First and foremost, it’s nice to see that most of what the “experts” are teaching isn’t much different than what I am already doing in my practice. There were two rhinoplasty seminars with excellent talks by Drs. Bahman Guyron, Dean Toriumi, Ira Papel, Pietro Palma, Jack Gunter, Norman Pastorek and Peter Adamson to name a few. A few of the take-home messages that I got were tips on reducing pain for the patient in rib cartilage harvesting and techniques for straightening out a crooked nose, which is the most difficult skill for perfecting a rhinoplasty.
Facial fillers have always been a hot topic at recent meetings and still were in Boston. Of course, everyone has their favorite fillers. The fillers change with the volume and applications. For smaller volumes, hyaluronic acid fillers such as Juvederm and Restylane still rule. For fine lines, Prevelle Silk. As we get to larger volumes, Radisse takes over and for the most volume and longest lasting results, Sculptra is likely best. Dr. Rebecca Fitzgerald gave a 1 hour breakfast seminar on Sculptra that actually lasted for two hours. Sculptra is now injected deeper under the facial tissues, just on top of the bones in most areas of the face.
What new products did I discover? Finally PDS foil is FDA approved for use. This has been used very successfully for years in Europe for nasal support in very crooked deviated septum repairs, revision rhinoplasty and other areas of the nose as well. I was invited to attend a special meeting in St. Louis in early November to learn the nuances of this new product. I was fortunate to have received a sample, which I used to help repair a much deviated septum. This particular patient had two prior attempts at correction, but the nose was still very crooked. I will discuss this procedure next week.
As much as I have learned in my past 22 years of medical practice and teaching Facial Plastic Surgery, it’s still important to keep on learning and modifying my patient care techniques.
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
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.
This was the title of an article from Forbes.com 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?
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.