Retin-A dilution

Hi Dr. Rivkin,
First I'd like to thank you for providing all this information to us...essentially free "consults"...it's so appreciated! I'm saving up so I can come see you for a non-surg blepharoplasty. I'll be coming all the way from the SF Bay area--so many of the practitioners who do it here have undereyes so stuffed with restylane that they have this "plane" extending from their cheekbone to their lower lashes, which looks horrible. You give people really natural results, which is no doubt because you take your time and do follow-up appointments to keep the contour human-looking. Wink

Anyway, my actual question is what I might dilute my retin-a with to use it on large parts of my body (legs, arms, etc.)....is vaseline OK? Moisturizer? I got my retin A abroad, so I don't have a derm to ask.

Thanks for any thoughts, and see you in a year or so!



hi,
thanks so much for the kind words.
yeah, i always think that if someone can tell you've had something done or if it looks unnatural afterwards, then you have wasted your time and money.
ok, that is definitely a new question.
i think that diluting with a moisturizer is ok. do you really want to have vaseline all over your body? i would maybe dilute it with something that feels good. i don't think that any of those things will interfere with the efficacy of the retin-a.

IPL and Brown Spots and Mouth Lines

I went to a dermatologist for a body scan for skin cancer, having been a sun worshipper for many years in my early adult life. I have no skin cancers, thank goodness. However I asked the dr what I could do about the brown spots and uneven skin color on my face.

He told me that IPL would get rid that that and also he could get rid of the wrinkles around my mouth with the IPL. Has anyone done this or know anyone who has?

Seems like a dermatologist would be better than a PS for skin issues, I don't really know. Judging from the results of people I work with, I don't like the results of fraxel or like procedures, and I am scared to death of peels of any kind. And I wonder, if IPL can truly remove the wrinkles around ones mouth, then wouldn't everyone be doing that? I appreciate any input on the IPL. Many thanks and aloha


hi,
no way is ipl going to remove the wrinkles around the mouth. you are right to be skeptical. it will certainly help with the brown spots - it is probably the best technology for reducing brown spots, but that's all it can really do. even fraxel is not strong enough to affect the lip and mouth lines. i have had good results with active fx, but it involves some down time - about a week of redness and some swelling.
another thing about ipl is that it can take up to 4 or 5 sessions and the spots can come back. you have to be really careful about the sun afterwards. make sure that you are not suntanned when you go for the treatment - it can burn you if you've had sun exposure prior to the treatment.
hope that helps

Juvederm and Lip Enhancement

Dr. Rivkin,

Is it possible, with Juvaderm, to make the top lip fuller, maybe the border a bit "lifted" .... but not jutting OUT? And can Juvaderm in the bottom lip be used to make the lip fuller by rolling it out a bit?

I've had Restylane and Juvaderm a few times, and all but one time, the top lip had a bit of a Marge Simpson look to it, kind of extending out shelf like, but not poofy and lifted.

Thanks


hi,
avoiding the marge simpson look has more to do with the injector than the product. both restylane and juvederm can give a really nice, natural and full effect (although i personally prefer juvederm - i think that it is smoother) if injected carefully, correctly and in moderate quantities. it sounds like you had too much material injected. and yes, rolling the bottom lip out should be not that difficult to do, although some people have anatomy that is resistant to a roll effect.
injecting lips is a bit of an art. not everyone can do it well. you should find someone who is really good at it and stick with whatever filler they prefer (as long as it is a hyaluronic acid like restylane or juvederm - nothing else belongs in the lips - not radiesse, not artefill and not sculptra).
cheers

Esthelis

Dear Dr. Rivkin,
I am planning to get Esthelis injected for cheek augmentation. Is Esthelis a safe product? I read that it is completely biodegradable and non-permanent and consists only of hyaluronic acid.

My injector offers only Esthelis. I actually looked for Voluma or Restylane SubQ.

Do you have experience with Esthelis regarding patient satisfaction, longevity, easiness to administer? It would be great to get to know your opinion. There is a post from a lady who had it injected in the undereye area with not so gut results, but I couldn't find anything on cheeks.

I have some remainders of Voluma left (injected 1.5 years ago). Can I top up with Esthelis? What quantity would you recommend?

Thanks a lot in advance,


hi,
yes, that is what i've read as well.
i have never used it - i think it just got fda approval in the USA, but has not appeared on the market as of yet.
i can't tell you how long it will last - they claim 9 months, but who really knows?
i like radiesse for the cheeks and it works very well. it goes deep, which is really important for cheeks and it lasts about a year or so.
my question is how can a good injector only offer one product?
you should be getting many options, not a requirement to get one product.
_________________

Restylane Doesn't Last!

Hi,
I am wondering if you can give me your opinion on when you would say that Restylane is just NOT working for you. What I mean is I have had quite a few treatments over a short period of time. I absolutely LOVE the results, but they just don't seem to stay.

So far I have had:
Feb 20th - 1.5 cc's
Feb 27th - 1 cc
May 3rd - 1cc

And...I am scheduled tomorrow (June 13th) for another "touch-up" Shocked I keep getting touch-ups because I was under the understanding that the more you do, the better it will hold, AND, the less amount it should take to achieve the same results. So, am I crazy, and should I just come to the realization that Restylane just DOES NOT work for me Crying or Very sad

Thanks in advance for your opinion!

hi

more is not always better, in fact putting more into the NL folds can make the filler go up above the line, making the line more, not less prominent. however, if you're saying that the results are good, its just that they do not last, then you may be someone who metabolizes restylane too quickly.
if this is the case, you should give juvederm a try.
juvederm is also hyaluronic acid, but its formulated a bit differently and i've had a good amount of patients for whom restylane didn't last very long be very happy with juvederm.
if juvederm also doesn't last very long, then radiesse is the next possibility.
hope that helps

Vertical Lip Lines - Botox, Juvederm and Active Fx

I am in my 50's and the deepest lines on my face are in the mouth area, vertical lines above the top and bottom lips. I am a non-smoker, light-skinned caucasian female. It has been suggested to use Fraxel over the entire face gradually lightening the intensity as we go up the face and later use a filler if needed for the smile lines. Is there something else at this time more effective and possibly with less down-time than Fraxel? I bruise easily. Do you suggest eating or taking something before a procedure to reduce the bruising?


Hi,
Vertical lip lines are not just for smokers, unfortunately. We see them also in people who have a genetic predisposition. Oh well.
In terms of treatment, your first option is Botox. 4 units in each lip, spread out in 1 unit injections works great to decrease the appearance of the lines. This works because these lines are caused by lip movement - smiling, kissing, pursing the lips in conversation. Botox will relax the muscles just a bit. Enough that the lines are less, but not so much that speaking or smiling is affected.
Your next option depends on how many lines there are, how deep they are and how thin your lips are. If you have thin lips and many lines, I would consider some Juvederm in the vermillion border of the lips (the junction between the red and white) as well as in the red portion to help with general lip volume. If you're going to do this, go to someone experienced - you don't want to come out looking like a duck or a fish.
If you have just a few lines, we can use Juvederm to fill them directly. Again, you do not want someone to put so much filler in your upper lip that you look like you've been sparring with Mike Tyson.
If you have many thin lines and you do not want more volume in your lips, I would consider laser treatment. I do not think that Fraxel will do the job, however. It is not powerful enough. In order to really improve those lines, you need a fractionated CO2 laser. I have the Active Fx and I get very good results, but the downtime is actually more, and not less than the Fraxel. I tell people to give themselves a week of redness and swelling.
Prior to any of these procedures, Arnica is a good idea. It will decrease bruising and swelling and you should take it afterwards as well.


http://www.westsidemedicalspa.com/botox.html
http://www.westsidemedicalspa.com/juvederm.html
http://www.westsidemedicalspa.com/activefxlaser.html

How to Improve an Abdominoplasty Scar?

Hi Dr.,
Just wondering if you've seen real good results with the use of lasers to diminish or lighten surgery scars i.e., abdominoplasty scars? And if you have typically after how many sessions do you begin to see results.
Thanks for your time!


hi,
well, it depends on the scar.
if it is recent, i would wait at least 6 months for it to mature before treating it.
if it is raised, i would start by flattening it out with kenalog shots.
if it is dark, i would start with IPL treatments perhaps and see if that lightens it. do several treatments to give it a good effort - 3 would be good to at least see progress. hydroquinone cream is also useful. use the 8%.
if not, then you can go to a more intense laser like the fraxel or active fx.
active fx is also good if the scar is lighter than the surrounding skin and needs to be blended in better.
hope that helps

Needling for Wrinkles and Skin Tightening

I would like to know more about skin needling.
A tattoo artist told me about this and I would like to have it done.
I have been reading on it and really would like to know how its done.
I'm now getting adult breakout and I'm in my 40's and would like to get rid of some fine lines and wrinkles, without the process of cosmetic surgery.


hi,
i do not know much about this procedure - i do not do it and i do not know many doctors who do.
it makes some sense that it would work to reduce wrinkles and tighten skin a bit. the principle is that i fyou poke holes in the skin, the healing process stimulates collagen and tightens the skin. the laser (Fraxel and Active Fx) works essentially the same way, its just that the holes the laser makes in the skin are microscopic. i prefer using the laser because it is more precise and i can control the depth and density of the holes. you can't do that with the needling procedures.
also, needling is pretty bloody and i've heard that there's quite a bit of swelling.

Skin Tightening aftter Tummy Tuck

just had a Mini tummy tuck 1 month ago..now have some minimal but apparent loose skin around the belly button area...(prob.b/c I fell lost some muscle repair and really swelled from a hematoma clot...
so i was hoping to do some touch up for that area...ps not happy w/thermage that i got prior to surgery (didn't work)..thanks in advance.

hi
yeah, skin tightening is always such a problem!
the devices out there are not great.
i use thermage and i've seen ok results, but i do not think that the other devices are that much better. i would, however wait before you try anything else - let yourself heal some more from the surgery. i would not try anything until your ps tells you its ok.
it may be that a bit of a surgical nip is your best option.
there does not seem to be one clear winner in the devices out there right now.

Botox and TMJ / Teeth Grinding

Can you answer some questions relating to Botox?
If the person needing treatment needs it mostly for Bruxism, but a little for jaw tightening/locking- what is the usual course? Where and how much is used? (Which muscles/units?)
How much Botox does it take to treat TMJ typically? (How many units?)
Also - how long does it last? And - what is the success rate?


i usually treat the masseter muscle with a dose that depends on how big and active those muscles are. usually it is 16 to 20 units per side, spaced apart so that the whole muscle is covered.
it lasts for about 3 months and is almost always successful.
exception is when the patient is just complaining of popping / locking - may be more of a joint issue than a overactive muscle issue.
i usually find that after a couple of treatments the patient's muscle is visibly smaller and we can sometimes stop and the grinding does not come back.

http://www.westsidemedicalspa.com/botox.html
http://www.westsidemedicalspa.com/tmd-treatment-los-angeles.html

Max Fx for Asian Acne Scars Part 2

You have no idea how much your reply has helped me ... thank you VERY much
> for your appreciated opinion. If you may, could you help me with a follow-up
> question?
>
> If I'm using hydroquinone (which I been prescribed) for 6 weeks prior to my
> laser treatment, will this aid me enough where the Max FX could be
> beneficial? Basically, given the risk of hyperpigmentation in my ethnicity
> ... will the preparation of hydroquinone make the use of Max FX a smart or
> decent choice? I do not want to take a huge risk, especially if the results
> (improvement of scars, rolling/boxcar type) may not even be that noticeable.
> It's just I am getting the treatment for a very good price because I have
> offered my photos to public view and if the improvement/risk is worth it ...
> I may take the shot.
>
> Like everyone else, I am looking for the best risk/reward situation and with
> all the lasers out there (Total FX, Ebrium) it's very difficult. My biggest
> fear is of course, worsening of my skin. And I'm not quite clear on how
> "bad" hyperpigmentation can get in a bad-case scenario - perhaps you can
> clarify?
>
> And lastly, do you have experience with Asian ethnicity and their acne
> scars? If you believe you can help me (w/ Total FX or anything you else you
> may recommend) ... I would be willing to drive down south for a
> consultation/treatment. Thank you Doctor, very much.


hi,
i honestly think that it is a mistake for you to do max fx.
some docs like to use hydroquinone beforehand, and some say that it really doesn't make a bit of difference.
i use it, but i don't think its that big of a deal. i do not think that it will reduce your chances of side effects from max fx to an appreciable degree
about half of my acne scar patients are asian - i'm right next to ucla, so we have alot of experience with asian skin.
it would be great if you could have me take a look at you.
to put things in perspective, many dermatologists and plastic surgeons stopped using max fx once the fractionated lasers came out because the risk to benefit ratio was just not worth it.
and they were mostly treating older caucasian patients.
in your case, the risk is significantly higher, so i do not see the point.
and when i say hyperpigmentation, i mean bad. bad to where your skin goes from bad to worse and you wish you hadn't done it.
i would encourage you to come in and we can chat.
cheers,


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

Thermage and Fat Loss

Dear Dr Rivkin,

I have read many horror stories of facial fat loss from Thermage on this site. I had two Thermage treatments - one last year and one in March this year as I was quite happy with the result from the first. My PS explained that instead of doing one session, another method is do to a lower setting and space these out over 2-3 sessions over several months. I had no anaesthetic and it did not hurt at all - a very warm but actually pleasant feeling.

If fat loss were going to happen, would this have happened by now, 3 months later?

Thank you


yes, don't worry about fat loss.
this was a side effect from over aggressive settings on thermage back when people really didn't know what they were doing.
the company has reconfigured the settings on the device since then and it is much safer now.
it sounds like they used conservative settings - my treatments are more aggressive and they usually hurt. if you got results, that's great, and don't worry - you're not going to see fat loss.
cheers,

Total Fx vs Max Fx for Acne Scars

Hello,
>
> I am interested in a second opinion from another professional and you caught my attention. If you may help me with these questions, I'd be greatly appreciated.
>
> My issue: Acne scarring (rolling scars) - I am of Asian ethnicity with light skin.
>
> My goal: To improve the scarring .. my acne is completely under control and breakouts are at a zero. And my regime is duac + tazorac.
>
>
> 1) I have been consulted 3 sessions of Max FX laser spaced 6 weeks apart. Is this ideal for my acne scars?
>
> 2) There is little information about Max FX and most information is Active or Deep FX. May you please clarify the differences and things I need to know like how deep they go, and types of laser they are?
>
> 3) Assuming money isn't an issue, what would you recommend to treat my acne scars?
>
>
> Thank you in advanced. I am worried about wasting money/time and I believe a second opinion from you will help.


hi,
if we both are thinking the same thing when we say max fx, then i think that you are talking about an extremely aggressive regimen, expecially for asian skin. do they mean total fx? max fx you go into the operating room under anesthesia. max fx is essentially the old school co2 laser resurfacing procedure that gives people pigmentation side effects and lots of problems and down time. if they mean total fx, then i still think that the time interval is too short. it is still a very aggressive treatment and you should be waiting at least 4 months between sessions.
second of all, you should not be paying up front for 3 sessions. this is a big time treatment, not a photofacial. they should charge you for one treatment at a time and play it by ear. what if you're happy after one treatment? what if you get alot of downtime and want to switch to something less invasive?
don't get locked in.
total fx is active plus deep in one session.
all that being said, i agree that total fx is the best treatment out there right now for acne scars, assuming that you go to an experienced, careful doctor who also has experience treating asian skin (its very different from caucasian skin).
by the way, you should count on at least a week of downtime.
cheers,

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

Radiesse for Cheeks

Hi Doctor,
I had Radiesse injected in my NL lines and cheeks (hollows, lower part of the face where I lost the most fat) one year ago. I was happy with the results, especially in my NL lines, and I'm contemplating to have it done again this month as some of the filler has dissipated. However, in one cheek where my doctor had to put more filler due to bigger hollow, the area that was filled took on a bluish-grey tint, that is still slightly visible under certain kind of light. He told me he injected it deeply and he is an experienced doctor. Is there anything that can be done to prevent that happening this time, short of using steroid injections to disslove it? I really like how it fills your face but not the color.
Thank you so much for taking the time to reply.
Lisa


hi lisa,
if you're talking about the cheek hollows, not the cheekbones, i would suggest sculptra instead of radiesse. its expensive, but it lasts alot longer (2 years or more) and you do not get as many problems with irregular contours or funny colors. i like sculptra for large surface area injection like the cheeks - i find that otherwise i have to use a large amount of radiesse and that gets prohibitively expensive. with radiesse, i would have to use 2 or 3 syringes and that comes to $1600 to $2400, whereas with sculptra, i can use 3 bottles, at $1000 per bottle (1 bottle per session, each session spaced a month or so apart) and get more than double the duration.
if you're talking about the cheekbones, then radiesse is the only one i'd use, but the soft part of the cheek is best with sculptra.

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

Retin-A and wrinkles

Hi Dr. Rivkin,

I have tested both, sequentially, 2 weeks each, starting with the lower strength. I can tolerate the 0.04% concentration every night, even in the eye area, with minor redness. I also started to see an improvement in my mild acne. I can tolerate the 0.1% every three nights with some mild to moderate redness, dryness, and discomfort (cannot use it around the eyes, though).

1. What would you recommend: using the 0.04% strength every night or the 0.1% every three nights? Should I keep trying the higher strength hoping for my face to get used to it every night?
2. May any of these two strengths of Retin-A Micro help prevent wrinkles or a different product would be recommended for wrinkles?

hi,
you know, i would use the 0.4% every night.
with retin-a, regular, long term use is the most important thing. you will be much more likely to use the 0.04% than the 1% regularly. i think the lower percentage one will be fine at controlling your acne and preventing wrinkles both. the fact that you can use it under the eyes is a good thing, considering that this is where alot of the first wrinkles form.
i would also make sure that you are using a good moisturizer, a gentle, exfoliative cleanser and a good sunscreen. an antioxidant like prevage or a vit c topical cream (skinceuticals makes a good vit c and e furrulic) would be a good idea as well for preventative purposes.

Miracle Cures for Stretch Marks

Hello Dr. Rivkin! I was searching the web for stretch mark treatments and came across a news article posted recently that states a Dr. in PA stumbled upon a new treatment to reduce the appearance of stretch marks. She says she uses the combination of a radio-frequency treatment to tighten skin and reduce cellulite and a laser designed to improve skin texture. I was just wondering what the names of these procedures are, and if you think I could ask for this combination at an office in my area.


hi,
i took a look at the article you're talking about.
there's no mention of what devices she is using, and i have not heard of this supposed miracle. so, that leads me to one conclusion: imaginative PR.
there is no solution to stretch marks right now. we can improve mild ones with Active fx and sometimes radiofrequency devices like thermage give slight improvement, but its a tough problem.
i would look for an office in your area that offers active fx and see if they will treat your stretch marks. we still do not know exactly how effective the device is for stretch marks, but reports are hopeful.

Fotofacial "burn"

Hello!I am writing this on behalf of my sister.Four days ago we went in for our 3rd Fotofacial RF treatment.After the Dr.finished working on her,I noticed she had burns all over her forehead.I said,"What happened to your face"?The Dr.confidently responded like it was no big deal.He said the wand was going flat on her forehead because she didn't have enough fat on it(she's very thin).BTW,the machine being used is Syneron's EMAX.I figured the burns would be gone the next morning,but no!My sister calls me and tells me they had gotten worse and there were now burns on her chin.She sent me a picture(see below).Today I spoke with her and she told me the burns were now scabbing up.She said one of the scabs was coming off and it was pink.My question is:Do you think that she will have permanent scars from this or will she completely heal?If so,when?Are there any creams,etc.that can speed up the process?Any information would be greatly appreciated!



hi,
i have seen this kind of injury from the RF devices. it looks like an arc burn because they were not able to have complete contact between the skin and the head of the laser on the rounded portions of the forehead and chin. i can tell you that it is a superficial injury and will heal quickly. it looks worse than it is.
these kind of injuries usually heal without scarring, but you do have to be careful. sunblock is critical - you can't let the areas get sun exposure. moisturizer is also a good idea, as is vitamin e cream. otherwise, you just have to give it a few weeks to a few months and it should be ok. after about a month or so, you can start using hydroquinone/retin-a topical creams.
this is one reason that i do not like the fotofacial machines.
hope that helps.

Non Surgical Rhinoplasty and Pain Control

Hi Dr. I'm going to have some Restyline injected in the bridge of my nose. The last time I had it done the Dr. numbed the nose with injections on each side of my nose and under the tip. Those injections caused me such emotional distress, the needles were huge. I was wondering if I would really need them to have the Restyline injected in the bridge. Before he did the tip as well, this time he is not. Is it really that painful in the bridge that I couldn't get away with some other kind of measure for pain? Thanks so much for your input.


hi,
the bridge really does not hurt.
you should not need anything more than some good numbing cream and ice just before the injection.
i never use numbing injections to the side of the nose - its more hassle than its worth.
in terms of the tip - i dont usually need anything more than numbing cream and ice. i rarely need a dental block. yes, the tip is sensitive, but injecting the tip takes a few seconds and then its over, whereas the numbing shot makes your lip numb for 3 hours.
are you getting good results with restylane for the tip? i find that i cannot get that much of a lift with restylane - i have to use radiesse to get good results.
also, if you know that you like the effect of the filler in the nose, artefill is a permanent filler that i am now converting my patients to. this way, they can get it done and not worry about it again.
hope that helps


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

Needle Marks from Fillers

Dear Dr. Rivkin,

I hope you can answer this question, because I still have not gotten a good answer from anyone. I have had fillers on my upper lip and above it for 6 years. I see dark needle marks on my upper lip and skin. These are not broken capillaries. I have gone only to experienced injectors. Is there anything that can be done for this? I don't really want to get into lasers, as I've had a bad experience with them. What about for future injections, any way that these marks can be prevented?

Thank you,


hi,
sounds like hyperpigmented scarring from needle marks.
if you do not want to get into lasers, i don't think there's much to do except for topical bleaching creams (hydroquinone 8%, retin a, hydrocortisone) and sunscreen and hope it fades.
i assume that you are using hyaluronic acid (juvederm or restylane) in your lips. you really should not be using anything else.
in the future, i would make sure that the injector is using a 30 gage needle - that way the needle is small and there is minimal trauma. try to have him / her stick you a minimal number of times. also cooling the skin prior to injection with ice may help.

Dissolving Juvederm and Radiesse

Dear Dr. Rivkin,

I have read some of your answers and I apologize if I am asking a question that has been answered before. You have mentioned that both radiesse and juvederm can be dissolved (or dissipated)--radiesse with kenalog and juvederm with "an enzyme." What are the side effects of this? Also, I had Radiesse injected about 6 months ago and the juvederm about a year ago. Is this too late to have them dissolved? Many dermatologists I have spoken to aren't aware of this--is this an area that you specialize in? Do people come to you to fix others' overfills?

How long does the kenalog take to work?

Thank you for your time.

Shikshik


hi shikshik,
the enzyme that dissolves juvederm or restylane is called hyaluronidase and it really dissolves them completely. it is very safe to use, i do it all the time. yes, my practice is exclusively non surgical aesthetics, so i specialize in this kind of stuff. the enzyme takes about a day or less to work
your juvederm should be mostly gone, but i'd be happy to take a look and see what we can dissolve.
radiesse can't be dissolved, but the appearance of lumps can be reduced with some kenalog. its important not to put too much in - you can get an indentation in the skin. the kenalog takes a week or two to work.
hope that helps