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Surgery with Symmetry
Injectables
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Injectables refer to products that are injected underneath the surface of the skin to add volume to the face or reduce wrinkles. Most products are temporary. However, products like Sculptra® offer more permanent results (more on Sculptra® below). Under the umbrella of injectables are fillers and chemodenervation (AKA Botox®, Dysport®)
The function of Botox® is much different than the function of fillers. Botox® and Dysport® act to relax muscles of the face to reduce wrinkling like crow’s feet and forehead lines. Fillers add volume to areas where fat was lost or to camouflage areas where tissue has fallen from age. This latter strategy is often termed liquid facelift.
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Correcting Jowls
Jowls are a definitive marker of facial aging. Face lift surgery is a wonderful procedure to correct jowls, as well as the mid face and neck. However, not every man and woman with jowls wants or needs a face lift—or any surgery for that matter.
To understand correction of the jowl, it is helpful to understand its anatomy. The jowl is composed of fat and skin that hangs in the mid portion of the jaw. It develops from both descent of tissue and loss of fat both in front of the jowl (referred to “pre-jowl”) and behind (“post-jowl”).
Thus, to correct the jowl, one of four options exist:
- Lift the jowl with surgery. A jowl lift is a major component of a face lift. With a face lift, the tissues beneath the skin called the SMAS is suspended. This includes both the cheek and the jowl.
- Remove the jowl. Liposuction can help eliminate unwanted jowls to a degree. Because the jowl is composed of loose hanging skin as well as fat, men and women who may benefit from liposuction of the jowl will have reasonably good elasticity of the skin. And, their jowls must not be just an issue of skin laxity.
- Thread lift. Thread lifting can offer a mild to moderate temporary correction of the jowl. With thread lifting, one to two barbed threads are placed per side under the skin, and the undersurface of the skin is pulled and secured by the barbs. Depending on the type of thread, the amount of threads, and the properties of the skin, thread lifting for jowl correction may last three months to over six months. It is unlikely that the results of thread lifting will last over a half of year anywhere on the face (or body).
- Fillers to camouflage jowls. With proper placement of dermal fillers such as Restylane ®, Juvederm ®, Radiesse ®*, Voluma ®, and Bellafill ®, the jowl can be camouflaged to a remarkable degree. Because the jowl exists with both pre-jowl and post-jowl concavities, volume placed in these regions to meet the jowl at its lowest point will eliminate the appearance of the jowl. Depending on the type of filler, one can expect results to last u to two years or longer, as in the case with Bellafill ®. The case here illustrates this technique. Both of the blue areas represent the pre-jowl and post-jowl sulcus. 1.5 cc of Radiesse ® was injected into these regions to hide the jowl. Results are immediate with little to no downtime.
*Radiesses ® is composed of calcium hydroxyapatite, which is the natural component of bone and teeth. It is considered a “semi-permanent” filler because it aids in the generation of collagen formation.
Differences
The most common injectable products are the hyaluronic acid based products such as Restylane®, Juvederm®, Perlane®, Belotero®, Volbella® and Voluma®. They differ by manufacturer, indication, and duration.
Temporary Fillers
Restylane® and Juvederm® are the most diverse fillers available for soft tissue augmentation. They are FDA approved for various areas, yet off-label use remains popular and safe as well. Juvederm® and Restylane® last about six months. Belotero® lasts three to four months and Voluma® results extend one to two years.
Voluma® is one of the newer long-lasting hyaluronic acid product available. The company that manufactures it, Allergan®, claims it lasts two years. However, its duration is likely related to factors such as anatomical region and other individual tissue properties. The product is more viscous than its cousins and is most effective in creating lifting effects on the face. Voluma® is not indicated for the lips.
Belotero® is indicated for fine wrinkles of the face, such as the smoking lines of the upper lip. Restylane® and Juvederm® are often used for deeper wrinkles, folds, depressions from volume loss, or cheek enhancement. While fine wrinkles can be reduced with Belotero®, the results are temporary. On the other hand, a good CO2 laser peel may produce results in the same areas that are much longer-lasting. The indication for Belotero® is minimal, but it does work in the right person for the right problem.
Semi-permanent Fillers
Radiesse® is calcium hydroxylapatite, the natural mineral component of bone and teeth. Its use is less diverse than the hyaluronic products, but it probably lasts longer because it may stimulate production of one’s own collagen. This benefit may classify Radiesse® as a semi-permanent filler. Radiesse® cannot be used in the lips or close to the eyelids, since nodules can develop in these areas. However, it works well for filling the cheeks and lower third of the face.
Because Radiesse® is firmer than hyaluronic acid products, it is Dr. Neavin’s product of choice for the jawline in men and women. Unlike hyaluronic acid products, Radiesse® cannot be reversed with injection of an enzyme, hyaluronidase. It must be removed by aspiration or surgery. Thankfully, it is an exceptionally rare situation that one would ask for the removal of this product. However, in patients who have never had fillers, Dr. Neavin often likes to start with a hyaluronic acid product for this reason.
Because Radiesse® is firmer than hyaluronic acid products, it is Dr. Neavin’s product of choice for the jawline in men and women. Unlike hyaluronic acid products, Radiesse® cannot be reversed with injection of an enzyme, hyaluronidase. It must be removed by aspiration or surgery. Thankfully, it is an exceptionally rare situation that one would ask for the removal of this product. However, in patients who have never had fillers, Dr. Neavin often likes to start with a hyaluronic acid product for this reason.
Permanent Fillers
Sculptra® and Bellafill® are perhaps the longest lasting injectables. Sculptra® is made of polylactic acid. It is generally injected multiple times over the course of several months to stimulate production of collagen. It cannot be used in the lips. The drawbacks to this product are price (it is more expensive than the other products), the need to pre-mix 24 hours prior to injection, and the risk for granulomas if the formulation is not injected deeply enough or mixed properly.
Sculptra® probably requires the most experience for successful injection than the other products. The company actually mandates that their injectors become certified via training with another skilled injector. Injectors should have a good understanding of facial sub-units and beauty to produce the best possible results.The results of Sculptra® are not immediate.
Bellafill® is an product composed of 80-percent bovine collagen and 20-percent PMMA (polymethylmethacrylate beads) to create immediate and long lasting results. After injection, the collagen will go to work immediately and add volume. However, over time the body will metabolize the collagen, and the effects will rely on the scaffolding properties of PMMA to generate new, permanent collagen. Allergy skin testing is required prior to injection. Bellafill® treats many areas of the face and can be used to smooth away acne scars. It is not indicated for use in the lips.
Neurotoxin Therapy
Chemodenervation (Botox®, Dysport®, and Xeomin®) acts by weakening muscles that contribute to wrinkles of the forehead. Injections of these products into the muscles can reduce or eliminate the wrinkles they generate. The downside to neurotoxin therapy is that It only last about four months (Dysport® produces even shorter results than Botox®), and over-injection can cause paralysis of the muscle resulting in the frozen face that has given these products a bad name. However, when used in moderation, these products truly refresh the face while still allowing animation of the brows.
Bruising from Botox® and Dysport® is rare. The most bothersome complication with these products is lid ptosis (drooping of the upper eyelid). While this is uncommon, the risks are not zero. It is generally thought that this develops from inadvertent migration of the toxin to the small muscle that helps keep the upper lid raised, known as the levator muscle.
Weakness in the levator muscle results in a dropped lid. If an injector tells you that this never happened to them, it is likely that they simply haven’t injected enough foreheads, or, they are not being truthful. To minimize this risk, an understanding of the regional anatomy is important, but not sufficient to eliminate the risk completely.
In addition, patients should be told not to exercise for 24 hours when the lower forehead is injected for fear of vasodilation and toxin migration. The good news is that this rare event is temporary and generally resolves within 3 to 6 weeks. Sometimes specific eye drops to stimulate the muscle can be applied to alleviate the droop.
Anti-Aging
This is a good question, because it is somewhat counter-intuitive that the addition of volume to a face can rejuvenate the face. To understand this phenomenon, one has to understand the components of a youthful face.
Skin: Young skin has small pores, good elasticity (tightness), and consistent color that lacks colored spots. It is generally void of wrinkles at rest.
Volume: Young faces are filled with fat, even in the thinnest man or woman. An extreme example of a fat, youthful face is a baby. As one ages, this fat is slowly lost. The fat that does remain descends. The result of fat loss and descent is shadows in the form of depressions or valleys. By filling in the valleys or depressions, we are basically restoring the face into one that is more youthful.
Shape: Young faces in women are heart-shaped, or top-heavy. As we age and volume is lost, the heart shape flips upside down and one is left with an older, bottom-heavy face. The goal for facial reshaping with fillers is to restore volume of the upper third of the face. Cheeks and cheekbones can be augmented with products such as Restylane®, Juvederm®, Voluma® or Radiesse®. The lower third of the face that may have developed jowling can be camouflaged with the addition of these products in front (pre-jowl) and behind the jowl (post-jowl) to generate a smooth jawline.
In the right hands, a combination of filling and camouflaging with products can take years off someone’s face. In fact, when used properly, it can give the illusion of a facelift. Thus, such procedures have been termed liquid facelifts. The results can be dramatic.
The photos illustrate jowl camouflaging and liquid lifting.
Are injectables safe?
Yes. Every time someone elects to receive an injectable they are asked to sign a consent form. The consent forms for these products are very long and they discuss virtually every potential complication witnessed with injectables. The good news is that complications from injectables are usually limited to bruising and swelling that resolve within a week.
However, this is a buyer beware industry, meaning that anything on those consent forms can potentially happen. It must be emphasized that even in the most skilled hands of board-certified plastic surgeons, unfavorable results can occur. Consumers should do their research and take injectables very seriously. At best, complications can be reduced, but never eliminated. In the event of something unpredictable and rare, you are better off with an experienced plastic surgeon to manage it. The following is an example that illustrates why you should have someone qualified inject your face:
Why Experience Matters
Skin necrosis. This is a very rare complication where the product embolizes or compresses an artery that provides blood flow to the skin. This very rare event can happen to the nose when the laugh lines are injected. Or, to the nose when the nose is injected.
Generally, a skilled plastic surgeon will ask (or evaluate) the patient to see if they had a prior open rhinoplasty. If so, he or should should know that one major artery to supply blood flow to the nose has been cut (columellar artery), leaving just the right and left angular arteries to supply the nasal tip.
These vessels sit deep near the laugh lines. If products are injected into this area without a good understanding of the anatomy, the vessel can be injured, compressed, or embolized, rendering insufficient blood flow to the tip. If this happens, it can be identified immediately if one knows the signs and symptoms of vascular occlusion. If it isn’t detected immediately, the results can be devastating.
Thankfully, vascular occlusion can often be reversed if identified AND if the doctor knows how to manage it (aspirin and immediate injection of hyaluronidase injection, and warm compresses). However, many offices don’t have this product available or have never used it.
Let’s say the complication is detected, the office has hyaluronidase (Vitrase), and it is immediately injected. There is a very, very small chance that anaphylaxis can develop resulting in intense swelling of the airway, obstruction of breathing, and death. I am aware of this happening at least once in Beverly Hills (to a major celebrity), and it was reversed with an epinephrine injection from the doctor who was smart enough to have it stored and ready to use. In the wrong hands, the outcome could have been far worse.
While this is an extreme example of what can go wrong, it is intended to make a point. Don’t skimp on your cosmetic treatments. Make sure the person injecting you knows what they are doing and your chances of something bad happening will be reduced tremendously. You will also enjoy a superior cosmetic result.
Botox® is most widely known as a vehicle to treat facial wrinkles particularly in the forehead, frown lines, or crow’s feet. But it has other uses, too.
Botox® has gained tremendous popularity over the last five years. It works by temporarily weakening or paralyzing the muscles that cause wrinkles and it works very well for this purpose. It usually takes a few days for the medication to begin working and its effects can last up to four months.
Botox® also has some other very interesting uses in the cosmetic world. Botox® is FDA-approved to treat excessive sweating in the armpits, feet, and palms, a condition known as hyperhidrosis. This is a helpful procedure for men and women who do a lot of hand shaking on the job or rely on gripping for work. Just one office treatment can last as long as six months or more.
Botox® is also used to treat migraines and severe headaches. Just a small injection in the frown line area has been shown to significantly reduce the incidence and intensity of migraines. Although the mechanism isn’t completely understood, it works and works very well for most patients.
Also, Botox® can also be used to feminize the face by shrinking the jaw muscles in women. This is done with just a few tiny injections in the jawline.
The video below demonstrates how volume can also be added to rejuvenate the hands.
Below, Dr. Neavin demonstrates the use of PRP for hair growth. More on hair restoration can be found at the Artisan Hair Transplant site here
Dr. Neavin has extensive training and experience using all types of injectables and can tailor your procedure to meet your needs and aesthetic goals. To learn more about these procedures, contact Artisan of Beauty Plastic Surgery today at 310-858-8811 or text 323-975-1287.
Dr. Tim Neavin is an outstanding plastic surgeon Professional with an uplifting bedside manner to make you feel comfortable post surgery; he sees the beauty in you and improves it with the right cosmetic technique so that your results looks as natural as possible. – Helena
Dr. Tim Neavin is an outstanding plastic surgeon Professional with an uplifting bedside manner to make you feel comfortable post surgery; he sees the beauty in you and improves it with the right cosmetic technique. – Hugo
Dr. Tim Neavin is an outstanding plastic surgeon Professional with an uplifting bedside manner to make you feel comfortable post surgery; he sees the beauty in you and improves it with the right cosmetic technique so that your results looks as natural as possible. – Tina
Dr. Tim Neavin is an outstanding plastic surgeon Professional with an uplifting bedside manner to make you feel comfortable post surgery; he sees the beauty in you and improves it with the right cosmetic technique so that your results looks as natural as possible. – Helena
