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How Long Do Dermal Fillers Last…..It Depends!

It happens everyday. Patients ask how long they can count on their dermal filler lasting. The problem is, is that there is no quick and easy answer. There are a number of variables that factor into filler longevity, with the ultimate unknown being that there is no way that a physician can determine how one’s body is going to degrade a particular filler.

In the US, the majority of patients are injected with Hyaluronic Acid (HA) fillers. The commonly known HA fillers are: Juvederm Ultra, Juvederm Ultra Plus, Restylane, Perlane, Voluma, and Belotero. The differences between the HA fillers are their manufacturing process, and the concentration of the HA in the filler. The harder the HA is for the body to break down, the longer it will last. A larger particle of HA has less surface area then multiple smaller particles taking up the same space. Less surface area means there is less area for the cells to “chew up” the HA. In general, larger particles will last a little longer than smaller particles. Another factor in HA fillers is how tightly the particles are bound together. Cross-linking, adding bonds between molecules of HA, has been shown to significantly add longevity. All HA fillers are a combination of cross-linked and non cross-linked HA. Too much cross-linking leads to a filler that is very hard to inject, and has led to more complications (in a filler that is no longer on the market). Non cross-linked fillers last only 3-4 months and are hardly used anymore. One last variable in HA fillers is their ability to attract water, their hydrophylic properties. The more they attract water, the longer the HA filler gives a correction.

The fillers that are collagen stimulators, tend to lead to longer longevity. Fillers in this group are: Radiesse, Sculptra, and Bellafill. While studies have shown a very mild collagen response to the HA fillers, the visible volume correction with the HA fillers is the gel, not the collagen. With the collagen stimulators, the body responds to what is injected by creating an inflammatory response and lays down collagen. Until the particle is degraded by the body, collagen will continue to be produced. Radiesse is made of calcium hydroxylapatite, and is the shortest duration in this group. Artefill should be considered a permanent filler, because its component, Poly Methyl Methacrylate (PMMA), does not get broken down by the body. Sculptra has consistently given about 2-3 years duration in studies and in the authors experience.

The location in the face a filler is injected is one of the most important factors to determine longevity. Areas where there is more movement, there is faster breakdown. In order of increasing duration in the face, the order is (in the author’s experience):

Lips
Marionette
Nasolabial Folds
Tear Troughs
Cheeks
Temples

(Forehead, nose, earlobes are variable)

A couple more very important variables that should be mentioned. The more filler that is injected, the longer it will last. This applies to all the fillers. Also, filler doesn’t stop working all of a sudden. It takes months of gradual loss to notice a difference in volume. In fact, even when the patient believes there is no longer results, biopsies have proven that there is still filler present.

After all the above explanation, the author’s experience with the commonly used fillers is:

Lips: HA fillers give about 4 months, longer with recurrently injected lips.
Tear troughs: HA’s – about 9-12 months, Sculptra and Bellafill – years. Juvederm could last years and should never be injected in tear troughs.
Nasolabial: similar to tear troughs
Temples: HA’s – 12-18 months, Sculptra and Bellafill – years
Cheeks: HA’s – 18 months, perhaps 2 years with Voluma; Sculptra and Bellafill – years

Remember that individual results are unpredictable. These are generalizations and offer no guarantee as to how long a patient’s results will last. There are many variables that factor into longevity that are listed above, not to mention how each individual responds, degrades, a certain filler.

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Amazing Things That Can Be Done (By the Experts) With Dermal Fillers

This is the golden age for minimally invasive cosmetic procedures. Who would have ever thought 15 years ago, that procedures done in the office in a matter of 20-30 minutes could result in demonstrable improvements in one’s appearance with results lasting, in some cases, a year or more? Without the need for downtime, anesthesia, or significant costs, cosmetic procedures have flourished, with many people who never would consider enhancements, “dipping their toe” in these procedures. The concept of “preventative maintenance” has spurred the younger generation to start earlier, with smaller, less dramatic, but noticeable procedures as well.

At the forefront of the wave of cosmetic enhancements are dermal fillers. When Restylane was FDA approved in 2003, a revolution in the field was born. Although the main focus was to improve the nasolabial folds, the “smile” lines, in its inception, the broad “off label” use of it, along with subsequent FDA approval of other fillers, treatments have spread to just about every area of the face. There are now about a dozen dermal fillers on the market, with the majority of them based on hyaluronic acid, a naturally occurring substance that is found in skin and joints. Hyaluronic acid fillers (Restylane, Perlane, Voluma, Juvederm, Belotero) provide a soft, very well tolerated fill, with an extremely safe profile. There is also a level of security knowing that these fillers are generally completely reversible, using the widely available enzyme, hyaluronidase, that can dissolve hyaluronic acid, in minutes to hours.

Although less popular, it must be mentioned that there are other dermal fillers which are FDA approved, each with their own niche market. Radiesse is composed of microspheres of calcium hydroxyapatite, and is known as a very robust filler, that has a very high G prime, a measure of it’s lifting ability. Sculptra is composed of Poly L Lactic Acid (PLLA), also naturally occurring as a sugar in the body, and is known as a collagen stimulator. Its use is for global, long lasting, volumization of the face. The longest duration FDA approved filler is Artefill. It is composed of microspheres of Poly Methyl Methacrylate (PMMA) which is a synthetic molecule. Artefill is considered a permanent filler and works as a collagen stimulator, similar to Sculptra.

The understanding of the aging face has made great strides in the last decade. It is now widely understood that loss of volume is the primary cause of the aging face. Leading this volume loss is the shrinking of the multiple fat pads of face, primarily of the cheek and periorbital area. This is why aging often begins to show around the eyes. Gravity contributes to our aging problems and often manifests itself by the descending of these fat pads. Relegated to a less relevant problem than 15 years ago, is the aging related to excess skin. Plastic Surgeons have tightened loose skin for decades during facelifts, often leaving people appearing skeletonized and hollow, but without wrinkles. It is now understood that most of the redundant skin can be improve with proper volumization of the offending fat pads, and most facelifts incorporate this during surgery presently. (In the author’s opinion, most of the patients undergoing the knife could have had their concerns addressed using a combination of fillers and skin tightening devices.)

The common manifestations of volume loss are:

Temporal hollows
Loss of cheek volume
Tear trough deformity
Excessive crows feet and forehead lines
Low hanging eyebrows
Hollowness of the eye (orbit)
Jowls
Poorly defined jawline
Small lips
Dropping of nasal tip
Lip lines (smokers lines)
Corners of mouth dropping causing sad look
Saggy neck
Elongation and narrowing of the face

All the above mentioned aging effects can be improved with dermal fillers. Expertise is required to recognize exactly what areas need to be treated to replenished the lost volume, while still maintaining a natural appearance. It’s been shown that the brain can recognize less than a 1mm change in brow position. When corrections are not done properly, it is very easy for the brain to catch it. Poor corrections of the lips probably stands out in most people’s memory, where they are either too full, out of proper proportion, or there was poor attention to landmarks.

Experienced dermal filler injectors are no longer “chasing lines”, the symptom of aging. The goal is to lift and replenish lost volume by addressing the cause of the aging of the face. Of note, even the neck’s problems can be improved by properly injecting the face. Choosing a doctor that has experience in recognizing the areas affected by volume loss and has the knowledge and expertise to improve those areas is essential for optimal patient outcomes.

Fractional Coagulation is in, Bulk Heating is out for Radiofrequency (RF) Skin Tightening

Ever since Rox Anderson suggested that treating a portion (fraction) of skin while leaving untreated healthy tissue behind as the basis for the Fraxel Skin resurfacing laser over 10 years ago, patients have been having less downtime, less risk, and less discomfort with their laser procedures. Healing is dramatically improved because the adjacent nontreated dermis is able to provide the needed blood supply, nutrients, and local immune response much faster than the traditional treatments and results have been shown to be very similar in efficacy.

Until recently, all RF devices have applied heat to the skin/dermis in a nonfractionated approach, called “Bulk Heating”. Whether the RF device is Bipolar or Monopolar, if the heating element does not penetrate the skin, the energy is pushed into the deeper layers using this method. The implication of bulk heating is that all precision is lost. Exact placement of the heat is impossible, with large opportunities for errors in depth of penetration and/or temperature control. When treating skin, heat from the RF device using bulk heating can be placed too superficial, leading to burns or pigmentation changes, or too deep, leading to fat loss. The dermis needs to be heated to 42 degrees C for 3 minutes to affect collagen stimulation. Only if skin temperature is measured can the operator be sure that the 42 degrees is reached with bulk heating, which is not the case for most bulk heating devices. One last temperature issue is that bulk heating devices are unable to obtain coagulation of the tissue, which occurs at about 67 degrees C, which is needed for maximal tissue contraction and collagen stimulation.

The Infini uses microneedles to deliver the radiofrequency energy IN A FRACTIONAL manner. Its unique array of needles allows the energy to flow between the needles, creating 49 coagulation points AT A SPECIFIED DEPTH in the dermis. Surrounding tissue is sparred, which makes for very little downtime. The superficial layer of skin is spared (because the needles are insulated), leading to no wound care, and markedly reduced risk of burns and pigmentation issues affecting the epidermis. The temperature created in the areas between the needle is enough to create coagulation, for maximal tissue contraction and collagen stimulation.

(Not all microneedling RF devices are fractional. Fractora uses microneedles, but because the energy is directed from the needles to the skin surface, the heating is in a fashion similar to bulk heating devices. Also, because more tissue is affected using this heating method, discomfort is much higher and local anesthetic needs to be injected in most cases.)

It has taken a long time for RF devices to catch on to the fractional technology revolution. The Infini has created much more precision in the delivery of RF energy to the dermis, allowing for higher degrees of skin tightening, while affording the safety and quick recovery time that fractional technology has created.

All Botox Providers are NOT the same. Choose carefully!

Botox injections are the most popular cosmetic procedure performed worldwide. Millions of patients are injected each year with the wrinkle fighting drug. Its popularity is attributed to:

There is minimal downtime – 15 minutes of bumps from the injection
The procedure is highly effective in improving wrinkles
Discomfort is usually minimal
Side effects are few and rare
Cost is fairly reasonably, but depends on how many areas are done
The time it takes to get a treatment is less than 10 minutes

So why is the “Was it Worth It” review on Realself.com for Botox only 69%? This can be attributed to multiple reasons, which be further elaborated upon in this blog. (A large volume practice should have a satisfaction rate in the >95%.)

Although the Botox procedure looks very routine to the observer/client, don’t equate this to being a simple procedure that all injectors can master easily.

All patients will age differently, so what areas need treating for optimal cosmetic results needs to be tailored specifically to each patient. A cookie cutter approach to every patient will not work. There are several areas of the face which can be considered advanced: lips, corners of mouth, neck, gummy smile, under eye, bunny lines, inner eyebrows which require a highly trained and experienced injector, or you will live with a disfiguring facial appearance for 3 months.

The trend is moving away from the frozen, no movement, very obviously treated face to a more natural appearance. Rather than blasting and overwhelming the forehead with Botox, a technique using very small, precisionly placed aliquots that allows for movement but with diminished wrinkles. This is a more difficult technique to master.

Shortcuts are often routine in regards to Botox. A majority of practices will draw up syringes of Botox in the morning, or the day before, by a nurse, medical assistant, or office staff. That means the patient will need to get injected in multiples of what is contained in a syringe, leading to limited customization. Also, errors in dilution and sterile technique are possible when filling the syringes is not done by the same person that is injecting the Botox. (Botox comes in a powder form and needs to have saline added to reconstitute it to become an injectable solution.) Dr. Weiner mixes all his Botox personally, and will draw up the appropriate amounts for each patient in the room, just prior to injection.

Discomfort related to the injection can be minimized using various techniques. Using preserved saline has been shown to result in less pain than using regular saline. Needle size, speed of injection, and using proper needle placement is also a key factor affecting comfort. Dr. Weiner also uses several distraction techniques, capitalizing on the Gate Theory (the brain has difficulty processing more than one sensory input at the same time).

Varying the concentration of Botox is a technique Dr. Weiner has used for years. Certain areas require different dilutions to lead to maximal cosmetic benefits.

Touch ups to correct minor imperfections require an advanced injectors experience. They also need a responsive provider, easily available for a drop in or work in patient.

Getting injected by an unknown provider at someone’s Botox party, is never a good idea, and almost always leads to problems that one has to live with for 3 months. The “savings” never is worth it.

Although Botox is extremely popular, as the Realself.com stats show, there are many people that are not pleased with their experience. This is not the norm for the high volume, experienced injector. As explained above, there are many intricacies which can contribute to better results. Hopefully the public will understand that Botox should not be considered a routine cosmetic procedure, and they need to select their providers carefully.

Beauty and Skin Tips for those on a budget.

This blog will elucidate that small changes to one’s lifestyle and a small investment in skin products, will lead to significant improvements in one’s skin health and beauty.

Protect from the sun with daily sunscreen, sun protection, and Heliocare. The number one enemy to skin is sun exposure. The sun’s UVB rays lead to activation of enzymes that destroy the skin’s collagen leading to wrinkling and thinner skin. Skin pigmentation problems (melasma, solar lentigos) are exacerbated by the sun. Skin cancers are almost always related to exposure to the sun’s damaging rays. Studies have shown that just using sunscreen can improve ones looks. Heliocare contains Polypodium leucotomos which is a fern extract that is an antioxidant that reverses and protects against the radiation effects of the sun on skin cells. Heliocare has also been shown to improve melasma, because even indoor artificial light can exacerbate this condition where sunscreens don’t offer protection. Wearing a large brimmed hat, SPF rash guard (if at the beach), and staying under an umbrella/shade should be considered during periods of prolonged outdoor sun exposure.
Stop smoking. Smoking is probably a close second to the sun as a factor affecting skin health and beauty. The toxins in smoking cause contraction in vessels in the skin, leading to poor oxygenation of the skin cells. Smoking essentially strangulates one’s skin causing loss of elasticity, viability, and thickness. Other side effects include increased wrinkles, a change in the color of the skin, thinning of the hair, halitosis, and dental disease.
Apply topical Retin A or Retinol. It has been well established with research dating back over 25 years, that Retin A has anti-aging qualities. It has been shown to increase cellular turnover in the skin, thus creating skin cells that are younger and more vibrant. It increases collagen in the skin and improves hydration in the skin by increasing the GAG’s. Pigmentation abnormalities are improved as well. Precancerous changes are reversed and prevented to a certain extent. Wrinkles and photodamage have been shown to improve with just using Retin A. One word of caution. If you choose to use Retinol because it has less peeling, you have to use a strength that is higher than what is found in most OTC cosmetics.
Maintain hydration, drink plenty of water. This is somewhat controversial, but there are anecdotal reports of improvements in overall looks with just making sure you are fully hydrated. There are obvious other benefits as well including kidney, bladder, blood pressure and circulatory health.
Topical Growth Factors and Antioxidants. Growth factors stimulate skin cells to become more youthful and recruit stem cells which may lay dormant in the skin. Antioxidants help the skin fight off the environmental stress that attacks the skin, including the sun’s damaging radiation. Products that fall into this category are: TNS Essential Serum, Lifeline Day and Night Cream, and Neocutis Journee.

These recommendations are a good start to improve skin health for all individuals, regardless of budgetary concerns. The younger these are implemented, the less correction that will be needed in the future. Consider following these guidelines as an “investment in the future”.

Coagulation is Necessary For Maximum Skin Tightening; Science and Experience Prove This – INFINI is the Best Solution

It is fundamental that my patients understand the science behind their treatments. There is too much “quasi science” in the aesthetic industry that is fooling the general public. As a result, many patients are dissatisfied with their outcomes and have buyer’s remorse. Perhaps the most controversial area of the industry is with “skin tightening” procedures. After reading this and my previous blog on the Infini, hopefully you will recognize the reasons why most of the devices/procedures for skin tightening don’t work well and why the Infini stands out from the crowd.

To achieve skin tightening, the deeper layer of the skin, the dermis, needs to create new collagen. It has been found that heating this layer of skin can stimulate neocollagenesis (new collagen production). The threshold is 42 degrees centigrade to impart a stimulus to the dermis, because at this temperature collagen denaturing occurs (the bonds holding collagen together break down). The body senses the injury, and during the repair of this area, new, youthful collagen is produced. The response is very mild at these temperatures. At higher temperatures, 55-70 degrees centigrade, coagulation of the collagen and surrounding tissue occurs, with more coagulation seen in the higher range of those temperatures.

WHEN COAGULATION OCCURS, THE BODY’S RESPONSE TO THE INJURY IS MUCH MORE INTENSE. TO ACHIEVE MAXIMUM SKIN TIGHTENING AND COLLAGEN FORMATION, COAGULATION IS NEEDED IN THE DERMIS.

Digression: The long standing “gold standard” for wrinkle control and skin tightening (without surgery) has been considered the fully ablative CO2 laser. It has been determined that its efficacy is based primarily on its significant coagulation effect. The risks associated with complete removal of the upper layer of the dermis – prolonged healing, redness, scarring, infection, and hypo and hyperpigmentation – have significantly curtailed its use. Recent technology improvements that have made the CO2 laser fractional (treating only a fraction of the skin) has greatly reduced the risks, but they are still present. Erbium laser resurfacing, which traditional has very little coagulation, has not been shown to have the same results as the CO2 laser. Changes in the Erbium to give it more of a coagulation effect on the skin have lead to better results.

The ideal skin tightening device would cause tissue coagulation in the dermis, but have very little of the risks and downtime associated with the CO2 laser. Radiofrequency devices have been trying for over 10 years to do this without success. They try to heat the dermis, but not the epidermis (upper layer of the skin) to the 42 degrees needed to get a mild neocollagenesis. THE PROBLEM IS THAT ALL THE NON PENETRATING RF DEVICES CAN DO, AT THEIR VERY BEST, IS HEAT, BUT NOT COAGULATE, TISSUE IN THE DERMIS.

So what devices can coagulate tissue is the dermis aside from the CO2 laser: Microneedling RF devices (like Infini) and Ulthera (High Frequency Ultrasound). In this category, Infini wins hands down. All of the other microneedling devices currently on the market have one or more of the following downfalls:

The needles are not insulated so the epidermis is at risk for injury (pigmentation or indentation risks)
The needle depth is fixed and not variable. The facial skin has a huge variation in depth, from 0.38mm to 3mm. Ideally, the coagulation is placed at the deep dermal layer. If it is too deep, there will be minimal collagen response.
The themal injury is not fractional. Treating fractionally is the way to treat in 2014. This allows for accelerated healing, minimal risks, without compromising results.
Their temperatures don’t reach the level high enough for coagulation. Without coagulation, results won’t be as good.

THE INFINI USES INSULATED NEEDLES, HAS VARIABLE NEEDLE DEPTH (0.5mm-3.5mm), AND CAUSES A FRACTIONAL COAGULATION INJURY IN THE DERMIS.
Infini Coagulates the Dermis

Ulthera has been a great tool in our office for the past 5 years. When comparing the Infini to the Ulthera, the following deficiencies in skin tightening have come up:

Ulthera currently only has 3 depths – 1.5mm, 3mm and 4.5mm. For most of the face, only the 1.5 is at the level of the dermis. Ulthera reportedly tightens at the deeper muscular layer, the SMAS, but this has yet to be a proven mechanism by histological samples (looking under the microscope at biopsies). Much of the coagulation from Ulthera is in the subcutaneous fat or fat layer, an area that produces very little or no collagen. It does explain the improvement in the jawline and upper neck though, the areas where there are fatty deposits.
Ulthera lays down about 15,000 thermal coagulation points (TPC’s) during a treatment. The Infini will create 50,000 or more of these TPC’s during a treatment. More TPC’s probably mean more results because Ulthera has proven that going from 7500 TPC’s to 15,000 TPC’s gave them better results.
Ulthera is more expensive for the physician to use, so the costs get passed on to the patients.

To summarize, skin tightening requires a coagulation injury in the deeper dermis. The discussion above has tried to show that besides the Infini, all other RF devices fail to deliver a predictable, safe, thermal injury to the point of coagulation in the dermis. Without the coagulation in the dermis, results will be unsatisfactory. In essence, the Infini has made Thermage, Venus Freeze, Exilis, Pelleve, Tripolar, Titan – all OBSOLETE.

To get a better grasp of the RF skin tightening Industry, please read the blog: “FINALLY…A Radiofrequency (RF) Skin Tightening Device that Makes Sense. Infini by Lutronic.” Includes an overview of the RF skin tightening industry.

The New Coolsmooth Handpiece for Coolscupting is a “Game Changer”

Coolsmooth Handpiece for Coolsculpting

Coolsmooth Handpiece cooling plates

Coolsmooth will be available April 2014

Dr. Weiner answers questions about Coolsculpting

Coolcurve Handpiece

Coolsculpting is a noninvasive way to treat undesired fat deposits using cryolipolysis. It
permanently removes the fat with no downtime, minimal side effects, and little to no pain. It’s
been available at The Aesthetic Clinique since December 2009, with Dr. Weiner being one of
the first 25 users in the Country.

Coolsculpting is the world’s leading technology for noninvasive fat removal. It was developed by physicians at Harvard University, Dr. Rox Anderson and Dr. Dieter Manstein. They coined the term “cryolipolysis” for the process of cooling fat cells to the point that they will gradually die through apoptosis. The fat reduction, around 25% of the treated area, becomes fully appreciated at about 3-4 months, and the results will be long lasting if diet, exercise, and weight are stable.

Until the Coolsmooth handpiece was developed, the Coolsculpting procedure involved placing a suction device to the area of excessive fatty deposits. This required that there was some tissue redundancy which could be drawn into the handpiece. A subset of patients were not treatable because the tissue was too taut despite there being excessive fat deposits.

The Coolsmooth handpiece doesn’t rely on suction to be able to treat. It can conform to any body type without the need for tissue redundancy. Instead of the cooling plates being located in the sides of a suction apparatus, the plates can be laid directly on the areas of the excessive fat. The Coolsmooth handpiece has opened up the treatment candidates to virtually everyone, even those with only very small fat reductions needed.

While the FDA has only approved Coolsculpting for use on flanks (love handles) and abdomen, physicians have been treating other areas off label including: inner thighs, arms, gynecomastia, bra fat, and back fat. In addition to treating previous untreatable patients, the Coolsmooth offers a treatment for the outer thighs.

Coolsculpting just announced that there have been 1 million treatments performed using its technology worldwide. This is a testament to its effectiveness and safety record and substantiates why it is the world leader in the field of noninvasive fat reduction.

Dr. Weiner is a Facial Plastic Surgeon who “laid down his scalpel” in 2005 and now concentrates solely and injectables and lasers for cosmetic enhancements. Santa Rosa is located between Destin and Panama City Beach, Florida.

To stay abreast with Dr. Weiner:
Blog: http://stevenfweinermd.wordpress.com
Website: http://www.theclinique.net
YouTube: http://www.youtube.com/user/StevenFWeinerFacial
FaceBook: https://www.facebook.com/TheAestheticClinique

How to Treat Acne in 2014 – Spectra Laser Acne Peel with No Downtime or Discomfort

Acne is a fairly universal problem, affecting 80% of the population at some point of their lives. A subset of people suffer from moderate to severe forms of the disease and seek medical attention. It’s the number one reason that people seek out a dermatologist. Treatment options consist of topical medications, oral medications, life style and diet changes, chemical peels, and laser treatments. There is a growing concern regarding long term affects of antibiotics and the potential for resistance as well as the very well known side effects of Isotretinoin. A very effective treatment gaining popularity has been off label use of Levulan. The downside with Levulan is that for 36 hours, the patient must completely protect from all sunlight exposure to avoid getting over treated, called “phototoxicity”. The Spectra Laser Peel offers a no downtime, painfree solution to acne. It can immediately help control active acne, as well as help prevent future outbreaks. It leads to decrease sebaceous gland production of sebum (shown in clinical studies), and excessive sebum is the primary reason an individual gets acne. The heat from the laser dries up the ongoing outbreaks and helps kill active infections. The Spectra Laser Peel begins with placement of a charcoal liquid on the skin. It is allowed to absorb for about 10 minutes into the superficial skin layers and the sebaceous glands. After the 10 minutes, the procedure starts using the laser to gently heat the skin and anywhere where the charcoal absorbed. The next pass with the laser causes vaporization of the charcoal and in doing so, about 20 microns of the epidermis is removed. This creates a nice superficial peel of the skin, leaving it with a clean, fresh appearance and glow. The active acne and sebaceous glands are further heated on this pass and subsequent 3 passes with the laser. The last pass with the laser just targets any ongoing acne with even more heat. Throughout the procedure, the patient experiences only a mild heat sensation. Immediately afterwards, they can go in public. Follow up treatments are scheduled at 1-2 week intervals until the acne is controlled.

A presentation at the annual meeting for the American Society of Laser Medicine and Surgery (ASLMS) 2014, showed prolonged (up to 3 years) acne control with treatments similar to the Spectra laser peel. An average of 8 treatments was needed for the study group, with some requiring as few as 3 and others requiring up to 16.

In patients without acne as their primary concern, the procedure has been called the “Hollywood Peel” because it has been used frequently on stars just before their red carpet appearance. It gives them a refreshed look with no downtime. Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables. Blog: http://stevenfweinermd.wordpress.com/ YouTube: http://www.youtube.com/user/StevenFWeinerFacial Website: http://www.theclinique.net Press Release about Spectra Laser Acne Peel

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

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[youtube=http://www.youtube.com/watch?v=9tZABRlpIUU]

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

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

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

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

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

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

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

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

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

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

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

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

Website: http://www.theclinique.net

Press Release of Dr. Weiner introducing Artefill to his practice.

How to Score Some Points with Your Plastic Surgeon/Aesthetic Physician

Getting on the good side of the doctor that makes you look better can definitely have its benefits. Following these suggestions can get you some brownie points.

Stay well informed. Search out your Doctor’s website, Facebook Page, Blog, and YouTube Channel to learn about the procedures that are offered. This can make the initial consultation go more smoothly. You can narrow the options before the office visit according to your lifestyle and concerns. Watching videos of the procedure being performed can greatly improve your comfort level by knowing what to expect.
Be Nice and Smile. Smiles are contagious. We are all here to make you look good and feel better about yourself.
If you have a budget, let us know. It’s very important that everyone is on the same page when deciding on a particular treatment. For example, lasers are usually more expensive for treating certain skin conditions (sun damage), but they get faster and better results than the less expensive options (chemical peels). Treatment plans can be tailored to meet all budgets.
Try to stay with one physician. The lure of a “Groupon Special” on Botox or fillers is enticing. However, pricing should not be the primary motivation for choosing where you go. Qualifications, experience, and customer service should be much more important factors in your decision-making. It’s often hard to piece together what was done if you have gone to several different physicians.
If you have a social event, try to get treated a week or two in advance. Waiting too close to an event can cause undue anxiety when there is some minor bruising or swelling. Give us doctors a little leeway (a week) so that everything can settle down from your filler administration. Even though Dysport may kick in faster than Botox, it still needs 3-5 days to see its full effect.
Try to hold off the blood thinners when coming in for injections. If you take herbal supplements, aspirin, anti-inflammatories, vitamin E, or fish oil, the chance of having bruising is much higher than if they were held for a few days (aspirin needs about 12 days). Even a physician with the most delicate touch and technique can’t always avoid bruising when injecting someone who has “thinner blood”. Of course, if the thinners are medical necessary, you must continue their use.
Don’t ask your doctor to make your lips too big. Remember, every patient is a walking billboard for the doctor’s practice. Most doctors want to be known for natural looking enhancements. There needs to be dialog between the patient and doctor when the patient’s wishes are beyond the realm of what is naturally appearing.
Don’t tan or use sunless tanners before laser procedures. The risk of pigmentary issue goes way up when lasers are used on tan skin. Usually at least 3 weeks are needed to be out of the sun for laser work. The problem with sunless tanners is that the pigment in the product can absorb or reflect the laser and cause potentially even more damage to the skin than a tan would.
Follow the recommended post treatment instructions. To get the maximum benefit with the least amount of side effects, there are certain do’s and don’ts after all procedures. Most physicians will either give a printed instruction sheet or will have them on their website.
Don’t use grandma’s homeopathic remedy on your skin after peels or lasers. After a laser resurfacing, the skin is 50 times more sensitive to topicals creams. Please use the skincare regime outlined by your physician.
If there is some issue after a procedure, LET US KNOW! Almost always, there are minor little adjustments which can be made to your Botox or filler treatment that can correct an undesired result. From a doctor’s perspective, we want to have happy clients. We would much rather have you call or come in for any issue rather than lament at home.
Give us a shout out. If you are extremely pleased with how you look and feel after a treatment, tell your friends. In fact, bring your friend(s) with you to your next visit. Write a review on Facebook, Yelp, or Google Plus.

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

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

Website: http://www.theclinique.net

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