lip augmentation Archives | The Aesthetic Clinique

Restylane Refyne and Defyne, New Fillers with Unique Benefits

(Dr. Weiner is one of the most experienced users of Restylane Refyne and Restylane Defyne in the US and has trained multiple physicians on his injection techniques of these new products.)

Restylane Defyne Treatment Radial Cheek Lines – Dr. Steven F Weiner

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Late 2016, two new dermal fillers, Restylane Refyne and Restylane Defyne were FDA approved. Although new to the US, these fillers had approval in Europe in 2010 and in Canada in 2015 under the name Emervel. The announcement flew mostly under the radar and it wasn’t until early 2017 that Galderma officially launched the new fillers. Although these fillers are similar in composition, hyaluronic acid (HA), to many of the other fillers on the market, it is the technology behind them that set them apart from the rest.

Restylane Refyne and Defyne are made with XpresHAn technology which adds flexibility to the fillers – “think honey” – and makes them perfect for treating areas of expression. (Other Restylane fillers are based on NASHA technology, and are particulate in nature – “think sugar”.) Additionally, Refyne/Defyne have high crosslinking that lends to their ability to stretch and recoil. Refyne has less links, so it can stretch more, while Defyne is more tightly bound.

The clinical outcomes of using Refyne and Defyne are unique and directly related to their manufacturing process. With placement in the dermis using small aliquots (a different technique than other fillers) in areas of high muscle movement (expression), the filler will support the skin and soft tissue in unparalleled ways. In fact, muscle strain around the mouth was tested before and after Refyne/Defyne placement and was shown to revert a 55 year old’s profile to one similar to a 30 year old on average. The hyperactivity of the muscles was “constrained” by the filler, just as Botox or Dysport does in the glabella and crows feet. The previously difficult to treat radial cheeks lines (smile lines) can now be improved significantly with the new Restylane Refyne/Defyne fillers. Other fillers used to treat this area are more apparent and obvious due to their lacking the XpresHAn technology, and don’t look as natural with movements. Adding bulk/volume to the lower face is usually not desired because beautiful and youthful faces are V or heart shaped. The unique placement of Refyne/Defyne in the dermis does not add fullness in the lower face during corrections of the marionette lines, prejowl sulcus, and smile lines in Dr. Weiner’s experience.

Cohesiveness is the ability of a filler to “stick to itself” and integrate with the surrounding tissues. Both Refyne and Defyne have a high cohesivity. This equates to more blending of the filler with the tissues, and a more natural appearance. In clinical use, these new fillers can be injected into the mid/deep dermis (a dermal filler actually being injected in the dermis!) and still go unnoticed, without nodules or lumps.

One final highlight of Refyne/Defyne is their low degree of swelling associated with injections. This is beneficial for areas such as lips and tear troughs, where swelling can lead to social downtime, precluding some clients from doing these procedures. When comparing all the HA fillers available in the US, it’s been Dr. Weiner’s experience that Refyne/Defyne have the least amount of swelling.

Restylane Refyne and Defyne open up a new treatment paradigm for the perioral smile lines (radial cheek lines) where previous corrections were usually suboptimal. This area is often overlooked or discouraged, but is a frequent concern for a majority of dermal filler clients. The satisfaction rate with these corrections have been extremely high in Dr. Weiner’s experience. With the additional benefits of high conhesiveness and low swelling, Restylane Refyne and Defyne are a great addition to the filler armamentarium of the advanced injector.

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.

The Top 14 Trends in Cosmetic Procedures (Plastic Surgery) for 2014 as Predicted by Dr. Steven Weiner

This coming year is an exciting one with a couple new FDA approvals expected. It’s also going to see several procedures fade away and new approaches with the “gold standards”.

Kythera’s ATX-101 will be approved for reducing the double chin fat using only an injection. The procedure will need to be repeated 3-5 times in most people, but there will be no incisions and minimal risks. Side effects will be swelling and discomfort that will last maybe up to a week. Off label, it could be used for fat in the belly, love handles, or thighs.
Longer acting dermal fillers for total facial volumization will catch on. Fillers such as Voluma, Sculptra, and Artefill can be used to add volume to the temples, cheeks, midface, jawline, and preauricular area. Even earlobes can use a little volume in most people. Very little side effects other than swelling and bruising are noted with these “Liquid Facelifts”, particularly when blunt cannulas are used. Results are instant with Voluma and Artefill, and gradual with the Sculptra. Duration of improvement is about 2 years with Voluma, 2-3 years or longer with Sculptra, and over 5 years (some doctors may say permanent) with the Artefill.
Botox administration will be “lighter” to give a more natural look. No more frozen faces leaving people expressionless. Particularly in the forehead, less Botox using a “micro injection” technique, means more movement and less risk of dropping the brows. The downside to this lighter dosing is that its duration will be slightly less.
A new topical neuromodulator, Revance’s RT001, will be FDA approved in 2014. Unfortunately, this won’t eliminate all the injections. It will be great for the crows feet area and possible for reducing underarm sweat though. It still will be administered in the doctor’s office (not for in home use).
Tattoo removal will become easier with less trips to the doctors office. With new protocols like the R20 and R0, several treatments (up to 4) can be combined into one office visit. It looks like the side effects and risks are the same as doing only one treatment per visit. The Picosure laser seems to also lead to faster ink removal but it is still too expensive to be widely available.
RF (radiofrequency) skin tightening will become even more popular, spurred on by microneedling devices which are more effective than transcutaneous ones. Being able to drive the RF energy to deeper levels both safely and reliably, as with the Infini, will lead to better and more predictable results. The other RF devices such as Thermage, Exilis, Pelleve and Tripolar will become less and less relevant as consumers are disappointed by their results.
There will be even more interest in noninvasive fat removal. Lead by Coolsculpting, people will find that having no downtime, minimal risks, and getting real observable fat loss is better than getting liposuction. Certain areas such as outer thighs have been difficult to treat noninvasively but new attachments with Coolsculpting and/or new devices using high frequency ultrasound (HIFU) might be developed to treat all the areas that liposuction traditionally treats. RF fat reduction will also become more popular because they will be more effective than prior versions. Zerona will lose all relevance due to its lack of sustained results.
Lip enhancements will be smaller and done using blunt cannulas. It seems like the trend for having your lips enter the room before you do is waning. People want to look like they have naturally beautiful lips and not obviously overdone lips. Using blunt cannulas enables one to have minimal downtime, minimal discomfort, and a naturally enhanced look.
People will become more concerned with anti-aging procedures of the hands and chest. Volumization using Sculptra in the declotage and Radiesse in the hands will become popular. Skin tightening using the Infini RF device will help with the wrinkles. Spots can be improved with the Fraxel Dual or Q-switched laser.
Tear trough injection will be the most popular area treated with dermal fillers. Blunt cannulas make this procedure both comfortable, safe, and quick. Restylane is the filler of choice for this area. By treating the tear trough and upper cheek, the nasolabial folds (smile lines) actually improve as well due to the lifting from above. Patients will have some swelling in most cases for a couple days which can be reduced by sleeping elevated. Bruising is minimal or none with the cannulas when compared to the needles which almost always has bruising lasting up to a week or more.
Men will do more cosmetic procedures. The drivers for this will be the competitive jobs market and the “no downtime” procedures. Sometimes experience isn’t all that is needed to land a job. To compete with the younger job seekers, the more “experienced” men are seeking procedures that can improve their looks, yet not keep them out of the public for very long. Botox, fillers, Ulthera, and Coolsculpting will become even more popular for men.
The number of people getting facelifts will continue to drop. With the improvements in skin tightening by Ulthera and full face volumization with dermal fillers, particularly collagen stimulators (Artefill and Sculptra) the aging face can be more naturally improved. There will be a trend for younger patients to start anti-aging treatments earlier leading to “more graceful” aging. People are not as willing to undergo the knife given the associated risks, downtime, and potential for undesirable results.
Artefill, a permanent filler that stimulates collagen, will gradually replace fat grafting for the face. As an off the shelf solution, Artefill is much more attractive to the patient than undergoing 2 procedures for fat; fat harvesting and then grafting. Also, fat is not always predictable with its “take”, and there can be a need for more than one procedure. Fine tuning with fat is also somewhat difficult and is much easier with Artefill. The apprehension behind the permanent aspect of Artefill has not been borne out and more of the well known injectors are warming up to Artefill.
Hydroquinones will gradually be replaced by other products to help with pigmentary problems. This trend started in Europe and South America. They have banned hydroquinones because of concerns over their potential carcinogenicity (even though there have been no known documented cancers from hydroquinones), ochronosis (pigmentation side effect that is very difficult to treat), and possible rebound hyperpigmentation. SkinMedica’s Lytera and Neocutis Perle will become acceptable replacements.

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

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

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

Website: http://www.theclinique.net

Press Release regarding these predictions by Dr. Weiner.

The best way to get your lips augmented…Hyaluronic Acid Fillers using Blunt Cannulas

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Lip augmentation has received a lot of press over the past couple years and its been mostly bad. That’s because most physicians either overfill the lips or don’t understand what makes lips attractive and natural appearing. In addition, most patients equate lip augmentation to severe pain and several days of downtime with bruising and swelling. I would like to try to convince the public that you don’t have to fear the process of plumping up your lips and don’t have to have days of downtime where you either are hiding in you house or explaining to people that your significant other didn’t beat you.

Blunt cannulas have changed the game for lip augmentation. Through one entry port (which requires a small needle poke) on each side, you can have both upper and lower lips filled with little or no bruising. After applying topical numbing creams to the lips for about 10 minutes, the procedure is very well tolerated. The other advantage is that the swelling is minimized because the lips are minimally traumatized. Many patients go straight out to lunch or drinks or back to work without being self-conscious of people looking at them. On the contrary, traditional lip augmentation using needles requires 4-5 penetrations (each time causing discomfort and risking bruising) per quadrant (so you have to multiply by 4). The blunt cannulas push vessels out of the way with their rounded tips so bruising is minimized. Also, most of the pain is in the surface penetration and once under the surface, the blunt cannulas give less discomfort.

Dental blocks are performed by many of my colleagues. I’m critical of this technique because:

Dental blocks are not comfortable
Often times the block is incomplete so there is still discomfort during the lip injection.
You often stay numb of a prolonged period of time with the associated drooling, etc.
The lip anatomy can be distorted with the block making precise lip enhancement difficult.

Some doctors are critical of using cannulas for the lips because they say the control of placement of the filler is less than when using the needle. Admittedly, there is less precision for the novice, but over time, I’ve become very efficient at using cannulas and there is little difference as far as results. Sometimes, after filling the lips with the cannulas, I will go back into the already numb lip and place minute amounts of filler along the vermilion border or in the tubercles with the needle technique. This usually does not cause significant bruising or swelling.

A natural set of lips is about 33-40% upper lip and 60-66% lower lip. Often doctors will make the lips the same size or the upper lip bigger and this looks very abnormal. Sometimes when the doctor is trying to improve the upper lip lines, this problem occurs by accident. The best way to correct the upper lips lines is to place filler in the area between the lips and nasal area with the cannulas in a horizontal fashion. This usually doesn’t affect the ratio described above. There is loss of bone in the upper jaw as well as loss of fat, and this injection technique replaces those tissue losses and improves the lines. (For more the most severe lines, I will use Belotero into these lines but this is with a needle and does lead to bruising in most cases.) Also, the lip is not supposed to go all the way to the corners. It should gradually taper off on the sides. Those people who get there lips injected evenly all the way across end up with “sausage lips”. Another error is placing too much filler in someones lips. Small lips can only be enhanced to a certain degree before they appear awkward and you look like a “trout mouth”. People with extraordinarily small lips are gradually made larger in my office. Over successive fills, they are slightly larger than their previous treatment. That way you avoid the lips which get through the doorway before the body.

Procedures which should be avoided at all costs, in my opinion are: permanent filler/ implants in the lips or the Valentine lip lift. These lead to abnormal lip appearance, unnatural mobility/movement, long-term complications (firmness, bumps) and unhappy patients. Some patients are trying to avoid repeated injections due to discomfort and resort to these solutions. Don’t do it!! Cannulas offer a more comfortable injection, and overtime, there is collagen stimulation which lengthens the times between treatments. My long-term lip augmentation patients get filled every 9-12 months.

In summary, lip augmentation doesn’t have to prolonged downtime, be considered intensely painful, and look unnatural. Blunt cannulas in the right hands can make for a much more pleasant experience. It’s important to seek out a physician who knows the anatomy of aesthetically pleasing lips and what is needed to achieve those results. Although bruising can occur with cannulas, it usually is minimal or nonexistent, and you can continue your active social schedule after the procedure.