swelling Archives | The Aesthetic Clinique

Commonly Asked Questions About Lip Filler Problems

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.

Video of Dr. Weiner discussing the most commonly asked questions about lip filler from RealSelf.com

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

Juvederm is one of the most popular dermal fillers in the US. As with most fillers, it is only FDA approved for the nasolabial folds, but is used “off label” in other areas of the face. Although Juvederm is a very safe filler for use around the face, there are certain characteristics that make it the wrong choice for filling the “tear trough” and areas around the eye.

Like many of the popular FDA approved fillers, Juvederm is a hyaluronic acid (HA) filler. The other commonly used HA fillers are Restylane, Perlane, Voluma, and Belotero. One of the characteristics of HA fillers that extends their longevity is that they are hydrophilic. Hydrophilic means “water loving” which translates into the HA fillers absorbing up to 10 times their volume with water from the surrounding tissues. Although all the HA fillers have this characteristic, Juvederm is the MOST HYDROPHILIC of the dermal fillers mainly because it is has the highest concentration of HA. This is a disadvantage around the eye because it often results in PROLONGED EDEMA around the eye. All the HA fillers have been known to do this but it is particularly common with Juvederm. Dr. Weiner has seen this problem with people that have been injected with Juvederm in the tear trough even up to 3 years earlier. RealSelf.com is replete with stories and pictures of very unhappy patients with this Juvederm problem.

Another disadvantage of Juvederm in the eye area is related to its cohesivity. This is the ability of the product to bind to itself. Juvederm has low cohesivity, which means it tends to spread to the surrounding areas, causing a correction to areas beyond the injected area. This is fine for some areas, but in the tear trough, which is a very small area, doctors need precise control of the filler. The physician wants to know that when he places the filler in the tear trough, it will stay exactly there, and it doesn’t with Juvederm.

Fortunately, hyaluronidase is an antidote for HA fillers, and can be used for dissolving fillers with poor cosmetic results. For Juvederm, dissolving with hyaluronidase is harder and requires more treatments than the other HA fillers. Some believe this is related to the higher cross linking in Juvederm than other fillers. Nonetheless, Juvederm can be successfully reversed even in instances where the chronic edema has been present for several years.

Around the eye and tear trough area, the HA filler of choice should be Restylane. There are some physicians that are happy with Belotero and Restylane Silk. Another great option is Sculptra but only in very experienced hands. Remember too, that cannulas are a much safer option for the injection in this area, with less risk, less bruising, and less downtime.

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

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Hyaluronidase – The “Magic Eraser” for Hyaluronic Acid (Juvederm, Restylane, Voluma) Dermal Fillers

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Hyaluronic Acid dermal fillers are the most popular fillers used worldwide. In the United States, the commonly used HA fillers are:

Juvederm Ultra and Ultra Plus
Voluma
Restylane
Restylane Lyft (Perlane)
Restylane Silk
Belotero

The beauty of HA fillers is that they are very well tolerated because hyaluronic acid is a component of skin, so it is a naturally occurring substance. It’s a soft product, and will last anywhere from 4 months, to up to 2 years, depending on the brand used, and the location it is placed.

Another key attribute to the HA fillers popularity is that it can be completely dissolved with an enzyme called hyaluronidase. It is manufactured from either bovine (cow) or ovine (sheep), so there is a remote possibility of having an allergic reaction to the commercially available products (Vitrase, Hydase, and Amphadase). There seems to be a crossover with people that are allergic to bees for these animal derived products. Hylenex is a recombinant form of hyaluronidase that is the human form that is the preferred form of Dr. Weiner for there are no allergies, yet it is a bit more expensive.

Hyaluronidase is useful for dissolving HA filler in the following instances:

The filler was over done/”over filled” and it is not aesthetically pleasing
There is prolonged swelling, particularly around the eye and most often with Juvederm
An infection has occurred in the area of prior filler
The filler is lumpy or has nodules and doesn’t respond to massage and time (especially lips)
Rare possible allergic reaction to the HA filler
When there is vascular compromise secondary to the HA filler injection which can be caused by external compression on a vessel or intraluminal (within the vessel) injection

My experience with hyaluronidase has been mostly with patients that have had Juvederm injected in the tear trough area from another facility. I strongly recommend that Juvederm not be injected in this area because of the risk of prolonged edema. The reason this happens more with Juvederm is speculated to be due to its ability to attract more water, higher concentration of HA in the product, and because it spreads more diffusely than the other fillers.

When injecting emergently for vascular compromise, at least 200 units (more is better) should be injected in and around the original site of injection of the HA. It has been shown that extravascular hyaluronidase is able to traverse the vessel wall to make it intraluminal, useful knowledge for the cases where the HA is within the vessel. (Blindness needs emergent Ophthalmology evaluation and might require arteriogram for placement of hyaluronidase. Even with such extraordinary measures, blindness is almost always permanent.)

When injecting hyaluronidase, it is mixed with lidocaine by the physician, so it is a fairly comfortable procedure. There are a couple limiting factors with the injection. It is not as precise as the filler injection, so it can remove some of the filler that you wanted to stay along with the unwanted filler. Also, dosing/how much to use, is not an exact science. It may take more than one treatment to dissolve the HA filler. The results can occur within minutes, but usually take about a day to fully appreciate. Also, Juvederm and Voluma tend to be the hardest to dissolve, and it is thought that this is related to the way it is cross linked (manufacturing process).

The bottom line is that you don’t have to live with HA filler that you are not happy with. You can easily reverse lips that are lumpy or too big, swelling around the eye from filler, or dissolve an over correction or asymmetry with hyaluronidase. An injection with hyaluronidase can get you back to where you used to be in about 24 hours. Also, it’s nice to have a little piece of mind when getting injected with an HA filler that the process can be completely reversed with a small procedure.

Dr. Steve Weiner is a Facial Plastic Surgeon who “laid down his scalpel” in 2005 and concentrates solely on non invasive and minimally invasive cosmetic procedures at The Aesthetic Clinique. His website is http://www.theclinique.net . Call for a consultation: 850.622.1214

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

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

Fraxel Dual Questions Answered by Dr. Steven Weiner, Destin, Florida.

****Please note that these questions were answered before Infini was available. It might be a better treatment option for certain conditions than Fraxel Dual or re:pair.****

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Q: Fraxel – which type for rejuvenation for mature skin?? I had the Palomar 1540 with a 50-15 setting.

A: Don’t be confused with imitations, there is the Fraxel Dual restore and Fraxel repair

There are many physicians who buy less expensive lasers and sell them as being Fraxel. The only thing in common with the Fraxel and the others is that they are fractional, like the Palomar. In my opinion, Fraxel Dual restore is the gold standard for non ablative skin resurfacing. The Fraxel repair is ablative, with more downtime, more pain, and more risk.

Q: Fraxel and Resveratrol?

A: Resveratrol is an antioxidant and should not affect recovery from Fraxel

I’m a big fan of Resveratrol. We sell the supplement, MegaResveratrol in our office. It has many studies behind it showing multiple benefits. It should not affect your recovery and may in fact speed the recovery from Fraxel.

Q: The Hyperpigmentation Post Fraxel Laser Treatment for Stretch Marks on Arms? (photo)

A: Hyperpigmentation after Fraxel for stretch marks is treated with hydroquinones

Hyperpigmentation after laser is more common in darker skin types and people with a lot of sun exposure. I can be treated most often with hydroquinones 4%. If not improving, adding Retin A +/- a steroid cream. It almost always resolves. A better, newer treatment for stretch marks, particularly darker skin types, is the Infini RF device. I would try it, but not many docs have it presently. Steve Weiner, MD, Facial Plastics, Destin, Fl

Q: Will Fraxel Laser Help White/mature Stretch Marks on Ethnic Skin? Stretch Marks Are on the Buttocks.

A: Fraxel will help mature stretch marks but don’t expect more than 30-40% improvement

Mature stretch marks are difficult to treat, particularly on an ethnic person because of the risks with laser of hyperpigmentation. It will help, but to the degree you desire, I don’t know. You will also need at least 5 treatments, maybe 10. A new technology called the Infini by Lutronic might be promising for this and time will tell. Steve Weiner, MD, Destin, Florida.

Q: Can Fraxel Be Used on a Scalp Laceration? (photo)

A: Fraxel 1550 is great to improve scars but using topicals first is probably a good idea for early wounds

The problem is that for the laser to work effectively, you must shave the area. This might not be what you want. In my opinion, use the Scar Recovery Gel from SkinMedica as well as Retin A, 0.05%, and the scar should heal up fairly well. Save the Fraxel if it doesn’t heal to your satisfaction. Another laser for early scars is the VBeam, but you also have to shave the area to be treated.

Q: CoolTouch, Thermage or Fraxel for Crows Feet?

A: Crows feet are best treated with Botox not laser.

Crows feet are produced with the active muscle contraction of the obicularis oculii. By relaxing with Botox this muscle doesn’t contract and the crow feet are less. If you are opposed to Botox you might want to try Belotero for your crows feet.

Q: Fraxel to Restore Pigment to Skin Damaged by Cryotherapy?

A: Hypopigmentation from Cryotherapy can be improve with the Fraxel 1550 Laser

Hypopigmentation is a difficult problem to fix. Having said that, the Fraxel has been shown to repigment areas which have lost pigment. It won’t usually completely come back. If cryotherapy was used for precancerous lesions, I prefer the Fraxel 1927 or Levulan because there is very little risk of hypopigmentation with these methods. They will be more expensive but well worth it in my opinion. Steve Weiner, MD, Destin, Florida, Facial Plastic Surgery.

Q: Does Fraxel Actually Work on White Stretch Marks?

A: Fraxel Dual works for mature white stretch marks but won’t resolve them

I have treated several people for this problem. The best you can expect is about 40% improvement, and thats after about 4-5 treatments. There really is no other treatments available for this problem other than excision.

Q: Can I Have Full Face Fraxel Laser After Having Had Facial Silicone Injections Several Years Ago?

A: After having silicon injections, even years prior, there is a risk of activating an inflammatory response w Fraxel or injections

Even though you’ve been doing relatively fine from the silicon, any invasive procedure might activate an inflammatory response or granuloma. Having said that, I’ve haven’t encountered problems with people that have had silicon but it is a risk you need to be aware of and the physician should discuss with you.

Q: Will Fraxel Laser Make Active Acne Worse? Will It Cause a Flare Up if You Are in Remission?

A: Fraxel can temporarily make acne worse but in long run it makes it better

The Fraxel Dual can stimulate acne for the first couple weeks. Acne prone patients I put on minocin to help prevent having a flair. However, it reduces the sebaceous glands and thereby helps with acne in the long run.

Q: I Am Planning on Having 3-4 Fraxel Treatments Spaced One Month Apart. What is Your Recommendation Concerning Sun Exposure?

A: Sun exposure inbetween Fraxel treatments (as well as after) should be minimized.

You want to have as little direct sun exposure as possible when receiving any laser treatment. I usually say 3 weeks before and after treatment at the very least. Sun exposure will lead to rev’d up melanocytes which will lead to pigmentation issues. It doesn’t mean staying indoors, it means wearing sunscreen, a hat, and avoiding intense sun exposure. Heliocare can help reduce the tan and burn associated with sun exposure too as well as antioxidants such as those found in TNS Essential Serum from SkinMedica.

Q: Still Have Very Distinct Red Square Patches and Microdot Tracks on Cheeks 11 Days After Fraxel – Should I Be Worried? (photo)

A: You did not get the Fraxel Laser..There are docs using other lasers and saying it’s Fraxel

Fraxel uses a rolling tracking system and the laser comes out in lines, not squares. The Fraxel is an expensive laser and there is a fee you pay the company every time it is used. It is the state of the art for laser resurfacing in my opinion. Doctors buy less expensive lasers and say they are giving you Fraxel. It looks to me like you have been overtreated for your skin type. You should go back to your doctor and get evaluated and look at the machine which you were treated with.

Q: Fraxel Dual 1927 Vs 1550?

A: Difference between the Fraxel 1927 and 1550 wavelengths.

As you stated, the 1550 wavelength is a deeper penetrating laser and is more suited for scars, wrinkles, and some mild pigment improvement. It is non ablative so there is no open wounds. It will have more swelling than the 1927. There is some peeling, but more with the 1927. The 1927 is a “partially ablative” laser that is very superficial and used to help pigmentation and superficial fine lines. Both laser wavelengths are approved for removing precancerous lesions (actinic keratosis). In general, I use both lasers at the same sitting, unless someone is only concerned about pigmentation or AK’s (1927), or more concerned about scarring (1550). My video show the 1927 laser. Also, because the 1550 goes deeper, it is more painful during the procedure.

Q: Are These Setting of Fraxel Really High? 55 Energy, 6 Treatment Level, 8 Passes

A: The settings for the Fraxel 1550 you had are for moderate wrinkles, scars

The highest setting for the energy is 70 and you were at 55mj. This is needed to improved deep wrinkles and scars. The second number is related to how much of the skin is treated. You were at the medium level for that. So these are very safe parameters. The passes really doesn’t matter in the end, it is basically how fast the procedure goes, but should be at least 6. The more passes, the less treatment per pass, the more margin of error for the operator in unintended overlapping of the passes.

Q: Will Fraxel Dual Laser Treatment Damage Gore Tex Line Lift or Filler?

A: Fraxel Dual is safe for fillers and Goretex implant

The laser from the Fraxel Dual goes about 1.5-1.7mm deep at most. Studies have shown that is does not affect fillers. Goretex is placed much deeper than the depth the laser penetrates to as well.

Q: Not Peeling After Day 3.. is This Normal?

A: Not peeling yet after 3 days from Fraxel Dual is fine, it will!

You describe the correct sequence of events. Your skin gets darker and the pigmentation looks more prominent after getting the Dual. You should start peeling from 3-5 days after the procedure and it will usually start around the mouth and then work upward. The cheeks might take the longest to completely peel. When all is peeled, you skin will be smoother and less pigmented. You must make sure the skin is moisturized before and during the peeling.

Q: Will Fraxel Restore Damage Hair Follicles at Level 9 and 75 Mj Setting?

A: Fraxel Dual or re:store laser will not damage hair follicles

Hair follicles are damaged by a laser that is attracted to melanin, the pigment in skin and hair. The typical wavelengths of the hair removal lasers are lower (Diode – 800, Alexandrite 765) than the Fraxel Dual (1550 and 1927nm). The Fraxel might singe the hair but won’t permanently affect the growth of the hair.

Q: Do You Need to Wear Eye Protection for Fraxel?

A: Eye protection for the patient during Fraxel should be done

Having said that, the Fraxel laser is not very dangerous to the eyes. It has to do with it’s wavelength. It’s attracted to water, so the most it would do is cause an injury to the conjunctiva or cornea. It’s not attracted to the retina or iris where the lasers that are attracted to pigment (KTP, Pulsed Dye, Diode, Alexandrite) can cause visual lose or blindness. So, the Fraxel is relatively safe to the eye. If you would have been injured to the eye with the Fraxel, it would present as pain immediately, and you would have irritation, swelling, pink/redness of the eye. If this didn’t occur, you’re good, but would use eye protection next time.

Q: Telangiectasias Appearing Ater Fraxel?

A: Telangiectasias are easily treated with VBeam

Telangiectasias can occur after any procedure, including Fraxel, injections, or Radiofrequency devices. The good news is that they are easily treated with a no downtime almost painless laser called the VBeam Perfecta. You might require a couple sessions.

Q: Will Acne Scar Resurface if I Dont Do Fraxel Regularly?

A: The improvement from Fraxel Dual re:store for acne scars is permanent

After the edema settles down and you are about 3 months out from your Fraxel treatment for acne scars, the result you have should last a lifetime, IF you don’t create more scarring with further acne. The question always asked of me is how many do I need. That is difficult to answer, could be 5 or 10, depending on the degree of scarring, and how much you want it improved. Also you can only expect improvement and not resolution of your scars. Unfortunately, the skin will never look entirely normal, but better.

Q: Have Heard Different Answers About Fraxel Recovery Time During Consultations, Which is Correct?

A: Downtime after Fraxel Dual is variable

Downtime after a Fraxel Dual depends on the settings and the individual. Obviously if your have more aggressive settings, you will have more swelling and downtime. Also, different people have different degrees of swelling and redness. Typically, after about 4 days, the peeling is done and there still is mild swelling. The skin is intact. Some of my patients go in public throughout their recovery, it depends on your comfort with the recovery process. I would say it would be unusual for the downtime to be 2 weeks though. You will have pinkness of the skin for several weeks, but I don’t consider this downtime.

Q: More Fraxel to Fix Fraxel Damage?

A: Try another physician

This doesn’t sound like normal care. I haven’t heard of treating with Fraxel and needling at the same time. Perhaps it was subcision, but still I would not do this at the same time. Also, only 7 weeks out, I would not treat with such a permanent filler. At this point, more fraxel or a pulse dye laser (V Beam) would probably be helpful.

Q: Side Effects of Too Many Fraxel Restore Treatments?

A: No issue with multiple Fraxel dual or re:store treatments

This very question came up at a recent meeting with all the best laser surgeons in the world at Mass General (Harvard). Dr. Rox Anderson, the inventor of fractional laser resurfacing said he saw no issues with multiple treatments.

He even stated that your incidence of skin cancer will be lower (not higher as some bloggers have stated) with the resurfacing.

Q: Fraxel Restore or Repair for General Improvement of my Skin?

A: For general skin resurfacing, both the Fraxel re:pair and Fraxel re:store Dual work well

I think that you have some scarring/textural irregularities on your face. I think the better result will probably be from the re:pair, perhaps even more than one. However, you have to be able to have downtime, do dressing changes, and have general redness for up to 8 weeks. If your lifestyle does not allow you to do this, the new Fraxel Dual is having great results for this problem with less downtime, but more treatments.

Q: Preventing PIH After Fraxel Restore or Repair

A: Using Hydroquinone a month prior and Gentlewaves helps prevent PIH from Fraxel

Starting hydroquinones 4% 1 month prior and restarting soon after the procedure will help prevent PIH from Fraxel. There is also a recent paper that suggests pre and post procedure Gentlewaves will decrease the risk of PIH as well. Avoiding the sun for 6 weeks prior to the procedure and good sunscreen also is important.

Q: Fraxel Restore Test Area for Dark Circles?

A: Dark circles around eyes is hard to treat

Please keep us updated about your results. Up to this point, dark circles have been hard to treat. Please moderate your expectations. Dermal fillers have seemed to be the most helpful, but smoothing out the shadows around the eyes from volume loss. I have a Dual and would love to add this application to my services if this works. The Dual is a very safe laser and test spotting is not a bad idea, but usually not needed.

Q: What is Fraxel Dual?

A: Fraxel Dual is 2 lasers in one treatment

Fraxel introduced the Dual about 1-2 months ago. I combines a 1927nm laser with an upgraded version of the 1550nm (re:store) laser. The 1927 laser is a superficial laser that is brand new to the aesthetics market. It is somewhat a blend of non ablative and ablative technology — referred by the company as “disruptive” to the skin. It removes pigment better than any laser I’ve encountered, in usually 2 treatments. It is relatively quick (10-12 minutes for the face) and fairly comfortable to have done. It will cause the skin to darken over the first 3 days and then peel. There is no wound care. Social downtime for about 3 days.

It is often combined with the 1550nm laser to give both a deep and a superficial treatment. When done with the 1550, there is slightly more swelling and redness. The 1550 has more discomfort. The Dual’s 1550 has been modified to be faster, more effective, and more comfortable (has integrated cooling) than the prior Fraxel re:store laser. Usually you will require 3 instead of 4 treatments with this laser as compared to the previous version. My experience with this laser has been very good. The satisfaction of my clients is high.

Q: Thermage Free with Fraxel, is It Worth It?

A: Thermage is a great addition to Fraxel re:pair or re:store

There have been recent clinical studies showing the benefit of doing both Fraxel laser treatment and the Thermage together. What happens is that you have tightening at both a superficial and and deeper layer of tissue leading to better results. The safety profile of the current Thermage CPT is extremely good and for the hour or so it takes to get the face treated, I would highly recommend doing the Thermage as well.

UPDATE: We no longer do Thermage. Ulthera is more precise and more consistent results.

Q: Treatment Spacing of 4 Days for Fraxel and Thermage?

A: Timing of Fraxel and Thermage

Thereare no restrictions regarding the timing of Thermage and Fraxel. They affect different areas of the skin. However, after having as many treatments as you describe, you probably have fully appreciated any benefits that you get from these treatments. If you want more improvement, I’d suggest the Fraxel re:pair.

Q: Should I Have Fraxel Re:pair or Active FX?

A: Recent study suggests better results from Fraxel Re:pair over the Active FX

In a paper recently presented at the American Society for Laser Medicine and Surgery, it showed both were effective, but the Fraxel Re:pair side had better tightening. It was a split face study, one side got the Fraxel Re:pair, the other the Active FX. The study was done by a group out of NY and NJ. It was a blinded study to the patients (they didn’t know which side was which laser). There were 10 patients.

Hope this helps!

Q: Fraxel Repair or Fraxel Restore for Loose Skin?

A: Fraxel re:pair more aggressive and more results than the Re:store

The Fraxel re:pair is a fractional CO2 laser. CO2 lasers are aggressive/ablative lasers that will give you the best results for skin tightening. They have been around for over 20 years. The recent resurgence of these lasers is the fractional technology which leads to less downtime, and less side effects.

The re:store is an Erbium laser that is non ablative. It typically will have less downtime, less results, and requires multiple treatments. When you add up all the downtime with the re:store (about 2 days with each treatment) it equals the downtime that a re:pair would have (about 1 week). My suggestion is to get the re:pair by an experienced physician for your best skin tightening results.

Q: Fraxel Repair Vs. Fraxel Restore

A: Fraxel re:store and re:pair are different

The Fraxel re:pair is a fractional CO2 laser and the re:store is a fractional erbium laser. The re:pair requires usually only one treatment (except for acne scars), whereas the re:store is usually a series of 4-6 treatments.

The re:pair will tighten the skin, the re:store will minimally tighten, even after 6 treatments. Wrinkle control is also far superior with the re:pair over the restore. The reason that the re:pair causes more wrinkle control and tightening is because it actually removes tissue, whereas the re:store thermally heats the tissue.

Also, CO2 lasers cause more thermal injury to the surrounding tissue, which leads to more collagen and better wrinkle control. The cost of 4 or more treatments with the Fraxel re:store is more than the cost of 1 Fraxel re:pair treatment. The Fraxel re:pair was introduced at the American Academy of Dermatology on January 31, 2008. The Fraxel re:store received FDA clearance July, 2004.

Q: Can Fraxel CO2 Be Used for Upper Arm Skin Wrinkles?

A: Use Thermage for tightening crepey skin

Fraxel has recently had FDA approval of a few new handpieces for the Re:pair laser. One of them is made to do body treatments as you are desiring. It will take a few months for those to be manufactured and in the hands of the physicians. The crepey skin can be improved but not redundant skin – this would have to be excised.

Answer updated 4/23/09:

I now feel that the best non surgical approach is Thermage. The new Fraxel handpiece hasn’t really turned out to be a revolutionary change.

I have recently added Thermage to my office. I have seen several clients who have had surgery that have been left with very large and long scars. Thermage seems to offer an alternative that has no real downside.

Q: Fraxel Re:pair Vs. Fraxel Re:store for Reducing Large Pores?

A: Both will work, but re:pair is overkill

I have seen improvements with the Fraxel re:pair for pore size which are dramatic, but if you don’t need all the other improvements (pigment, scarring, tightening, texture), then stick with something that is less expensive and less downtime like the re:store, Lux 1540, or IPL.

Steve Weiner, MD Facial Plastic Surgeon, Destin, Florida

Q: What is Fraxel Recovery Like?

A: Painless after Fraxel, swelling lasts under 5 days

Universally, nobody complains of pain after the procedure. Swelling is the worst on the second day after the procedure and gets better by day 5 or so. Seeing streaking is common and will go away. Redness lasts up to 3 months, but usually about 3 or 4 weeks.

Q: Fraxel Restore Vs. Fraxel Repair

A: Fraxel repair is the best laser for skin tightening and wrinkles

The Fraxel re:pair has fractional laser technology that made the CO2 laser much safer than completely ablative CO2 lasers. The company has seen none of the risks that the older CO2 had – hypopigmentation, scarring, and lines of demarcation. The CO2 laser has been long regarded as the gold standard for wrinkles and tightening, but with the previously mentioned risks happening in about 15 percent of patients, it fell out of favor.

Another benefit of the Fraxel re:pair is the depth of penetration, up to 1.6mm, much deeper than the prior CO2 lasers which went 0.3mm as well as the 2 competitive lasers – Mixto – 0.7mm, and the Deep Fx, which is 1mm. Deeper treatments mean better results.

The other Fraxel (re:store) is an erbium laser, and is considered non-ablative (does not remove tissue) whereas the re:pair causes ablation. Removing tissue will result in more wrinkle correction and tightening. The CO2 also causes some peripheral heat damage which also leads to more tightening. The erbium causes very little peripheral heating.

There is more downtime with the re:pair but it’s only one treatment. All my patients are extremely pleased with the re:pair, and I can’t say that about the re:store.

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.

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

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

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