jowls Archives | The Aesthetic Clinique

Dr. Weiner’s New Treatment for the Aging Neck – “TriNECKta”

The aging phenomenon affects all the areas of the face and body. Sun exposed areas will be most affected due to the collagen destroying effects of UVA and UVB light. Dr. Weiner has developed a technique which addresses many different aspects of the aging neck, and, better yet, it’s all minimally invasive.

Pigmentation

Hyperpigmentation is a sign of UV damage and aging. It can be addressed with nonablative lasers, such as the Thullium 1927nm laser (Fraxel Dual/LaseMD). In some patients, there is also an associated redness, such as in poikiloderma. Redness needs a vascular laser such as the Excel V + laser. Skincare products are essential in maintaining results and must include a retinol, growth factor, and SPF.

Volume Loss

Much has been written about fat loss in the face, but this process will also affect the neck. Recent articles have validated safety with collagen stimulating fillers in the neck if done with careful technique. Deeper lines and wrinkles might also require a hyaluronic acid filler (HA) for improvement

Laxity

Loss of collagen, elastin, and gravity contribute to skin laxity in the neck. Radiofrequency seems to be the leader of the pack for tightening skin and building collagen and elastin. There are a couple different methods to use RF in the neck such as The Genius, FaceTite/NeckTite/AccuTite.

Hyperactive/hypertrophic Platysma

There is more literature supporting the platysma muscle becomes stronger as one ages. This leads to neck bands, jawline sagging, and corners of the mouth drooping. Strategic placement of a neuromodulator in the platysma can improve the appearance of the jawline and neck.

Excessive fat

Fat can accumulate in the chin area (double chin) and along the jawline. Methods used to improve the appearance of the fat in these areas includes: Kybella, Genius, FaceTite/NeckTite/AccuTite. If these procedures are done, the other procedures listed above will have to done on a different treatment day. Jowling can also be improved with these methods.

By combining these treatments, usually done in a series, multiple areas of the aging process can be addressed. Upkeep with future treatments and skincare is essential to maintain long-term results. To see if Dr. Weiner’s “TriNECKta” treatment is right for you, please call the office: 850-622-1214.

STEVEN F. WEINER, MD DEMONSTRATES THE LIQUID FACELIFT

Questions Answered by Dr. Weiner on Radiesse

This is Dr. Weiner from The Aesthetic Clinique, demonstrating a Liquid Facelift. A Liquid Facelift is when dermal fillers are used to replace lost volume in the entire face which has occurred due to aging, exercise, and/or weight loss. With no incisions or cutting, you can lift the skin around the eyes, upper cheeks, and improve the jawline and upper neck by just injecting fillers. He uses Radiesse, Belotero, and Xeomin to improve the tear troughs, temples, upper and lateral cheeks, preauricular area, jawline, jowls, nasolabial folds, lip lines, frown lines, crows feet, bunny lines, and forehead wrinkles. She had minimal bruising, and went to work later that day. Blunt microcannulas were used in all but the lip line area (the only area which bruised). www.theclinique.net 850.622.1214

The Genius is Truly a Huge Step Forward for RF Microneedling

The initial studies of radiofrequency microneedling (RFM) were performed by Hantash et al. in 2009. What Hantash was able to demonstrate was that RFM produced a fractionated radiofrequency thermal zone (RTZ) with coagulated tissue surrounded by normal tissue. Overtime, multiple growth factors and inflammatory components led to complete replacement of the RTZ with neocollagenesis and neoelastogenesis over the following 10 weeks.

Delivery of the RFM energy varies according to the device used. Unfortunately, there has been a paucity of solid research behind the majority of the devices. There is confusion in the marketplace for both consumers and providers as to what constitutes the best delivery system for outcomes, safety, and comfort. Lutronic decided to breakdown all the components of RFM energy delivery and optimize them in their development of the Genius.

One of the selling points of many of the devices has been that they are comfortable and have minimal downtime. What this actually means is that there is minimal energy delivered to the dermis. Discomfort is directly related to the amount of energy delivered. Lutronic’s research has shown that needle depths and energy settings don’t necessarily correlate to the what really occurs in the tissues.

Needle Depths

Skin intrinsically resists puncture by outside forces. If is especially difficult for 49 needles to penetrate the skin in a small area (1x1cm2). The natural tendency is for the skin to buckle with the needles “bouncing off the surface” and several of the RFM devices tested have been documented to exhibit this phenomenon. Furthermore, needles have a harder time penetrating deeper into tissue than superficially, so deeper depths are even more challenging to accurately place than more shallow treatments. Unfortunately, setting needle depth on the device doesn’t always correlate to actual tissue depth. Requirements for accurate depths include:

Sharp needles – but not too thin as to bend or dull during hundreds of pulses
Powerful motor – underpowered motors prevent accurate penetration
Quick motor – slower motors will lead to pushing the skin rather than penetrate it

Energy Delivery

One of the fallacies of RFM devices is that higher treatment levels correspond to higher energy delivery. Best results will be related to turning the energy settings “all the way up” is ABSOLUTELY FALSE. Too much energy in too short a period will lead to rapid rises in tissue impedance (resistance) and cut off energy flow immediately. Performance by the operator can affect the energy delivered if handpiece pressure is light or not flush with the skin as well.

Tissue Impedance

Impedance in the dermis is highly variable between patients and even within different areas of the face and body. Variables affecting impedance are: hydration, solar damage, collagen and hyaluronic acid content, and scarring. Using settings based on clinical findings and desired outcomes is not enough precision for optimal energy delivery.

Coated vs Uncoated Needles

Coated (insulated) needles allow the microneedles to penetrate the skin and deliver energy to the dermis while bypassing the heating of the epidermis. Some devices will use uncoated needles which will increase the risk of post inflammatory hyperpigmentation (PIH), particularly in darker skin types. To minimize this risk, uncoated needles use low energies and therefore sacrifice results. There will also be more downtime/wound care with uncoated needles because the skin surface will be more affected than with the coated needles.

The Genius Advantage

Proprietary needle design – sharp and coated for minimal resistance to insertion
Improved motor insertion – high torque and quick needle insertion
Improved protocols – changes to energy and pulse durations to avoid sharp rises in impedance based on Lutronic proprietary research
Impedance Feedback – the needles monitor tissue impedance every 2 msec and give feedback to the device to optimize energy delivery and adjust flow as resistance changes. This is the “brains” of the Genius.
Energy delivered feedback – each pulse is monitored and amount of energy delivered is noted. If energy is not exactly as desired/set, both a visual and audible signal is sent to operator. Adjustments in settings or technique can be made to improve energy output.
Total Treatment Energy – a running total of energy given is kept. This allows the provider to base treatments on energy delivered. Cumulative energies delivered from multiple treatments will become the standard of care to achieve clinical outcomes for a given diagnosis.

With the advancements made with the Genius, suddenly, all other RFM devices are now obsolete. Genius delivers a precise, safe, and efficacious treatment for laxity, wrinkles, neck lines, acne scarring, and hyperhidrosis in all skin types.

The Jawline – Beauty, Differences Between the Sexes, Aging, and Correction (reJAWvenation)

Nefertiti was recognized for her crisp jawline and smooth neck. Her bust is one of the most famous of the ancient Egyptian sculptures. A razor sharp jawline and well defined ascending ramus (or gonial angle) are hallmarks of beauty, both male and female. Jowling, submental fullness, blunting of the gonial angle, and an irregular jawline are all signs of aging.

While there are many commonalities between the sexes of what constitutes an attractive jawline, there are fundamental differences as well.

Males:

Broad/wide rami of mandible leading to a near vertical appearance on frontal projection
Approximately a 110-115 degree gonial angle (more acute than female)
Significant height of the body of the mandible
Wide defined, projected chin

Females:

V-shaped rami of mandible on frontal projection. A more masculine (vertical) ramus is also considered beautiful in some women (Such as Alessandra Ambrosio)
A more obtuse gonial angle of approximately 135 degrees
Shorter height along the body of the mandible
Pointed, less projected chin

There are considerable age related changes of the mandible.

Loss of bone along the body of mandible leading to loss of vertical height. This change is accelerated in an edentulous patient
Blunting of the gonial angle eventually leading to a curvilinear jawline
Narrowing of the male chin and widening of the female chin
Deepening of the gonial notch

The age related mandibular changes lead to loss of support of the soft tissue in the lower face – falling forward and downward. Jowling and submental fat is exaggerated. The upper neck skin shows more laxity as facial skin drops into the neck.

Correction of age related jawline changes with fillers- reJAWvenation

Dr. Weiner has perfected a correction using dermal fillers which he has coined “reJAWvenation”. It is based on restoring the age related loss of bone and leads to support of the lower face soft tissues. Filler is placed along the inferior border of the mandible as well as filling the gonial notch. The gonial angle is recreated. The lower aspect of the jowl is considered the new baseline and filling is made on either side to “camouflage” the jowl. Filler is also placed along the posterior aspect of the ascending ramus. The prejowl sulcus is filled, with emphasis to include the space beneath the inferior mandibular border. The chin must also be corrected to the male/female appropriate projection and shape.

reJAWvenation offers a quick (10-15 minute) correction of the age related changes to the jawline. Improvements in jowls, upper neck, jawline, and chin can be expected. There is minimal or no downtime. Even with facelifts, jawline volume is not typically addressed and needs to be corrected either during the procedure with fat grafting, or in the office, after healing, with fillers.

Treating the Double Chin and Jawline Fat Has Become Easy

Until recently, the dreaded double chin has been fairly difficult to treat. Liposuction was the mainstay of treatment. This can be performed under local anesthetic, but there is downtime, bruising, need to wear a chin strap, and some risks. Now, there are 3 non surgical options to treat this area and along the jawline (with 2 of them) which have no or minimal downtime.

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Kybella is a bile salt (deoxycholic acid) that is found in the gallbladder. It is natural secreted to assist the body in digesting consumed fat. It is now available in an injection form and can be used in the submental area to permanently reduce fat. It typically requires 1-2 vials per session, and about 2-4 session. This is all dependent on the amount of fat in this area. 1 month to 6 weeks in the recommended period between treatments. The procedure takes about 15 minutes. There is very minimal pain at first. It then starts burning and this lasts for up t0 30 minutes. Swelling occurs for the first 3 days that is significant. Most of the swelling is gone by a week. All swelling is gone by about 3-4 weeks and results are seen at this time. Areas other than the submental area are being investigated

Pros: short procedure, effective for submental area, long lasting results

Cons: swelling, can’t be used along lateral neck – only central portion, multiple treatments

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CoolMini from Coolsculpting is a new handpiece that is designed to treat the upper neck area. At this point, most people have heard of Coolsculpting. This technology cools fat down to a certain temperature to where it will partial die, but leave the other structures intact. The CoolMini is a newer technology from Coolsculpting that uses more uniform cooling, and doesn’t require the full one hour to get treated. It’s suction grabs onto the fatty area and stays attached for the 45 minute cycle. It can be used to the central and lateral portions of the neck. If there are large areas needing treatment, more than one session is needed and more than one attachment is needed per session.

Pros: minimal or no downtime, can treat lateral as well as submental fat, proven technology that is permanent

Cons: treatment times are 45 min per application, might need more than one application and more than one session

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Infini uses high intensity radiofrequency to treat excessive fat in the neck. It gets to the fat by use of the microneedling delivery system. It can go up to 3.5 mm which is into the superficial layer of fat. By adjusting the power and pulse duration, fat along the jawline, jowls, and submental areat can be treated. It is usually a series of 3 treatments, spaced about 4-6 weeks apart.

Pros: can treat all areas of fat in the neck and jowls, tightens skin as well and improves wrinkles

Cons: requires topical anesthetic (more painful than others), requires 3 treatments usually, mild redness and swelling afterwards for a couple days

There are now a few ways to treat the neck and double chin area. Which one is best for you is based on your desires, lifestyle, and anatomy. All are effective with minimal or non invasive techniques.

3 Year Experience with Infini – High Intensity Focused Radiofrequency

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It’s been a little over 3 years since the Infini was introduced in the United States in August, 2013 by Lutronic. It was developed in Korea, and had been used in the prior 2 years in Asia and Europe. Infini brought a significant evolutionary change to treating the skin with radiofrequency (RF). Although RF has an over 50 year history of medical uses, Lutronic’s Infini innovations has elevated the precision in which the RF energy is delivered to an entirely new level.

It been long established that heating skin causes an inflammatory response that results in collagen stimulation, tissue contraction, and skin rejuvenation. While 42-45 C (denaturing) has shown to be enough to create this cascade, 65-70 C (coagulation) has been shown to lead to maximum collagen deposition. Radiofrequency devices which push their energy through the skin without penetration are limited to temperatures of 45 C because of the risk of harming the skin surface (blisters/scarring). Bypassing the surface with microneedles, as Infini does, temperatures can go up to the coagulation point with very little risk. In addition, Infini can place this energy at the “sweet spot” of the skin, the mid to deep dermis. The depth of most of the predecessor RF devices was always in question, and was often too deep (fat necrosis risk).

Over the last several months, there have been significant treatment innovations with Infini. With diligent research and histological evaluations, optimal settings were further enhanced. These settings lead to larger zones of coagulation during each pulse. This translates into fewer pulses needed (shorter treatment times), and better results. In addition, the treatment tip was modified to allow for a more even distribution of energy, which also leads to better outcomes. The “price to pay” for these innovations is slightly more prolonged redness, possibly up to a week. Also, “microdots”, the grid-like white marks from the needle tips, might last for more than a couple weeks. These have always resolved without scarring or complications.

Dr. Weiner has performed approximately 1000 cases in the past 3 years with Infini. (Cases = areas treated, i.e face, neck, chest). A summary of his findings:

There have been no long term complications in his patients. There have been no incidences of scarring, unwanted fat loss, or pigmentation issues.
Infini is safe to use on all skin types.
Infini is the most effective device available for acne scarring when compared to ablative, non ablative lasers, and other RF devices.
Significant improvements can be established in the neck wrinkles, necklace lines, and creepy skin of the neck.
Superficial fine lines on the face are well treated.
Jawline and submental definition are improved in most cases. Purposeful fat loss is possible in these areas with deeper, more aggressive settings.
Infini is an option for axillary hyperhidrosis with proven long term results.
Infini can be safely used all over the body but the small footplate limits treatments on large surface areas.
Treatment of stretchmarks is only mildly effective. Further refinements in settings and combination therapies are still being researched.
Treatment of malar festoons (fat pads) is moderately effective with Infini (and will soon be even better with new protocols).
Over 95% of patients can be treated with only topical anesthesia. With the addition of the Superficial Skin Block, treatments are extremely well tolerated by the remaining patients.
For optimal results, some patients need volumization and Sculptra can be done simultaneously with Infini treatments.

Infini has already established itself as a low risk, low downtime, skin tightening procedure. Expect better results, less number of treatments needed, and new indications in the future. Significant resources at Lutronic will build upon the Infini platform to maintain its market dominance in the Aesthetic RF market.

PDO Threads – The Latest Minimal Invasive Lifting Procedure

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Thread lifting is not a new concept. It was first developed in 1999 by Dr. Sulamanidze in Russia. APTOS Threads (a non absorbable suture made of polypropylene) were used for lifting and tightening skin without surgery. Contour threads of similar make up were introduced in the US in the early 2000’s. There were problems with these procedures. Placement was fairly complicated, requiring deep fixation points with hooks on the suture. The downtime was several days, skin redundancy was frequent, and sutures extruded or needed to be removed. Complications rates were very high and by 2007, the Contour threads were taken off the market. Thread lifting was not ready for “prime time” at this point.

After heading “back to the drawing board”, a simpler, less invasive, less risk thread was developed, PDO Threads. PDO (also known as PDS) sutures have over 30 years of safety use in Cardiothoracic, Plastic, OB Gyn, and Trauma surgical procedures. This material (polydioxanon) is highly flexible, elastic, strong, and absorbable. It is hydrophobic (does not absorb water) so swelling is kept to a minimum. Gradually over 4-6 months, the suture is degraded by the body’s immune system and replaced with collagen. Patients with immune system diseases, on immunosuppressants, or smokers are not good candidates for threads.

The placement of these PDO sutures is done with minimal discomfort (somewhat similar to filler placed with a cannula). They are placed just underneath the surface of the skin and don’t require the deep fixation that the prior threads needed. Downtime is minimal, with only possible bruising holding you back from social events. The risks and complications have been significantly reduced as well. It is extremely rare that a thread needs to be removed because they are much smaller (therefore less noticeable) than prior threads and because they can be dissolved with using heat (most often RF energy). The ability for the threads to dissolve over time increases the comfort level of all involved in PDO Threads. Results can last from 12-18 months, depending on the area treated (lip area is maximum 4-6 months). Only about 30% of the full result is seen immediately. It takes about 3-4 months to see the final result as the body reacts to the thread.

There are 4 design variants of the PDO Threads:

Smooth threads: these are used in areas where collagen stimulation (dermal thickening) is needed. Often they are placed in a cross-hatched pattern. They are commonly placed in areas of superficial wrinkles or crepey skin. Common areas used are: cheeks, neck, marionette lines, glabella, temples, forehead, lip lines, lips.
Twisted threads: these are smooth threads which are coiled. They give more collagen production than the smooth. These are used mainly in the nasolabial folds and marionette areas.
Single Barbed threads: these threads have barb on them (cut with a laser) to lift and tighten sagging skin. Once they are placed, the physician runs his hand over the thread to engage the barbs to help pull the skin up or back. The ideal areas for these threads are the mid/lower face, jowls, and upper neck. Keep in mind these can be used anywhere on the body and some physicians are using these in the knee area, chest, and breast area. Think of these threads as “creating a collagenous tendon” as the body breaks the PDO down and replaces it with collagen.
Double Barbed threads: similar to the single barbs but they have 2 sets of barbs going in opposite directions. They are placed slightly differently and require an exit point as well. Once the suture is in position and engaged, both ends are cut at the level just below the skin. These are used in similar areas as the single barbed threads when cheek fullness is desired or additional lifting is needed.

PDO threads aren’t for everyone. Severe skin laxity won’t be improved with these. It is important that patients are volumized to their fullest prior to or during the procedure. It is vitally important that patients and physicians have realistic expectations for threads. The results won’t be comparable to surgery but will offer improvements which might push surgery out for a few years. The great thing about the threads is that more can be added down the road to maintain or get additional correction.

Dr. Weiner is a physician trainer for PDO Treads (Nova Threads) and was one of the earliest adopters of this new procedure in the US.

Blog: https://stevenfweinermd.wordpress.com/

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

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Ulthera (Ultherapy) Questions Answered by Steven Weiner, MD, Facial Plastic Surgeon

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Q: Is it okay to use hand held tightening devices for the face after ultherapy?

A: Hand held tightening devices can be used after Ulthera, but waste of time and money

Hand held devices for skin tightening do very little. You are better off to save the money for skin care products, dermal fillers, or other treatments. The energy the FDA allows for the home devices is so low that they don’t work.

Q: If you currently have fillers like Sculptra can you have Ulthera?

A: Combining Ulthera with Sculptra is the bomb!

Absolutely, you can combine the 2 treatments, Sculptra and Ulthera. You obviously recognize that the 2 do different things, Sculptra fills volume loss and Ulthera tightens loose skin. When done together, they are synergistic, meaning 1+1=3! My blog goes into details about doing both of these, please read. Steve Weiner, MD, Destin, Florida.

Q: Ultherapy Vs. Refirme Vs. Accent XL for Thin Face

A: Don’t bother with Refirme or Accent XL for the face, Ulthera is much more reliable

All the RF devices which try to transmit their energy through the skin are unreliable with very inconsistent or no results. These include: Thermage, Refirme, Accent XL, Pelleve, Venus Freeze, Exilis. The only one worth using from the RF family, at the present time, is the Infini by Lutronic. Please see my blog which goes into more depth on the technology. (I also have another blog about the benefits of Ulthera plus Sculptra.) Ulthera is a very reliable device, placing the right amount of energy at a given level, at all times. No, it does not affect the natural fat of the face. Steve Weiner, MD, Facial Plastic Surgeon.

Q: Which is more effective thermage or ultherapy for tightening skin?

A: Ulthera is far superior to Thermage for skin tightening results

Ulthera reliably places energy in the dermis and SMAS layer. The energy is always above the critical temperature to cause tissue contraction and collagen formation. Thermage is very unreliable in it’s placement of energy through the skin and therefore it’s results are very unreliable (some have results, while most do not). There is a new device called Infini, which uses RF energy like Thermage, but it places the energy very reliably in the dermis and is therefore much more effective than Thermage as well. I consider the Ulthera for tightening the jawline, turkey neck, raising the cheeks and the brows. Infini would be better for the superficial fine lines, lip lines, necklace lines, cheek lines. I used to have Thermage but sold it the same month that I bought Thermage – 3 years ago. I have much happier patients. See my blog below. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Are these results of Ultherapy really true?

A: Ulthera is not a surgical result, but some people don’t want surgery

There is no debate whether or not the energy is delivered by Ulthera to the precise location that the device is made for. Most people, 8-9 out of 10 get noticeable improvements from the procedure. Are they the results similar to which surgery can give? Most of the time the answer is no. But, if you want little or no downtime, want a result that doesn’t leave scars, and has minimal risks (no long term risks), it is the procedure for you. Surgery has it’s inherent risks: bleeding, infection, scarring, anesthesia, need for redo, poor cosmetic results, nerve injury, as well as downtime (up to a month for a facelift). I have written a blog about why I believe that Sculptra and Ulthera are better than a facelift. Steve Weiner, Facial Plastic Surgeon. Destin, Florida.

Q: How Often Can Ultherapy or Thermage Be Applied? Do Repetitive Applications Have Any Side Effects or the Opposite?

A: Ulthera can be repeated in 4-6 months; Don’t bother with Thermage

Repeat treatments with Ulthera will help you keep up with the aging process. There is no exact right answer as to when you should do this. Getting more treatments will only improve the results and won’t be harmful. I have given up on Thermage 3 years ago when I got the Ulthera because results are so much better and more consistent with Ulthera. Read my blog about RF devices and see why Thermage doesn’t work well. Infini is a good skin tightener too and it’s full ability has yet to be determined. Steve Weiner, MD, Facial Plastic Surgeon, Panama City Beach, Fl.

Q: If I Have a Plate in my Neck Can I Still Have Ultherapy?

A: Ulthera can be performed on someone with a plate in their neck

Because the penetration of the energy is only 4.5mm deep, the plates will not be a factor. You can safely have the procedure. Steve Weiner, Destin,FL

Q: 1. Can This Procedure Affect/injure/change the Thyroid? 2. Why is Thyroid Area Avoided During Ultherapy Precedure?

A: Ulthera will not affect thyroid nodules

The thyroid area is avoided because of the cartilage that is close by. It has nothing to do with the thyroid gland. In fact, I could see the Ulthera technology being used to treat thyroid nodules in the future. You have nothing to worry about. Steve Weiner, MD, Destin, Florida.

Q: Can I Get Ultherapy ?

A: Ultherapy for someone who gets cold sores and shingles is ok with prophylaxis

We have done many treatments on patients like you. It just requires taking a dose of Valtrex before and a few doses after to prevent the problem. If you sense that there is an outbreak coming on despite this, take a therapeutic dosing for the recommended time by your doctor.

Q: Can an Ultherapy Side Effect Be Burning and Tingling on Scalp?

A: After Ulthera there is some burning and tingling of scalp, this can be related and will go away quickly

There are nerves in the forehead which travel to the scalp. During Ultherapy, it is possible to bruise these nerves and the result can give you abnormal sensations of the scalp and forehead. To my knowledge, there have been no reported long term issues with Ulthera. This should go away within a few weeks I suspect.

Q: Can Ulthera Be Done on the Neck Only, or is the Lower Face with It Necessary?

A: Ulthera can be done on neck only but not what I would recommend.

Ulthera was recently FDA approved to be done on the entire neck. Best result for the jawline would include the lower face as well to get some lifting above the jawline.

Q: Can Ultherapy Reduce the Size/appearance of Large Submandibualr Glands?

A: Ulthera won’t improve appearance of large submandibular glands

Ulthera won’t get deep enough to hit the submandibular glands. One thing you might consider is having them injected with Botox. I have seen at meetings that Botox reduces the size of enlarged parotid glands so there is no reason why it shouldn’t work for the submandibular glands.

Q: Nurse Squeezing and Tapping Foot During Ulthera?

A: Distracting during Ulthera treatment can decrease pain

The Gate theory goes back to the 1950s which states that the brain has trouble processing two stimuli at once. So when there is a competing sensation, the brain will block out one partially. This leads to less discomfort. We add vibration and cold air so the brain gets really screwed up. Steve Weiner, MD, Destin, Florida, Facial Plastic Surgeon

Q: Thermigen Vs Ultherapy?

A: I have the Ulthera and have seen Thermigen. Please read my discussion to get a better idea.

My clients have been very happy with the results they have seen with the Ulthera. They can walk in and do anything they want to do afterwards. Thermigen is quite similar to the new Precision Tx laser. It requires tumescent anesthesia and requires a chin strap afterwards. It goes under the skin and heats up the fat and skin to dissolve the fat and tighten the skin. It has thermal controls so the skin doesn’t heat up to a dangerous level. I have seen it performed and the patient was comfortable during the procedure. It all boils down to results, and I haven’t seen the “wow” results that would convert me from Ulthera to Thermigen. Thermigen is not FDA approved for this procedure either. The cost of the device is a lot less to the physician than the Precision Tx laser so the procedure should be less to the patient. It depends how invasive you want to be as to which you do. I’m staying with Ulthera for now. If you want more aggressive results, also look at the Precision Tx, which is the same technology as the Cellulaze laser.

Q: Should I Stop Taking Supplements (Eg. Fish Oil, Ubiquinol) After Ultherapy?

A: There is theoretic concern with anti inflammatories after Ulthera

There are no studies to suggest that anti inflammatories decrease the effect of Ulthera but some docs suggest not taking them after the procedure. The risk they say is that the healing process is subdued and therefore you are not getting the full effect of the treatment. I think this idea started with Thermage as an excuse when they weren’t seeing results. I don’t tell my patients to stop these supplements.

Q: Can Have Ultherapy Done Under my Chin and Neck if I’ve Had Cystic Acne Before?

A: Ulthera in patients with prior cystic acne is no problem

Ulthera can safely be performed in patients which have had cystic acne. As Dr. P has said, we don’t do it in the case of an active infection. In the long run, it might actually help the acne by partially destroying the sebaceous glands which are the source of the acne problem. There is an active clinical trial to see if Ulthera can actually be used for acne treatment.

Q: Now That They Have Had the Benefits of Experience Behind Them, Does Ultherapy

A: There have been improvements since Ulthera first came out about 3 years ago.

The changes which have occurred are:

There are now 3 different depths for treatment, 1.5, 3, and 4.5 mm.
There are about twice as many treatment lines being laid down as to when it was first introduced.
Topical lidocaine is being used and having an effect in improved comfort.
Lowering the intensity of the treatment lines give better comfort but same results.

All the above results in more comfort and/or better results (more aggressive treatments). It only makes sense that over time, everyone learns more about the potential of the technology and becomes more comfortable at trying new protocols.

Q: Can You Get Ultratherapy with a Titanium Piece in Your Cheekbone?

A: Ulthera cannot be done in face with Titanium plates

The ultrasound waves will bounce off the metal and scatter unpredictably. This is one of the only reasons someone can’t have an Ulthera treatment.

Q: Had Ultherapy on Upper Face, Had Little Pain, Will It Be Less Results?

A: Very little pain with Ulthera for upper face is a good thing, not bad.

Several measures have been done recently to reduce the discomfort with the Ulthera. A new protocol uses less energy but more treatment lines and seems to have equal results. We also use topical numbing creams and cold air, both seem to help as well. Because protocols are fairly standardize, at least the minimums are, I wouldn’t worry about your treatment. We tend to stay at the upper end of the protocols and give more treatment lines than the norm, but that doesn’t mean it should hurt.

Q: Ulthera After Peel?

A: When Peeling is done after a Peel, it’s ok to have Ulthera

You could probably do the Ulthera immediately after the peel, but because there is liberal use of ultrasound gel, it’s better to wait til the skin is done peeling. It really does nothing to the outer skin, so don’t worry about affecting results of the peel.

Q: Could Ultherapy Be Performed on a Person’s Neck, if That Person Has Some Nodules on the the Thyroid?

A: Ulthera on the neck can be performed on patients with thyroid nodules

The Ulthera (Ultherapy) penetrates 4.5 mm into the skin. The thyroid is much deeper than that, with a layer of muscle between the skin and thyroid as well. There is no worry whatsoever. Dr. Steve Weiner, Panama City Beach, Florida.

Q: How Long After Ultherapy Do I Need to Wait Before Getting Lip Waxing?

A: Waxing after Ulthera (Ultherapy) can be done immediately after treatment

There is no reason to stop doing anything you normally do after Ulthera. There is no downtime. If you use Retin-A or similar, you should wait about 4 days after stopping to get waxed, but this has nothing to do with Ulthera.

Q: Can I Drink Wine the Same Day As Having Ultherapy?

A: Wine after Ulthera is perfect, there are NO RESTRICTIONS

The beauty of Ulthera is that it is a no downtime, fairly risk-free procedure. No long term complications have been reported to my knowledge. Having wine afterwards is quite alright and we encourage people to do their daily routine after Ulthera. There is no data to support this, but some doctors recommend not using anti-inflammatories for about 6 weeks, but we don’t. Steve Weiner, MD, Santa Rosa Beach, FL

Q: Does Ultherapy Work for a Brow Lift?

A: Ultherapy is a noninvasive FDA approved method for Brow lifting

If you desire no downtime and a very low risk procedure to raise your brows, Ultherapy (Ulthera) is a great option. It won’t give a surgical result, but will give a natural look. If you want more results, a second procedure can be done. It takes about 15 minutes to do with only mild bruising or temporary numbness as a side effect.

Q: Aftercare for Ulthera on Lower Face and Neck Yesterday?

A: Aftercare following Ulthera is NOTHING

After having Ulthera, there is no need to do anything special. It is recommended not to use steroids or other anti-inflammatories, but this has yet to be proved to be detrimental to your results (its theoretic). That’s the beauty of Ulthera, no downtime, no aftercare! Please see my video too.

Q: Can I Take a Steroid Medicine (Methyprednisolone) After Ulthera?

A: Taking steroids for a brief period after Ulthera has a theoretical risk of decreasing the effectiveness of Ulthera

Although there are no studies, and it would be very difficult to do a study, there is the feeling amongst some doctors that anti-inflamatories after Ulthera can decrease it’s effectiveness. This is based on the fact that you need the inflamatory factors to produce the collagen and tissue tightening. This would include steroids, motrin, advil, aspirin, but not tylenol. If they can be avoided, it’s advisable but not absolutely. This is a gray area, so don’t worry too much about it.

Q: Does Ultherapy Work for Upper Cheeks?

A: Ultherapy is great for lifting the cheek area

Yes, Ulthera is perfect for lifting the cheek area. Ulthera works by laying down very precise lesions in the skin at 4.5, 3, and 1mm, which over time, leads to collagen stimulation and tightening. Results take about 3 months to fully appreaciate, and some people will want a second treatment. You can see lifting of the brows, improvement in wrinkles around the eyes, lifting of the cheeks, firmer jawline, and tightening of the upper neck.

Q: Ultherapy for Excessive Sweating (Hyperhidrosis Treatment)?

A: Ulthera does work for hyperhidrosis in one study by Dr. Nester

There was a poster presentation at a conference I was at describing very significant improvement in the sweating scores after 2 treatments of Ulthera for axillary hyperhidrosis. The proposed way it works is by destroying the sweat glands with the ultrasound from the Ulthera. It requires lidocaine injections to numb the area treated, just as the Miradry device does. The study was done by Dr. Nester from South Florida.

Q: Can Ultherapy Be Done on the Eyelids? Or is It Not Safe? Or Just Not Tested?

A: Ulthera is not to be used on the eyelids

The company has been evaluating the Ulthera treatment on the eyelids, but as of today, they have not found a good way to shield the eyes from the energy of the treatment. Therefore, it is not recommended to treat the eyelids. Who knows what the future holds though.

Q: What Risks Are Involved with Ultherapy?

A: The risks from Ulthera are mainly some mild bruising and discomfort which is short lived.

Ulthera has been proven to be an extremely safe procedure. According to the company, and our 2 years of experience backs this up, there have been no long term side effects. Some people might experience some mild swelling and bruising right after the procedure, but this subsides rather quickly. Very rarely, some people experience some temporary numbness. With new treatment protocols which are more aggressive, there is slightly more discomfort during the procedure. With topical anesthesia, this has been reduced.

Q: Is It Safe To Do Ultherapy One year Later?

A: Repeat Ulthera treatment is safe and is going to give longer and improved results.

Ulthera is a very safe procedure and there is no risk of repeating treatment after 1 year. In fact, several of my clients have a planned second treatment at 3-6 months after their initial one. The results will be better than just having one, and longevity will be increased.

Q: Ulthera – Are Welts a Normal Side Effect?

A: Swelling / Welts after Ulthera can happen but go away quickly

Occasionally, a person which has Ulthera can have overall swelling which is very short lived. Sometimes bruising can occur and present with firmness under the skin. Visible dermal swelling/welts can occur if the ultrasonic skin injury occurs too superficial. It can occasional have a little fluid like a cyst or pimple, but will resolve within about 5 days.

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.

Tired of All the Injections…Time to Consider Bellafill, a Permanent Dermal Filler

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The aging face is the summation of several different factors. Skin pigmentation (hyperpigmentation, solar lentigos) and textural changes (wrinkles, pores) are the results of accumulated UV damage (sun damage), age related tissue changes (loss of collagen, thinning dermis) and over-activity of the facial muscles. These skin issues can be improved with lasers, chemical peels, neuromodulators (Botox or Dysport) and a high quality skin care regime that includes some form of Retin A (or retinoid) and growth factors. However, the most significant reason a face “looks old” is the due to volume loss. As a person ages, fat, muscle, and bone are lost leading to:

Temporal wasting which also causes laxity of the skin around the eye
Bags under the eyes
Droopy upper eyebrows and eyelids
Tear trough and malar (cheek) groove formation
Sagging or loss of well defined cheeks
Deepening of the nasolabial folds
Jowls and marionette lines
“Pointy” chin
Lengthening of the space above the upper lip (because of bone and fat absorption)
Hollowing in the area in front of the ear
Loss of the well defined jawline
Loss of lip fullness
A nose that appears longer (actually its not, but looks that way because the surrounding tissue has resorbed)

Another “by-product” of volume loss is overall facial skin laxity. Up until recently, the consensus among plastic surgeons was that the loose skin was mainly the result of the effects of gravity. This lead to the rational for tightening the face with facelifts. Unfortunately, many people who had this procedure, had tighter skin but actually looked worse. The surgeons weren’t accounting for the volume loss, and faces looked windblown or skeletonized.

In reality, many people can be completely improved with fillers for volumization and avoid surgery altogether, or at least put if off for several years.

The popularity of dermal fillers has grown from filling the smiles lines and lips to placing them in just about every aspect of the face. Fat loss is the primary reason for the volume lost in the face and there are dozens of named fat pads throughout the face. The most popular products, such as Juvederm and Restylane, are made from hyaluronic acid (HA), a naturally occurring component of the skin and joints. There is a “dissolver” called hyaluronidase which can be injected into the filler and within hours to days can remove any misplaced product. This is a nice safety valve for the patients that have some hesitations about the procedure. Unfortunately, the results of these fillers usually last for about a year. A new hyaluronic acid filler, Voluma, has been reported to last up to 2 years.

Another class of fillers is called “collagen stimulators”. These products, when injected, stimulate the body to produce collagen. Newly formed collagen can last years if it was not subject to breakdown by UV exposure, oxygen radicals, and aging. Radiesse and Sculptra fall into this category, and are made from naturally occurring substances in the body, calcium and a sugar, respectively. These products last longer than the HA fillers, up to 2-3 years for Sculptra, and there is no “dissolver” for these. Most patients who get these fillers have already tried the HA’s and want a longer duration correction.

Bellafill is a collagen stimulating filler that can be considered a permanent filler. It is composed of poly methyl methacrylate (PMMA), a synthetic material, which has been used in the operating room since 1949. The filler is composed of millions (per cc) of symmetric, identical spheres of PMMA, that are a little bigger than a white blood cell. They are suspending in bovine collagen which is absorbed in 4-6 weeks. There is a chance of an allergic reaction of the collagen, so all people need to be tested (by placement of a small quantity in their forearm) before getting Bellafill. The correction obtained by the Bellafill is long lasting because the body can’t break down the PMMA. As the body digests the bovine collagen, it is creating its own collagen in response to the PMMA spheres. Studies have shown that the correction at 5 years is even better than the 1 year result. The only other fillers that come close are fat and silicon. Fat requires a harvesting procedure (liposuction) and is very difficult to fine tune. It also has unpredictable “take” so touch ups are the norm. Silicon, is not an FDA approved filler, and requires multiple procedures to get to the end result. It has also been noted to have a significant risk of granulomas, something that has not been borne out with Bellafill.

Bellafill is typically injected in a kit of 5 syringes, but many people will require more than this. Also, it is probably best to plan the full correction in 2 stages – with the first one being about 2/3 of what is actually needed and upon a follow up visit 2-3 months later, the fill is completed.

Certainly Bellafill is not for everyone getting filler. The best candidates are patients with mild-moderate volume loss who are experienced with other fillers and have “injection fatigue”. Although the cost upfront is more than other fillers, it is more economical than all other fillers when considering its longevity. One other very important factor is to choose your physician carefully. The results of Bellafill are permanent, so you want to go to a very experienced injector who is very comfortable with using blunt cannulas (the preferred method for filling) and knows the anatomy of the aging face extremely well.

Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.

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