- Dr. Weiner is Board Certified in Facial Plastic Surgery and is an expert on the anatomy of the face. He trained, and was a faculty member, at the number one rated Otolaryngology/Head and Neck Surgery Department in the country at The Johns Hopkins Hospital.
- He started injecting Botox in 1994. His initial uses for Botox were for spasms of the vocal cords and neck, as well as excessive muscle tension, particularly in the TMJ area. Even prior to FDA approval for cosmetic use, Dr. Weiner was using Botox for improving wrinkles around the crows feet and forehead in the late 90’s.
- Dr. Weiner is a physician trainer for injections techniques of: Sculptra, Restylane, Restylane Silk, Restylane Lyft, Bellafill, and Dysport.
- Dr. Weiner is a lecturer for Galderma (Restylane Family of Products, Sculptra, Dysport) and Suneva (Bellafill)
- Multiple techniques (cooling, vibration, small needles) are used during the injections to minimize the discomfort without the use of “dental blocks”
- Dr. Weiner is on the physician’s advisory board for Allergan (Botox, Juvederm, Voluma, Kybella)
- Dr. Weiner is a Key Opinion Leader (KOL) for Bellafill.
- Dr. Weiner is the only one that injects neuromodulators and fillers at The Aesthetic Clinique
- Dr. Weiner has experience with all the FDA approved neuromodulators (Botox, Dysport, Xeomin, Myobloc) and fillers (Restylane, Restylane Silk, Restylane Lyft, Juvederm, Voluma, Radiesse, Bellafill, Sculptra, Belotero, Prevelle Silk, Evolence (off market), and Cosmoderm (off market).
- Dr. Weiner uses exclusively blunt tipped cannulas for his filler injections (except Restylane Silk in lips) since 2012. Cannulas are much safer and lead to less bruising, less discomfort, less complications, and less downtime. Less than 5% of providers use cannulas.
- Fillers, neuromodulators, and lasers are all Dr. Weiner does at the Aesthetic Clinique for the past 10 years. He is completely focused on Aesthetic Medicine.
- Dr. Weiner has participated in 2 clinical trials for Juvederm.
- If there is bruising after treatment, Dr. Weiner offers complimentary laser treatment with the Excel V. This is a couple minute procedure that decreases the duration of bruising from up to 2 weeks, down to 1 or 2 days.
- All patients are photographed with TouchMD, which allows for patients to see their own before and after photos either online or on a phone app.
- 3D photos are taken of all filler patients to show the volume improvements much more precisely than 2D photos.
- There is an extensive library of videos on Dr. Weiner’s YouTube channel that shows his techniques so patients can learn what to expect during their visit. Gain confidence and trust even before the actual visit.
- Dr. Weiner is a Presidential Champion Level for Galderma, the highest volume level for their products: Restylane, Restylane Silk, Restylane Lyft, Sculptra, and Dysport.
- Dr. Weiner is a Platinum Plus Level for Allergan Products: Botox, Juvederm, and Voluma.
- My lips are swollen, lumpy, and a little uneven, when will they get better? This is the most commonly asked question on Realself.com. The lips take about 7-10 days to settle down after getting filled. Restylane Silk will swell the most of all the fillers. Juvederm, and Restylane are the most commonly used fillers and the swelling and lumps will all even out gradually over the first week. Sometimes there is asymmetrical swelling, and that usually evens out too. Elevating the head of bed will help lessen the swelling. Unless there is bruising, ice will not change the swelling, nor will antihistamines. The swelling is most often related to the HA filler absorbing water from the surrounding tissues. On an extremely rare occasion, the lips and surround tissues swell abnormally, and this is called angioedema. This most often occurs in people that take a blood pressure medicine that is in the “ACE inhibitor” family. If this occurs, immediate attention is needed by your doctor or the emergency room.
- I’m very bruised, when will it go away? Bruising is related to technique, not the filler itself. Bruising can take up to 10 days to go away. Early bruising can be treated with a laser (VBeam or Excel V) to decrease the duration to 2 or 3 days. It is best to stop all supplements, anti inflammatories, fish oils, vitamin E, or all other medications that can thin the blood a few days before injections if possible. Aspirin takes 12 days to get out of the system. Cannulas help minimize bruising as does careful technique, but bruising isn’t always avoidable. Arnica will help bruising too.
- My upper lip is very full, is this normal, I look like a fish or duck? There is an art to filling the lips. The upper lip should be smaller than the lower lip by the golden ratio of phi, 1:1.6. If the doctor does not abide by normal anatomic ratios, the lips look done and abnormal. It does not happen to most people and is unrelated to the product injected. It is poor technique by the injector. In ethnic people, sometimes a 1:1 ratio does look normal, but never when the upper lip is larger. Click here to learn about perfect lip anatomy.
- Can the corners of mouth be turned up, I always look sad? The corners of the mouth can be lifted with properly placed filler. Also, an injection with a neuromodulator such as Botox or Dysport can be injected into the depressor angularis oris, DAO, to relax the muscle pulling the corners down. Often, support is also needed in the above the upper lip in the triangle of volume loss near the corner. Also, injection into the corner (commisure) is needed.
- I’m not happy with my lips after injection, what can I do? First thing is to discuss with your injector. After waiting the 10 days, lips that still have bumps, look odd, or are uneven, can be dissolved with hyaluronidase. This is not a precise procedure, so fine tuning is not possible. Most often, one treatment is needed but sometimes 2 are needed. Sometimes a little filler can be added to make things more symmetric. Asymmetries are very frequently noticed after injections by patients, but after careful review of photos, were present before the procedure too.
- I have severe pain, days after the injection. Pain should not be present after about a day or 2 from the procedure. This needs to be discussed with your injector. Concerns would be possible injection, or herpetic outbreak. Severe overfilling can cause this too.
- What can be done for my upper lip lines, “smokers lines”? Upper lip lines, “smokers lines”, are some of the hardest wrinkles to treat. This occurs even in non smokers and is mostly a volume related problem. Best treatments include filler placed horizontally in the white lip or ergotrid (with cannulas), a fine bead of filler along the vermilion border, and a small amount in the lip body. Adding Botox in small amount help too. Don’t expect elimination, just improvement. Longer term solutions are laser resurfacing with ablative lasers, Infini, or dermabrasion.
Enhancing lips has become a very popular cosmetic procedure. Most of the press has been negative because of the abundance of poorly performed injections, particularly on celebrities. Instead of improving ones looks, and sensuality, they become a turn off, negatively affecting one’s attractiveness if not done properly. A slew of new terms for these lips has arisen: “Fish Lips”, “Sausage Lips”, “Trout Mouth”. Patients go into the doctors office with aspirations of “Angelina Jolie” lips and leave with “Lisa Rinna’s” lips. Unfortunately, the bad outcomes of these celebrities and close friends, scares off a number of interested women, fearing they too will end up like Goldie Hahn from the “First Wife’s Club.”
Fortunately, with an experienced injector, and the newly approved filler Restylane Silk, cosmetically attractive lips are well within reach for most clients. Restylane Silk’s advantage lies with it small particle size. This enables the injector to more precisely place the filler, for better contouring, and with less chance of leaving lumps or bumps. Also, because it is superficially placed, there is less bruising and less discomfort during injections. It’s not just the filler though, it takes the skilled eye, technique, and knowledge of an experienced injector to get the lips just right.
Knowing the esthetically correct dimensions and landmarks of the face goes back to Leonardo Da Vinci, in the 1400’s. He recognized the golden ratio, phi, that equals 1.618. Throughout the face, he saw that relationships between spacing and dimensions of the face, and all were related to the pi ratio. In the lips, the golden ratio is found between the upper and lower lip, with the upper to lower lip ratio being 1:1.618. In African Americans, this can be close to 1:1 and Asians are somewhere in between. Several other aesthetically appealing features of the perfect lips are:
- Prominent tubercles in the middle of the upper lip, and either side of the midline on the lower lip
- A strong cupid’s bow and philtrum
- Corners of mouth that are neutral or turn up slightly
- Very little red lip visible on the lateral 1/3rd of the upper and lower lip
- The length between the columella and space between the lips should be about 1/2 of the length from the space to the chin
- The peak of the cupid’s bow is continuous with the philtrum
- The upper lip should project more than the lower lip when visualize on a lateral view
- A “Paris Curl”, lips curling up at their vermillion borders
- Phi ratio: length between cupids peaks: length between corner of mouth and cupids peak
What goes wrong with lips that look obviously done or unattractive? The simple answer is that ratios and landmarks are ignored. Several common errors are: upper lips that are bigger than lower lips, lower lips that project more than the upper lip, tubercles (or other landmarks) that are obliterated, and no attention to the cupids bow. Also, enhancing lips to the “age appropriate size” is part of the art of an experienced injector. Selecting the appropriate filler is important too. Fillers other than Restylane Silk, are too thick to be added superficially in the lips without the risk of being noticeable or palpable. Silk can be injected just beneath the surface of the lip and not be perceptible. Fine tuning is much easier with this technique rather than the deeper injections that have more associated bleeding, bruising, and swelling.
The take home messages are that achieving desirable, sensuous lips requires a skilled injector with a keen awareness of natural ratios and landmarks. Using the newly approved FDA filler for lips, Restylane Silk, allows for greater control and results that can’t be achieved with the other, more viscous, hyaluronic acid fillers.
(In the older patient: It is very hard to restore lips to their youthful state when there is severe volume loss, multiple upper lip lines, and loss of the normal curvature of the lips. The lip muscle in a young lip forms a “J”, creating a natural curl in the lip. In some patients, this elongates into an “I” shape, making it difficult to create the natural shape with a filler injection without it appearing abnormal. In these patients, the author gradually enhances over several months and this seems to lead to better outcomes.)
Restylane has become the number one trusted dermal filler in the world. With over 20 million treatments worldwide, and numerous publish studies, Restylane’s safety and efficacy is well established. It is composed of hyaluronic acid (HA), a naturally occurring substance that is found in skin and joints. It’s duration of action is about 6-12 months, depending on the location it is placed. (My other blog explains duration in more detail) Crosslinking, a process that joins adjacent strands of the HA, is essential, because the breakdown of the HA would occur in weeks without it.
Restylane is composed of similarly sized HA particles, with a concentration of 100,000 per ml. Perlane, a “cousin” of Restylane, is exactly the same as Restylane, except that it’s concentration is 10,000 particles per ml. Both of these products have been on the US market for years, Restylane since 2005, and Perlane since 2007. Restylane Silk, the newest US FDA approved filler, is composed of 500,000 HA particles per ml.
This means that the Restylane Silk HA particle is 1/5th the size of the regular Restylane HA particle, and that’s the reason behind it’s magic.
Although Restylane Silk was approved in the US in 2014, it has been used under the name Restylane Fine Lines for over 15 years in Canada. There has been a huge experience in Canada using this product to improve superficial fine lines and in LIP ENHANCEMENT. In the US, there are now only 2 FDA approved fillers for the lips, Restylane, and Restylane Silk. Silk is also approved for the perioral area (area around the mouth). It’s the author’s opinion that part of the problem lip enhancement has been disappointing to many patients is that US physicians didn’t have access to the proper filler. Fish lips, sausage lips, uneven lips, overfilled lips have dissuaded many potential patients from ever trying lip enhancement.
The small particle size of Restylane Silk allows the skilled and experienced physician to add product in the very superficial aspect of the lip, in the submucosa. This was impossible with other fillers without lumps being visible. The product spreads in this plane, so only a couple points of injection are needed in each quadrant of the lip. By being so superficial, and with only a couple injection points, the discomfort associated with the injection is markedly decreased. In addition, by staying superficial, and not deep, the risk of a bruise is significantly less. Very precise alloquots of Restylane Silk can be placed along the border of the lip (vermillion), cupids bow and peaks, in the tubercles, and corners of the mouth much easier than the larger particle HA fillers.
The addition of Restylane Silk to the aesthetic physician’s armamentarium fills a necessary niche that was missing in lip enhancement. Patients can now anticipate less bruising, less discomfort, less lumps, with better and more natural results, thanks to the smaller particle size of Restylane Silk.
Realself.com is a public forum for asking questions about cosmetic procedures which patients have had or are thinking of undergoing to the website’s participating physicians. The website allows doctors of the following specialties to respond:
- Plastic Surgeons
- Facial Plastic Surgeons
- Oculoplastic Surgeons
Unfortunately, experience and credentials are not always fully evaluated by the public, and undesired outcomes, often with long term repercussions, can result. Sometimes with only a few weekend courses under their belt, Internists, Family Practitioners, Dentists, ER Physicians or OBGyns hang up a shingle Aesthetic Procedures. An article by Tom Seery, CEO of Realself.com, points out that consumer satisfaction rates are about 30-35% higher when a specialist is performing Botox or Dermal Fillers vs. “all providers”.
Now for the most Botched Cosmetic Procedures:
1. By far, the #1 most botched procedure is tear trough injection with fillers. Complaints range from lumps, prolonged swelling, worsening of appearance, pain, prolonged bruising, vascular injury, numbness, and firm nodules. The skin around the eye is very thin, and there is very little room for error in this procedure. Dr. Weiner is a firm believer that this injection should be performed using blunt cannulas with Restylane. There is less swelling, bruising, and significantly less vascular risk with cannulas. Lesson: Leave this injections to “the pros” for better outcomes and safety.
2. Botox being botched is a close 2nd. Common problems are eyebrow or eyelid droop, uneven smile, ineffectiveness, bruising or swelling, or “Dr. Spock” look. Sometimes a touch up can improve these results, but often one has to wait for the Botox to wear off. This can be 3-4 months. So that deal on Botox that is supposed to improve ones looks becomes a nightmare where one looks abnormal and/or worse. Lesson: Botox deals aren’t usually worth it.
3. Laser hair removal resulting in burns is fairly commonly asked about on Realself. If the laser operator is not using the appropriate laser or settings for one’s skin type, permanent pigmentation problems can result. Fortunately, most superficial burns will reverse over the course of several months. In several states, rules for operating a laser are very lax, allowing techs without significant training to use the laser. Florida is one of the strictest in the country. The operator can only be a nurse practitioner, physicians assistant, doctor, or specially trained electrologist. Lesson: Get the most qualified person to operate the laser, preferably a physician with years of laser experience. Dr. Weiner has over 25 years of laser experience.
4. Lip augmentation with dermal fillers is another highly botched procedure. The most common lip problem is uneveness and lumpiness. These are a direct result of poor technique by the injector. Hyaluronidase to dissolve the filler is usually required, and then you are back to where you started (so 2 procedures to get back to square one). Bruising, swelling, and prolonged downtime is seen when lips are injected using needles in combination with injector inexperience. Dr. Weiner is a huge fan of using blunt cannulas for the lips to minimize the recovery time and bruising. Overfilled, and unnatural lips are also a problem, mainly due to lack of knowledge of the natural anatomy of lips by the provider. Lips should have a ratio of about 40% upper to 60% lower. When the upper lip is larger, or the natural landmarks (tubercle, cupids bow, shape) are not preserved, the lips become obviously “done” and unattractive. The sausage lip is when the lips appear tube like (like a sausage link) which is another common error by the inexperienced injector. Lesson: Lips are another area with several intricacies that require an experienced injector. Cannulas limit bruising, swelling, and downtime so you can enjoy your lips without interrupting your social life.
The take home message is that all providers are not equal. Please do the homework, look at reviews, ask friends, and ask the facility “Who is actually doing my procedure?”. In general, specialty trained physicians will give better outcomes with higher satisfaction rates.
A: Hyaluronidase is the easiest solution for improving botched lip injections with Juvederm
A: Anyone who injects Juvederm or other fillers SHOULD HAVE HYALURONIDASE, don’t go to them if they don’t
A: Juvederm leaving swelling around the eyes is seen often
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.
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.
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.
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.
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
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.
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.
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.
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
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 🙂
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
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.
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..
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.
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.
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.
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.
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.
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.
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.
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.
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.
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!!!
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.)
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.
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.
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.
About 2 years ago, I had one of those “AHA” moments when I saw a physician from France demonstrate the use of blunt cannulas for injecting dermal fillers. Since then, I have hardly used the traditional needle method for fillers and my patients love it. I have become one of the strongest advocates of this technique, and it has revolutionized my thoughts about fillers.
Blunt cannulas have a rounded tip and are very flexible. The advantages are:
- The bruising and swelling post procedure are dramatically reduced. So you don’t have the social downtime after having your lips done (which can be up to 2 weeks). Blood vessels bounce off the tip and are not injured as easily with the cannulas.
- Procedural discomfort is much improved in most areas.
- With only 2 entrance “pokes”, I can enhance the lips, vs. at least 10 pokes using needles.
- Overall time of procedures are significantly reduced. Because I’m not using topical anesthesia in most cases, the total time to have your smile lines injected can be only a few minutes. Under eye injections are the same. In and out of the office more quickly and then go to lunch.
- The risk of a vascular catastrophe is almost eliminated because you can’t enter a vessel with a blunt cannula. You can still compress a vessel, but this is a much easier problem to deal with than an intravascular injection. So BLUNT CANNULAS ARE A MUCH SAFER WAY TO INJECT DERMAL FILLERS.
- I can inject the upper lip lines, lips, nasolabial folds, marrionette lines, and lower cheek, all through the same entrance site.
- Tear trough injections can be done deep to the muscle to avoid the filler from showing (“Tindel Effect”)
- I can use the cannulas for all fillers except Sculptra.
My YouTube videos with blunt cannulas: http://www.youtube.com/user/StevenFWeinerFacial?feature=guide
The only area which I might use a needle to inject filler now is along the vermilion border of the lips and for superficial fine lines or scars.
When choosing a physician for filler, technique makes a world of difference…ask my patients.