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Facial Fillers New York City

Facial Fillers – Juvederm, Perlane, Radiesse, Restylance and Sculptra

New and better ways to use facial fillers for facial folds and anti-aging

New York City, NY – As I perform more and more facial filler treatments, I am using less and less in the nasolabial folds and more in the mid-cheeks for a more youthful appearance.

Most patients seen in consultation for treatment with fillers point to their nasolabial lines and folds. The nasolabial folds are the lines and folds that go from next to the nostrils to the corners of the mouth. They are caused by the facial muscles inserting into the skin at that fold. Smiling, laughing, living creates the folds and etched lines in the overlying skin. Add this to sagging of the cheeks over this fixed line of attachment. The cheeks drape over the fold creating a mound that exaggerates the fold.

When patients with nasolabial folds are examined, most have both the fold and the mound. As explained above, the mound is partially draping of the skin and underlying fat/muscle over the fold. A third contribution is age related loss of volume in the mid-cheek.  If we just fill the nasolabial fold below, patients might appear almost like a rhesus monkey. What most patients really need is refilling of the mid-cheek area, and then only a little filler is necessary for the nasolabial fold. By re-inflating the cheeks, the nasolabial mound and fold are lifted up and out creating a natural, more youthful facial appearance.

If you want to simulate what this looks like, just smile. Mid-face fullness might be one of the reasons why people look better when they smile.

Which fillers do I use? For first timers and those who need a little filler, I prefer 1 to 2 cc of Juvederm Ultra Plus. A little more, Radiesse and for the most volume and longest lasting result, Sculptra.

Steven J. Pearlman, M.D., F.A.C.S; Facial Plastic Surgeon

Sculptra New York City

Facial Fillers New York City

New York City, NY – This is a filler update from the Fall AAFPRS meeting, where there was a big push from the new fillers on the block. Though Sculptra has been around for years to treat facial wasting, it was recently FDA-approved for cosmetic use to treat “shallow to deep smile lines (nasolabial fold), contour deficiencies and other facial wrinkles.” However, many of us facial plastic surgeons have already been using it for years as “off label” for cosmetic treatment of the face.
Over the past decade, we have taken a new look at facial aging. Faces don’t just droop and get wrinkles, often they lose volume. Dr. Sydney Coleman was one of the first doctors to disseminate that concept, and treated facial volume loss with fat liposculpture, which was a powerful adjunct to treating facial aging. Some patients really don’t need facelifts, and others need both volume replacement and lifting. Until Sculptra – as well as some of the other longer lasting fillers such as Radiesse, Perlane and Juvederm Ultra Plus – fat was the best option. However, fat rejuvenation is a surgical procedure that comes with prolonged healing and downtime, and some patients only retain 60 to 80% of the injected fat on average, so results are often unpredictable. And to inject more fat requires another semi-major procedure. You might also be one of the rare patients in whom 100% of the fat lasts, resulting in an over-filled face.
Alternatively, Sculptra, a non-invasive injectable, can treat volume loss precisely and effectively in just two to three treatments… no operating room, sedation or significant recovery required.
Results typically last two or more years.
Why Sculptra instead of other fillers? This is really a choice to be decided upon between physician and patient. As I mentioned above, Sculptra may require two to three treatments a month apart, lasting an average of two years before it starts to slowly go away. No other fillers last as long. So, do you want to have this “in and out” treatment with little to no down time and maybe a tweak in one and two months, or get treatments every 6 to 9 months with other fillers, which can be costly over time. Though Sculptra is more expensive, it really doesn’t cost more than shorter-lasting fillers when amortized over two years.  

Before Sculptra

Before Sculptra

After Sculptra

After Sculptra





Facial Fillers New York: Juvederm, Restylane, Perlane, Hydrelle, Prevelle Silk and Prevelle Shape

To continue my summary of new innovations presented at the fall meeting of the AAFPRS in San Diego, I am going to review the latest Hyaluronic Acid (HA) facial fillers. New fillers are continually being developed and released on the market. Which are good, which are not so good and which are going to fade away – that is fade from use not just fade from your face.

The fastest growing selection of facial fillers is the HA fillers. One of the first to be FDA approved and widely used was Restylane followed by Juvederm. Along with Restylane there is Perlane, a thicker version and Juvederm Ultra Plus; a thicker version of Juvederm. Historically, Captique and Hylaform were early contenders but these fell by the wayside as not measuring up to Restylane and Juvederm. New to the market is Hydrelle; the first HA to have local anesthetic right in the syringe. Many of us now combine HA with local anesthetic to reduce the discomfort on injection. This saves a step. However, will Hydrelle stand up as a filler? The presentation on new fillers compared Hydrelle to Captique, which really couldn’t hold a candle to Restylane or Juvederm.

An exciting new pair of HA fillers are Prevelle Silk and Prevelle Shape. These also have local anesthetic. According to the new technologies seminar, Prevelle Silk has the smallest HA particle size. This may work well for treating very fine lines in the skin, especially around the mouth. Right now, the HA options of Restylane and Juvederm can be used, but when injected too superficially, the clear gel may be visible as a bluish bump within the skin called the Tindal effect. A smaller particle should reduce this potential side effect. For really small, superficial lines, the best stuff out there right now is Cosmoderm, but there is a rumor going around that Cosmoderm and Cosmoplast might be dropped from production due to low sales from HA competition and high production costs. I will definitely try Prevelle Silk since it will fill a needed niche in facial fillers.

Next week I will expand on fillers (no pun intended) to discuss Evolence, Radiesse and Sculptra.

Looking Gorgeous:, Botox, Restylane, Juvederm, Radiesse

This was the title of an article from that I was quoted in: Looking Gorgeous: What Women Won’t Give Up. I have been lucky to have had very good media exposure in the past, including recent mentions in Vogue, More and New York Magazines. However, all I’m asked lately is how the economy has affected business.  Cosmetic surgery and other aesthetic treatments such as Botox and Facial fillers (Restylane, Juvederm, Radiesse, Cosmoderm,  Perlane, Sculptra, Evolence) really can be categorized as luxury items. Given the state of the economy, people are becoming more choosey about what they do and should be more choosey about who they go to.  I did send discount cards to many of my recent Botox and Filler patients. I apologize if we missed you; my lists aren’t totally up to date. If you were left out, just mention this blog when you come in for treatment and we will honor the same discount for the next 6 months.

My offering a discount was quoted in Crain’s in the February 16-22 issue. Or should I say misquoted. I did say that “I sent out discount cards to my loyal patients.” However, during the interview I also qualified that by stating that this discount was JUST for Botox and fillers. Surgery is a more personal issue. It should not be about negotiating fees. I feel that once you find the surgeon who you trust, it should be more about getting the right result from a specialist instead of discount surgery. If you go elsewhere and get discount surgery, will you also be getting a discount result?  

I feel the same about fillers and Botox. Any doctor can purchase Botox legally, even dentists! The physicians with the most experience using Botox and Facial fillers are termed “core specialists.” These include Plastic Surgeons, Facial Plastic Surgeons, Cosmetic Dermatologists and Oculoplastic Surgeons.  There is a website with information called the Physician Coalition for Injectable Safety. Treatments are now offered by Family Physicians, OB-GYN’s and many other specialists. And yes, dentists too. Don’t get me wrong, I know a few primary care and GYN docs who are excellent practioners of facial injections. They have advanced training and perform many of these treatments. It’s the doctors who only perform these treatments occasionally and learned at a one day for profit course you should steer clear of.

So first and foremost, it’s your face. Do you really want to skimp? Make sure your physician has the proper training and experience. If they give you a nice discount, GREAT. If not, is it really worth saving money to have a less than ideal result?

Beautiful cheeks

As I perform more and more facial fillers to restore youthful cheeks, I continue to be excited about the wonderful changes we see with only one or two cc’s of filler. Most patients who are candidates either ask about treating nasolabial lines and folds (they run from the corner of the nose to the mouth). However if you look more closely at their cheeks, as people age beyond the mid 30’s we lose the baby fat that gave us youthful fullness. Remember those cheeks that your aunts and grandmother used to pinch?

Now, when I look closely at these cheeks, I often see a mound (cheekbones), hollowness beneath, then a nasolabial “mound” then the nasolabial fold. Filling just the nasolabial fold doesn’t go very far in making patients appear more youthful. What I prefer, and most patients agree, is to first restore volume to the cheeks. I use filler to restore volume under the cheekbones. Then I need only a little filler in the actual nasolabial fold since the volume restoration lifts the nasolabial folds up and out. On “beginners” we often start with only 1 cc (syringe) of filler. For more volume, 1 per side is sufficient. To enhance cheekbones, the filler can be tailored to each patients’ needs by highlighting, restoring or creating beautiful cheekbones as well.

What filler do I like to use? On a first-timer, I usually start with Juvederm Ultra. This is the smoothest, most mold-able filler and it gives the most subtle enhancement. I sometimes use Restylane as well but find that Juvederm is more mold-able. These fillers typically last from 6 to 9 months in the cheeks. For more volume and a longer lasting effect the next choice is Juvederm Ultra Plusor Perlane (basically, this is thick Restylane). These fillers provide more volume. Plus they often last from 9 months to a year. Want even longer lasting effects, especially for building high cheekbones? I will address this in a future blog. It is what I call Runway Cheeks. The next choice following hyaluronic acid fillers (Juvederm, Restylane and Perlane), I use Radiesse, for a 1 year plus result.

When patients have very hollow cheeks and require a large volume replacement. My first choice is Scuptra. Using one’s own fat for fat transfer is also an option.

So for beautiful, youthful cheeks there are many options. The best option is to come in or visit your favorite facial plastic surgeon for personalized recommendations. By the way, the same choices and process applies to melolabial folds or marionette lines that run from the corners of the mouth downward.

Relax and fill your face

Over the past two decades facial rejuvenation has made a large paradigm shift. As facial plastic surgeons, we used to do two things to the face: peels or dermabrasion for skin color and texture, and facelifts to surgically lift sagging faces. Now we do more commonplace things: Fill theFace. Enter Botox®; Botox®  has been used for cosmetic purposes since the early 1990’s and was first published in medical literature in 1992. I don’t feel I need to go into much more detail here since Botox® has been significantly covered by the lay media and in advertising. Check out my site link for more info: The other area of facial rejuvenation that is rapidly growing, both literally and figuratively, is facial fillers.  Looking back to the early 90’s, we had very few choices for facial fillers. Other than a few fillers that came and went, all we had was Collagen. Collagen was an excellent product to treat facial lines. The addition of Zyplast, a thicker version of the original Zyderm type Collagen, allowed us to go a little deeper and treat some facial folds. Some docs even started injecting Collagen into lips (beautiful lips are another story for another time/blog). The biggest drawback of Collagen treatment was that it didn’t last very long, plus you had to come in for a test one month prior to make sure you weren’t allergic. 

Around the same time that Botox® was first being used for wrinkles, my friend Dr. Sydney Coleman was modifying the once little-known technique of fat transplantation to create what is considered to be one of the most dynamic contributions to cosmetic surgery for that entire decade. Despite controversy over the longevity of fat transplantation, Dr. Coleman expounded upon the concept of facial deflation with aging. Few surgeons ever considered this third dimension of facial aging: that we lose facial volume as we age. From the first time I saw Dr. Coleman lecture on facial fat transplantation, it became evident that facial volume loss is significant in many of our patients. However, performing fat transplantation correctly to get longevity is akin to a surgical procedure and may be accompanied by significant post-treatment swelling. As I started to perform fat transplantation, I realized that the evaluation of facial volume is necessary in all patients.  With the new Millennium, so came new fillers to the market. With so many available fillers we have long lasting products that can be taken out of a box instead of surgically removed. The process of facial volume restoration is now much simpler. We can treat facial lines, wrinkles, folds and even restore significant volume loss without a surgical procedure.  So, which filler to choose? Firstly, are we treating lines, folds, crevasses or volume? Treatment differs for each. The more superficial the wrinkle, the thinner the filler required. Longer lasting (thicker) fillers often leave lumps. The filler needs to fit the treatment; here are my current choices for facial fillers.  

  • Superficial etched or “stiletto” cut lines. These can be along the corners of the mouth, smile lines around the mouth (naso-labial folds) and around the eyes: Cosmoderm, Restylane Fine Lines (not FDA approved so I don’t carry this yet), and Juvederm
  • Facial folds, naso-labial folds and marionette lines below the corners of the mouth: Juvederm, Restylane
  • Crevasses (deep folds), same as facial folds only deeper: Juvederm Ultra, Perlane (thicker version of Restylane), Radiesse
  • Facial Volume Enhancement, cheeks, hollowing below the cheekbones, jawline, temples and under the eyebrows: Juvederm Ultra, Perlane, Radiesse, Sculptra, fat grafting 

When deciding which filler to choose, an easy guide is: the longer a filler lasts, the higher the price, the longer the healing time and potential side effects.  I purposefully left out the latest filler to be approved, Artefill. I choose not to use Artefill at present. Its predecessor, Artecoll was available in Europe and Canada in the past. Some patients developed granulomas (small lumps under the skin) up to three or four years following treatment. The manufacturer claims that the cause has been eliminated. Since there are so many reliable options already available, I prefer to wait a few years to make sure Artefill is completely safe before using on my patients. If you are being offered this by a surgeon I advise you to research further before consenting to Artefill injections. Remember, all aging still cannot be fixed with injections.

We can relax and fill the face but none of these (nor any existing laser) can really re-suspend sagging facial tissue like surgery. Beware when you are told about a “non-surgical” facelift. A true non-surgical facelift does not exist; it is fancy marketing speak for in-office quick fix procedures that are, in essence, nothing like a facelift in technique or result. Needle injections, lasers and peels can make faces look much younger but they will not lift the face. So, which facelift, short flap, deep-plane, SMAS lift or lifestyle lift is right for you? I will address this in a future blog. 

For those of you who had the kindness and interest to read to the bottom, what’s filling up my life are my new twin girls born October 2, 2007. Certainly not a relaxing undertaking to be sure, but the ultimate definition of “true beauty” as far as I can see. 

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