4/14/2019 3:38:55 PM
Acne scarring has significant debilitating effects on one’s overall self-worth and confidence. Millions in the US are affected. There have been improvements in techniques and energy devices in past few years which have led to better outcomes for acne scar treatments.
Subcision – This is process of breaking up deeply tethered scar bands associated mainly with atrophic/rolling scars. Subcision has be performed for acne scars for decades and just using this procedure alone has proven to lead to significant acne scar improvements. Recently there have been a couple publications suggesting that cannula subcision had better outcomes, less downtime, and less discomfort than the traditional method of using a Nokor needle. A cannula has a blunt tip so it is also safer – less chance for cutting a nerve or blood vessel than the knife-like edge of the Nokor needle. In the study, both patients and the performing doctor rated the results better when using the cannula. Subcision is particularly important, in Dr. Weiner’s opinion, to be performed prior to any energy device for tethered scars. This is based on the fact that RF and laser will preferentially travel through collagen – which is high is water content – than fat or most other tissue. Scars are predominantly collagen, so it makes sense to cut the connection of the scar to the deeper tissue. Through personal communication with Dr. Davin Lim, biopsies he performed have shown scar band that reach the deeper fat pads from tethered acne scars. Transmission of the energy through the scar can theoretical lead to collagen contraction and deepening of the tethered scar. Sometimes fillers are placed at the time of the subcision to improve the volume loss associated with the scarring. Some hypothesize that putting a “spacer of filler” might improve results as well. Dilute lidocaine during the initial passes allows for this procedure to be well tolerated.
TCA CROSS – TCA (Trichloroacetic Acid) is a chemical peel used to improved acne scarring by placing minute quantities in the scar using a toothpick. CROSS stands for Chemical Reconstruction of Skin Scars. The most common use of this procedure is for ice pick and small boxcar scars. The process of causing a controlled chemical burn, allows for the body to heal from the deepest part of the scar towards the skin surface. This makes the scar smaller in diameter and shallower. Usually a series of 3-6 treatments are needed, with 3-4 weeks between treatments. There will be some mild scabbing for a few days which needs to be kept moistened for best results. Risk include widening of the scar or post inflammatory hyperpigmentation (PIH).
Radiofrequency Microneedling – This technology (RFM) has been available in the US for about 6 years and has revolutionized acne scar treatment. Using needles which are insulated, energy is delivered into the scar tissue directly and bypassing the epidermis, for the most part. The insulation protects the skin surface from heating so darker skin type individuals are at much less risk of PIH (post inflammatory hyperpigmentation) vs a laser treatment. The needles allow for deeper penetration than lasers as well. Overall, downtime is less than ablative lasers in most individuals (when insulated needles, proper technique, and appropriate settings are used). With acne scarring affecting darker skin types disproportionately, this is an excellent alternative to lasers. The Genius has recently been FDA approved and is now the “best of bread” RF microneedling device. There is now impedance feedback from the needles which allows for improved and exact energy delivery. The resistance in the tissues being treated is measured and this is important because throughout one’s face, there are differences, as well as between different individuals. Also, as tissue are heated or subcised, the resistance changes. Prior to Genius, there was no idea of how much energy was being delivered. There is now an accurate total energy for each pulse and a cumulative total. Other improvements include needle design-sharper, stronger motor, and feedback regarding quality of each pulse fired.
There is a myth that needs to be busted. Deeper does not mean better for acne scars.
The needles must stay within the scar for best results. If the needles go beneath the dermis, there is a risk for heating the fat and fat loss. Let it be known that the actual depth of the needles in most RFM devices is less than the settings, and becomes less accurate, the deeper the settings are. There is inherent resistance of the skin to penetration and many needles aren’t sharp enough or motors aren’t strong enough to get to the desired levels in the time required. This has also been addressed with the Genius and it’s depths are very accurate after extensive testing.
In addition, higher energy levels on any device which doesn’t monitor impedance, can actually result in very little energy delivered. Once the tissue is heating beyond a critical level, the resistance becomes so high that energy output cuts off. However, when higher energy levels are desired when using the Genius, the energy is adjusted to the increasing impedance and it is successfully delivered.
Fillers – Fillers are a very integral part of improving acne scars. They are extremely useful for the atrophic scars and the lipoatrophy associated with these scars. The aging process leads to dermal thinning and fat atrophy, which makes the acne scars appear worse, even if active acne has long been controlled. Fillers need to be injected deeply for correcting large areas of volume loss and superficially in minute quantities for focal defects. A hyaluronic acid filler will give about 12 months of improvement vs Bellafill which can give near permanent improvements. Bellafill does require a skin test to see if one has a allergy to the bovine collagen (0.5% chance) which needs 3-4 weeks to determine. There is some who feel fillers in areas of subcision will prevent re-adhesion of the scars. Most failures from other treatments are related to not recognizing the need to fillers to improve the acne scars.
Lasers – Erbium/CO2 ablative lasers still are beneficial for acne scars but have more downtime and risks vs RFM. Deeper skin imperfections are not improved with lasers and require fillers. These devices are best reserved for more superficial scars, mainly boxcar scars. Non ablative lasers are less affective but safer and in the author’s opinion give very minor results.
Microneedling – Also know as “Collagen Induction Therapy” CIT, has become popular in recent years. There are rollers available for home use and then there are medical grade devices which go to depths of 2mm or deeper and create thousands of penetrations per second. Rollers should be not be used at home for 2 reasons – questionable sterility at home and they tear tissue more than the in-office devices. Often these treatments are combined with topicals and PRP. It is highly recommended to not use any products on the skin which would normal not be injected. There have been many cases of infection and granulomas from these practices. Even when done in the office with PRP or amniotic membrane products, the efficacy of this procedure is minimal, and should be reserved for only mild acne scarring.
PRP/Amniotic membrane products – There is some date to support that better results and faster recovery with less side effects if PRP or amniotic membrane products are used during acne scar treatments. There is a movement more towards amniotic/placental products and away from PRP because there are more growth factors/healing properties in these vs PRP.
LLLT – There is a plethora of studies to suggest that using low level laser light (LLLT) is beneficial to results and healing times. The most researched device is Healite, and this should be performed immediately following all acne scar procedures which use energy devices. It calms the skin and improves circulation.
Acne scarring procedures are continuing to improve as technology and techniques evolve. One must understand that results require months to fully appreciate and multiple treatments (3-5 or more) are often needed to optimize results. Expectations need to discussed with providers/patients so that all are on the same page as to what one can achieve with treatments.
Dr. Weiner is an Acne Scar Center of Excellence designated by Bellafill and is a specialist on acne scars. He is a lecturer and trainer for Bellafill. He has become one of the leading authorities on Radiofrequency Microneedling and travels the globe lecturing on this technology. He performed the FDA trails for the Genius. He recently authored a chapter on RF Microneedling which soon will be published in the Facial Plastic Clinics of North America. He also wrote a recent chapter on Radiofrequency Safety and Complications which will be part of a book titled “Complications in Minimally Invasive Facial Rejuvenation: Avoidance and Management” by Paul Carniol, MD
1/29/2019 7:02:02 PM
It appears that 2019 is the “Year of the Jawline”. A strong jawline is interpreted as a characteristic of strength, beauty, virility, and power. In a study of S&P 500 CEO’s, 95% were considered to have a well defined jawline. With advances in aesthetic technology and techniques, achieving that perfect profile is becoming easier, with less downtime, costs, and risks. Here are the top 5 procedures to improve your jawline:
5) Neck Lift/Lower Face Lift: With incisions placed behind the ears, this surgery can be performed with just local anesthetic. Downtime is about a week or 2. For severe jowling and platysma bands, this will give the best results.
4) Ablative Laser (Erbium/CO2) or Renuvion(J Plasma): These procedures have significant wound care for a week or more. The skin is stimulated by the heat of the laser/plasma to contract and create collagen. Healing time can take weeks and redness can persist for months. Risks include infection, scarring, hyper and hypopigmentation. Procedure is limited to the face, and can’t achieve fat reduction.
3) FaceTite: A minimally invasive procedure whereby radiofrequency is placed below and on the skin surface. Requires tumescent anesthesia only for most patients. Procedure takes about an hour, more if liposuction is added. There is minimal bruising and swelling afterwards but requires a compression chin strap for a few weeks (constant for the first 48-72 hours). The RF energy causes deep collagen stimulation and contraction as well as dermal collagen remodeling. Jowls and submental fat can be attended to with RF and liposuction.
2) Genius/Infini: Radiofrequency is placed into the dermis (and subdermis for jowls/submental) using insulated microneedles. The downtime is 2-3 days but it requires 3 treatments. The procedure takes about 30-45 minutes. Most patients require just topical anesthetic with about 5-10% opting for Pronox (Nitrous Oxide – laughing gas). Results take 3 weeks to start to become apparent and 3 months for their full effect. It is the least downtime, least invasive of the top 5 procedures, outside of #1.
1) “reJAWvenation(TM)”: Using microcannulas, filler is placed along and below the jawline to enhance and restore the profile. Typical procedure time is 10 minutes or less and there is no downtime. The amount of syringes required varies, but can be anywhere from 1-6. Multiple sessions are required for the patients with severe jowling. While there is no actual removal of fat from the jowls or submental area, these areas appear improved due to the lifting by the filler as well as camouflaging the trouble areas.
It is left up to the individual as to what procedure is right for them. Lifestyle, degree of correction desired/needed, and finances all factor into one’s decision making. Dr. Weiner is world renown for his “reJAWvenation(TM)” procedure and is known as the reJAWvenator.
(Threads are notably absent because the author believes the expense, duration, and results, don’t warrant them to be a consideration for jawline improvement.)
12/10/2018 1:10:15 AM
The initial studies of radiofrequency microneedling (RFM) were performed by Hantash et al. in 2009. What Hantash was able to demonstrate was that RFM produced a fractionated radiofrequency thermal zone (RTZ) with coagulated tissue surrounded by normal tissue. Overtime, multiple growth factors and inflammatory components led to complete replacement of the RTZ with neocollagenesis and neoelastogenesis over the following 10 weeks.
Delivery of the RFM energy varies according to the device used. Unfortunately, there has been a paucity of solid research behind the majority of the devices. There is confusion in the marketplace for both consumers and providers as to what constitutes the best delivery system for outcomes, safety, and comfort. Lutronic decided to breakdown all the components of RFM energy delivery and optimize them in their development of the Genius.
One of the selling points of many of the devices has been that they are comfortable and have minimal downtime. What this actually means is that there is minimal energy delivered to the dermis. Discomfort is directly related to the amount of energy delivered. Lutronic’s research has shown that needle depths and energy settings don’t necessarily correlate to the what really occurs in the tissues.
Skin intrinsically resists puncture by outside forces. If is especially difficult for 49 needles to penetrate the skin in a small area (1x1cm2). The natural tendency is for the skin to buckle with the needles “bouncing off the surface” and several of the RFM devices tested have been documented to exhibit this phenomenon. Furthermore, needles have a harder time penetrating deeper into tissue than superficially, so deeper depths are even more challenging to accurately place than more shallow treatments. Unfortunately, setting needle depth on the device doesn’t always correlate to actual tissue depth. Requirements for accurate depths include:
- Sharp needles – but not too thin as to bend or dull during hundreds of pulses
- Powerful motor – underpowered motors prevent accurate penetration
- Quick motor – slower motors will lead to pushing the skin rather than penetrate it
One of the fallacies of RFM devices is that higher treatment levels correspond to higher energy delivery. Best results will be related to turning the energy settings “all the way up” is ABSOLUTELY FALSE. Too much energy in too short a period will lead to rapid rises in tissue impedance (resistance) and cut off energy flow immediately. Performance by the operator can affect the energy delivered if handpiece pressure is light or not flush with the skin as well.
Impedance in the dermis is highly variable between patients and even within different areas of the face and body. Variables affecting impedance are: hydration, solar damage, collagen and hyaluronic acid content, and scarring. Using settings based on clinical findings and desired outcomes is not enough precision for optimal energy delivery.
Coated vs Uncoated Needles
Coated (insulated) needles allow the microneedles to penetrate the skin and deliver energy to the dermis while bypassing the heating of the epidermis. Some devices will use uncoated needles which will increase the risk of post inflammatory hyperpigmentation (PIH), particularly in darker skin types. To minimize this risk, uncoated needles use low energies and therefore sacrifice results. There will also be more downtime/wound care with uncoated needles because the skin surface will be more affected than with the coated needles.
The Genius Advantage
- Proprietary needle design – sharp and coated for minimal resistance to insertion
- Improved motor insertion – high torque and quick needle insertion
- Improved protocols – changes to energy and pulse durations to avoid sharp rises in impedance based on Lutronic proprietary research
- Impedance Feedback – the needles monitor tissue impedance every 2 msec and give feedback to the device to optimize energy delivery and adjust flow as resistance changes. This is the “brains” of the Genius.
- Energy delivered feedback – each pulse is monitored and amount of energy delivered is noted. If energy is not exactly as desired/set, both a visual and audible signal is sent to operator. Adjustments in settings or technique can be made to improve energy output.
- Total Treatment Energy – a running total of energy given is kept. This allows the provider to base treatments on energy delivered. Cumulative energies delivered from multiple treatments will become the standard of care to achieve clinical outcomes for a given diagnosis.
With the advancements made with the Genius, suddenly, all other RFM devices are now obsolete. Genius delivers a precise, safe, and efficacious treatment for laxity, wrinkles, neck lines, acne scarring, and hyperhidrosis in all skin types.
11/25/2018 4:44:41 PM
Removing hair using a laser dates back to 1995, when the first laser was FDA approved for this purpose. The LightSheer laser (Diode) was approved in 1997 and has been the most popular laser for hair removal since then. About 6-7 years ago, the LightSheer Duet was developed for faster and safer treatments and was the laser used by the author for the past 6 years. The Alexandrite (855nm) wavelength has been consider possibly a more effective laser for hair removal, but it’s limitations have been pain and speed. In addition, both the Diode and Alexandrite laser aren’t considered safe for the dark skin tones where a 1064 (Nd:YAG) laser is needed. The Splendor X has solved all these problems and is now the most innovative laser for hair removal on the market.
The concept of laser hair removal was invented by Dr. Rox Anderson from the Wellman Institute at Harvard’s Mass General. To permanently remove hair, the hair germinal cells must be killed. This is done by using a laser whose wavelength matches the pigment of the hair. The heat absorbed by the pigment travels to the germinal cells and permanently injures them. In the growth phase of a hair cycle (one of 3 phases of the life of a hair), the hair is attached to the germ cells so the heat is effectively transferred to them. In the other 2 phases of the hair cycle, the heat will not lead to killing the germ cell. This is why several treatments are needed, so as to eventually hit most of the hairs in the growth phase. One should expect about 75-85% hair reduction after 6 treatments, and the need for touch ups, 1-2 times per year.
What makes Splendor X different?
Dual (Blended) Wavelengths: Spendor X has both the Alexandrite 855nm and the Nd:YAG 1064 wavelengths. It can safely treat all skin types. For the lighter skin, mostly the 855nm is used. For darker skin, the laser uses a blend of the 2 wavelengths while in type 6’s, only the 1064 is used. While some companies had 2 wavelengths on their device, it is either one or the other, and not a synchronized output. The benefit of the 1064 laser for lighter skin types is that it penetrates deeper than the 755 laser and can attack deeper hair follicles as well as the vasculature feeding these follicles.
Square Footprint: The pulse from the laser is uniquely square. This overcomes the uneven treatments which are inherent in the typical circularly outputs. With the circular footprints there will be potential for skipped areas and/or over-treated areas from overlapping pulses. The Splendor X has a glow-in-the-dark marking system to guide the operator to place pulses abutting each other with minimal overlap.
Double Cooling System: The Splendor X uses both integrated Zimmer Air Chilling as well as a chilled tip to doubly ensure a safe treatment. By chilling the skin surface, the laser will preferentially heat into the deeper dermis where the hair follicles are and is less likely to be attracted to skin pigment (less burn or PIH risk).
Highest Speed: Improvements in speed was one of the major attributes to the LightSheer Duet. It could do a man’s back in about 15 minutes, down from the 45-60 minutes it took previously. With the Splendor X, we can now do the back in about 6 minutes with the same or more safety.
High Power: There is higher power than most lasers with the Splendor X – 75% more – 7 Kw vs 4 Kw. Higher power equates to more efficient treatments, more results, less sessions needed.
Plume evacuation: There is a built in suction to remove the plume of the the vaporized hair. Besides removal the smell, this is important as we learn there are possible negative side effects from the plume.
There has been a lack of innovation in the laser hair removal arena for years. Now the Splendor X leaps to the front of the line with its innovative blended wavelengths, square footprint, and lightening speed. Patients can be confident they are receiving a highly effective, comfortable, and quick hair removal treatment.
11/18/2018 9:13:21 PM
Acne scarring is a significant psychologically debilitating disease affecting millions in the US, approximately 1% of the adult population in one study. Treatments for acne scars include:
- RF Microneedling
- TCA Cross
- PRP (Platelet Rich Plasma)
- PDO Threads (?)
Most of these techniques are based on trying to make the disorganized collagen in the scar to be more organized and natural. Using carefully induced tissue trauma with heat or microneedles (mechanical), the body initiates a healing process to smooth the scars.
Acne scars will often affect tissues deeper than the dermis. Fibrosis/scarring can affect the subcutaneous tissues and fat and lead to tethering of scar to the deeper structures. Lipoatrophy (fat loss) can occur as the result of the inflammatory mediators released from the acneic process. When heating from lasers and RF is applied, it is preferentially conducted through the collagen because the water content of collagen is high. Heating collagen will lead to collagen remodeling but also collagen contraction. If the collagenous attachments to the deeper tissue are not cut (subcised), there is actually potential for worsening the appearance of the scars with these heating devices.
A recent paper suggested that using a cannula to subcise acne scars is better tolerated, with less adverse events, and judged to have better results by the patients. This is Dr. Weiner’s (and acne scar expert Dr. Davin Lim’s per personal communication) preferred method of subcision vs using a Nokor needle. By subcising, the energy flow to the deeper structures is severed and harm to fat is less as is the risk of pulling some scars deeper. Placement of filler (Restylane Defyne, Bellafill) is often done simultaneously with the subcision to help elevate the scars and prevent reattachment of the scars.
Subcision has been around for decades for acne scar treatment. It is now even more important when energy devices are used to maximize the benefits of these treatments. The use of cannulas for this procedure leads to more comfort, less risks, and better satisfaction.
The Aesthetic Clinique has been designated an Acne Scar Center of Excellence by Suneva (Bellafill) and is considered an acne scar expert.
**(Subcision is also useful for treating cellulite as there are fibrous attachments from the skin which cause the dimpling.)
8/26/2018 2:30:28 PM
People chew gum to help clean their teeth after eating, freshen their breath, and even try to keep them whiter. What isn’t readily known is the havok gum chewing has on the aesthetics of the lower face.
The simple act of excessive chewing will lead to muscle hypertrophy of the masseter. Enlargement of this muscles leads to squaring of the lower face and jawline, an undesirable shape in females. The aesthetically pleasing lower face is V-shaped or Heart-shaped. Widening of the lower face is particularly prevalent in the Asian population where the women go to great lengths to slim their face with cosmetic procedures, including surgery. Gum chewing leads to similar problems which fortunately can be reversed with weakening of the masseter muscles with Botox/Dysport.
A much more problematic issue to fix is the negative side effects which occurs around the mouth secondarily to gum chewing. The movements of the soft tissue and perioral muscles is significantly more when chewing than in a relaxed state. Just as with the frown lines and crows feet, the more movement in these areas, the more wrinkles and etched in lines are created. (Ever notice Kim Kardashian doesn’t smile in pictures? It’s because she’s afraid of creating wrinkles, so she limits her facial movements.) In essence, gum chewing accelerates the aging process around the mouth and lower face. Unfortunately, Botox/Dypsort aren’t as easy a remedy for this area because restricting muscle activity can lead to eating and vocalization difficulties. However, lasers, radiofrequency, microneedling, and judicious use of Botox/Dysport can improve the perioral aging process.
Straws can also lead to upper lip lines due to excessive muscle use of the lip muscles (orbicularis oris). The recommendations to improve lower face and mouth asethetics: stop gum chewing and straw use and consider breath mints as a substitute.
6/2/2018 2:06:16 PM
It’s been the dream of generations. Hundreds of machines have failed. Now there is Emsculpt. It is now possible to strengthen your abdominal muscle muscles effortlessly and pain free. How about lifting and shaping the buttocks without squats? In fact, you can drink wine, eat a donut, or watch a movie while this is happening – NO JOKE!
The science behind the device is fairly simple to understand. The Emsculpt uses electromagnetic waves to stimulate the underlying muscle. Think of the TENS unit that is used to improve aches and pains, ON STEROIDS. The contractions are “supramaximal”, meaning more intense than a person can do on their own. During a 30 minute session, the abs/buttocks contract equivalent to a workout of 20,000 crunches/squats. The usual protocol is to have a total of 4 sessions in 2 weeks. Expect some muscle soreness the next day or 2 but there is essentially no downtime. Better yet, there is really no risks either. There are 2 handpieces for each machine. This means that 2 patients can be treated simultaneously on the abdominal area or one patient on the buttocks area.
There were 7 different sites that studied the Emsculpt. Before and after CT scans, MRIs, and Ultrasounds were taken in the study group. Results showed muscle mass increased 16% consistently. What is even more interesting is that the average fat loss was 19% and waist measurements decreased by 4 cm.
Another treatment area is the gluteal area. Using 2 handpieces simultaneously, the buttocks is treated. The settings are adjusted so as to not cause any fat destruction but just muscle hypertrophy. Other areas being treated experimentally by some physicians are the thighs and calves. The pectoralis muscles definitely can’t be treated because they are too close to the heart and the strong electromagnetic waves might stimulate the heart.
There have been anecdotal reports of enhanced athletic performance after Emsculpt treatments. Is this a new legal way to get an edge on the competition?
Contraindications are people who have pacemakers, metal IUDs, metal implants or surgical clips (close to the treated area).
Bottomline, six pack abs and brazilian butt lifts can now be obtained using the noninvasive, risk free, no downtime, Emsculpt.
Call The Aesthetic Clinique for more details, the Emsculpt headquarters of the US.
3/27/2018 3:00:42 AM
Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.
There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.
A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.
The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.
In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.
There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.
The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)
Techniques for optimizing safety during dermal filler administration:
- Know the major vascular structures and their landmarks
- Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
- Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
- Use cannulas whenever feasible, preferably 25/23g or larger
- Avoid boluses, small linear threads are safer
- Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
- A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
- Injection onto periosteum is safest but does not guarantee a vascular free injection
- Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
- Retrograde injections are safer than anterograde injections
- Dermal injections should be relatively safe
- Avoid deep injections in the lips. Stay superficial to the muscles
- An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
- Have on hand 6-8 vials of Hylenex
- Any unusual bruising, pain or visual change needs immediate evaluation
The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.
Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.
2/16/2018 3:03:52 AM
Nefertiti was recognized for her crisp jawline and smooth neck. Her bust is one of the most famous of the ancient Egyptian sculptures. A razor sharp jawline and well defined ascending ramus (or gonial angle) are hallmarks of beauty, both male and female. Jowling, submental fullness, blunting of the gonial angle, and an irregular jawline are all signs of aging.
While there are many commonalities between the sexes of what constitutes an attractive jawline, there are fundamental differences as well.
- Broad/wide rami of mandible leading to a near vertical appearance on frontal projection
- Approximately a 110-115 degree gonial angle (more acute than female)
- Significant height of the body of the mandible
- Wide defined, projected chin
- V-shaped rami of mandible on frontal projection. A more masculine (vertical) ramus is also considered beautiful in some women (Such as Alessandra Ambrosio)
- A more obtuse gonial angle of approximately 135 degrees
- Shorter height along the body of the mandible
- Pointed, less projected chin
There are considerable age related changes of the mandible.
- Loss of bone along the body of mandible leading to loss of vertical height. This change is accelerated in an edentulous patient
- Blunting of the gonial angle eventually leading to a curvilinear jawline
- Narrowing of the male chin and widening of the female chin
- Deepening of the gonial notch
The age related mandibular changes lead to loss of support of the soft tissue in the lower face – falling forward and downward. Jowling and submental fat is exaggerated. The upper neck skin shows more laxity as facial skin drops into the neck.
Correction of age related jawline changes with fillers- reJAWvenation
Dr. Weiner has perfected a correction using dermal fillers which he has coined “reJAWvenation”. It is based on restoring the age related loss of bone and leads to support of the lower face soft tissues. Filler is placed along the inferior border of the mandible as well as filling the gonial notch. The gonial angle is recreated. The lower aspect of the jowl is considered the new baseline and filling is made on either side to “camouflage” the jowl. Filler is also placed along the posterior aspect of the ascending ramus. The prejowl sulcus is filled, with emphasis to include the space beneath the inferior mandibular border. The chin must also be corrected to the male/female appropriate projection and shape.
reJAWvenation offers a quick (10-15 minute) correction of the age related changes to the jawline. Improvements in jowls, upper neck, jawline, and chin can be expected. There is minimal or no downtime. Even with facelifts, jawline volume is not typically addressed and needs to be corrected either during the procedure with fat grafting, or in the office, after healing, with fillers.
1/23/2018 3:27:24 AM
On October 12, 2017, Galderma was notified by the FDA that Restylane Silk was approved to be administered using blunt microcannulas. Galderma deserves a huge “high 5” for stepping out of the box in recognizing the improved patient outcomes and safety benefits of cannulas. No other dermal filler in the US has been approved for use with cannulas, it is a “First for Fillers”. Galderma is researching other areas for cannula use and expect approval in 2018 for another 1 or 2 indications.
What’s the big deal with cannulas?
The traditional method to administer dermal fillers is using a needle. Unfortunately, there are many side effects and risks using needles. These include:
- Bruising – sticking a needle into a highly vascular organ, skin, will lead to bruising a majority of the time. This is corroborated by the FDA studies for all the US approved fillers.
- Pain – needles require multiple entry points to deposit the filler. Pain fibers are most prevalent in the dermis.
- Vascular Occlusion Risk – when a blood vessel is cannulated with a needle and the filler is injected directly into the vessel, occlusion of the vessel occurs. The sequelae of such event can result in skin necrosis, eye injury, or even blindness.
Cannulas have a blunted, rounded tip which is less likely to injure blood vessels than a needle is. When the cannula brushes up against a vessel, it is deflected away, in distinction to a needle which will often pierce the vessel. When a vessel is traumatized, a bruise will occur.
To use cannulas, a small pilot hole using a needle is required. Unfortunately, completely eliminating needles is not possible. However, after that entry is performed, the cannula can be placed through the dermis and into the subcutaneous tissue or deeper fat compartments. The areas below the skin surface are generally less innervated and are more comfortable to place filler.
The most important quality of cannulas is their safety. By design, they are much less likely to result in placement of filler within the lumen of a blood vessel. The rounded tip eludes lumens of blood vessels whereas needles don’t offer that protection. Although vascular occlusion is possible with cannulas, it is much less likely when compared to the risks associated with needles.
Dr. Weiner has been an advocate of injecting dermal fillers with cannulas for the past 6 years, since 2012. He has become one of the most experienced cannula users in the US. He has been chosen by Galderma to use his cannula experience to “Train the Trainers” in the use of cannulas for Restylane Silk in the lips.
12/16/2017 11:34:34 PM
Lutronic has added a new laser to it’s armamentarium and it is called the Action II. There are several different applications for this laser which include: fractional laser resurfacing, the “Shining” laser peel, skin lesion ablations, and the “Bella V” procedure for vaginal rejuvenation.
Erbium lasers are ablative lasers, they cause ablation of the tissue treated. This means that there will be vaporization of the treated skin. The Action II is a fractional laser, so only a “fraction” of the area treated will be ablated. Studies show that fractional lasers are safer and provide improved recovery times when compared to total (100%) ablative lasers. Comparing an erbium laser to a CO2 laser (which is also ablative), the erbium will have less coagulation of the tissue – less heat is transmitted to the surrounding tissues. The clinical result is that there is less crusting, less wound care, and faster healing with the erbium vs the CO2 laser.
- Fractional Laser Resurfacing: The Action II uses a stamping handpiece that has approximately 15% coverage (15% of the skin is ablated) per pass. Depths are controlled by varying the energy as well as the pulse stacking. Typically patients will receive between 1-2 passes. The procedure takes about 30 minutes to complete. Only topical anesthetic is needed and patients are very comfortable throughout the procedure. Wound care which includes soaks and specialized creams is required for about 4 days. There is minimal to no crusting with this laser. More than one treatment might be needed to get optimal results.
- Indications: Treating deep wrinkles, sun damaged skin, pigmentation, and laxity
- Shining Peel: This is a very superficial laser resurfacing with minimal depth and can be done without topical numbing creams. It takes about 15 minutes and is meant to have almost no downtime. It causes a rejuvenation of the skin
- Indications: Treat superficial wrinkles, minor pigmentation, enlarged pores
- Surgical Handpiece: This is a microfocused beam to treat very small skin lesions. No anesthetic is needed.
- Indications: Treat sebaceous hyperplasia, seborrheic keratosis, actinic keratosis, benign nevus, skin tags, warts
- Bella V: This handpiece/procedure is used for vaginal rejuvenation and stress incontinence. The handpiece is insert to the vagina. It has a unique 360 degree treatment zone as the laser is pulsed. There are 2 pulses, a shorter ablative or subablative pulse, followed by a longer nonablative (heating) pulse. The handpiece is gradually withdrawn about 0.5cm and another pulse is fired. The is done throughout the entire vagina and introitus and then repeated. If there is a component of stress incontinence, the area of the tissue around the urethra is treated more aggressively. The entire procedure takes about 10-15 minutes and no topical anesthetics are required. (At this time, external vaginal treatments are performed using the ThermiVa at the Aesthetic Clinique.)
- Indications: vaginal laxity, vaginal atrophy, decreased moisture, stress incontinence
12/10/2017 2:48:52 PM
“A picture is worth a thousand words”. It’s true, seeing a great before and after speaks volumes for a certain physician’s or practitioner’s abilities. Unfortunately, there are some deceptive practices that can trick the eyes into believing results are better than they are really are. Instagram is a showcase for the aesthetic industry, but there is no oversight as to the claims made on the photos displayed. The bullet points below will help one to develop a critical eye to discern the truth from the “fictional results”.
- Lightening must be the same in both pictures. A common misleading practice is to have a dark before picture and a light after picture. In the lighter picture, wrinkles and shadows are going to be less, and fool the observing into thinking these were related to the procedure.
- Angle of the neck/head must be the same in both pictures. Take a look at the nose and jaw to see if the head is in the exact same position. If the head is tilted more upward in the after picture, the neck will appear to have less fullness, less wrinkles, and be firmer. This is particularly popular in the Kybella before and after photos.
- The expression must be the same in both pictures. If a patients is partially smiling in the before and not in the after, the wrinkles around the mouth and cheek will appear falsely improved.
- Sculptra pictures should have at least a 3-6 month interval. Sculptra is always mixed with water or saline for reconstitution. The immediate results after injection reflect merely the effects of the water/saline and not that of Sculptra. The collagen stimulation from Sculptra will take at least 3 months to appreciate, with 6-9 months being even a better gauge of results.
- Using company photos or other physician’s photos without noting this or giving the appropriate credit on their websites or posts is also a common practice.
- If make-up is used, it must be similar in both photos. Too often the before has none and the after has make-up.
Perfect before and after photos are very challenging. Even when results are extraordinaire, there are often difficulties trying to capture these changes with the camera. However, purposely trying to “enhance” photos with the practices above must be pointed out to the practitioners.
11/13/2017 11:58:51 PM
In surgery, sterile technique is “the law”. Any break in sterility places the patient at risk for a potentially life threatening infection. It is the duty for the surgeon(s), scrub tech, and circulating nurse to self report or call out any suspected or potential contamination risk. Immediate actions are taken to remedy the situation and to limit the risk to patient.
Why should dermal fillers be treated as anything differently? They shouldn’t! Fillers are semipermanent or permanent implants, and they must be administered in aseptic technique. The majority of injectors are not trained as surgeons and therefore don’t fully comprehend what sterile technique entails. Granulomas, one of the more serious complications from fillers, have now been traced to biofilms. Biofilms are latent bacteria that somehow get activated and present as infection or granulomas, months to years after the initial injection. Most often biofilms are deposited in the tissues during the initial injection procedure. Clearing infections or granulomas takes weeks or months to clear and often entails antibiotics, steroids, 5 FU, and hyaluronidase (if a hyaluronic acid was used).
The following guidelines should serve as a reference for physicians and nurses to minimize infectious complications during dermal filler injections.
- The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
- Never inject someone with a current/ongoing infection. Even if the infection is not in the area of the dermal filler, bacteria can seed the filler from distant areas through the bloodstream (bactermia).
- If a patient is in the process of getting dental work or even dental cleanings, hold off on injections until after the work has been completed. Bactermia is well documented during dental cleanings. It is recommended to wait at least 2 weeks after fillers to get dental cleanings. The areas of filler placement will initially have increased blood flow (hyperemia) so it is best to wait until this settles down.
- Skin should be prepped for injection with chlorhexidine, with Hibiclens being the preferred form by the author. Although isopropyl alcohol (70%) is effective in killing bacteria and fungus, it is only effective for seconds and becomes ineffective as soon as it evaporates. Hibiclens kills germs on contact and will give persistent bactericidal effects for at least 6 hours, and up to 24 hours. It will bond with the skin even after washing to give continued killing effects. Isopropyl alcohol doesn’t give this lasting bactericidal effect, so anytime after the initial cleaning that an unsterile glove touches the skin, that area is now contaminated. (Hibiclens must be kept out of the eyes because it can burn the cornea). Technicare is also a great antiseptic but the author doesn’t have experience with it. Too many patients are allergic to Betadine for it to be used routinely.
- Do not use tap water when applying Hibiclens or to clean the face after completion of the injections. There are several bacteria, fungi, as well as mycobacterium in water which can seep through the injection ports and cause infection.
- If the filler is prepared by mixing lidocaine or saline, this must be done in a sterile fashion. The female/female connector used to connect the 2 syringes together must not be reused. It can only be used for the current patient and cannot be sterilized for use on other patients. The tops of all the solutions used must be wiped with an alcohol wipe. Routine use of blending fillers opens up more avenues for filler contamination and must be done with the strictest of sterile technique. If any of the solution vials becomes unsterile, all future filler patients using that vial will become infected.
- Blunt tip cannulas can be used for multiple injection sites ON THE SAME PATIENT and are not intended to be used for multiple patients. When changing the cannulas between syringes, they should be recapped first. It is not sterile technique to lay the cannula on an unsterile tray or even a sterile drape when uncapped. After a syringe of filler is removed from its sterile packaging, the areas touched with the exam gloves become “contaminated”. Therefore, the sterile drape is not a sterile field anymore, once the syringes is placed on it. Best practice is to cap the syringe every time it is laid down.
- Blunt cannulas are much longer than needles and must be kept sterile throughout their entire length. The cannula is contaminated if anywhere along its length it touches non sterilized skin, gloves, or hair.
- It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
- The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
- Unless the gauze used during the procedure is specifically labeled as sterile, it is not, and introduces another route of contamination. Gauze that comes in sealed pull away packs and labeled as sterile is best to use. The author will take unsterile gauze, place in autoclave packs, and place in the autoclave to obtain sterility.
- Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
- If ice or devices for vibration are used to control discomfort, these should be cleansed with Hibiclens prior to applying to the skin. In addition, the areas where these were applied should be “re-sterilized” prior to injections.
- When the procedure is complete, sterile water or saline on sterile gauze should be used to clean the patient. Again, if tap water is used, this can seep through the injection ports and lead to infection. Also, when soaking the gauze, best practice is to pour the water/saline over the sink onto the sterile gauze so as to keep the remaining fluid in the container sterile. By tipping the water/saline onto gauze that is covering the top, there is risk of contamination going back into the container.
- Make-up should not be applied to the skin until the morning. At this point, the injection ports have all healed and there is no risk of contamination.
- Dental procedures, even cleanings, should be postponed for at least 2 weeks.
Although the details above are fairly lengthy, any break from any step will lead to a possible source of granuloma or infection in the future. Strict sterile technique will lead to better outcomes and happier patients,
10/2/2017 12:49:38 AM
A couple years ago, I wrote a blog that stated deep injections along the periostium using Sculptra were the best way to enhance temples suffering from volume loss. I would like to update everyone to a newer technique I have perfected that gives better results.
Although the Sculptra temple injections are safe and long lasting, there were deficiencies:
- Multiple treatments were required – 3 or more
- Results take weeks or months to occur
- Final results still showed volume loss in the temporal fusion line and supraorbital area
- Significant volumes of Sculptra were required
- Needle injections inherently lead to more bruising than cannulas
The temporal fossae is a very large space and when Sculptra is injected in this area, there is tremendous spread of the product due to its watery consistency. In addition, the deep temporal fascia is a thick and unyielding tissue plane that resists lateral movement from filler placed deeply.
My current preference for volumizing the temples uses large (23g) cannulas and a diluted HA (Refyne) dermal filler. I use large cannulas because they are safer than the smaller cannulas and needles for preventing vascular occlusion. I have found that the larger cannulas navigate the numerous veins in the temples well with minimal discomfort. My entry point is the zygomatic arch, about 1 cm posterior to the brow. The plane of injection is between the superficial temporal fascia and the deep temporal fascia. This is the exact area where the temporal fat pad is situated and where fat loss occurs. Surrounding areas such as the superior orbital rim, supraorbital area, forehead, and hairline can all be injected from the temporal approach. By diluting the Restylane Refyne with 1cc of saline and 1cc of lidocaine 1%, the thinner product is able to distribute very evenly throughout the plane of injection. Refyne’s high tissue integration and low swelling properties makes this the optimal filler for this area. I have found that a total of 1-2 syringes of the filler is needed to achieve correction in most patients. Massaging at the time of injection and periodically afterwards by the patient will give the smoothest results. A follow up in 3 weeks is typically made to make final touch ups if needed.
Techniques must constantly be re-evaluated and refined to achieve the optimal and safest results for our patients.
9/24/2017 7:47:38 PM
Aesthetic physicians are constantly striving to find the best procedure/device to turn back time. This time, it is actually a procedure which has been used for decades, but with some modifications. Fat grafting is a procedure that harvests fat from one part of the body and then injects the fat into another area. It has been used to volumize the aging face, hands, and even breasts. Benefits of fat grafting in repairing slowing healing wounds and radiated tissue have shown there are additional qualities to this procedure other than just volume. It turns out that fat contains stem cells and growth factors, more than any other tissue in the body, even more than bone marrow. The component of the fat that contains the stem cells and growth factors is called the “stromal vascular fraction”, also know as SVF.
When digging down into the research, an interesting finding has been discovered. It turns out that most of the fat cells injected don’t actually survive. What actually happens is that the stems cells (Adipose Derived Stem Cells – ADSC) injected along with the fat cells (SVF) leads to new fat cell production.
So here’s the new modification of the procedure. There is new a way to separate the SVF from the fat, without affecting the viability of the stem cells. This process creates the so called Nanofat, a highly concentrated solution of stem cells and growth factors.
It is a process of using filters and screens which takes less than 15 minutes to perform. It turns out that fat cells make up about 80% of the volume of the fat extracted during the harvest. The filtration system leads to destruction of the fat cells (which don’t live anyways) and leads to a much thinner solution which can be injected using smaller cannulas or needles than typical fat grafting procedures.
It turns out that Nanofat actually contains little to no viable fat but is the popular term for the SVF derived from fat. To even further “energize” the Nanofat injections, PRP or PRF is mixed with the solution. This process gives additional growth factors which benefit in the fat production and overall repair and rejuvenation of the areas treated.
Nanofat injections are often combined with fat grafting which is modified from the classical method. It has been found that the inconsistent “take” and lumpiness of fat grafting is related to large size and nonuniformity of the fat harvested. To overcome these hurdles, the harvesting process is now done with smaller cannulas and the fat is pushed thru filters to make uniformly smaller sized fat globules.
Nanofat is useful to treat:
- Crepey skin around the eyes
- Superficial lines and wrinkles
- Smoker’s lip lines
- Thin, atrophied skin
- Severely sun damaged skin (in combination with other procedures)
The use of Nanofat, with or without fat grafting, requires a minor liposuction procedure to harvest the cells. This is done completely under local anesthesia. Only syringes are used as suction and the cannulas used are much smaller than typical liposuction. There will be some downtime of swelling, bruising, and redness, that typically lasts a few days or up to a week (longer in a minority of patients). Full results require about 9 months to fully appreciate – the time required for new fat and skin cells to be generated.
We now have a completely natural way to rejuvenate and reverse the affects of aging, using stem cells derived from fat cells – Nanofat. The process of isolation of the stem cells and growth factors from fat has become an extremely viable option with a 90 minute procedure.
7/3/2017 1:42:19 AM
The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.
There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.
The reasons to dissolve HA filler are:
- Poorly placed filler giving an aesthetically poor result
- Where too much filler was placed
- Filler that is infected
- Filler is forming a granuloma
- Filler is causing ischemia/vascular occlusion
- Filler is causing visual changes or blindness
The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.
It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours.
Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.
6/21/2017 12:23:48 AM
The nonsurgical aesthetic industry has finally hit an important milestone. Using a combination of techniques, cosmetic physicians are now able to halt, and even reverse, the age-related changes which occur to one’s face. In the past, technologies would allow for turning back time for a few years but eventually, the inevitable and undeniable signs of aging would occur. As lasers, radiofrequency (RF), filler and neuromodulator techniques have improved, the aging face is a thing of the past. The concept of “age freezing”, keeping ones looks for a decade or more, is not merely a dream, but reality. More importantly, this all can be done without surgery!
Not everyone is a candidate for “Age Freezing” unfortunately. The stipulations are:
- Must be a nonsmoker – There are several significant skin and health issues associated with smoker which can’t be overcome. Many procedures require healing and collagen stimulation which are inhibited by smoking.
- Free of chronic debilitating disease – There are tolls long term diseases take on the body which lead to premature aging, cellular changes.
- Stable weight – As Katherine Deneuve once stated, at the age of 40, you must decide between your ass or your face. If you lose too much weight, fat is lost from your face. In most instances, this can be overcome but not always. However, in patients with significant weight gains, there can be some difficulties maintaining the same look one had in the years prior.
- Alcohol consumption in moderation – Alcohol can take a toll on the body in the long run when taken in excess. 1-2 drinks per day is the recommended maximum intake that the author recommends.
- Healthy lifestyle and diet – Although this topic overlaps some of the previously mentioned necessities, a good exercise regime is also required. The benefits of exercise on weight, hormones, circulation all benefit the facial appearance. Obviously, a well-rounded diet full of antioxidants, vitamins, and nutrients is beneficial too. There is research to support telomere lengthening with these measures as well.
The requisite procedures for “Age Freezing” are:
- Neurotoxins on a regular basis. Relaxing the hyperdynamic muscles of the face with either Dysport or Botox needs to be performed at least 3 times per year. The regularity is needed to keep the muscles weak and prohibiting them from regaining strength.
- Dermal Fillers for lost volume. Fillers are the epicenter of the whole “Age Freezing” concept. Beginning in the mid 30’s, at least a cc of volume is lost per year. This is the result of fat, bone, and muscle loss. Replacing and keeping up with this process is tantamount to looking young. Large volumes are best replaced with using Sculptra, a collagen stimulating filler. It is best to recreate the foundation with Sculptra. Superficial fine tuning is best performed with a hyaluronic acid filler, such as Restylane. New techniques using blunt cannulas permitted safer, less downtime procedures. A comprehensive understanding of the aging process has enlightened our specialty as to what needs to be corrected for accomplishing age reversal.
- Skin Tightening to reverse gravity. The constant downward pull due to gravity leads to skin laxity, above and beyond what is attributable to volume loss. Devices that heat up the dermis will stimulate collagen and tissue contraction. Devices vary in their ability to tighten, often with a tradeoff of more downtime/discomfort/risk for more results. Ablative lasers, CO2 and Erbium, will give the most tightening for lasers. Radiofrequency can also be used, with the microneedling RF, such as Infini, giving the best results. A new procedure called JPlasma, looks like it may have promise in significant tightening, but does have about 14 days of downtime and a month of redness.
- Skin Resurfacing to improve pigmentation, fine lines, and thicken the dermis. The aging process, primarily due to sun exposure, causes skin to thin with loss of collagen and elastin. Dyspigmentation, pigmentation problems, occurs as well. Renewing the surface of the skin can be accomplished using lasers, such as the Fraxel Dual, or chemical peels. Microneedling can thicken the skin by producing small injuries in the dermis with very little downtime or risks. There may be benefit to adding PRP, platelet rich plasma, to the skin, but the jury is still out.
- Skin Care is essential to achieve the optimal results from any of the above mention procedures as well as to improve one’s skin health. Retin A or Retinol should be a staple in one’s nightly regime. These products stimulate skin turnover, reversal of pigmentation problems, better hydration with hyaluronic acid stimulation, and collagen production. Blemishes/Acne breakouts are improved with these products as well.
- Oral Supplements are key to good, healthy skin. Oxidants are the source of disease, cancer, aging, and skin damage. To neutralize the oxidative stress, strong anti-oxidant supplement(s) are necessary. Examples include: superoxide dismutase, fish oils, resveratrol, Polypodium leucotomos, turmeric, and glutathione. In addition, the antiaging benefits of Metformin are hard to dismiss with the current research published. Lengthening one’s telomeres with TA65 is probably beneficial as well.
One must understand that the “Age Freezing” concept is a process. It is a lifestyle, a choice. It is not a “one and done” procedure. It consists of regular visits to an aesthetic physician. There are big steps and little steps along the way. The author has dozens of “Age Freezing” patients whom look younger and better, 10 or more years after initiating treatments. “Age Freezing” will eliminated the need for future cosmetic surgery.
6/17/2017 10:38:51 PM
It’s been touted for years by the aesthetic physicians – “Prejuvenation” – starting maintenance treatments in one’s late teens or early twenties. The Kardashians have popularized these minor cosmetic tweaks to stay youthful and refreshed with visits to their Beverly Hills physician, documented regularly on “Keeping Up with the Kardashians”. There is increasing pressure to get that perfect selfie for Instagram or to look cool and attractive on a “Snap”. Unfortunately filters don’t work well with videos unless you want to look like a cute puppy. Doctors are in agreement (for any disease process) that it is much easier to treat problems in their early stages than to reverse them after they have spiraled out of control. Small preventative treatments early on, can maintain and even enhance one’s looks for many years and avoid invasive surgical procedures in the future. The question is, which procedures should be considered for Prejuevenation?
Neuromodulators: These wrinkle improving injections take less than 5 minutes and have no downtime. Millions of these procedures are done each year and it is the most popular cosmetic procedure performed worldwide. Most often these are used in the younger population in the frown lines (glabella), forehead lines, and crows feet. Treating these areas before the lines set in at rest, known as “etched in” lines, is one of the fundamental concepts of Prejuvenation. (Suggestions: Dysport, Botox)
Dermal Fillers: Dermal fillers made from hyaluronic acid (HA) are used to improve the minor volume loss which occurs with age. In the more athletic patients, fat loss can be appreciated in the face as well as throughout the body. Supple enhancements can be added to the mid cheek and around the eye to stave off this premature volume loss. HA fillers are also used to plump up the lips to create a youthful appearance. (Suggestions: Restylane Refyne, Restylane L, Restylane Lyft, Sculptra)
Chemical Peels: To keep the skin in top notch shape and to reverse early sun damage, chemical peels can exfoliate the superficial layers of skin. This renews the texture and pigmentation and leaves a youthful and glowing quality to the skin. (Suggestions: Illuminize, Vitalize, ZO 3 Step Peel)
Skin care: Great skin care is the basis for good looking skin. Most would agree that some type of Retin A or Retinol is essential for maintaining youthful skin. These products lead to increased turnover of the skin cells, improve dyspigmentation (pigmentation problems), thicken the skin, and create a more hydrated skin. Sun protection with an SPF should be part of one’s daily regime. It is also highly recommended to apply growth factors to the skin to reverse the aging process. (Suggestions: ZO Skin Health, Lifeline Stem Cell Skincare)
Prejuvenation is a trend that is here to stay. Preventative maintenance will prolong the need for more aggressive corrections in the later years. With short, no downtime procedures such as neuromodulators, chemical peels, fillers, and a good skin care regime, youthful, natural appearances will persist for years. Stay ahead of the curve with Prejuvenation.
6/16/2017 1:48:18 AM
Acne affects millions of people in the US, and is the most common reason to seek medical attention from a Dermatologist. Billions of dollars are spent on medications to control the disease, both over the counter and prescription. Medications have potential side effects, and compliance is difficult. Even with aggressive medical therapy, acne can be difficult to control, which leads to frustration by patients, parents, and physicians. With prolonged cases of acne, scarring can set in, creating an even more difficult problem to treat.
It’s the early teen years, as one is experiencing puberty, when acne usually starts. This period coincides with high school, selfies, and an interest in dating. Acne can negatively impact social interactions and lead to depression, moodiness, negative self-worth, and isolation. Controlling acne is a top priority for large number of teenagers in the US.
A cascade of events leads to acne:
- A trigger: hormonal, emotional, stress, metabolic
- Increased sebum (oil) production from sebaceous glands
- Plugging of the follicles by the sebum
- Infection of the sebum by bacteria
- Inflammation related to the infection/immune response
Treating acne with lasers is not a new concept, but the Aerolase has made the process more effective and safer. Even the wavelength, 1064nm YAG laser, is not novel to the Aerolase. However, having a pulse width of 650 microseconds is unique. The Aerolase sits in the middle of the prior lasers used to treat acne, the Q Switched (nanosecond) and the Excel V/VBeam (millisecond). It has been shown that this pulse width is better tolerated than faster and slower lasers, and therefore more pulses and even stacking can occur. Deeper and more broadly-based heating occurs with the Aerolase. With the increased heating of the acne, the laser becomes more effective in its eradication. The 1064 wavelength is safe for all skin types, but settings are reduced for the darker skin patients. The Aerolase laser treats acne by:
- Heating up and shrinking the sebaceous glands leading to lower sebum output
- Killing the acne bacteria
- Reducing the redness associated with the acne
- Improving early scarring
- Reducing the inflammatory component of acne
Typically, a series of treatments are needed, 4-6, about a week or two apart. Touch ups are needed every 1-3 months. Flairs should be treated acutely, so they are controlled quickly. Continues use of topical therapy is usually recommended, such as Retin A and benzyl peroxide. The Aerolase gives patients a unique, no downtime, near painless 10-minute procedure to help control even the most difficult cystic acne.
“Get rid of that Instagram filter and show your true selfie.”
5/28/2017 2:24:27 PM
Coolsculpting’s original FDA approval was in 2009 and it was initially cleared to cool skin prior to dermal procedures. It was later in 2010 that the FDA approved Coolsculpting for fat reduction in the flanks (love handles). Over the next several years, the procedure has been approved for abdomen, thighs – both inner and outer with various sized handpieces to treat every body type.
What’s new is that there are 2 new indications for Coolsculpting treatment. The submental fat (double chin) can now be treated with the Cool Mini handpiece. Depending on the needs of the patient, one or two applications are needed. Treatment times are 45 minutes. There is no downtime as is customary with all Coolsculpting procedures. A 2nd treatment is needed in some patients who need larger corrections. Another exciting area of recently approved treatment is the underarm area. This is where the new Cool Petite handpiece is used. Loose skin is not going to improve but that annoying “bat wing” can be reduced with these treatments.
In 2016, there was a significant change to the handpieces used for treatment called the CoolAdvantage Handpieces. (Not all practices have upgraded to these, so patients must inquire). The difference is that these handpieces are more shallow – the amount of suction witl therefore be less. The cooling plate is continuous rather than just the sides. The area treated is now more uniformly cooled than with the prior handpieces. These changes result in:
- More comfortable treatments
- Treatment times of 35 minutes vs the usual 60 minutes
- Faster onset of results – as little as 3 weeks
- Less bruising and post procedure pain
Soon after Coolsculpting’s approval it had been noted that manual massage post treatment led to improved results. About a couple years ago it was found that using the Zimmer Z Wave in place of the massage yielded even better results. It was found that adding the Z Wave increased the treatment efficacy by 68-100%. The Z Wave uses Acoustic Pulsed Technology, which sends shock waves through the skin and fat. It is a painless 5-10 minute procedure. These shock waves further injure the fat cells leading to a better result. After the Coolsculpting treatment, there are fat cells which are killed, some unaffected, and some which are “on the fence” as to whether they will survive or die. The Z Wave pushes some of these “undecided” cells over the brink. Z Wave has also been shown to lead to less post procedure discomfort.
“If one is good, two is better”. In some practices, a second Coolsculpting machine has been purchased. This allows for “DualSculpting”, treating 2 areas simultaneously. Treatment times are then cut in half using this technique.
Comparing the DualSculpting to treatments 1 year ago, two areas can now be treated in about one quarter of the time when adding the benefits of the CoolAdvantage Handpieces.
The Aesthetic Clinique has been one of the pioneers in Coolsculpting treatments. Its first machine was obtained in 2009, being one of the first 25 in the country, even before the formal FDA approval for fat reduction. All the latest handpieces are available including the CoolAdvantage, Cool Mini, and Cool Petite. The Zimmer Z Wave is a complementary service added to all Coolsculpting treatments. A second machine has just been purchased, so DualSculpting is now available at The Aesthetic Clinique.
Recent advances have made Coolsculpting significantly faster, more comfortable, and more effective. It is a great noninvasive procedure for reducing unwanted fat without downtime.
3/14/2017 9:00:28 PM
(Dr. Weiner is one of the most experienced users of Restylane Refyne and Restylane Defyne in the US and has trained multiple physicians on his injection techniques of these new products.)
Restylane Defyne Treatment Radial Cheek Lines – Dr. Steven F Weiner
Late 2016, two new dermal fillers, Restylane Refyne and Restylane Defyne were FDA approved. Although new to the US, these fillers had approval in Europe in 2010 and in Canada in 2015 under the name Emervel. The announcement flew mostly under the radar and it wasn’t until early 2017 that Galderma officially launched the new fillers. Although these fillers are similar in composition, hyaluronic acid (HA), to many of the other fillers on the market, it is the technology behind them that set them apart from the rest.
Restylane Refyne and Defyne are made with XpresHAn technology which adds flexibility to the fillers – “think honey” – and makes them perfect for treating areas of expression. (Other Restylane fillers are based on NASHA technology, and are particulate in nature – “think sugar”.) Additionally, Refyne/Defyne have high crosslinking that lends to their ability to stretch and recoil. Refyne has less links, so it can stretch more, while Defyne is more tightly bound.
The clinical outcomes of using Refyne and Defyne are unique and directly related to their manufacturing process. With placement in the dermis using small aliquots (a different technique than other fillers) in areas of high muscle movement (expression), the filler will support the skin and soft tissue in unparalleled ways. In fact, muscle strain around the mouth was tested before and after Refyne/Defyne placement and was shown to revert a 55 year old’s profile to one similar to a 30 year old on average. The hyperactivity of the muscles was “constrained” by the filler, just as Botox or Dysport does in the glabella and crows feet. The previously difficult to treat radial cheeks lines (smile lines) can now be improved significantly with the new Restylane Refyne/Defyne fillers. Other fillers used to treat this area are more apparent and obvious due to their lacking the XpresHAn technology, and don’t look as natural with movements. Adding bulk/volume to the lower face is usually not desired because beautiful and youthful faces are V or heart shaped. The unique placement of Refyne/Defyne in the dermis does not add fullness in the lower face during corrections of the marionette lines, prejowl sulcus, and smile lines in Dr. Weiner’s experience.
Cohesiveness is the ability of a filler to “stick to itself” and integrate with the surrounding tissues. Both Refyne and Defyne have a high cohesivity. This equates to more blending of the filler with the tissues, and a more natural appearance. In clinical use, these new fillers can be injected into the mid/deep dermis (a dermal filler actually being injected in the dermis!) and still go unnoticed, without nodules or lumps.
One final highlight of Refyne/Defyne is their low degree of swelling associated with injections. This is beneficial for areas such as lips and tear troughs, where swelling can lead to social downtime, precluding some clients from doing these procedures. When comparing all the HA fillers available in the US, it’s been Dr. Weiner’s experience that Refyne/Defyne have the least amount of swelling.
Restylane Refyne and Defyne open up a new treatment paradigm for the perioral smile lines (radial cheek lines) where previous corrections were usually suboptimal. This area is often overlooked or discouraged, but is a frequent concern for a majority of dermal filler clients. The satisfaction rate with these corrections have been extremely high in Dr. Weiner’s experience. With the additional benefits of high conhesiveness and low swelling, Restylane Refyne and Defyne are a great addition to the filler armamentarium of the advanced injector.
3/12/2017 4:21:05 PM
The value of volume replacement in the aging face is now universally recognized as one of the most beneficial procedures to restore youthfulness. The combination of sun exposure, aging, and genetics leads to collagen, fat, muscle, and bone loss. Reinflating the cheeks, lips, and tear troughs are routinely done by physicians across the world on a daily basis. Most of these patients will have a week or more of downtime – swelling, bruising, discomfort – but that doesn’t have to be. Blunt cannulas can minimize most of these side effects associated with filler injections and has become standard practice for Dr. Weiner for the past 6 years.
The benefits of blunt cannlas are:
- There is only one insertion point to treat multiple areas. This equates to less intrusions through the skin and therefore a more comfortable procedure.
- The tip is rounded and blunted. This very fact accounts for less bruising/swelling. When a blood vessel is encountered with the end of the cannula, the vessel is more likely to be gently displaced rather than punctured.
- There is increased safety. A phenomenon termed “vascular occlusion” occurs when a filler is injected into a blood vessel. The filler then blocks the blood flow and can lead to necrosis (death of skin) or even blindness. It is much less likely to occur with blunt cannulas, particularly larger cannulas (23 or 25 guage), because they don’t enter blood vessels as easy as needles do.
- Allows treatment in areas otherwise not easily accessible. Due to the safety of the cannulas, there are now areas of the face which are more easily treated. The superficial temporal area, supraorbital, forehead, piriform, periocular and lower eyelid are now routinely treated with cannulas whereas with needles, these areas were very precarious to inject.
- Downtime is minimize. As a result of all the benefits listed above, most patients have significantly less healing time and are much happier after receiving their filler treatments with blunt “safety” cannulas.
If blunt cannulas have so much benefits, why are only 5% of the providers using them for dermal fillers? The art of using cannulas is not an easy one. Patience is required because directing the tip to the exact spot it is needed is not always easy. Remember, when the tip encounters an obstruction (vessel, ligament, collagen), it will need to traverse around it and not pierce it (as needles would do). This can be frustrating and lead to longer and less satisfactory results for the inexperienced cannula injector.
Dr. Weiner is one of the leading authorities on cannula injections of dermal fillers and has used them for over 6 years for nearly all of his injections. The cannulas provide a safe, comfortable, minimal downtime technique for volumizing the aging face, even with multiple syringes being used simultaneously.
1/25/2017 2:46:54 PM
Tattoo removal is most effectively performed with lasers. The mechanism by which the laser works is by breaking up the larger ink granules into smaller particles. The body is unable to clear the larger particles but when smaller, the immune system is capable of clearing the ink. Successful clearance of a tattoo is dependent on several factors which will be highlighted in the remainder of the blog. While the experience of the physician performing the tattoo removal can’t be ignored, he/she is limited by the laser being used.
There are 3 aspects that need to be considered in a tattoo laser. They are power (and spot size), wavelengths, and pulse durations.
Power is a measure of how much energy can be delivered to the skin. What’s more important is how much is getting to the level of tattoo. It remains obvious, the more power delivered to a tattoo, the better clearance there should be. This is limited by the damage to the skin and surrounding soft tissue. Excessive energy to the superficial skin can lead to blistering, prolonged healing, scarring, and pigmentation changes. High-power lasers are able to use large spot sizes (10-15mm) to deliver the energy to the tattoo. Larger spot sizes give deeper penetration of energy and a safer treatment. Under-powered lasers need smaller spot sizes to get enough energy into the skin to cause an effect on the tattoo. This leads to the superficial skin heating up and potential for blistering/scarring.
When comparing energies between lasers, most companies measure the output from the laser. What is not discussed is how much the energy is diminished while going through the arms, mirrors, and handpiece. This can account for 20-30% less energy at the skin than what is the measured output of the laser in the lab. (The energy measured by the Piqo4 system is to the skin while all other systems is output from laser.)
The wavelength of a tattoo laser determines what colors it can treat. The most common color in tattoos is black. The best wavelength for treating black inks is 1064nm. This wavelength also is the safest for darker skin type. Even if the tattoo doesn’t look like it has black ink, over 95% have some component of black ink. It is imperative that the laser chosen for tattoo removal has a 1064 wavelength. The next most common ink is red. This is best treated with a 532 wavelength. Almost always, the 532 and 1064 wavelengths are packaged together in the same laser. It requires a doubling of the frequency to go from 1064 to 532 (double frequency means halving wavelength). The remaining colors require a variety of wavelengths so it is essential to have multiple wavelengths to treat colored tattoos. The lighter the color – pink, yellow, white, light blue – the harder it is to treat.
The lasers for tattoo removal are much faster than lasers used for hair removal, photofacials, telangiectasias, and leg veins. Where as the typical pulse duration is measured in milliseconds for the dermal treatments, tattoo lasers are measured in either nanoseconds or picoseconds (1000x – 1,000,000x). These extremely short pulses lead to extremely high energies being placed into the tattoo. This energy leads to a shock wave hitting the ink and breaking it up. The faster the pulse, the higher the energy and the more directed the energy is to the ink and less to the surrounding tissues. The longer the pulse, the more time the energy has to spread to the tissues. In the author’s opinion, initial treatments for tattoos are best performed with nanosecond pulses (to break up the larger ink particles) while the later treatments need picosecond pulses to clear the remaining ink particles which are smaller in size. It is most effective to have a laser with both nano and picosecond capabilities for treating tattoos.
The Best Laser for Tattoo Removal
After understanding the important qualities required in a laser for optimal treatment of a tattoo, it becomes fairly easy to see the obvious best laser. The Piqo4 has the highest energy (to the skin) of all nano/picosecond lasers. As a corollary, it has the largest spot sizes on the market – meaning safer, deeper, and faster treatments. With it’s 4 wavelengths, it has the capabilities to treat the 9 most common colors. It has 4 different pulse durations – 2 and 8 nanosecond and 600 and 800 picosecond. In conclusion, the Piqo4 combines high power, 4 wavelengths, and multiple pulse durations to enable it’s lasers to be the most effective option available on the market.
1/22/2017 4:40:52 PM
Melanocytes are the cells responsible for the pigmentation in the skin. Their activity can be increased in response to inflammation. When skin becomes hyperpigmented from an injury, it is called “post inflammatory hyperpigmentation” or PIH. This is particularly prevalent in darker skin individuals, where there is more melanocytic activity, but can occur in lighter skin individuals as well.
The widely accepted scale for skin pigmentation types is the Fitzpatrick Scale. The Fitzpatrick Skin Type 1 are extremely light skinned, have blue eyes, and burn extremely rapidly with sun exposure. Type 6 individuals have very dark skin, dark eyes, and tolerate prolonged sun exposure without burning. In general, the type 4-6 skin types are the ones at risk for PIH.
PIH is possible after the following:
- Laser procedures (mainly laser resurfacing)
- Surgical incisions
- Chemical peels
- Radiofrequency (Infini is low risk)
The best way to treat PIH is prevention, if possible. Prevention consists of calming down the melanocyte metabolism. The standard recommendations are Retin A and hydroquinones. If there is a procedure a darker skin individual is planning that has risks of PIH, this regime should be started at 3 weeks prior to the procedure. It should be continued at least a month and up to 3 months afterwards. These 2 topicals are also standard therapy for patients with PIH.
Prolonged inflammation after a procedure (more than a week) in a darker skin individual, is a risk for PIH. The practitioner needs to recognize this and treat the inflammation appropriately. If there is prolonged redness of the skin, steroids and/or vascular lasers are needed to reduce this. If infection suspected, antibiotics are needed. Calming the skin is essential to prevent PIH.
The timing of PIH is very predictable. It almost always occurs about 3 weeks after a “at risk” procedure is performed.
If there is already PIH, treatments which can be used are:
- Topicals such as Retin A, hydroquinone, and steroids; Triluma contains all 3
- Chemical Peels
- Gentle laser treatments with a 1064 laser (nanosecond or picosecond)
- Possibly PRP with microneedling (experimental but minimal risk)
- Antibiotics for ongoing infections
- Laser hair removal for PIH associated with folliculitis
In general, PIH is best prevented then trying to treat after it occurs. Recognizing risk factors with certain procedures is the key to success. Treating prolonged redness is often overlooked and must be treated aggressively rather than taking a “wait and see” approach.
1/8/2017 5:51:10 PM
The concept of applying radiofrequency energy into the skin has changed in the past few years. The “older” methods use a process called “bulk heating” to apply the energy to the surface of the skin which will diffuse to the deeper layers of the dermis. The deficiencies of this method are:
- The heating is not precise, with the depths unknown.
- The epidermis is at risk for too much heat, leading to potential for scarring or pigmentation issues.
- Subdermal fat is at risk if the heating goes too deep.
- The heating is bulk and not fractional, so safety is less.
- The highest temperature achieved is about 45 degrees, enough to minimally stimulate collagen.
The progression of technology with RF heating of the skin has evolved to a process that is more precise. Using microneedles, RF energy is able to be placed at desired depths in the dermis. The deeper, fractional heating is much higher than if placed on the skin surface. It enables the temperatures to get to 65-70 degrees C, enough cause coagulation. Coagulation leads to maximal collagen stimulation and tissue contraction. In regards to the microneedles, there are 2 types of needles used: Insulated and Noninsulated. The noninsulated needles deliver energy only at the exposed tips, completely bypassing the more sensitive epidermis. On the other hand, noninsulated needles allow the energy to transmit along the entire length of the needle, creating a wound that includes the epidermis. When the epidermis is heated to point of coagulation, there is wound care and potential for pigmentation and scarring. The only way these uncoated needles get around potential safety problems is by delivering less energy. The advantages of microneedling insulated delivery of RF are:
- More precise level of RF energy delivery.
- Fractional heating of dermis, which is safer than bulk heating.
- Bypassing the epidermis so darker skin types are more safely treated.
- Higher energies can be placed leading to coagulation and better collagen stimulation.
- Insulation leads to better epidermal protection, less downtime, and potentially higher energies.
The main devices that deliver RF through microneedles with insulated needles are Infini and Profound. There are actually significant differences that might not be apparent to even the most informed providers.
- Infini uses 49 needles while Profound uses 10 needles.
- Infini can treat at 0.25 mm incremental depths between 0.1 – 3.5 mm while Profound has just 2 possible depths.
- Infini’s pulse durations are up to 500 milleseconds while Profound’s pulses are 3-5 seconds.
- Infini uses multiple passes to create thousands of coagulation zones whereas Profound uses only one pass.
What does this all mean? It means that the coagulation wounds placed with the Profound are less in number but much larger in size. The downside to larger wounds is that there is longer healing times because the unaffected tissue which is needed to assist in healing is further from the center of coagulation. With smaller coagulation zones as in the Infini, the wound healing is shorter in duration. In addition, the healing in the desired fashion (without scarring) is easier to control with multiple smaller wounds than it is for fewer, larger wounds. The concept of fractional ablation being safer and with less downtime (popularized by the Fraxel laser) loses it advantage as the wounds get larger.
It boils down to: The Infini creates smaller and many more coagulation zones than the Profound which creates larger and fewer zones. Safety and recovery are improved with the more plentiful, smaller coagulation zones of the Infini.
12/23/2016 8:49:41 PM
The ideal facial shaped has been described as “heart shaped”, “V shaped”, or “Upside Down Egg”. A youthful face draws attention to the upper face and eyes. With aging, the lower face becomes “heavier” and more dominant, as laxity and volume loss set it. Instead of round or oval, the shape of the face becomes closer to square. The underlying cause for these changes is primarily loss of fat, muscle, and bone.
The upper face’s width is determined primary by the temples. Fat pads in this area are particularly susceptible to atrophy associated with aging and exercise. To reestablish the youthful facial shape, it is essential to reflate the temples. There is a contiguous fat pad in the preauricular area which follows similar volume loss as the temples and should be volumized simultaneously. When the lateral cheeks are given filler, the temporal deficits become exaggerated and more obvious. Patients must be counseled on their temples whenever cheeks injected.
Besides the overall facial shape change, the benefits of filling the temples are the lift given to the surrounding tissues. The brow, and upper eyelid will be elevated with temporal filler. Placement of filler along the orbital rim and lower forehead further enhances this effect. The ideal temple should be convex in a women and slightly concave in the male.
The filling of the temples is reserved for the experienced injector. Dr. Weiner’s choice for this area is Sculptra because of its safety and natural appearance. The only downside to Sculptra is that when placed along the bone in the deepest aspect of the temporal fossa, a large volume of product is needed for complete correction. To finish corrections after the deep Sculptra placement, a superficial layer of HA filler (Restylane, Juvederm) can be safely placed using large bore cannulas. The filler is placed immediately below the dermis in the subcutaneous layer or just below the superficial layer of the temporalis fascia.
To reverse the signs of aging and restore the upper face dominance, temple volumization is required. It must be considered for patients that have brow and eyelid heaviness as well. This is an area that is difficult to treat with higher than average safety risks, and should be reserved for the most experienced injectors.
11/11/2016 6:52:46 PM
There are now several procedures to make those private moments even better. There is no downtime and minimal discomfort with these procedures and they should boost your self confidence.
- Botox for sweating: Most people are familiar with Botox for wrinkles. What most don’t know is that it also stops sweating. It works by inhibiting the nerves to the apocrine and eccrine glands from secreting sweat. Botox can be injected in the pubic area to improve the sweat and the odor associated with it. It can be done in less than 5 minutes and should last 4-6 months. Dr. Weiner has developed a technique that makes it go faster and gives less discomfort than standard injections. The results are apparent about 3-4 days after treatment. Men and women can benefit from this procedure.
- Fillers for the labia: Just as with the face, as we age, the labia (majora) loses fat. This can easily be improved with fillers. Dr. Weiner uses cannulas for this so the amount of insertion points is either 1 or 2 per side maximum. All the fillers can be used here but Radiesse and Sculptra are the preferred choice.
- ThermiVa for rejuvenation: ThermVa is able to improve multiple different problems with a series of painless 45 minute procedures. It uses a temperature controlled wand that cause collagen stimulation, tissue contraction, and rejuvenation of the vaginal mucosa. The treatment improves: dryness, laxity, labial (minora) hypertrophy, urinary incontinence, and in some cases, orgasmic dysfunction.
Build you confidence and pleasure under the sheets with these 3 easy procedures. Downtime, side effects, and discomfort are minimal. These are procedures both you and your partner can enjoy.
11/9/2016 11:07:01 PM
It doesn’t matter how long you spend in the gym. Most women still want a more rounded, lifted buttocks and legs with less cellulite. Wouldn’t it be nice if both of these could be improved with just injections?
There is a new procedure that uses a long term filler for a new purpose. Sculptra has been FDA approved since 2004 for use in the face for volume loss. It works by stimulating one’s own body to produce collagen in response to the PLLA (Poly L Lactic Acid), it’s main component. It takes 2-3 months to appreciate the correction from Sculptra. The result of Sculptra should last years because newly formed collagen lasts 7 years in other areas of the body.
How the procedure works is by filling in the dimples and creases associated with the cellulite with injections. The correction is seen immediately but that subsides rather quickly because it is mostly saline. Over the next several weeks, collagen is gradually built up from the PLLA injected, and the cellulite appearance improv es. Severe laxity and “cottage cheese” of the skin is not correctable.
Creating a Brazilian Butt Lift with Sculptra is an extremely easy procedure to get done. There is no liposuction required, no healing/soreness from fat harvest, no need to sit on donuts or in some cases “avoid sitting at all costs”. It can be done in 15 minutes and is nearly painless. Dr. Weiner prefers to do the procedure in a series of 3-4 treatments. Each injection is done using cannulas for minimal bruising and discomfort. Approximately 4 vials are used per treatments. Long lasting improvements in lifting and fullness should be expected from Sculptra which appears gradually over several months.
Having a minimally invasive alternative to these traditionally difficult to treat “problems” is a breakthrough for those patients “on the go”. In contrast, a formal BBL requires weeks to recover, restrictions on exercise/sitting and sometimes need “redos”. These Sculptra injections can be done in about 15 minutes and have no downtime except for bruising, with results lasting for years.
11/6/2016 5:44:14 PM
Some of the fastest growing and most popular procedures in the Aesthetic Industry are radiofrequency and laser procedures. The most sighted obstacle for patients doing these procedures is pain. Dr. Weiner has develop and perfected a method to numb the face fairly thoroughly that is fairly quick and simple. The “Superficial Skin Block” takes about 3 minutes to administer for the entire face. It requires no knowledge of neural anatomy and is less invasive/more comfortable than nerve blocks. The anesthesia kicks in within minutes and will last at least a couple hours. It is ideal for improving comfort when undergoing the Infini, CO2, Erbium, or Fraxel laser resurfacing. Dr. Weiner’s mixture for injection is:
- Lidocaine 1% with 1:100,000 Epinephrine (Standard premixed from most medical suppliers)- 5cc
- Bacteriostatic 0.9% Sodium Chloride with Preservative – 5cc
- 8.4% Sodium Bicarbonate – 1cc
- All this is drawn up in a 10cc syringe
The “Superficial Skin Block” starts with placement of topical numbing cream. Dr. Weiner uses “Lipothene” from Central Avenue Pharmacy which contains 23% Lidocaine and 7% Tetracaine. It is left on the face for at least 1 hour. Do not place on face and neck simultaneously. This is too large a surface area for the topical. The neck doesn’t require this strong a topical in Dr. Weiner’s experience.
The injection requires a mesotherapy apparatus from Mesoram.com. The exact device used is found at: Dr. Weiner’s Preferred Mesoram Needles . The needles are 4mm, 30g and the plate is circular with 7 needle connectors. Plates can also be purchased without needles and 32g needles can be purchased from the site and attached manually.
The topical is wiped off and the face is cleaned with alcohol and hibiclens. The injection is started on the cheeks with 0.5 ml aliquots placed in each injection. The areas injected are slightly overlapped. A small amount of the mixture is placed above the upper lip with a needle that is removed from the device. A few minutes are allowed before starting the procedure to allow for the small blebs to diffuse into the skin tissues. You will notice areas injected become pale and this is the epinephrine effect. This helps in controlling bleeding and bruising.
Dr. Weiner’s Superficial Skin Block has been used by multiple practitioners with great success. It’s effectiveness, ease of use, and limited downside make it perfect for many aesthetic procedures, particularly Infini and laser resurfacing.
11/4/2016 8:22:29 PM
Until recently, the dreaded double chin has been fairly difficult to treat. Liposuction was the mainstay of treatment. This can be performed under local anesthetic, but there is downtime, bruising, need to wear a chin strap, and some risks. Now, there are 3 non surgical options to treat this area and along the jawline (with 2 of them) which have no or minimal downtime.
Kybella is a bile salt (deoxycholic acid) that is found in the gallbladder. It is natural secreted to assist the body in digesting consumed fat. It is now available in an injection form and can be used in the submental area to permanently reduce fat. It typically requires 1-2 vials per session, and about 2-4 session. This is all dependent on the amount of fat in this area. 1 month to 6 weeks in the recommended period between treatments. The procedure takes about 15 minutes. There is very minimal pain at first. It then starts burning and this lasts for up t0 30 minutes. Swelling occurs for the first 3 days that is significant. Most of the swelling is gone by a week. All swelling is gone by about 3-4 weeks and results are seen at this time. Areas other than the submental area are being investigated
Pros: short procedure, effective for submental area, long lasting results
Cons: swelling, can’t be used along lateral neck – only central portion, multiple treatments
CoolMini from Coolsculpting is a new handpiece that is designed to treat the upper neck area. At this point, most people have heard of Coolsculpting. This technology cools fat down to a certain temperature to where it will partial die, but leave the other structures intact. The CoolMini is a newer technology from Coolsculpting that uses more uniform cooling, and doesn’t require the full one hour to get treated. It’s suction grabs onto the fatty area and stays attached for the 45 minute cycle. It can be used to the central and lateral portions of the neck. If there are large areas needing treatment, more than one session is needed and more than one attachment is needed per session.
Pros: minimal or no downtime, can treat lateral as well as submental fat, proven technology that is permanent
Cons: treatment times are 45 min per application, might need more than one application and more than one session
Infini uses high intensity radiofrequency to treat excessive fat in the neck. It gets to the fat by use of the microneedling delivery system. It can go up to 3.5 mm which is into the superficial layer of fat. By adjusting the power and pulse duration, fat along the jawline, jowls, and submental areat can be treated. It is usually a series of 3 treatments, spaced about 4-6 weeks apart.
Pros: can treat all areas of fat in the neck and jowls, tightens skin as well and improves wrinkles
Cons: requires topical anesthetic (more painful than others), requires 3 treatments usually, mild redness and swelling afterwards for a couple days
There are now a few ways to treat the neck and double chin area. Which one is best for you is based on your desires, lifestyle, and anatomy. All are effective with minimal or non invasive techniques.