Palomar Lux 1540 vs Active Fx

Dear Doctor,

I am considering having a series of 4 laser treatment for the area around my eyes which looks hollow with fine lines/crows feet and slightly puffy.
The instrument to be used would be the Palomar Retractional Laser. I understand that the results last up 15 years which is why I am seriously considering it.
Any information you can give me would be greatly appreciated.


hi npm,
i assume that you are referring to the palomar lux 1540 fractional laser.
this is a fairly new device that is a that companies version of the fraxel. like the fraxel, its an erbium laser. its an ok device, nothing amazing, though. one thing i can say for sure, though, is that the effect does not last for 15 years. i have the fraxel and the active fx, so i've seen what fractional lasers can accomplish. the results are impressive considering there is little downtime, but the best one is the active fx. the others, fraxel included, give subtle results that last a couple of years.
no device can stop time, and promising 15 years is pretty silly.
in my opinion, active fx would be more worth your time and money. it is more expensive, but results are really good. take a look at the internet reviews for the 2 devices.

Tear Trough / Under Eye Treatment with Juvederm

Hello, Dr. Rivkin.

I had Juvey Ultra done yesterday in several places on my face, one syringe total. I had one NL fold done (other was still holding up from previous filler injection) and the orbital area of both eyes (not really TT area) and one lower cheek area where I had some focal fat loss (ugly blue bruise there now).

I have what this doctor said is mild malar/festoons (ugly name isn't it?) under one eye in particular. He said no surgery would fix it.
The worst bag looks like a Nike Swoosh (their trademark) or crescent moon shape about 1/2" below the orbital bone rim--I have prominant cheek bones. It's worse or more noticeable in certain lighting. Since this puffy area rests about 1/2" below the top ridge of my orbital bone, there's a slightly concave area between the top of the orbital bone and the beginning of the puffy area. Does that make sense? Anyway, he suggested filling in the area the below the bags, slightly and very deeply??? The way he explained it was a little lost on me, but he was confident it would help. In hindsight, it was not such a good plan. Since he injected the Juvy, the bag looks MUCH more noticeable to me. He went deep as it hurt a lot. I'm worried that since this area was already susceptible to swelling/edema anyway, that even after the Juvey dissipates, it will always look worse.

Okay, background info done...Here is my question: I know malar bags are the bane of existence for most PSs as there appears little solution for them. But, based on my description, could some type of filler be put in between the orbital rim and the puffy area to make it all one level and perhaps make a smoother transition (more of a half moon than a crescent) or would that just make this all that much more puffy looking?

I should have left it alone but others have had success with fillers in this area and this new fellow came highly recommended. Now I'm left with a more noticeable problem than I had. Suggestions? Sorry this was so long, I have a problem with brevity.

Thank you very much.

D


hi D
first off, get the juvederm dissolved with hyaluronidase. there's no reason for you to suffer for a year and a half with larger malar bags.
in terms of whether anything else would work, i'd have to see a picture of you to know for sure, but in general when injecting the undereye area, an experienced injector is extremely important. so, make sure that this doc has done alot of this specific procedure.
also, don't lose hope. i have had patients where we went back and forth a few times - filling it in and bringing it down, but it looked really good in the end and lasted several years.
cheers,

My opinion on Fat Transfer

Dr. Rivkin, I had fat transfer to my nasolabial folds about three years ago. It was a bust and didn't hold up beyond several weeks. A different PS injected my lips with Resty several months ago (just to restore a little volume loss due to aging) and I was really pleased with the results. This doc says fat transfer for the naso labial lines and lip enhancement is the gold standard. When I told him about my former experience with fat transfer he told me that he gently "sifts" the fluids from the fat rather than centrifuge it and feels that his methodology renders a longer-lasting result. I've found some negative postings about fat transfer to the lips - that even years later you can develop lumpiness. I'm really torn as to what to do. The Resty is a very nice product but my results only lasted maybe four months. That gets pricey. I would appreciate hearing your opinion of fat transfer for the lips & naso labial lines.

hi kellster,
i'm glad you asked.
i do not like fat transfer and i do not do it.
no matter what anyone says about their magic, super-duper way of processing the fat and how it lasts forever if they do it, fat is unreliable.
it can last a few months or it can last a few years, and no-one can tell you ahead of time what's going to happen.
the other problem with fat is that it is not that precise, whereas you have to be super precise for the lips to look good and natural. you never want to lose the cupid's bow of the top lip or the gentle curve of the bottom.
i have been injecting restylane and juvederm for a long time. they are both super precise and i find that juvederm ultra plus lasts longer than restylane by a few months (about 7 to 8 months total).
i've seen that, after a few sessions, there is collagen stimulation that tends to last, so you tend to need the injections less and less often.
the same points apply to nasolabial folds
hope that helps

i just read the story about the teenager in florida dying from plastic surgery a few days ago.
although she didn't die because she was a teenager, graduation present boob jobs are really ridiculous! these parents should really have their heads examined.
there should be ethical restraint among some of these plastic surgeons - they are doctors, after all!
18 yr olds are still growing (especially breasts) and just shouldn't get elective surgery, no matter what that does for the surgeon's financial well being.
having a nose job at 17 because the girl has a big bump or has a real cosmetic irregularity is one thing - the nose matures faster than breasts and no-one thinks that someone is ugly because they have an a or b cup.
also, boob jobs need to be redone every 10 years or so, so if you're starting at 18, you're committing that girl to 3 or 4 re-operations. that is a guarantee of scarring and unnatural appearance, as anyone who does breast surgery will admit. its one thing to be in a society with twisted morality that values big fake boobs. its much more twisted to actively participate in that process by performing these operations on young girls and subjecting them to these kinds of risks.

Lip Enhancement

I recently had my first lip augmentation with Restylane and I like the results but with my budget I was wondering when I return for another treatment which filler is noted to last the longest ie: Restylane, Radiesse, Juvaderm, etc. I want the most for my hard earned money. I want plumper lips, but not hudge lips that people will know I had my lips done (which I have now, but after 3 weeks I already see them starting to decrease in size).

Also is it normal for my lips to appear larger when I wake up in the morning than when I go to bed at night?

hi,
first off, yes, its normal for your lips to look bigger in the morning - its swelling overnight - that happens. as long as it resolves during the day, i wouldn't worry about it, its going to decrease.
second, i would try juvederm ultra plus in your lips. it should last for about 7 or 8 months or so. never do radiesse in lips - the risk of bumpiness is too great. restylane is good, but in my experience, it lasts about 5 to 6 months. perlane may be another good option that lasts as long as the juvederm ultra plus.
so, those are the only 2 i would consider for you: ultra plus or perlane, and i prefer the ultra plus right now.
in terms of natural looking enhancement, that is something that a good injector will be able to provide you. i rarely use more than 1 cc of product in the lips (and that's for both lips). you can always come back if its not enough to get more. natural appearance is absolutely critical. if the injector doesn't get that, you should find someone else.
cheers,

Botox

I got my last Botox injections 6 months ago. Had the 11's done, forehead, crows feet, above eyebrow. I do not have complete movement back in my those area (can move some) but I want to go get the botox next week because my doctor is running a special for $10 a unit and I have a cruise I am going on in April and I want to look good.
Question.........I would think that because I do not have total movement back that I would not need as much botox but nurse is trying to tell me that I still need just as much because I need to "bank" the botox. Have you ever heard of that? Also, I want the doctor to look at my face as if I am coming for the first time and not rely on what I already had done even though it did work at the time. What do you think?
Jitterbug

hi jitterbug,
6 months is a long time. usually botox lasts for 3 or 4 months, but not too much longer. it may be that you are getting that long term relaxation effect that happens sometimes with botox.
that is good.
when you get botox, you should be getting only as much as you need.
if you're moving less, you should be getting less botox.
period.
i have never heard of this "banking" business.
i agree with your approach completely. that is how i do things as well.
cheers

What can I expect during recovery from a cosmetic injection?

What you can expect following a cosmetic injection depends not only on you and how your particular body reacts to the injectable, but also on the skill of the injector.

Bruising, swelling, redness and discomfort after injections vary with the patient and with the injectable agent used. That's true. However, a good injector will be able to dramatically reduce the likelihood of these after effects.

First he or she will communicate with you and determine what your downtime tolerance is. If you are going to an event in a few days, Radiesse would not be a good filler to use - there is too much of a risk of bruising and redness. If, however, you are prepared to tolerate some short term bruising but want a filler that lasts the maximum time, then some of the thicker, longer lasting agents may be what you will select. Communication between you and the physician or nurse is key. If you do not feel like you have it, you should go to another practitioner.

If the injector is gentle and knowledgeable, they will know subtle techniques that minimize bruising and redness. They would know the fillers and Botox well and how to inject without leaving a significant mark. They will also know how to achieve good results without alot of needle sticks. Experience is key.

Finally, the office should tell you what to expect, depending on the filler or injectable used. They should be happy to answer questions and they should respond to concerned phone calls with compassion and patience, even if they're busy.

Smoking and Plastic Surgery

I went for my first consult today with a PS. I was heavy smoker for years and finally quit a few weeks ago. Was inquiring for a forehead lift and neck lift to be done this summer. PS told me that I will never be a candidate for any cosmetic surgery due to my smoking history. The smoking damage has been done and it's to late.
He did say my skin was wonderful and if not for the smoking history I would love the outcome.
Is that your policy also?


hey peeker,
well, i don't do operations, so i don't deal with this question much. however, i really doubt that, because of your smoking history you are forever excluded from cosmetic surgery.
it was pretty cruel to say that if you hadn't been such a big smoker you would have had a great result.
last time i checked, the pope did not give doctors license to make moral judgements about our patients.
i think that you should get some more opinions - you'll probably hear that if you wait several months you can get cosmetic surgery.
cheers,

LED devices for home use

Hi Doc,
I have seen these at-home devices advertised on the Internet. I was wondering if the really have any effect at all...on acne, wrinkles etc? They claim to rebuild the skin.

Thanks,
Amber


hi amber
i wish i could tell you.
they don't give alot of specifications on the enrgy used, etc. if you can find that, i can compare it to the devices i use in the clinic - i have led light devices - and tell you how intense or non intense they are. my guess is that they are a weak version of the devices i have.
i can tell you more if i see the numbers.
in general, led devices work if used frequently. the effects are subtle, but not bad.
cheers,

Skin Care Questions

Good morning Dr. Rivkin - thank you so much for your recommendations on skin care lines as well as your other advice - so appreciate it!! I do have a few more questions (ofcourse)!

Can I purchase these products from your office on-line?
Also - you mentioned using a retina at nite - how often do you
recommend and is that in place of a nite time moisturizer?
Do you think it's important to have a day time moisturizer (I also
apply a spf of 45) and then a nite time one too - or can I use one
moisturizer am & pm?
You mentioned micro treatments - do you mean microdermabarion
home treatment kits - I do have one but hardly use it.
Do you ever recommend alpha lipoic acid products for exfolliation?

Can't wait to try the eye last treatment -sounds amazing.

One last question - I have some broken blood vessels and the foto facials zap them temporarily - but they do creep back; lighter but still around.
What type of laser do you recommend for this problem???

Next time in LA would love to come for a consultation -you've been so helpful and honest - thank you again!!!!

Laura



hey laura,
1. sure, just let the front desk staff know and we'll ship it out. the number is 310 443 5273
2. no, the retin-a goes on first, massage it in, and then put on moisturizer.
3. i think that simple is best - one for both
4. no, i mean microdermabrasion treatment in the office. the home kits are usually pretty useless, i think. the only one i recommend and know is revision at home treatment.
5. well, i don't know them very well. doesn't mean they're not good. i just know the retin-a, microdermabrasion and glycolic or salicylic products.
6. i would consider yag laser - should work better than ipl.
yes, it would be a pleasure to see you in the office.
cheers,
azr

IPL vs Fraxel and Active Fx

Aloha Dr.
I went to the dermatologist yesterday for a body skin check (no problems anywhere). I asked what I could do that wasn't drastic to even the skin tone on my face, I have sun spots and age spots.

He immediately suggested IP Laser, also he offered that he could get rid of the lines around my mouth with the same treatment.

Is this a good idea? Would that really work? How long do those results last? He told me I may need up to 5 or 6 sessions or I could be lucky and see results in 2 or 3 sessions. Any input would be appreciated as I am clueless about lasers. I am nearly 5 years post op from f/l, mid f/l, bl and alloderm lip enhancement.
Many thanks and aloha.


aloha elaine,
i'm sorry to say that an IPL (intense pulsed light) device will not remove the lines from around your mouth. it does not go deep enough into the tissue to cause the kind of remodelling that is necessary to smooth out lines, especially the deep ones around the mouth.
IPL is pretty good with spots, and he's right in that treatment sessions required to make a difference do vary. most people need 5 sessions and then they need to really watch out for the sun. use sunblock and wear a hat or the spots may come back.
if you want to treat the spots and the lines, you would need more of a resurfacing laser like fraxel or active fx. i would recommend the latter. there's a bit of downtime, but the resurfacing effect is really good. it is, however, more expensive (about $2500 to 3000 for one session, which is all you should need).
hope that helps

Hyaluronic acid lump in lip

Hello

I have recently had half a syring of hydrfaill with a bad result - the product has collected in the wrong part of the lip
if I was to use hyaluronidase to correct an uneven result I have had recently with Hydrafill, would it dissolve all product in the mouth or would you be able to inject a tiny amount into certain areas without it spreading?
I have been having injections for 10 years and am happy with the size of them so am worried it will completely dissolve them and I will have to start from scratch
Thanks

hi sally
hydrafill is not available in the US, so I had to look it up. its a hyaluronic acid filler, similar to restylane. all of the hyaluronic acid fillers are temporary, so you would not have to worry about dissolving built up hyaluronic acid. hyaluronidase is very effective at dissolving hyaluronic acid and yes, i use it to dissolve small parts of an injection. around the eyes, for example, i sometimes need to bring down a small part of one saide and i can do that effectively by putting in a small ammount of hyaluronidase.
i would certainly go to a physician who has lots of experience with fillers and hyaluronic acid ones in particular. someone who has never used hyaluronidase would have a hard time figuring out the ammount of enzyme to use.
cheers,

Lumpy Artefill

Hello Doctor,
My doctor put .08 of artefill in my n/l folds four days ago and so far it looks pretty good, except there's a small lump on one side of my nose, it's kind of red still and when i touch it, it feels like there's something in there. i tried to smush it down, and that didn't help. i'm wondering if there's any hope that a) it will subside or b) some of the substance can be removed?
thanks for your time!
Karla

hi karla,
this is a common problem.
four days is not a long time, so most likely it will subside, but i think that it desrves to be looked at by your doctor. if he/she is injecting artefill, he/she should have no problem seeing you back even this early with concerns about lumpiness. at this early stage perhaps he can massage it flat. lumps is the only real concern with artefill, so you have a legitimate question.
cheers

Kinerase vs Prevage, Vivite, IS clinical, Skinceuticals

Hi Dr. Rivkin - thank you for the information on skin cells in skin care - you did just save me some $$$'s!!

Do you recommend a skin care line that is more advanced targeting fine
lines, texture of the skin and overall clarity? I have been using Kinerase
products - they are fine but nothing amazing!!

Thanks again - Laura


hi laura,
yeah, i agree - kinerase is nothing amazing, but pretty good.
we carry a few lines - i pick and choose products between lines.
i like IS clinical and skinceuticals for their antioxidants and serums and cleansers. i like prevage for antioxidant and fine lines. some of the prevonia line is good and the vivite eye creams are good. we also carry revitalash and it works like a charm - my staff all have bushes growing out of their eyelids!
the products i like are the physician exclusive lines - the over the counter stuff doesn't really do much.
my position on products is always to keep it simple. using something once in a while doesn't really help - its repetitive use that works. so, get a good cleanser, moisturizer, sunscreen, antioxidant and eye product and you should be ok if you use them regularly. also retin-a at night. that helps treat sun damage and aging. you can use micro every day or every other day, depending on whether it irritates your skin.

artefill vs bioalcamid for chin enhancement

I will definately take your advice and go for artefill rather than bio-alcamid.
I actually had 2 syringes of radiesse (my apologies, I think I originally said 2 cc's) injected for a non-surgical chin procedure. And the doctor informed me that if I choose to decide on a permanent solution for my chin, that bio-alcamid would be best.
I have quite a weak chin and he injected the radiesse into my jowls as well (to make it appear smoother).

I would like to go permanent though. How long shall I wait before a permanent solution such as artefill? Does the radiesse in my chin have to be completely gone or somewhat gone? For anything permanent, I have always planned a visit to you and this decision has been confirmed by your honest advice. How much (approximately) does the equivalent injection (2 syringes of radiesse) for artefill cost at your clinic?


hi orilia,
you don't to wait until its all gone, but you should wait until you see that it is mostly gone. if you do not, you'll have to make more trips out.
if you come out here, try, if possible, to stay a week. artefill is partly collagen, so after the injection it fades a bit over the following few days. it would be nice to do the injection and then see you a week later for a touch up. if this is impossible, i would ask you to come back in for a follow up visit a month or so after the first visit.
i would start with less than 2 syringes - maybe 1 to 1.5 and then do the rest on the touch up. artefill is $1500 per syringe, but if you're doing a couple, i will charge you less than $3000.
hope that helps,

Is laser hair removal painful?

Good Laser Hair Removal Does Not Have to Hurt!
Alexander Rivkin, M.D.Alexander Rivkin, M.D.
Los Angeles Facial plastic surgeon

It is very simply incorrect to say that effective laser hair removal will be painful. Each laser device hurts more or less depending on how it is made, what energy it uses and how that energy is released. Most clinics will claim that their laser is the best one. However, as a consumer, you should get multiple opinions and make up your own mind.

Diode works well, Alexandrite works well, even IPL can work well. But, depending on the machine being used, the experience can be extremely different. I started with an IPL device because it could perform a variety of treatments (laser hair removal, photofacial, vein treatment) moderately well. When my practice expanded and I could afford it, I bought a LightSheer Diode because it was a more effective laser hair removal device. The pain factor was about the same (maybe a bit more with the LightSheer), but the results were certainly better (less treatments to achieve hair clearing). About 6 months ago I sold my LightSheer and bought the Soprano Diode because, as I experienced on myself, it was a close to painless experience. The effectiveness is the same as the LightSheer, but I barely felt it. My clients have echoed my enthusiasm.

I'm not trying to give a sales pitch, just relating my own experience. Ask around, gather your information, but don't accept the simplistic "if it doesn't hurt, it's not working" line.

I've heard a lot about Fraxel. Acne has always been a problem for me and I have the scars to prove it - can Fraxel treat acne or acne scarring?

Fraxel is a very good treatment for acne scars. It does make a difference (how much of one really depends on the individual, but the difference is certainly noticeable after a few treatments) and that is more than I can say about any of the older technologies. Currently, Fraxel is probably the standard of care for acne scars.

That being said, I am not sure that it is the best treatment out there for acne scars. Fraxel hurts. Topical numbing cream and oral pain medication help alot, but it is a hassle to get 5 or more monthly treatments that are uncomfortable. There is some downtime with Fraxel - at least 3 days of redness, some swelling and some peeling. Then you look like you have a sunburn for a week. This can be covered with make-up, but its also a hassle. My biggest gripe with Fraxel, however is that I do not think that the results are good enough. Even after 5 or more treatments, I still see the scars. Sure, the skin is smoother, but the scars are still noticeable. I think that we can do better.

I am looking at the Active Fx device for acne scarring. It is already good with fine lines and pores. The Deep Fx head should make this device excellent for acne scars. It is more aggressive than Fraxel, but it hurts a bit less. The downtime is a bit more, but perhaps by 1 day, not more than that. We still do not have a consensus opinion, but physicians outside the US who are using the Deep Fx and the few docs that have it in the US give it rave reviews for acne scars. I think that it is not going to be a one time procedure, but after a couple of treatments, the improvement should be better than Fraxel could ever do.

Does Sculptra work for lips?

Sculptra is best in the cheeks and other areas where you want to get more fullness in an section of the face of large surface area. Sculptra is a collagen stimulator, not a filler. It works slowly over time and it is not as precise as fillers are.

Aside from the cheek area, I like to use Sculptra in the temples to replace volume lost as a result of age, weight loss or other causes. It makes people look less gaunt, and more youthful. These days, most good aesthetic physicians understand that a youthful appearance means recapturing the fullness and volume that has been lost over time, not just pulling the skin or erasing lines.

That being said, I do not think that Sculptra belongs in the lips. Lip enhancement is a procedure that requires precision and finesse. Sculptra is not a tool that provides precision and finesse. It is also designed to be injected into deep skin, not into the muscle and not underneath the superficial mucosa of the lips.

Artefill vs BioAlcamid for permanent Non Surgical Nose Jobs

Hi Dr. Rivkin,

To obtain a permanent look (I have tried radiesse and am happy with the result and would like to go permanent), so my question is....which is better....Artefill or Bio-alcamid? Is there a reason why you do not offer bio-alcamid (note, I am from canada and have seen bio-alcamid adverts)? Since you invented this, I am confident with your professional opinion.

In addition, if I had 2 syringes of radiesse used, what is the equivalent in artefill and bio-alcamid? Do you personally use more or less of the product or is the amount the same as radiesse?

Thanks in advance.


hi orillia,
i assume that you are referring to the non surgical nose procedure.
first of all, i really doubt that you had 2 cc of radiesse actually injected into your nose. you may have been charged for 2 cc, but that's an awful lot of filler to put in your nose. i usually use about 0.5 cc or less. maybe the doctor charged you a procedure fee (although that's pretty expensive)?
anyway, i don't have experience with bioalcamid personally, but i know some information about the product. what i know concerns me very much. i would recommend that you (and anyone you know) stay away from that product under all circumstances. there are many rather gruesome stories throughout europe of bioalcamid problems (lumps, infections, etc.). i think that it is a truly inferior product and will ultimately disappear from the market.
artefill is ok, and it is the permanent filler that i use.
it will require multiple follow ups, but will give results similar to radiesse. you have to be very careful who injects it because, as a permanent filler, there's no going back. make sure that the doctor has plenty of experience with artefill in the nose specifically. don't take any chances.

Treatment Resistant Acne - What To Do?

OK-I am 52 years old and still break out. I have tried everything-laser, dermabrasion,peels,antibiotics, 2 rounds of accutane, topical lotions and potions and every other product known to mankind.
I still have oily acne prone skin. I am at my wits end. Every doc has a different "treatment" and nothing seems to work. I travel quite a bit and break out just from sitting in airplanes. No matter how much I work out, eat right and use good skincare practices, I get zits.
I have drawers filled with retina A prescriptions, topical antibiotics, benz peroxide, etc.
My derm recommended hormones!! Says its all related to testosterone. I am a female and still menstruate.
Any thoughts? What really works? I have spent thousands and just want clear skin.


treatment resistant acne sucks.
i have a good number of people just like you in my practice.
its a matter of trial and error, but i think its really important to hit the acne from several directions.
hormonal treatment is a good idea. birth control pills and spironolactone will help. the other thing to consider is photodynamic therapy - a blue light treatment with a light sensitizing topical treatment. getting the acne under control with extraction facials is also a good idea.

What can I expect from permanent lip augmentation treatments? What are my options for permanent lip augmentation?

There is currently no permanent filler that is FDA approved for use in the lips.
Artefill is the only FDA approved permanent filler and it can be used for the naso-labial folds and other areas of thicker skin in the face, but it should never be used in the lips.
There are several doctors using silicone for lip augmentation. The process involves several injection sessions and is gradual. I have seen good results, but I have also seen really terrible results. Trouble is, when the result is terrible, there is absolutely nothing you can do.
I am in the process of FDA trials for a permanent filler that is quite popular in Europe, Asia and South America called Aquamid. It looks like it will be good for the lips, but is still awaiting FDA approval.
Fat transfer to the lips can have good results. It can also have not so good results because the surgeon has to overcorrect and then hope that when it comes down it looks good. Also, the duration of effect from fat transfer is variable. I personally do not like the technique very much.
It may be a pain to come back every 6 to 8 months, but take my advice and just do Juvederm or Restylane. We will be able to do reliable, precise, permanent lip enhancement within 1.5 years. Don't take unnecessary risks. This way you know that, if you go to a good injector, your lips will look natural and you're not harming yourself.

What should my doctor do to minimize pain during laser treatment?

There are several ways to reduce the pain of a laser treatment.

The first and easiest way is to select the least painful laser. Laser hair removal is a great case in point. I recently switched my clinic's hair laser from the Lumenis LightSheer to the Soprano system by Alma lasers and it has been a great move. I know that this will sound like I'm just trying to promote the laser that I have - but its really not. This laser is markedly less painful than the others we have used. Clients say so and so do I - I get it on the back of my neck. It is just as effective as the lasers that feel like you're being being branded.

If you're getting IPL / photofacial, you usually should not use numbing cream - it affects the results. Vicodin an hour before, however, is a great idea.

For Fraxel, Active Fx and other lasers that hurt you can use a combination of Vicodin, Xanax, numbing cream, ice and cool air (during the procedure). Most people sail through the procedure (actually "fly" would be the more accurate description of the experience) on this kind of combination treatment.

The other piece of advice is to go to a reputable clinic (duh!) with an experienced doctor who cares enough to have the most potent numbing creams and good technicians who are speedy and empathetic to your experience.

Why are Radiesse injections so painful?

Radiesse is a good filler, but it is thicker than others and so hurts and bruises more. On the other hand, it lasts longer than many fillers and can be injected into the deep tissues.
Discomfort depends on a few variables. One is injector skill. Good injectors know how to inject quickly and with a minimum of pain, no matter what they are injecting. Another is anesthesia. It is nice to do a nerve block with Radiesse. In the marionette lines, that is often difficult. One other technique is to have your injector mix the Radiesse with a bit of lidocaine. Experienced injectors should know how to do this. Ice before and after the injection is also important to prevent pain and bruising.
If you go to someone who is experienced (not the cheap-o guy in the weekly paper), they should discuss all this with you before the injection.

How can I ensure my cosmetic injection is safe?

Cosmetic injections can be divided into 4 categories: neurotoxins (Botox), fillers (Restylane, Juvederm), collagen stimulation agents (Sculptra) or fat injections.
Safety concerns depend on the injectable that you are seeking to use.
Botox is very safe. It is derived from a poison, but, despite the recent press brouhaha, side effects are miniscule if you take into account how many of these injections are performed around the world. As long as you go to an injector (MD or RN only!) who is experienced, who uses the US FDA approved product exclusively and who performs the procedure in a medical setting with proper lighting and cleanliness, you will be safe. Doing your research into the injector is, of course up to you.
Don't be like most of the US population who puts more time into researching what TV to buy than what doctor is going to change their appearance!

Fillers and Sculptra often require more talent to administer well than Botox. The same rules apply, however. The injector should be experienced, and not just in fillers, but in the specific filler that he wants to use on you. Don't ever go for the cheap-o medical spa in the weekly free paper. You don't have to pay exhorbinant fees, but its easy to figure out what the standard price range is among physicians in your area. If you cannot get a recommendation from a friend and the internet is not helpful, pick someone in the middle of that price range. He/she should have a clean, nice office and should take the time to talk to you and listen to your concerns. Assembly line injection clinics compromise on safety and results.

Fat injection is surgery. Go to someone with excellent references and credentials (board certified in dermatology, plastic or facial plastic surgery) who does alot of fat injection in a certified surgery center. If you choose this injectable (I personally am not a big fan), do not mess around. Complications can be difiguring and dangerous.