from any of the above mention procedures as well as to improve one’s skin health. Retin A or Retinol should be a staple in one’s nightly regime. These products stimulate skin turnover, reversal of pigmentation problems, better hydration with hyaluronic acid stimulation, and collagen production. Blemishes/Acne breakouts are improved with these products as well.
Oral Supplements are key to good, healthy skin. Oxidants are the source of disease, cancer, aging, and skin damage. To neutralize the oxidative stress, strong anti-oxidant supplement(s) are necessary. Examples include: superoxide dismutase, fish oils, resveratrol, Polypodium leucotomos, turmeric, and glutathione. In addition, the antiaging benefits of Metformin are hard to dismiss with the current research published. Lengthening one’s telomeres with TA65 is probably beneficial as well.

One must understand that the “Age Freezing” concept is a process. It is a lifestyle, a choice. It is not a “one and done” procedure. It consists of regular visits to an aesthetic physician. There are big steps and little steps along the way. The author has dozens of “Age Freezing” patients whom look younger and better, 10 or more years after initiating treatments. “Age Freezing” will eliminated the need for future cosmetic surgery.

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 Temples Shouldn’t be Ignored When Filling the Face

The ideal facial shaped has been described as “heart shaped”, “V shaped”, or “Upside Down Egg”. A youthful face draws attention to the upper face and eyes. With aging, the lower face becomes “heavier” and more dominant, as laxity and volume loss set it. Instead of round or oval, the shape of the face becomes closer to square. The underlying cause for these changes is primarily loss of fat, muscle, and bone.

The upper face’s width is determined primary by the temples. Fat pads in this area are particularly susceptible to atrophy associated with aging and exercise. To reestablish the youthful facial shape, it is essential to reflate the temples. There is a contiguous fat pad in the preauricular area which follows similar volume loss as the temples and should be volumized simultaneously. When the lateral cheeks are given filler, the temporal deficits become exaggerated and more obvious. Patients must be counseled on their temples whenever cheeks injected.

Besides the overall facial shape change, the benefits of filling the temples are the lift given to the surrounding tissues. The brow, and upper eyelid will be elevated with temporal filler. Placement of filler along the orbital rim and lower forehead further enhances this effect. The ideal temple should be convex in a women and slightly concave in the male.

The filling of the temples is reserved for the experienced injector. Dr. Weiner’s choice for this area is Sculptra because of its safety and natural appearance. The only downside to Sculptra is that when placed along the bone in the deepest aspect of the temporal fossa, a large volume of product is needed for complete correction. To finish corrections after the deep Sculptra placement, a superficial layer of HA filler (Restylane, Juvederm) can be safely placed using large bore cannulas. The filler is placed immediately below the dermis in the subcutaneous layer or just below the superficial layer of the temporalis fascia.

To reverse the signs of aging and restore the upper face dominance, temple volumization is required. It must be considered for patients that have brow and eyelid heaviness as well. This is an area that is difficult to treat with higher than average safety risks, and should be reserved for the most experienced injectors.

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Dr. Weiner’s “Superficial Skin Block” to Numb The Face for Aesthetic Procedures – Infini and Laser Resurfacing

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Some of the fastest growing and most popular procedures in the Aesthetic Industry are radiofrequency and laser procedures. The most sighted obstacle for patients doing these procedures is pain. Dr. Weiner has develop and perfected a method to numb the face fairly thoroughly that is fairly quick and simple. The “Superficial Skin Block” takes about 3 minutes to administer for the entire face. It requires no knowledge of neural anatomy and is less invasive/more comfortable than nerve blocks. The anesthesia kicks in within minutes and will last at least a couple hours. It is ideal for improving comfort when undergoing the Infini, CO2, Erbium, or Fraxel laser resurfacing. Dr. Weiner’s mixture for injection is:

Lidocaine 1% with 1:100,000 Epinephrine (Standard premixed from most medical suppliers)- 5cc
Bacteriostatic 0.9% Sodium Chloride with Preservative – 5cc
8.4% Sodium Bicarbonate – 1cc
All this is drawn up in a 10cc syringe

The “Superficial Skin Block” starts with placement of topical numbing cream. Dr. Weiner uses “Lipothene” from Central Avenue Pharmacy which contains 23% Lidocaine and 7% Tetracaine. It is left on the face for at least 1 hour. Do not place on face and neck simultaneously. This is too large a surface area for the topical. The neck doesn’t require this strong a topical in Dr. Weiner’s experience.

The injection requires a mesotherapy apparatus from Mesoram.com. The exact device used is found at: Dr. Weiner’s Preferred Mesoram Needles . The needles are 4mm, 30g and the plate is circular with 7 needle connectors. Plates can also be purchased without needles and 32g needles can be purchased from the site and attached manually.

The topical is wiped off and the face is cleaned with alcohol and hibiclens. The injection is started on the cheeks with 0.5 ml aliquots placed in each injection. The areas injected are slightly overlapped. A small amount of the mixture is placed above the upper lip with a needle that is removed from the device. A few minutes are allowed before starting the procedure to allow for the small blebs to diffuse into the skin tissues. You will notice areas injected become pale and this is the epinephrine effect. This helps in controlling bleeding and bruising.

Dr. Weiner’s Superficial Skin Block has been used by multiple practitioners with great success. It’s effectiveness, ease of use, and limited downside make it perfect for many aesthetic procedures, particularly Infini and laser resurfacing.

Cellfina: Improving Cellulite Dimples For Years

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There have been hundreds of potions, lotions, and procedures claiming the end to cellulite. All have basically failed…until now. Finally, there is a way to cure those cellulite dimples on the buttocks and posterior/lateral thigh. The procedure is called Cellfina, and at the ASLMS in April, 2016, there was data presented showing 3 years of persistent improvements. One presenter suggested that the very early test subjects from 5 years ago had similarly persistent results.

Cellfina is done in the office using just local anesthesia. Start to finish, it takes about 1 1/4 hours, and patients are able to drive themselves home. There is very mild discomfort during the procedure (4/10) and is associated with the numbing of the areas to be treated. Afterwards, no pain medication is required, and some go back to work immediately afterwards. Most will take the remainder of the day off and head back to work the following day. Physical activity can resume after 1 or 2 days. Bruising is the most common side effect, but can be treated at the Aesthetic Clinique with the Excel V to cut down the duration to a couple days. There have been no long term side effects noted in any of the study patients.

The procedure starts with pictures and identification of the dimples that need treated. These are only able to be treated on the back part of the thighs and buttocks. After marking the sites, the patient lays prone on the table and the areas are cleaned/prepped. The Cellfina suction plate is placed over the marked areas and controlled injection of tumescent anesthetia is placed. After about 15 minutes, the same suction apparatus is placed on the sites again, and a motorized reciprocating needle-like device is inserted. This device releases the fibrous bands which are pulling the skin down. By releasing the bands, the skin elevates and viola… gone dimple. This process is continued until all the areas marked are treated. Pads are placed on the treated areas because there may be some leaking of the tumescent fluid for the next day or so.

Results begin to appear within a few days. Results are stable after a couple months for years to come.

With years of research behind Cellfina, it appears that there is finally a long term solution for correcting the nagging dimples associated with cellulite. With minimal side effects and downtime, it seems likely to be a very popular procedure, given that over 85% of females over adolescence have some degree of cellulite.

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.

Filling The Temples Should Be Done With Sculptra…Period.

Temporal volume loss is part of the natural aging process of the face. It is the result primarily of fat pad atrophy, but loss of bone, soft tissue, and muscle also contribute. Losing volume in the temples leads to:

Lowering of the eyelid and eyebrow
Skin laxity in the periorbital and cheek area
Changes to the overall shape of the face

Temporal volume loss changes the shape of the face

Probably the most significant of the above changes is #3. A youthful face is “upside down egg” or “heart” shaped. The upper face is rounded, with the widest part being the upper cheeks. The center of beauty is the eyes, and the youthful face emphasizes this. With the temple wasting associating with the aging face, the overall shape turns more square, and the lower face becomes dominant. Filling the temporal defect can help to re-establish the upper face dominance that is the hallmark of youth and beauty.

There are basically 2 ways to fill the temples. Filler can be placed deep to the temporalis muscle, at the level of the periostium of the bone in the temporal fossa. This type of correction will lift the muscle, fat, and soft tissue “en mass” for a very even appearance. Needles are needed for this technique because the temporal fascia is difficult to pierce with cannulas. This is the preferred method of the author. The second method is placement of the filler just below the dermis, in the subcutaneous tissue. Imperfections caused by uneven placement of the filler will be more visible because the tissue in this area is very thin. Bruising is more likely as well because there are multiple veins in this area. Using blunt cannulas helps to mitigate bruising but not eliminate it.

Risks associated with temporal fillers are similar to placement in all other areas: bleeding, bruising, infection, unevenness, unsatisfactory result, need for more filler, vascular compromise including necrosis AND BLINDNESS. Fortunately, blindness is an extremely rare complication of fillers with somewhere between 100 and 200 cases reported in the literature. The most common “filler” sighted for this complication is fat, but it has occurred with all the fillers. It is the duty of the injecting physician to take all precautions to minimize this catastrophic risk. The etiology of blindness is occlusion of the retinal artery by filler that is obstructing its blood flow. Filler makes it to this area because there are natural occurring anastomoses between the external (face) and the internal carotid (ophthalmic) systems. Techniques to minimize blindness are:

Slow injection of the filler which prevents retrograde flow of filler
Use of large cannulas or needles which makes entry into vessels more difficult. (Using cannulas has been shown to be significantly safer than needles because their blunt tip is less likely to result in an intravascular injection)
Moving the end of the needle or cannula constantly to avoid a bolus injection within a vessel
Aspiration prior to injection to see if there is a flash of blood, indicating a intravascular location

Sculptra is ideally suited for correcting the temple defects. When placed at the level of the periostium (the author’s preferred method), it creates a very long lasting correction (at least 2-3 years) formed by collagen and neo-osteogenesis. More importantly, it is the only filler in which aspiration can be relied upon to produce a flash. Sculptra is nearly the consistency of water and will flash with a red reflux of blood if intravascular. The viscosity of all the other fillers makes this technique an unreliable indicator for testing where the tip of the needle is. That makes Sculptra much safer for use in this area.

For improving temporal volume loss, Sculptra will produce a long acting and natural appearing correction with a safety profile that is superior to all other fillers on the US market.

What Everyone Is Missing About Neothetics (NEOT) Lipo 102 Drug Candidate…Potential Blockbuster Status

Lipo 202 for abdomenal fat reduction with injections.

Lipo 202 for abdominal fat reduction with injections.

Removing and reducing fat in Americans is a huge industry in the Aesthetics market. There are multiple ways to do this:

Suction (traditional) Liposuction
Laser Liposuction
“Tickle” (vibration) Liposuction
Water Liposuction
Freezing the Fat (Coolsculpting)
Heating the Fat (Vanquish, TruSculpt, Sculpsure, Ultrashape, Liposonix)
Chemically with Injections (Kythera’s Kybella, Neothetics 102, 202)

There are positives and negatives to all the above methods. Some are more aggressive but have more downtime and risk. Pain is a limiting factor for wide acceptance with others. Devices tend to cost the physician $80,000 and up, which keeps costs high to patients. The public demands little to no downtime with reasonable costs.

Kybella’s FDA approval recently has opened up a new way to remove fat…using just injections. Kybella drug, deoxycholic acid, is a bile salt. It is normally excreted by the liver to aid in the breakdown of fat that is ingested. It has been shown to be effective in reducing the double chin fat through a series of injections. Most people will require between 2-4 treatments. The fat cell that is affected is permanently killed. That doesn’t mean your chin will stay the same after you are done with treatment. Residual fat cells will enlarge, if there is an overall weight gain due to eating habits, exercise change, or other systemic disease. There are already trials going on to use Kybella for other areas and it is just a matter of time that it will be approved for the excessive abdominal fat. It seems like a great way to remove fat…but there is one catch. There is swelling and discomfort for a few days at least. Most will overlook this minor point, but it is just this issue that makes room for Neothetic’s Lipo 102 to become a blockbuster. Neothetics doesn’t cause the fat cell to lyse (burst open) and therefore leads to significantly less inflammation and swelling.

Neothetics is researching Lipo 202 for abdominal fat reduction and Lipo 102 for fat reduction in the eye area for Graves disease patients (off label use for treating cosmetic unsightly fat bulges around the eye is obviously their intention). Neothetic’s Lipo 102 and 202 are both made with salmeterol xinafoate. Salmeterol is an asthma drug, a beta adrenergic agonist. In layman’s term, this drug acts like adrenaline (epinephrine). Fluticasone is a strong steroid and helps reduce swelling and is added to Lipo 102. The way Lipo 102 and 202 work on fat is that the salmeterol mimics exercise of the fat cell, by increasing the metabolism of the cell. Glycerol and fatty acids are expelled from the fat cell because it percieves (it is tricked into believing) that the body needs these energy sources. This will result in shrinkage of the fat cell. Just as with Kybella, multiple treatments are needed.

NEOT, Neothetics, Lipo 202 causes fat cell shrinkage

Neothetics NEOT Lipo 202 causes reduction of abdominal circumference

One of the big questions is: “How long do results last with Lipo 102 or 202?”. This question is being researched in a follow up study to the phase II study on abdominal fat using Lipo 202. Although a concern to investors, whether or not the results are long standing or not is almost irrelevant in the authors opinion. For a procedure that is 5 minutes from start to finish, with very little downtime, it’s perfectly acceptable to require touch ups months after treatment. This is the norm for Botox, dermal fillers, laser procedures, and skin tightening procedures.

The hidden gem with Neothetics is Lipo 102. There is currently no easy way to treat fat around the eye without surgery. Lasers have been tried and were abandoned because of numerous complications. If there were a way to reduce bulging fat around the eye with injections, it would be a HUGE drug. Kybella has too much swelling to be considered for this area. The eye cannot tolerate post septal swelling (within the orbit) without risk to visual loss. It is conceivable that the procedure would be similar to getting Botox around the eye, but in a slightly different area, with little to no downtime. Again, the need for touch ups would be perfectly acceptable to most patients as long as pain, risk, and downtime are minimal.

Neothetics’ Lipo 202 for treating abdominal fat in less than 5 minutes with injections seems like a great story. However, Lipo 102 has an even greater potential and without competitors for treating the bulging eye fat. With the recent acquisition of Kythera by Allergan, the other 2 large players in the aesthetics industry, Galderma and Merz, may want to have a competitor to Kybella. A fat busting injectable seems to fit in well with the offerings of either company, but it’s the authors opinion that Merz will eventually be the buyer of Neothetics later this year. With Kythera being bought by Allergan for $2 Billion, and Neothetics $146 Million Market Cap, with $70 Million in cash, it makes the buy out all more likely. In addition, there were several insider buys at the IPO price of 14 when NEOT went public late last year. There have been no insiders selling after the IPO despite the stock’s dip to just under 6 a few weeks ago. Since the purchase of KYTH by Allergan, the stock has moved up to 10.73 on large volume.

Disclosure: Dr. Weiner is a share holder of Neothetics (NEOT) and was a shareholder of Allergan (AGN) and Kythera (KYTH). At the time of posting this blog, NEOT had closed at 10.73.

Sculptra is Different Than All Other Fillers: Natural, Structural Support, Cost Effective

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The concept of volume loss in the aging face is a relatively new realization by the aesthetic industry. Up until about 12-15 years ago, the dogma was correcting loose skin using primarily surgical approaches. Post surgical patients were very pleased parading around their newly tightened faces, free from wrinkles and sags, but prominently showing off their skeletonized features. There was no hiding the fact that something had been done, it wasn’t subtle, and it was obvious. Something didn’t jive with what the brain recognized as youthful or aesthetically pleasing. This dichotomy between what Plastic Surgeons and the brain thought was beautiful was due to the lack of understanding of the impact of volume loss on the aging face.

It is now widely documented that there is significant loss of volume in the face as one ages. Fat pads throughout the face become less prominent, and there is also bony resorption throughout the entire facial skeleton and jaw. Even if the skin didn’t stretch from gravity, there would be sagging related to loss of the structural support. A great analogy is in a youthful face, the dress (skin) and your body (facial structures) are the same size. An aging face wears the same dress, but the body is now a size or 2 smaller, so the dress doesn’t fit correctly.

How much volume loss occurs? Beginning at the age of 30, about 1-2 cc of loss occurs per year. However, it is so slow and subtle, and it isn’t until the late thirties or early forties that there is any noticeable changes. It seems to match the so called “tipping point” in women, just as they end their most “fertile” years. Doing the math, a person in their 50’s can have 20-30 cc’s of volume that needs replacing. Its up to the aesthetic physicians to combat this long standing evolutionary process, and keep women (and men) beautiful, well beyond their child bearing ages.

Fortunately dermal fillers can reverse the loss of volume that inevitably comes with aging foregoing the costs, downtime, and risks associated with surgery. The most recognized fillers, Restylane, Perlane, Juvederm, Voluma, are hyaluronic acid fillers. These all last about a year, with most of their longevity based on their ability to absorb water, hydrophillic characteristics. These are great fillers for small corrections around the eyes, lips, marionettes, and nasolabial folds. The cost/benefit ratio turns negative, once the number of syringes exceeds about 6. At this point, correction is still far from optimal, but the costs are significant. Also, in the author’s opinion, multiple syringes of HA filler give a “boggy” appearance to the correction, directly related to their hydrophillic nature.

The only filler that can correct large volume deficits in a cost effective manner is Sculptra.

Sculptra works by stimulating one’s own collagen to volumize the face “naturally”. Studies have shown Sculptra’s effect to last at least 2 years. The problem is, aging is always going to happen, so even after full correction with Sculptra, touch ups with one to two vials every 12 to 18 months are required. Not only does Sculptra produce a long lasting and natural result, it is a cost effective solution. When comparing Sculptra to an HA filler, one vial of Sculptra will volumize what approximately 4 (4 cc) syringes of an HA will do. The cost of Sculptra is usually about 1.5x the cost of a syringe of HA filler. It turns out that full volumization is usually about “1 vial per decade” with Sculptra. Sculptra should be considered the “workhorse” for replacing the structural loss of the face. Fine tuning, once the volume is replaced, is the job of the HA fillers.

Darker skin ethnicities are naturally better protected from the sun so the aging process is delayed (Skin aging is mostly related to sun exposure). These patients require less volume when compared to lighter skinned individuals. Also, severely sun damaged and unhealthy skin won’t respond quite as effectively in collagen production from Sculptra as the healthy, well protected skin, and will require more volume than the norm.

Although there is still a component of excess skin in the aging face, the primary cause of wrinkles and skin laxity is due to volume loss. Correcting volume deficits should be the primary focus of reversing the signs of aging. Of the fillers, Sculptra stands out from all the others in it’s ability to produce a long lasting, cost effective, and natural solution for large volume replacements.

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