hyaluronidase Archives | The Aesthetic Clinique

How to Minimize Risks of Vascular Occlusion and Blindness During Filler Injections

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

Know the major vascular structures and their landmarks
Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
Use cannulas whenever feasible, preferably 25/23g or larger
Avoid boluses, small linear threads are safer
Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
Injection onto periosteum is safest but does not guarantee a vascular free injection
Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
Retrograde injections are safer than anterograde injections
Dermal injections should be relatively safe
Avoid deep injections in the lips. Stay superficial to the muscles
An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
Have on hand 6-8 vials of Hylenex
Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.

Dermal Filler Providers Must Also Be Proficient With Hyaluronidase

The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.

There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.

The reasons to dissolve HA filler are:

Poorly placed filler giving an aesthetically poor result
Where too much filler was placed
Filler that is infected
Filler is forming a granuloma
Filler is causing ischemia/vascular occlusion
Filler is causing visual changes or blindness

The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.

It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours.

Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.

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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The Most “Botched” Cosmetic Procedures Dr. Steven Weiner Is Asked on Realself.com

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

Plastic Surgeons
Facial Plastic Surgeons
Dermatologists
Oculoplastic Surgeons

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

Now for the most Botched Cosmetic Procedures:

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

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

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

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

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

Restylane Questions (50) answered by Dr. Steve Weiner, Facial Plastic Surgeon

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Q: Is Belotero BALANCE or Restylane better for tear trough?

A: Both Belotero and Restylane can be used for the tear troughs…Restylane will last longer I suspect

You’ve chosen the 2 fillers I use for the tear trough. I mainly use Restylane but have used Belotero for people who could not tolerate much swelling afterwards. Belotero absorbs less water and therefore has less swelling afterwards but this decreases it longevity as well. Most important is that blunt cannulas are used to decrease the bruising, swelling, and risks. See video. Steve Weiner, MD, Facial Plastic Surgeon. Destin, Florida.

Q: Is reusing Restylane injection safe?

A: Studies have shown that Restylane is safe to store at least 9 months after it was used initially

After using a portion of a syringe of Restylane, it is safe to store up to nine months without risk of infection if the needle is changed out before storing and replaced again before using it. Some docs will give to the patient but I always do the storage myself to ensure proper temperatures (room temp) and sterility is followed. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Tyndall effect, overfill, or bruise? (photo)

A: Looks like you have been overfilled in the tear trough area with Restylane

Don’t worry about using hyaluronidase. I wouldn’t do anything other than that to treat this area. Either he is inexperienced with this or trying to bill you more. Using hyaluronidase should fix the problem pronto.
Steve Weiner, MD, Facial Plastic Surgery, Destin, Florida.

Q: Filler to outer lip line left me with blue tinted lips and it’s lumpy 4years after

A: Lumpy lips and blue tint 4 years after Restylane – Try hyaluronidase

Although it is unlikely that there still is filler in your lips, it sounds like there might be. I would give hyaluronidase a try. If this doesn’t work, the vbeam might be helpful for improving the color.

Q: I had lip fillers in September of last year and I’m not happy. How can I correct them? (photo)

A: To correct lips which you are not happy with use hyaluronidase to dissolve

Hyaluronidase is very quick to dissolve hyaluronic acid fillers, which I assume you had. I would start back at square one and get someone else to fill them. Hyaluronidase needs to be injected into the areas of filler just as if you are getting filler.

Q: Restylane injection under eyes. How long for bruising and bags to clear up? 12/17/2013–1/3/2014

A: Under eye injections should be done with blunt cannulas and expert injector

Having under eye injections is a procedure with the most complaints on realself for fillers. It needs to be done with cannulas to decrease bruising, swelling, and other side effects. You might have too much filler or improperly placed filler which needs hyaluronidase to dissolve. Get it redone with cannulas and a very experienced injector.

Q: My doctor hit a vein between my eyes with restalyne. I have purple vein lines will they go away? (photo)

A: Using Restylane in the glabella and a vein was hit, now with prominent vein – you must go back to Doc

It looks like the vein in your forehead is more prominent than it was before the procedure. This means that there is more pressure in the vein either from being occluded or from external pressure. This needs to be addressed by your doctor soon. I think it probably needs to be dissolved with hyaluronidase. This area is particularly prone to vascular problems and should only be injected by the most experienced physician. Steve Weiner, MD, Facial Plastic Surgeon, between Destin and Panama City Beach, FL

Q: Which Filler is Safer, Restalyne or Juviderm?

A: Both Juvederm and Restylane are equally safe

Both are safe. My overwhelming preference is for Restylane. Restylane has a higher G prime which will lead to more lifting ability. It also is much better for tear trough area because it is less hydrophilic (less water absorption). It also gives more structure to lips that are small and lack definition. Juvederm tends to spread as well leading to correction in a general area and not exactly where it’s placed. I do use Juvederm in the temples placed superficially. Overall there are more applications in my opinion for Resty.

Q: How Do Doctors Handle Uneven Restylane Results?

A: Uneven Restylane results could be result of asymmetry unrecognized before the treatment

Most often, the asymmetry which is seen after filler is something that was pre-existing. That’s why photos are very important. The patient often looks at the area treated much more critically than prior to the treatment. If indeed it is due to the filler, that all has to be negotiated with the office. Since you are one month out, the swelling should have already subsided, but if you were only a few days out, I’d tell you to wait 2 weeks before we re-inject. Steve Weiner, MD, Facial Plastic Surgeon, Panama City Beach, Florida.

A: Restylane will help for acne scars, but don’t expect great results

I have been only mild impressed with fillers for acne scars. The problem is often the skin is tethered down and the filler doesn’t lift the depressed area well. For a quick fix, its the only thing available. Besides lasers, there is TCA cross and radiofrequency devices such as the INFINI by Lutronic. See my blog about acne scars. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Skin Necrosis from Dermal Injection?

A: Skin necrosis on bridge of nose can occur from dermal fillers. Need to be evaluated ASAP

The nose is particularly prone to skin necrosis, especially if you had previous rhinoplasty or any scarring. The vascularity can be compromised with filler by compression of vessels or by direct intraluminal (inside) injection. The first signs are blanching, which occurs almost immediately. Later signs are a blue reticular pattern that can occur in areas far from the actual injection point. Late signs are dying of the skin which is dark or black. You must catch things early in order to avoid necrosis so its best to see someone right now for evaluation. No one can tell what’s going on without seeing you. I don’t inject the nose anymore after seeing at meetings the number of complications in this area. Steve Weiner, MD, Facial Plastic Surgery, Destin and Panama City Beach, Florida.

Q: How Many Days Will It Take for Hyaluronidase to Stop Functioning and After How Many Days Can I Perform Filler Injection Again?

A: After hyaluronidase to remove poorly injected filler, wait about a week to re-inject.

Hyaluronidase works very quickly. Sometimes you will see improvements before leaving the office. You could probably get filled in a couple days, but waiting a week is definitely safe. Good luck. Steve Weiner, MD, Facial Plastic Surgeon, Panama City, Florida.

Q: Post Restylane Lip Injection?

A: Restylane for lips, minimal swelling after 1/2 syringe, that’s good not bad. Blunt cannulas are great for the lips.

Most patients will have some swelling after their Restylane injection in their lips because the product is hydrophilic, loves water, and therefore pulls in water and swells a little. If you had blunt cannula technique and only a small amount of filler, the swelling should be minimal. Some of my patients go right out to lunch or dinner. Please see the attached links and videos. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Can Restylane Be Used in Lips for Patients Under 21?

A: Restylane can be injected in lips if you’re under 21

The reason Restylane stated that you needed to be 21 was because their FDA trials were done on people 21 years and older. So that’s what they got approval for. It can be used off label for people under 21 in their lips, and anywhere else, as long as its within the standard of care. Hope you have a doctor who uses cannulas because there is much less bruising, swelling, and discomfort doing it this way. See my blog below!! Steve Weiner, MD, Destin, Florida.

Q: If Sculptra is at All Risky for Someone with Autoimmune Issue(celiac), Would Restalyne/Juvederm Be Suitable for Facial Plumping?

A: Volumizing a face can be done with fillers other than Sculptra, like Radiesse, Restylane, see video

Sculptra is an ideal volumizer because it is long lasting. The problems with autoimmune disease were that on retrospective review, with the old dilution, that people who got granulomas had a higher frequency of having autoimmune disease. I don’t believe that celiac disease was one of those found. You can probably have Sculptra, but Radiesse is a great volumizer, along with Restylane or Belotero. It will cost more to use fillers other than Sculptra, and results won’t last on long, but you can do it. I have a video attached which shows a “Liquid Facelift” using Belotero and Radiesse. Steve Weiner, MD, Sculptra Trainer, near Destin, Florida.

Q: Rippling and Lumpiness in Injection Site from Filler?

A: Swelling and lumpy filler around the eyes should gradually resolve.

I tend not to like Juvederm around the eyes because of its characteristic to draw in water which can lead to prolonged swelling. It should get better, but if not, hyaluronidase will help dissolve it. Bruising can take up to 14 days to improve. I like to use blunt cannulas which leads to less swelling and bruising. Sometimes some mild massage in the lumpy areas can help out uneveness.

Q: Risks of Repeated Injections and Damage to the Skin with Dermal Fillers?

A: Long term use of dermal fillers is actually good for the health of your skin and maybe for you in general

At the most recent Multispecialty Cosmetic Symposium in Las Vegas, several Plastic Surgeons noted that the skin was much more youthful appearing when they were doing facelifts in patients who did filler. I think that doing filler with needles around the tear troughs is not the state of the art and only cannulas should be used there. This will decrease the bruising and swelling after the procedure. I have written a blog recently discussing that HA fillers might actually help with cancer prevention and increase your longevity. Please read it. Steve Weiner, MD

Q: Restylane in my Lips – Will It Take 2 Weeks to See the Final Result? (photo)

A: I agree that after about 2 weeks from lip filler is your final result.

Restylane typical has some mild swelling after injection particularly around the eyes and lips. This is due to the product absorbing water and from the “trauma” of the injection. This usually takes 2 weeks to completely settle down. Sleeping more upright helps to relieve some swelling. The total volume from one syringe of filler is 1 cc. This is one fifth of a teaspoon, which isn’t much. You might want another syringe in your lips. It’s my practice to wait two weeks before reinjecting after filler so I know where I’m starting at again (the new baseline). Keep in mind that it is impossible to go from someone which has no lips to real full lips in one session without looking strange.

Q: 10 Days Since Restalyne Under my Eye. I Still Have a Little Lump. How Can I Tell if It’s Excess Filler or Bruising? (photo)

A: After 10 days, lumps from bruising around the eye should be almost gone and most likely is the Restylane.

It’s very hard to tell from the pictures anything about the “lump” you describe. However, if it were due to bruising, it should be almost gone by 10 days and shouldn’t be just appearing. It most likely is related to a clump of filler which could be dissolved with hyaluronidase. Around the eyes is a difficult injection and should be done with the most skilled injectors using blunt cannulas.

Q: Restylane Lip Injection Getting More and More Swollen? (photo)

A: Severe swelling that you have after Restylane looks like a rare side effect called angioedema

Angioedema is a rare rapid excessive swelling that some people get after any type of manipulation on the face (dental, trauma, injections). It most often occurs, in my experience, in people which are taking “ACE inhibitors” for their blood pressure but occurs with other medications or for unknown reasons too. There is a hereditary form of this condition too. It will respond to high doses of steroids and antihistamines. Will this happen again? Not always, but to help prevent it from happening again, you should take steroids before and after any procedure you have on the face or dental area. You should see an internist to look for the root cause of the problem and switch medications if possible.

Q: Injecting VOLUMA After Injecting Restylane? (photo)

A: No problem with mixing fillers like Restylane and Voluma

The current trend is to use multiple different fillers in the same patient. There is absolutely so problem with having different fillers in the same or nearby areas. Each filler has its unique qualities which make them better in certain applications/areas. The more robust fillers for lifting and filling are: Radiesse, Perlane, Voluma, and to a lesser extent Restylane. Juvederm and Belotero, are softer, more diffusing fillers. Sculptra is unique in that it volumizes and thickens the skin. More of a global fill. By the way Voluma is not widely available in the US at this point.

Q: Two Lines Appears Under my Eyes After Eyes Filler? is It Normal? (photo)

A: Swelling around eyes after fillers

My guess is that you got Juvederm in the tear troughs, which in my opinion is a mistake because it leads to prolonged edema. Other thoughts are that too much was placed in the area. My guess is that is will improve but not resolve and should probably be dissolved. The biggest area of complaints on RealSelf.com is related to filler around the eye. I can’t stress this enough..you need to go to an experienced physician in this area and shouldn’t use Juvederm. Also, blunt cannulas should be used. Steve Weiner, MD, Santa Rose Beach, FL

Q: Restylane Touch Ups After Lip Augmentation?

A: Touch up with Restylane can certainly be done at 2 week follow up for your lips

Touching up with Restylane in the lips should be no problem at the 2 week mark. I usually like to wait that amount of time because if there is any swelling or bruising, it is gone by then. If you have remaining Restylane from your previous procedure, its up to the doctor whether there is an injection fee or if it is complimentary. I use blunt cannulas for the lips..less swelling, less bruising.

Q: Would You Recommend Dermal Fillers for Under Eye Hollows? (photo)

A: I would recommend filling your eye hallows (tear troughs) with Restylane

By the looks of your picture, it appears to me that you would greatly benefit from tear trough and upper cheek filling with Restylane. I would use blunt cannulas in this area to avoid bruising and vascular risks. It should give you about 9-12 months worth of improvements. I would start with about 1 syringe per side. You might need more but that can be evaluated after about 3 weeks. See my video please.

Q: I Had Restylane Injected on 4/14/13 Underneath Both Eyes. Now Have Very Large Lumps! Does This Look Right? (photo)

A: Lumps around eyes after Restylane are usually related to poor injection technique

From your photo, it looks like too much Restylane was placed in too small an area. This can be dissolved with hyaluronidase. It is of upmost importance that the undereye injection be done by an experienced physician. This is the number one area for people’s dissatisfaction on RealSelf.com. I can’t stress this enough. Also, using blunt cannulas is the best way to treat this area for less swelling, less bruising, and less risk.

Q: Am I a Good Candidate for Restylane Under the Eyes? (photo)

A: Are you a candidate for Restylane under the eye..YES

You have pseudoherniation of fat in your lower eyelid. This is caused by a combination of factors. For you and your age, my recommendations are blunt cannula augmentation of the upper cheek and tear trough. This will improve your situation with minimal downtime, cost, and discomfort. I would start at 1 syringe on each side with Restylane. Add more if needed after 2-3 weeks. I have never had the blueish Tyndall effect with cannulas because I inject below the muscle. It takes only a couple minutes per side and bruising is rare. Please see my video. Steve Weiner, MD, Santa Rosa Beach, Florida.

Q: Candidate For Restylane Under Eyes? (photo)

A: Tear troughs are a great place for Restylane or Belotero from experienced injector

It looks like you have a fairly deep tear trough. Fillers are great to improve this area. I would make several recommendations:

Go to someone that does this often. There are too many people with bad outcomes in this area because of poor injection technique
Use only Restylane or Belotero. Other fillers will lead to nodules, or swelling.
The injector should use blunt cannulas to minimize bruising and risk.
Don’t overfill. It’s better to get two treatments because it was underfilled the first time.
Stop all blood thinners 3-4 days before, aspirin – 10 days. Although I inject people on aspirin and even Plavix, if the injector is using a needle, you must decrease the chances for bruising.
Avoid strenuous activity for the rest of the day you are injected.

Q: Am I Too Young for Nasiolabial Fillers? ~ 18 Years Old

A: Filler for nasolabial fold in 18 year old is fine

There is no problem with getting fillers at age 18. I would make sure that it’s not a problem with your cheeks needing filler before filling the nasolabial folds. Its not a permanent solution, so if you don’t like it or can’t afford further treatments you will go back to baseline in about 9 – 12 months.

Q: I Have Blueshift Bruises Appearing Above my Top Lip After Having Restalyne Could It Be Necrosis? (photo)

A: After Restylane in lips, bruising is fairly common but less with cannulas

The lips tend to bruise with dermal fillers but when the injection is done with cannulas, there is much less chance. Necrosis is a rare complication with fillers, and again, the blunt cannula technique will reduce this chance even further because an intra-vessel injection is almost impossible. I don’t see any evidence of necrosis in your picture. Warning signs are immediate blanching of the area and area around the injection. It then turns mottled, with bluish hues within several hours.

Q: Restylane Applied Under my Eyes to Get Rid of the Dark Circles Under the Eyes? (photo)

A: Bruising from Restylane under the eye can be minimized with blunt cannulas

Addressing your exact question is tough without seeing you in person. If the problem is a shadow from loss of volume, more Restylane will help. Restylane won’t help dark circles from pigmentation. Also, sometimes residual pigmentation from a prior bruise can take a long time to resolve. I always use blunt cannulas in this area and rarely get a bruise. It’s also a lot safer too.

Q: Uneven Restylane Lip – Should I Go to a Different Doctor? Should I Dissolve or Add More to One Side? (photo)

A: Uneven lips after Restylane will usually even itself out after about a week.

Sometimes after lips are injected with filler, they appear uneven. This is possible for a number of reasons. First, they weren’t even to start with. Second, there is assymetric swelling or bruising. Third, there was an uneven amount of Restylane or Juvederm placed. The best thing is to wait about a week before doing any modifications. Sometimes adding a little to the less filled side will be sufficient. Sometimes you need to dissolve a lump with hyaluronidase. But, most of the time, nothing needs to be done, and it all looks OK after a week. It’s important to have the doctor take good before pictures so that pre-existing assymeties can be evaluated.

Q: Can I Get Restalyne Now and Have Fraxel to my Face a Few Months Later?

A: Fraxel Dual or re:store (or any other laser) has no effect on your dermal fillers such as Restylane and Juvederm

It is quite alright to get filler now and then get Fraxel Dual a few months later. There will be no change in the results of the filler and it will not adversely affect the Fraxel. There are a number to studies to support this.

Q: Restylane and Blindness?

A: Restylane injected around the eye is extremely safe with blunt tipped cannulas

Restylane is my choice of dermal filler for injecting around the eye. I can not confirm or deny the 2 cases you state of blindness from injecting Restylane around the eye, I just don’t know. This horrible complication has occurred with other dermal fillers and has been discussed at several meetings I’ve been too. It has nothing to do with the brand of filler injected and can occur with any of them. It has to do with an intravascular injection that travels retrograde from a vessel around the eye back to the retinal area. It would occur rather quickly (ie, in the office). HOWEVER, this complication is near impossible or impossible if blunt tipped cannulas are used. There is practically no way to enter a vessel with a blunt tipped cannula so injecting filler inside a vessel is extremely difficult. I also am constantly moving the cannula so as not to put too much product in one place or more than a minute amount if I’m near a vessel.

Q: What Might Affect the Amount of Swelling and Feel of Restylane in the Lips?

A: Swelling after Restylane in lips could be a small collection of blood, of product, or related to the injector

Technique is so important when injecting lips with dermal filler. It is the most unforgiving area because a little issue can be very obvious, unlike the marionette or nasolabial area. I feel that the less trauma you cause when injecting, the less downtime the patient has and the happier they are. In my hands, that means using blunt cannulas. There is less bruising and swelling when injecting with the cannulas. In your particular instance, you need to see you doctor so he can look and feel your lips to see if there is an accumulation of Restylane or a small hematoma (blood collection). If there is a “bunching” of the Restylane, hyaluronidase will solve the problem rather quickly. In very rare instances, a condition called “Angioedema” can occur with is marked swelling that is rapidly progressive. In cases of AE, one needs to be treated quickly so the swelling does not progress, with high doses of steroids and antihistamines. Please see my video too.

Q: Swelling After Restylane Injection? (photo)

A: Swelling after Restylane under eye is minimized with Blunt Cannula technique

Your picture shows moderate to severe swelling after your injection in the tear troughs. I’m not sure if this is related to the manipulation or the injection itself, but it should improve gradually. I highly recommend the blunt cannulas for this area because you get minimal or no swelling in this area. If the swelling persists, hyaluronidase might be needed to decrease the amount of Restylane in this area.

Q: Can Restylane Injections Damage my Eyes?

A: Restylane injection under the eye is very safe to correct tear troughs and hallows with blunt cannulas.

Restylane is a great filler to improve the under eye hallows and tear troughs. It is extremely safe. Using blunt cannulas, this is even safer because the vessels around the eye will be even more difficult to enter. Blunt cannulas also lead to less bleeding, less swelling, and less bruising in this area. I have been doing this procedure since early 2011 with the blunt cannulas and urge you to get a doctor that is experienced with this technique for your treatment. Most questions and problems with fillers on Realself.com stem from injections around the eye so you need to do your research. Please see the attached video to see how quickly this is done.

Q: Dark Circle Under One Eye From Restylane. How Long Will it Stay? (photo)

A: Restylane around eyes can lead to bruising, but much less chance if blunt cannulas are used

As a long time Realself.com physician, I must say that the eye area gives the most questions regarding fillers. Unfortunately, several people have had lumpiness, blueness, swelling, and bruising in this area. You, the patient, must go to the most qualified physicians to get good results with filler around the eye. You must have Restylane and not Juverderm, Sculptra, or Radiesse. I have been using blunt cannula’s for about 1.5 years in this area and the bruising has been minimal. It looks to me that the filler was place too superficially and should be removed with hyaluronidase. Without actually seeing you, it is possible that this is residual from a bruise, which can unfortunately take a very long time to resolve because the hemosiderin (pigment in blood) can sometimes persist even after the initial bruise is gone.

Q: Is One Standard, Full Size Syringe of Restylane 1 ML?

A: Restylane comes in 0.4, 1.0, and 2.0 ml syringes

There are actually 3 different sizes of Restylane. As stated above there are 0.4, 1, and 2 cc syringes. Keep in mind that a teaspoon is 5cc, so 1cc is actually 1/5th of a teaspoon. Any other sizes are not from the company in the US and are either made up by the physician or purchased outside of the US. The size which most people feel is standard is the 1 ml syringe.

Q: What Type of Certifications Must a Doctor Have in Order to Inject Restylane?

A: Certification for Restylane injection by Physician not needed

As far as I know, any physician can inject Restylane. However, certain malpractice carriers, hospitals, or group practices might set their own set of rules. This makes it so important to go to the physician that is recommended to you by your friends, or has the credentials behind him. If you just go to the lowest priced physician, you might not get the result you were hoping for. Keep in mind, the lowest priced Restylane might be the least busiest doctor, and he/she is using pricing to bring in patients.

Q: Allergic Reaction to Restylane 18 Months Later, Should I Be Concerned?

A: Reaction 18 months after Restylane

One possible explaination is a smoldering infection that was quiet for a long time but got activated for some reason. This could be the result of bacteria being “dragged in” with the injection, or bacteria in the blood stream that got caught in the Restylane. Antibiotics would help is this was the problem. See the doc who placed the Restylane for more advice.

Q: Why Are Veins Appearing After Restylane in Nasolabial Folds and Nasogenian Grooves?

A: New appearance of purple splotches is a concern after dermal filler

I would go to your physician and have him look at this. It’s hard to advise you without a photo but what you can possibly have is occlusion of the vessels around the nose. This can lead to the overlying skin dying from poor circulation. It can usually be improved if recognized early by Hyaluronidase, heat, blood thinners and nitro paste.

Q: Can Restylane Be Used to Fill Eye/Cheekbone Area?

A: Restylane is great for under eye and cheek rejuvenation

Restylane is my preferred filler for the under eye and upper cheek filler. It can help fill in the hallows and replace mid cheek flatness that occurs with age. My preference is to be conservative in this area and reinject after 4 weeks if needed rather than inject too much at the initial treatment. I’ve seen too many unhappy patients which have been over injected. Bruising is slightly higher in this area vs. other areas.

Q: Does Restylane Increase Collagen Production?

A: Restylane increase collagen in area of treatment

Restylane does help in stimulating collagen in the treated area. One frequent finding is that fillers tend to last longer the more you use them, and this is mostly due to the collagen production. The same can be said for all fillers too.

Q: Is Q-Med Filler Similar to Restylane?

A: Q-Med has licensed the filler to Medicis in the US

Q-Med makes several different fillers and does license the rights to Restylane and Perlane to Medicis in the US. I agree with all the comments below concerning safety and outcomes. My favorite saying is “The results don’t depend on the filler, but the filler (injector).”

Q: How Long Can Open Restylane Last if You Are Getting Touch Ups?

A: One study says opened Restylane lasts 9 months

There has been a study on the sterility of opened Restylane. The study concluded that an opened Restylane syringe stays sterile for at least 9 months.

Q: Restylane vs Juvederm

A: The physician is more important than the dermal filler brand

I agree with Dr. Persky. Either is a good choice. My preferences are:

Eyes – Restylane
Lips – Juvederm
Nasolabial and Marionette – Either, but I lean towards Juvederm.

Remember, it’s the Doc that’s most important. A physician trainer for other physicians is a good choice, but not necessarily a requirement. Steve Weiner, MD Facial Plastic Surgeon.

Q: How Long Should I Wait Before I Get my Restylane Injections “Topped Up”?

A: My style is to not wait until it is completely gone

This is more of a question about doctor’s style. There is no right answer. My style is to touch up the previous injection when the correction appears to be waning. It makes more sense to me to walk around with a full or near full correction most of the time then to have swings from full correction to no correction. There is no problem with putting a different filler on top or using the same filler. In some areas, like the lips, sometimes a mild enhancement is done initially. Then, before it is gone, I will enhance the lips further than the original results if the client desires large, full lips. This avoids the “coming out” with real big lips, dividing it up over time.

Q: Can Restylane Be Combined with Other Fillers to Lessen Side Effects?

A: Severe Swelling can be Angioedema

There have been cases of angioedema after injections with dermal fillers. This is an abnormal swelling, not just the usual minor swelling one gets after HA dermal fillers. The cause is usually unknow, but frequently it’s related to someone taking an ACE inhibitor antihypertensive (usually the medication name ends in -ace). It doesn’t always happen to a person who has had it before and it only very rarely will occur in someone taking ACE inhibitors. It can also run in families. There are measures you can take to help prevent it in the future like taking steroids before and after.

To have an actual allergy to HAs is extremely rare.

If you suspect angioedema is the problem, this should be worked up by your internist.

Q: Cause of Allergic Reaction to Restylane?

A: A granuloma is not an allergy

Granulomas are when the body reacts to a substance and considers it foreign material. The is an intense inflammatory response, but not an allergy. This creates redness and swelling. Steroids are usually given to reduce the swelling. Sometimes, dissolving the filler with hyaluronidase will resolve the problem too.

You can form granulomas with any filler. Also, it doesn’t happen every time you get the same filler.

Interesting, I was told that Radiesse forms the least amount of granulomas of the fillers, but I can’t substantiate that. Radiesse does form more nodules than other fillers, which is bumps that are not swollen and do not hurt.

I don’t have any personal experience with the granulomas, but have been to several meetings where they were discussed.

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

[youtube=http://youtu.be/tOA_Xr5VLDc]

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

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

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

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

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

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

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

A: Juvederm leaving swelling around the eyes is seen often

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

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

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

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

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

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

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

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

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

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

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

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

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

Q: Will Juvederm XC work for my hollow eyes?

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

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

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

A: Using a laxative should not affect the Juvederm

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

Q: Just Had Juvederm and Belotero Need Help?

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

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

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

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

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

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

A: Swelling after Juvederm in the Lips

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

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

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

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

Q: Can Filler Injections Cause Blurry Vision?

A: Blurred vision needs an Ophthalmology evaluation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A: Hyaluronidase will dissolve Juvederm as fast as anything

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

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

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

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

Q: Necrosis from Dermal Fillers in Tear Troughs?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q: DMSO for Bruising from Filler Injections?

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

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

Q: Fillers for AIDS Patients?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q: Depressed over juvederm lip injections?

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

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

Q: Juvederm and Possible Headaches?

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

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

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

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

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

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

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

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

Q: Dermal Filler and Tetracycline?

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

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

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

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

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

Q: Compatibility Juvederm/Restylane?

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

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

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

A: Bruising and swelling after Juvederm to lips

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

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

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

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

Q: Juvederm Removal with Hyaluronidase Injections?

A: Hyaluronidase breaks down HA fillers, not collagen

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

Q: More Juvederm on One Side? (photo)

A: Assymetry after Juvederm in Nasolabial Folds

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

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

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

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

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

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

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

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

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

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

Q: How to Treat Eye Swelling After Juvaderm Injections?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A: Severe Swelling after Juvederm

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

Q: Juvederm Lips

A: Juvederm is great for lip enhancement

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

Q: Juvederm Bruising

A: Bruising from Juvederm is much better using blunt cannulas

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

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

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

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

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

A: Juvederm will diffuse slightly so correction is not precise

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

Q: Juvederm Ultra Plus for Indented Smile Lines?

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

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

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

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

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

Q: Does Juvederm Help Lines in Eye Corners?

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

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

Q: Juvederm with a Dental Block Cause More Swelling?

A: Juvederm can be injected very comfortably without dental block

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

Q: Downtime for Juvederm on Nasolabial Folds?

A: Typically, no downtime after getting Juvederm

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

Q: Lower Lip Asymmetry and Lumps After Juvederm

A: One other thing to consider

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

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

Q: Juvederm Bruising on Nasolabial Fold

A: Sounds like Tyndall Effect after Juvederm

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

Q: Risks of Using a Stored Syringe of Juvederm?

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

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

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

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

Q: Can Juvederm Add Volume to Sunken Cheeks?

A: I prefer Radiesse or Perlane for cheek augmentation

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

Steve Weiner, MD Facial Plastic Surgeon Destin, Florida

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

A: It varies

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

Q: Juvederm Gone in a Week?

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

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

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

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

How to Minimize Risks of Vascular Occlusion and Blindness During Filler Injections

Dermal Filler Providers Must Also Be Proficient With Hyaluronidase

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

The Most “Botched” Cosmetic Procedures Dr. Steven Weiner Is Asked on Realself.com

Restylane Questions (50) answered by Dr. Steve Weiner, Facial Plastic Surgeon

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

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