Pearl laser

Do you have any opinion on the Pearl laser? Is it gentler than other lasers on the market and would it be better for someone with very sensitive fair skin?
Also, what is the difference in using a Pearl laser (or other laser) to improve complexion vs a chemical peel?

hi,
i have not used the pearl laser myself, nor do i know of anyone who has it. i have taken a look at the wavelength and specs for the laser and read some of the MD comments and i can't say that i am very impressed. its tough to get good results with the minimally invasive lasers and pearl sounds like it may be a little less effective than fraxel. i prefer the active fx for skin resurfacing. it gets the job done in one session, as opposed to 3 to 5 with fraxel. i don't really like chemical peels very much - they are more destructive than lasers for the most part and you can't control a chemical peel like you can a laser.

How long do different wrinkle fillers last?

There's alot of wrinkle fillers out on the market today and it is sometimes difficult to figure out which one is appropriate for you. Fillers are also location specific - some belong in certain areas and are really not a good idea to inject in some areas. It is important to consult with a trusted and talented aesthetic physician and make a decision together.

Also, there is wide variation among individuals in how long fillers last. That being said, here is the average duration as I have seen it in my practice:

Radiesse - 8 to 12 months
Restylane - 5 to 7 months
Perlane - 6 to 8 months
Juvederm - 6 to 8 months, except under the eyes where it lasts for 1.5 years.
Juvederm ultra plus - 7 to 9 months
Sculptra - a long time - maybe 2 years
Artefill - many years - probably permanent

But.

Radiesse should not be injected in the lips or under the eyes. I like Sculptra in the cheeks, but not as much under the eyes. I think that Juvederm is a bit smoother and easier to use than Restylane, so I use it preferentially. I use Artefill only in select situations - mostly after the patient has tried a temporary filler like Radiesse and likes the effect. Mostly I use it for facial sculpting: chin or cheek augmentation, Non Surgical Rhinoplasty, etc.

I have also found that even the temporary fillers like Juvederm and Restylane stimulate collagen and when they dissolve, there is often a residual improvement.

Jowls, Thermage, Titan and Perlane

At 57 I have a thin face, no sagging of the neck to speak of, but weird looking jowls and marionette lines around the mouth. THe jowls look weird because here is this jawline with no neck fat and there they are--they almost look like growths in pictures. Anyway, I have researched everything and had four consultations. Two of the PS suggested a skin only minilift because the neck was fine and upper part of face isn't sagging--not even eyes. The Titan people have been very upfront about what they can and cannot do--they have told me that some people see very little results. Finallyl, one of the PS said since I was hesitant about surgery maybe fillers (radiesse) would be a good experiement. Most of the people on the forums I have asked say this would probably make the jowls look worse. The Titan is a $3000 gamble and I hear very little positive about it but it seems to me the best thing is to always try the noninvasive stuff first. Any thoughts on this? Also, I am sorry my question is so long. Thank you for any input.
Also, is Perlane a good joice for marionettelines and chin creases? Thank you.

hi,
i would definitely try titan or thermage first. i have seen very good results for the jawline. it is certainly worth it. fillers may be ok, but they're temporary.
perlane is a good choice. juvederm is also good.
cheers,

What's the best filler for wrinkles?

That depends!
I use Juvederm more than any other filler. It is smooth, soft, natural looking and temporary. Juevederm will correct most lines - deep or shallow really well.
Juvederm does last only 6 to 8 months, though. That's OK for some, but some people want a longer duration in areas like the nasolabial folds. Then Radiesse is an option, assuming the folds are deep. Radiesse is not good for shallow folds.
I do not use Sculptra much for wrinkles. I'm not that impressed by the precision of Sculptra's filling. It is really great for filling in large areas like the cheeks, but not as good for well defined lines.
Some people really want permanent filling, in which case Artefill is a good option. I have injected a good amount of Artefill and the results are good. The technique is important, so if you want Artefill, you should go to someone who has lots of experience with it.
Other fillers are in the process of being FDA approved, but these are the best ones available today, in my opinion.

Radiesse for Lip Enhancement?

A lot of people talk about how good Juvederm and Restylane are for lip augmentation, but I want something more permanent. Is it safe/effective to get lip injections of Radiesse?

Radiesse does not belong in the lips. It is a thick, calcium based filler that goes into the deeper layers of the skin. This makes it ideal for facial sculpting - filling in areas such as cheeks, chin, jawline, nose, and even the brow ridge. It is also a good longterm filler for the nasolabial folds.
The lips, though are a different story. You can't inject deep into the lips because of the particular anatomy involved. We have to use fillers that are injected superficially and are smooth. Juvederm is great for that. I think that it is even better than Restylane.
At this point, Juvederm is the only lip filler I would recommend. I would stay away from implants, silicone, Radiesse and other injectables that promise longer duration. The risk is not worth having lumpy or unnatural looking lips. There are new fillers getting FDA approval all the time, though. So, its just a matter of time before something good and longer lasting will be on the market.

Active Fx, CO2 laser and Who Should Do Face Lifts?

Hello,
I consulted with a derm, he has reccommended laser resurfacing for my crowsfeet and under eyearea (where my wrinkles are the worst) and a TCa peel elsewhere for general sun damage...... they have told me I will need 10-14 days off work --- what is the norm recovery time b/f you can go back out in public, how risky are these procedures, would a derm or PS be better? Are some lasers better than others?
Also he also suggested a mini face lift said he would do at the same time, is this safe? What about contour theards, less invasive?

hi,
there's alot of blurring between specialties in the cosmetic field these days - derms doing what surgeons do and vice versa. however, this goes beyond the pale. you should not be getting any kind of face lift from a dermatologist. they just do not have the same training as a plastic or facial plastic surgeon, and they are more likely to recommend the shortcut facelifts that do not last long and do not give you such great results. i'm not a big fan of threadlifts - the procedure is expensive and doesn't last very long, and the strings can pop, leaving you with a bad result.
although my training is facial plastics, i do not operate, so i'm not really biased one way or the other.
i think that full bore operative CO2 laser is overkill for eye wrinkles these days. active fx is a fractionated (less downtime, pain and redness, no need for anesthesia) version of the CO2 laser that has similar results. i think you can get all the stuff you want done without surgery, unless you really need a facelift because of alot of skin laxity. in that case, you should really consider the real thing - these little shortcuts really don't last very long.
hope that helps

Non Surgical Nose Job

I too have a bump on my nose. I was curious if the procedure makes your nose bigger looking?

hi,
no the procedure just makes your nose straighter. this makes the nose blend in better to the rest of your face. the nose actually looks smaller if it is in better harmony with the rest of your face.

http://www.westsidemedicalspa.com/non_surgical_nose.html

Active Fx for chest wrinkles

Hi Dr. Rivkin,
I have very good skin on my face because I have used sunscreens and a hat for many years. I am 58 but my face looks much younger. However, the same can not be said for my chest. I have alot of vertical wrinkles from not protecting my chest in the sun and the way I sleep sort of hunched over that creates wrinkles also.
I had microdermabrasion done a few years ago and that did absolutely nothing. Do you recommend peels or laser for this delicate area?
Thanks.
Jitterbug

hi jitterbug,
i've used lasers on the chest extensively, with very good results. my favorite laser right now for fine lines and wrinkles is the Active Fx. it does a good job of decreasing the wrinkles in about 2 or 3 session without alot of downtime (3 days or so) or pain. The Fraxel is OK, but it takes more sessions and is more painful.

Artefill Nose Jobs and VeraFil for lip enhancement

Hi Dr. Rivkin:

Happy New Year to you. I have several questions on the above subject matter.

1. Artefill used as non-surgical nose job: What are the limits with Artefill as compared to traditional rhinoplasty for building height to the bridge and tip of the nose ?
For example: If I wanted a higher bridge for my nose or a lift at the tip of my nose - can Artefill produce these results or Rhinoplasty can yield "height" better ? Or the limits are dependent on the patients actual nose ?

2. What are your thoughts on Perma and VeraFil for the nose, lips, and face and will you be offering them in the future in your practice ? If you don't offer/perform this can you refer a doctor in CA. that does ?

Thank you and I look forward to your reply shortly.


hi,
1. lifting the height of the bridge will depend on the individual patient. if you've had surgical rhinoplasty before, your skin will be scarred and it will not lift up nearly as easily as it would otherwise. i like to maximize lift by bringing people back 2 to 4 weeks after the intitial procedure to add to the bridge for more height. i can usually get a couple of mm on an unoperated on nose.

2. i'm suspicious of implants. you can't control the shape nearly as well and the chances of the lips looking unnatural is much higher. i would never consider something like that for the nose. the advantage of injections is that i can shape the lips according to the individual anatomy of the patient. i find it hard to believe that a pre-made implant can look good on everyone.

hope that helps

http://www.westsidemedicalspa.com/non_surgical_nose.html

CO2 Laser Resurfacing Around the Eyes

I had CO2 lower eyelid skin resurfacing with 2 laser passes. It was performed by a plastic surgeon. Today is my 13th day after the procedure. I have noticed the emergence of two deep wrinkles starting at the inner corners of my lower lids inner corners. They are about one inch and a quarter. Is that normal? Please let me know.


hi,
yes, i think that this is a consequence of normal swelling. the skin around the eyes is delicate, so swelling around there can take a while to resolve. the swelling often produces the kinds of wrinkles that you are talking about.give it about a week or so to resolve. i would talk to your doctor about what he likes to do to speed up resolution of the swelling.
hope that helps

How can I prevent wrinkles?

There are many factors that determine when and how many wrinkles you're going to get.
The first and most important is genetic. Look at your parents and your grandparents. Frequently the patterns of their wrinkles will be reflected on your face as well. You can use that information to determine where to concentrate your preventative methods. If everyone has deep 11 lines between the eyebrows, for example, you may want to think about Botox earlier rather than later to prevent the onset of those lines.
The second component is more under your control. Some of the things you do to your skin are not doing you any favors in terms of wrinkles.
Sun exposure - wear sunblock and don't go to tanning booths. C'mon - you know that.
Smoking - stopping will improve your skin and allow it to heal.
Dryness - use moisturizer and a good cleanser daily.
Oxidative stress - this one is a bit controversial, but it seems that antioxidant topicals like Prevage and others do help.
Making facial expressions - OK, I'm not saying not to do that, but over the years it will generate lines in certain areas (vertical lines
between the eyebrows, forehead horizontal lines and crow's feet are the classic ones). I'm also not saying to start Botox at puberty, but for
some people, preventative Botox in their late 20s to 30s (SMALL, non paralyzing doses) really keeps their face young.
Regular facials and microdermabrasion do help maintain your skin.
Don't listen to all the marketing hype about the newest cream or potion. Even if it has a doctor's name on it. Especially if some celebrity is hawking it on the Home Shopping Channel. Its a waste of money. Talk to friends you trust, doctors you trust and make up your own mind about a daily regimen you can stick to. If you keep it simple, you're more likely to follow a regimen.
If you just take care of your skin with simple things like these, you'll be far ahead of most people.

Active Fx and Under Eye Crinkles

hi i am an asian female 34 years old and i would like to soften the crinkles under my area. i already do botox for the crows feet, but everytime i smile, i feel like i age 10 years b/c of those crinkles. is there anything i can do for that area like chemical peel or laser resurfing? i have done microdermabrasion for the last 3 years and that doesn't help that problem. i have been using the obaji system with retin and i for the most part except for the crinkles my skin looks better than ever... my skin is sensitive so any suggestions are appreciated. thank you for your time and expertise


hi,
i would really recommend Active Fx. it is a fractionated co2 laser that came on the market very recently
i have been looking for a way to help under eye crinkles for a long time and have been really frustrated. the active fx is the only laser that i have seen that actually makes a difference for lines under the eyes. i tried fraxel, chemical peels - nothing worked.
i used the active fx on my nurse - she is a volleyball player and has extensive sun damage on her face and especially under her eyes. the results were great. she had about 4 days of redness and swelling and then she was back at work. the lines under her eyes and throughout her face were much improved and her pores were much smaller. i bought the machine after that and have been using it with great results for several months now.
the active fx laser will not damage delicate asian skin, but you have to be careful that the person operating the laser is experienced.

Accent Radiofrequency Device for Skin Tightening

hi,
accent is a radiofrequency device that is supposed to tighten skin. the technology is similar to thermage and titan. i have not really seen a huge difference in performance between the three devices. i have the thermage device none of them does a spectacular job.
i would not count on dramatic tightening. the pictures that they show are more dramatic than you're going to see on yourself. if you're ok with subtle changes, though, this may be a good treatment for you.

Radiesse Injection in the Nasolabial Folds

Hi Dr. Rivkin,

Is it possible for Radiesse to migrate a little? I have had Radiesse several times in naso-labial folds. Despite multiple injections in the upper part of the folds (lateral to the nares--I think some injectors refer to the area as triangles?), after initially looking corrected, that part of the fold seems to always show up again within a couple days to a week. I would have thought it was just the swelling going down and that I needed more filler, but I think I've had more than enough in that area to fill the folds over the last 2 months (I went back for more 3x's). When I've noticed the folds coming back I've wondered if the material moved to the ridge that's just above the fold making it all look worse. So I've tried to smooth/push it back down to the fold area which seems to actually work, but just temporarily. This problem doesn't seem to occur in the lower part of the fold that's injected.

Any thoughts?
Thanks!


hi,
what you are describing is really common.
you have to make sure that the person you are going to is experienced injecting radiesse because this is what happens when you put too much radiesse into the triangle area. unfortunately, there is a difference between a fold and a wrinkle. its easy to fill in wrinkles - more difficult to fill in folds. it may be that the skin in that triangle area will never lift up to where the fold is completely smoothed out. an experienced injector will stop before making the fold look worse by injecting too much in and having the material move above the fold. in this case, shooting for perfection may ruin a good result.
one solution if the area above the fold is visibly bigger is to inject steroids in there to bring it down. kenalog 10 should do just fine.
next time, i would consider using something like juvederm. you don't have to inject it quite as deep, so you will get more lift out of the skin. hope that helps

Under Eye Bags, Wrinkles and Hollows - Juvederm and Active Fx

HELP! I am a 56 year old woman looking to get a non-invasive face treatment especially to tighten the bags under my eyes, but also other some wrinkles around the eyes. With so many options, I am at a loss as to which treatment would give me the best results. I read Thermage is the treatment to go with but will Polaris or Arte the permanent filler be better for my eye problem? I am so confused!!! Is there something else for treating puffy eyes I don't know about? Also, can you give me the average cost and how many treatments would be needed for the procedure of choice?


hi,
well, its tough to tell you without seeing you firsthand.
tightening skin around the eyes is tough. thermage does an ok job, but not great. the only device i have seen that tightens under eye wrinkles well is the Active Fx laser. polaris is the same as thermage. artefill should never go under the eye. the only filler that should go under the eye is juvederm. it is smooth and natural looking and lasts for 1.5 years.
each is one procedure, not multiple. active fx runs about $3000 for the face, including the eyes, and juvederm under the eyes is $600 to $1000.
so, you may need a combination of active fx and juvederm, or you may need surgery if the bags are very prominent.

Fraxel vs Pixel, plus Lustra and Dermaplaning

Dr. Rivkin,
I have heard about pixel but am wondering how it differs from fraxel. I have hyperpigmentation in splotches on my face from a co2 treatment in early '06. I had 2 fraxel treatments which got rid of it by half. Not sure if I should try to use Lustra for a while to get rid of the rest. It didn't work before the fraxel. I'm concerned with it coming back by using Lustra. I am hopeful I can get some sun without it coming back. What do you recommend?
Also, I have a 3/4" surgical scar in the crows feet line of my eye. The fraxel helped alot, but am wondering if I can do something less expensive to level it off, as it is slightly indented. Do you think dermaplaning is a viable option and can I do it myself? Noone in the area I live does it.
Thanks!!!
Poundpup

hi poundpup,

i do not think that pixel gives you better results than fraxel. fraxel is the more established of the lasers and i think that it will give better results overall.

if lustra didn't work the first time, i am doubtful that it will work now. what about photofacial? if all you're concerned about is hyperpigmentation, perhaps IPL will do it for you. of course, you have to be careful of IPL if you have darker skin.

yeah, i would think about an at home microdermabrasion system for your scar - cheaper and easier way of levelling it off. i don't recommend dermaplaning - the results are very dependent on a good person doing it. the blade is very sharp, so there is some risk of injury. also, if it is indented, you should consider just filling it in with juvederm.

LED light treatment

Dear Dr. Rivkin,

What is your opinion of LED light therapy to reduce signs of aging? Do you think it's possible products for home use (such as the Baby Quasar) are actually effective?

Thanks,


hi,
i have LED light at my practice and i think that it is an effective antiaging treatment. blue light is certainly effective for acne. i only know about the in-office light treatments, though. i'm not sure about the at home treatments. are they any stronger than a flashlight? i don't know. i don't have alot of patients who use them, although i do have people who use at home microdermabrasion, and that seems to help.

Is laser skin resurfacing a good skin care treatment?

Lasers are a tool. Like any tool, they have very specific uses and limitations. Any particular laser has things that it is very good at doing and it has things that it is really not very good at doing.

It used to be that laser resurfacing meant that you went under general anesthesia in the operating room to undergo a full strength ablative CO2 laser treatment. Your skin was red, swollen and weeping for days afterwards and you needed several weeks to recover. The results were sometimes excellent, but sometimes there was hypopigmentation or a waxy cast to the skin.

About 3 years ago, the Fraxel came on the market. It was a new technology that permitted us to resurface the skin without the downtime and risk of the CO2 lasers. Instead of vaporizing an entire layer of skin, the Fraxel is a fractionated treatment. It places microscopic holes in the skin, leaving healthy tissue around the holes. Healing is much faster, we never see the pigmentation problems that the CO2 treatment caused and downtime is limited to a couple of days of swelling and a week of sunburn - like redness. The Fraxel is still the standard of care for acne scars and is one of the most popular lasers.

A new resurfacing laser has recently become very popular called the Active Fx. This is a fractionated CO2 laser that works similarly to the Fraxel (which is an Erbium laser). The Active Fx treats fine lines and tightens skin better than the Fraxel and it is a one treatment procedure (as opposed to the Fraxel, which usually needs 3 to 5 treatments to achieve maximal benefits). It will treat fine lines under the eyes and around the lips much better than anything else (including chemical peels). Downtime is similar to Fraxel and pain is less. Risks are minimal, but Active Fx should really not be used for dark skin yet. We don't know how risky it is for darker skin individuals.

So, laser skin resurfacing is now much safer, easier and cheaper. This makes it accessible to a much broader segment of people. The answer to the question is that yes, it is a good treatment, but you still have to have a doctor you trust check to see how good of a candidate you are.

Hypopigmentation after Laser Burn

Hi Dr. Rivkin,

I was burned by a Dr. with his laser. Now I have little white circles on my chest. Is there anythin that I can do? I try to put makeup on it, but...


Hi,
that is a difficult problem. i'm sorry.
there really isn't anything out there i know of to effectively repigment a hypopigmented area, especially after a laser burn. microdermabrasion can help blur the borders so that the spots do not stand out as much from the surrounding skin. active fx or fraxel may help, but i'm not sure - we're still investigating these lasers for hypopigmentation. i think you should do microdermabrasion about 5 times or so and see if you get benefit. if its not enough, maybe try a bit of active fx.
i'd love to know how it goes.

More Juvederm Under the Eyes Issues

I also had the same experience with under eye injections of juvederm. Bruising and swelling under one eye that was pretty bad, although the other eye was fine. I am 3 weeks out and have definite bags under my eyes from what I believe to be too much product injected. I have been to my doc for follow ups each week and he has said he thought I was still swollen and need to wait a bit. I can tell the product would look great if either the swelling would go down or just a bit of the product is removed. Problem now is that the doctor just told me that he has never injected hyaluronidase under the eyes! When he "sold me" on the juvederm procedure, he made it sound like he did this all the time. I am thinking I have been a guinea pig here--guess I should have asked more specific questions. In any case, no sense complaining, sounds like the problem is fixable, but I need to find a more experienced doc. So, I have three questions: 1. is is possible that what I am seeing under my eyes after 3 weeks is still swelling, even with the eye that I didn't have any bruising with? I can tell the eye that bruised still has some swelling. 2. Can you dissolve just a portion of the product or will the enzyme take it all out? Can you get lumps after the enzyme is injected if it only takes out part? 3. Can anyone recommend a doc with alot of experience in this that is close to Michigan? I will travel to some extent--either cheap flight or drive a few hours--chicago and detroit are both close. New york can be a cheap flight. Any suggestions? I truly believe that Juvederm has great potential under the eyes, but gotta find someone who does it all the time. I get the sense it is a tricky area and the bruising is hit or miss, even with an experienced doc.

Hi,
you're right - this procedure is tricky and should be done by someone experienced. hyaluronidase is a basic element of the procedure - there's frequently some reduction to be done.
to answer your questions:
1. i don't think that what you're seeing is swelling. i think that you're seeing too much product.
2. yes, you can dissolve part of it by injecting just a bit of the enzyme and it will not leave bumps. however, it takes experience to know how much to put in so that all of the juvederm does not disappear.
3. don't know anyone in your area really. i would ask the docs that sound like they do alot of these kinds of procedures exactly how much of the under eye juvederm they do.
hope that helps.

Sculptra after Chemotherapy

Hi:

My question is about the filler sculptra. I have read that it is good for AIDs patients because it fills in the depressions that are a result of illness. I do not have AIDS but I recently finished up treatment for breast cancer. As a result of the chemo I ended up with a lot of depressions in my face especially in the area of the chin and under the cheek bones. I am a thin person anyway but my face appears to have lost more than the rest of me.

I finished chemo 18 months ago - I had lost a lot of weight but have been putting it back on. I am 48 and I was hoping for a non-surgical "fix" to just fill things out a little. I don't want surgery because I had too much of that but thought that I deserve to do something nice for myself and would like to see if I can get back a little of my pre-cancer face.

Thanks
Jeannie



hi jeannie,
first of all, congratulations on finishing chemo. i know that this was a hell of a process.
in terms of the sculptra, i would want to know if these are separate small depressions or a few large areas of indentation. if it is large areas, then sculptra will be a good choice. it is a very safe product and as long as it is injected by someone with experience and an aesthetic eye, the results are very good. the downsides of sculptra are that it is expensive and you will need to have 2 or 3 separate injection sessions in order to achieve optimal results. results last for a couple of years or so and are very natural appearing.
hope that helps

Puffy Eyes and Dark Circles

I have puffy eyes with dark circles under them, and everyone always says I look tired. What can I do?


There are usually four components that make up the appearance of puffy and tired looking eyes.

1. Dark pigmentation of the skin under the eyes. Usually genetic.
2. Fine lines and wrinkles throughout the lower and upper lids - "creppy" skin.
3. Bulging of the skin under the eyes caused by fat tissue that is "pooching" out.
4. "Tear trough" under eye area indentation caused by loss of volume with age in people that are genetically prone to having this problem. A shadow falls into the indentation, causing the dark circles that give a tired appearance.

Loose upper eyelid tissue that overhangs the eyelid is another element in making the eyes look tired, but we're concentrating here on the lower eyelids.

1. Not alot that can be done about this. Bleaching creams with hydroquinone or kojic acid sometimes help.
2. The only solution to this issue is laser treatment. The only laser that I have seen that actually makes any difference in under eye wrinkles is the Active Fx. The treatment is quick and easy, with about 4 days of downtime. Results are dramatic.
3. This is usually a surgical issue. If there is a large amount of bulging, only blepharoplasty with fat repositioning will really help. However, if there is only a small to moderate amount of bulge, I usually use Juvederm under the bulge to camouflage the appearance. If you raise the skin under the bulge with a filler like Juvederm, filling in the valley underneath the bulge, the observer no longer sees the bulge. Its a bit tough to explain - I have lots of examples on my website.
4. This is the situation that is most common in my practice. Time and genetic predisposition cause an indentation in the "naso-jugal groove" (the area underneath the lower eyelid), a shadow falls into the groove and the person's eyes appear tired. This is easily corrected with a hyaluronic acid filler. I prefer Juvederm because it is smooth and lasts for over 1.5 years in that area. This is a technically difficult procedure and should be done by experienced injectors only, so if you're thinking of having this procedure done, you should certainly find out how many the doctor has performed.
Aside from filler there lasting 3 times as long as any other area, the otehr unique quality to the under eye area is that it is pretty much painless. The skin doesn't seem to have alot of pain nerve connections.

How Do I Get Fuller Lips?

Lip enhancement is an art. If done correctly, it is one of the more difficult of the non surgical procedures because the shape of the lip is individual and complex. A good lip augmentation has to have the following qualities:

1. the lower lip should be a little bigger than the upper lip and can roll out a
bit in a pout.
2. the upper lip should have the shape of the cupid's bow area in the middle
preserved. The lip should not go straight across - it looks fake that way.
3. the upper lip should have a smooth and well defined transition from the red of
the lip to the skin. It should not have a big ridge - that looks fake too.
4. both lips should be symmetric from one side to the other and they should be
smooth. There's nothing that looks more fake than bumpy lips.

My emphasis in lip augmentation is always on a natural, subtle look. The patient's friends should not immediately notice that she has had her lips augmented. They should just notice that she looks great but they should not be able to put their finger on why.

The difference between a good and bad job with lip enhancement is a matter of a millimiter or less. This is why I really do not think that imprecise techniques like fat injection, surgery or insertion of solid implants like Alloderm or GoreTex are any good.

I use Juvederm exclusively these days - I find that it is less likely to have bumps than Restylane and it seems to last a bit longer (5 to 7 months). Any of the hyaluronic acid fillers do a good job - Restylane, Perlane or Juvederm - as long as the doctor or nurse injector is very experienced doing lips with that filler.

Another major point with lip augmentation is that it should never hurt. I still have people coming to me who recall their previous lip injections with horror because the injector used topical numbing creams. Lips should always be numbed with a dental block. They are some of the most sensitive tissue in the body and sticking a needle in them hurts like hell. Fortunately, septocaine and other dental injectable numbing preparations do a great job at making the experience completely painless.

Juvederm Nightmare

Hi Dr Rivkin.
I hope you can tell me what you think of my problem. This has really got me down. Back in the fall I had a couple of skin cancers removed from my face by a local dermatologist. The one on my cheek required an incision. I was left with a scar over a half inch long. In November I went in to get checked and the doctor suggested Juvederm for the incision. He also said he would inject it under my eyes. To tell the truth, I didn't know why because I'd never noticed wrinkles there.
I knew nothing at all about Juvederm and feel I was talked into this treatment. This dermatologist even told me that if I was unhappy with what he did, I wouldn't have to pay. So I agreed to it. Biggest mistake of my life.
He ended up putting it under my eyes and in the crease on both cheeks (that incision was very near the crease on one side). The procedure was very painful. He pushed and pushed the gell around and I can out of the office very swollen. Of course I thought this was normal and didn't say anything.
By the next day, I had terrible purple bruises under my eyes and on my cheek near the incision. I was also in alot of pain. I have photos if you'd like to see them. The bruises lasted for over a week.
It's been months and I am left with these puffy areas under my eyes. They look terrible.
When I went to the doctor several weeks after the procedure, I told him how unhappy I was, I showed him pics of my bruises, and I told him that I wanted my money back. He insinuated that I was kuckoo by asking if I was going through a tramatic event in my life. He obviously was trying to get out of giving me my money back.
He gave me some kind of medicine for inflammation and told me to come back in two weeks. I ended up cancelling the appointment because I figured it would be a waste of my time. He'll never give my money back.
Have you heard of any experiences like this? Do I have any recourse? Is there anything that I can do to get rid of this swelling?

Thanks so much for any reply.

Dawn

hi dawn,
it sounds like you had a bad experience - that sucks.
the good news is that you can certainly get rid of the puffiness very quickly.
you should go to someone who knows what they are doing and have them inject an enzyme called hyaluronidase into the puffy area. the enzyme will remove the juvederm and will make the puffiness disappear overnight. tell the doctor to put just a little bit in - that way only part of the juvederm gets dissolved and perhaps you will keep the positive effects but get rid of the swelling.
i assume he put the juvederm in there because you have dark circles under the eyes.
unfortunately, bruising and swelling for this kind of procedure are fairly common. some people get none and some get lots - its random.
its pretty tough to get your money back in this kind of situation if the doc is unwilling to engage in a discussion. i would say that you can usually negotiate free treatments, but it doesn't sound like the type of practice that you'd want to go back to.
well, the good thing is that your situation is very fixable.
hope that helps,

Ice Pick Acne Scars and Active Fx

My sister has bad"ice pick" scars. Would a filler like artefill correct this? Most of her scars are on her nose,it looks bad.

hi,
ice pick acne scars are very difficult to treat. if there is only a few of them, i would consider treating with fillers. artefill or juvederm would be fine. if, however, there's alot of them, fillers may not be the best option. a laser such as fraxel or active fx would be better. i have still not evaluated active fx for acne scars, but i hear good things about it. fraxel works, but it takes a while and involves multiple treatments (about 5). the advantage to active fx is that it is only one or two treatments and it is more intense than fraxel in terms of results. downtime is the same.
hope that helps

Non Surgical Nose Job Questions

Dr. Rivkin,
i had a septorhinoplasty procedure 2 years ago. I have been left with a scooped out ski-slope type profile. Can this procedure be used to fill in this scooped out part and make my nose appear straight?


hi,
yes, absolutely. i have used filler to fill in aggressively resected dorsums and it works really well. the nasal profile looks perfectly straight afterwards.



Dr Rivkin
I am really considering getting the non surgical nose job. I would love to have you do it, but I live in NJ, so you are quite far away from me. I was wondering if you know of any doctors near me that you trust would do just as good a job as you?
Thanks
bubbies

hi bubbies,
unfortunately, i do not know of anyone out there doing this procedure well. i know a few people doing it out there, but no-one good. i have plans to start
teaching it soon, but i have not yet set up the training structure. most people fly out for it if they can afford the time. its still a big savings over surgery and, since its LA, people make a little vacation out of it.


http://www.westsidemedicalspa.com/non_surgical_nose.html

Thermage Worries

Hi, I've been reading some negative outcomes about Thermage on the board. Am very upset because I had it done in Sept, 2007--realize I should have researched more before spending almost $3,000.--but was sold on it being safe by a bunch of local Doctors. What is your opinion on this procedure? So far I have not noticed any bad side effects, such as fat loss on the face or denting and sagging. But I feel like I look more bloated rather than firm, and it comes and goes at times--esp. goes after working out. Have I done something terrible and permanently damaging to my face by having this procedure? When do I know if I'll not have any bad side effects? Thanks for any info, comforting or not.

hi,
if you had the modern day version of thermage (in office procedure, no anesthesia) you should have nothing to worry about. the accounts of fat loss and denting are all about the old version of the machine.
the benefits of the technology are subtle. the improvement is not nearly as dramatic as surgery, but for alot of people that's all they need to correct a little mild skin laxity. i find that it works best around the jawline, by the way.
the bloating is strange - i have not heard that be a side effect of thermage.
so, all in all, don't worry - you have not done anything terrible.
hope that helps

Thermage, Refirme and FotoFacial

I have an appt to get both these procedures done later this week. However after reading some horror stories about Thermage (fat loss, indentations, etc), I'm really wondering what to do. Isn't Refirme very similar to Thermage? And it's so new. The doctor seemed to think I was the perfect candidate for both these treatments as I have brown spots and acne scarring (both readness and some indentations). I'm 43, and I'm also noticing my neck skin getting loose. But I'm mostly looking to smooth out the texture of my face.

Any thoughts on the safety of these procedures, particularly Refirme?

Thanks!
CC

hi CC,
the accounts that you are reading about thermage are old. the thermage system and radiofrequency technology in general have imporved in the time frame since these reports. i have a thermage system and i have not had any trouble with the treatments, in fact they have had better than expected results.
it used to be that the machines were designed to deliver high intensity energy deep into the tissues. this was painful and dangerous. we have seen that lower intensity works just as well and the current machines (thermage and refirme) are therefore safer, less painful and more effective.
fotofacial is not going to do that much for skin texture, although it probably will help with the redness.
hope that helps,
cheers

Permanent Non Surgical Nose Job using BioAlcamid

do you think bio-alcamid is an option as a filler for the non-surgical nosejob?
im in europe and some ps use it on face.
i want to use permanent one and i think bio-alcamid is.

hi,
unfortunately, bio-alcamid is not FDA approved in the US at this time, so i don't know that much about it. i do know that it is supposed to be permanent and i have heard that it is a good filler. the most important thing is to choose someone who is experienced in performing the non surgical nose job procedure, especially since you want to use a permanent filler. here, i use artefill and it gives good results. you also have the option of using a temporary filler first and then converting to a permanent one later.
hope that helps,

Juvederm in the Under Eye Area

I'm considering having Juvederm injections in my Tear Troughs. Can you recommend a good surgeon in the Boston area?
Also, do you think Juvederm is the best filler for the Tear Trough area?

hi,
yes, i think that juvederm is the best filler for the tear trough area. it is the smoothest, longest lasting filler on the market for this area. juvederm will last for over a year and a half there. interestingly, it only lasts for 6 or 7 months everywhere else. i can only think that there is more collagen stimulation under the eyes than in other areas, due to specific anatomic singularities there.
one thing about juvederm is that it is reversible with an enzyme called hyaluronidase. so, if the results do not look good, your doctor can always adjust them by injecting a little enzyme.
the most important thing is that you choose someone who has alot of experience injecting filler into that area. it is a tricky procedure and a plastic surgeon is not necessarily the best person to do it. the criteria to choose a provider of a particular cosmetic procedure is how experienced they are in that specific procedure. a plastic surgeon may be very good at it, but not always. it may be that a dermatologist or an oculoplastics specialist is better (i'm not biased - my training is facial plastics, but i do injections exclusively).
i would suggest asking colleagues or friends and reading internet information to determine who is good in your area. its tough, but the information is out there.
cheers,

Active Fx

Hi Dr Rivkin,
I was reading a post below about how the activ FX is good for crepey undereyes, and was wondering if this could be used on the arms. I have lines developing on my arms and am really starting to freak out about what to do about it.
Thanks heaps.

hi,
usually, the active fx laser is used for the face, but i think that using the active fx on the crepey arm skin should be no problem. it will depend on how dark the arm skin is, of course. i'm still hesitant in using the active fx for darker skin. the cost of it will depend on how extensive the surface area to be treated is.
but overall, i think it is a good idea
cheers,