Non Surgical Blepharoplasty

Is Juvederm best injected deeply or just under the surface of the skin for the hollows under the eyes/tear trough area? Is one less likely to created a baggy look? Is a numbing cream sufficient for painless injections or are numbing injections necessary too?
I'm trying to locate a doctor in Orange County who won't create undereye bags but with a minimal amount of pain.

This is a procedure that I perform daily. After trying all the different techniques, it has become pretty clear that some work better than others. This is a tricky procedure - even the smallest over injection can leave an unsightly lump. It takes experience and some skill to do it right.

I like Juvederm a bit more than Restylane. In my experience under the eyes, the Juvederm is a bit smoother and is a little less likely to leave lumps. The difference is not that important, however, as long as either product is injected slowly and carefully deep on top of the bone. I agree that massage just after injection should be kept to a minimum. I have not seen Juvederm to migrate.

Numbing cream should be fine - I would not suggest the use of numbing injections. It distorts the anatomy and is not needed.

I like to bring my patients back after 2 weeks to inspect the results and offer them a touch up treatment if needed. If there is some lumpiness, I can sometimes massage it down. If it is puffy, I can inject a bit of hyaluronidase and dissolve some of the Juvederm. So, if done well, this is a very effective procedure and there is minimal risk because any problems with the results can always be corrected.

Because it is a tricky procedure, you should do your research and choose a doctor who comes highly recommended and is very experienced in this particular procedure. A board certified plastic surgeon who does breast augmentation all day is NOT the person who should be injecting your under eyes. When you consult with your doctor, i would insist on seeing before and after pictures. The results should be natural and smooth.

Hope that helps!

For more info, you can go to: http://www.westsidemedicalspa.com/non_surgical_bleph.html

Radiesse for Chin Augmentation

I think my face would look better with a bigger chin.


Filler chin augmentation is quick, easy, immediate and essentially painless. There is minimal swelling and hardly any redness after the procedure. You can go back to work within an hour of getting it done.

It is a bit difficult to tell from this picture whether augmenting your chin would give a significant aesthetic improvement. It would be best to have profile and straight on pictures. The reason for that is that chin augmentation happens in 2 main directions - down or out - or a combination of the two. Most people need greater length and greater projection, so I augment so that there is an increase in both.

I think that injectable chin augmentation will actually provide very uniform results and is considerably more versatile than surgical placement of a silicone implant. With Radiesse, I can adjust contours or asymmetries to a precision of a millimiter. There is no way that a surgical implant can be that precise.

The downside is that Radiesse lasts only one year. I have done Artefill chin augmentation and results have been good, but alot of touch ups were necessary. I am looking forward to FDA approval of more permanent fillers. These should do a great job.

The only other limitation is that Radiesse can only stretch out the skin a certain amount. If someone needs more than a moderate advancement, I usually recommend surgery. I have had dramatic advancement, its just that if the patient needs more than 1cm, the skin will not stretch that far with an injection.

Hope that helps

Non Surgical Nose Job

good morning doctor rivkin,

if possible, i would like to ask you another thing about radiesse for a no surgical nose job:

1. i wear glasses, are there any problem with the filler? is it possible that radiesse will migrate o move with the little weight of the glasses?
2. i've some red capillars on my nose. could i remove it with the radiesse on or the filler could give me some problem?
3. the last thing..if one day i would like to have a surgical rinoplastic to remove the hump on my nose , the radiesse that now i will put could be a problem?

many thanx doctor.


hi,
1. i tell my patients to hold off on wearing sunglasses for a week after the non surgical nose job treatment. if that is not possible, i just ask them to do their best and perhaps wear light weight glasses or decrease the use of glasses, or wear them in a position that does not press upon the area of the nose where radiesse was injected. i have never had a case where glasses caused a dent in the nose after radiesse, but i just want to be sure.

2. we can treat the capillaries with a device that eliminates them after the procedure. occasionally, the radiesse injection makes capillaries like that a bit more noticeable, but we can always treat them.

3. this is a concern that some doctors have raised. i really think that, if you wait a year or so after the radiesse injection, surgery should be fine. if you want to be really sure, wait 18 months. Radiesse is a temporary filler. the body breaks it down and it should never cause permanent scarring under the skin. i have had some patients have rhinoplasty after the radiesse injection. they waited the appropriate amount of time and everything was ok.

Fraxel Re:pair / Active Fx Aftercare

I am getting fraxel re:pair next week. I am getting my face and neck done. I am curious to ask you how long the general recoup time is of your patients? Also my doctor said tylenol will relieve the pain afterwards along with the vinegar soaks, pea bag packs and aquaphor. Does OTC tylenol adequately relieve the pain? I guess just looking at the after pictures makes me cringe and think the pain could perhaps be relieved better for the first couple days with something prescribed stronger. What has been the feeling of your patients who have received this procedure? Thanks in advance for any and all information.


hi,
well, tylenol should be ok - if you need stronger stuff, your doc should be able to provide it for you. however, i am a bit concerned about your aftercare regimen. i would suggest antiviral medication at least - we give our patients antibacterial, antiviral and antifungal prophylaxis. we also give our patients a whole kit of products to use after the treatment, including arnica montana, sunblock, a gentle cleanser and a strong moisturizer to use after the aquaphor.
here is the aftercare schedule for my patients with active fx, which is essentially the same laser:
http://www.westsidemedicalspa.com/postoperatinginstructions.html
this is a serious laser and you should make sure that you are taking all of the necessary precautions.

Soprano and PDT Questions

hey doctor i have two questions

1. Does the soprano diode laser work in skin types 2, 3(light skin) or just dark skin because i heard gentlelase is better for ligher skin. will you get the same results?
2. Does Photodynamic acne treatmeant clear acne 100% or just for a couple of months?
ive been on accutane twice and my acne keeps coming back.

Hi,

1. soprano works very well for light and dark skin. the advantage of the soprano treatment is that it is close to painless. sometimes it takes one or two more sessions with the soprano, but it is worth it because every other laser that i have tried is very painful.

2. nothing will clear your acne 100%. pdt works well, but acne is a complex issue - it varies so much with the individual that it is very difficult to make predictions of how long the effects last with the treatments we currently have.
pdt is worth a try, in my opinion. i would combine the pdt treatment with antibiotics (minocycline works well). also, if you have active acne, i would get an extraction facial a few days prior to the pdt.

Non Surgical Nose Job

Is there a way for the non-surgical nose job to make your nose bigger or wider? I ask this because as a man, I feel my nose looks weak for my appearance, and I am wondering if this procedure can help me out.

The non-surgical nose job procedure can make your nose bigger and wider, in a subtle way. It may be your best option, but it depends on what you are looking for...

So, what it will come down to is how much of a change you are looking for. I do this daily and I can get several millimiters of increased width from the frontal view using fillers. Lengthening your nose with fillers is more difficult. I can usually get a millimiter or two of increased length, but that's really all. We are limited by the ammount that the skin will stretch, and the skin on the tip (which is the area that has to be injected to make the nose longer) will not stretch too much. That being said, I usually bring my patients back for a second session several weeks later, once the skin has adjusted to the filler and try to put a bit more in. Most of my male patients who have wanted this kind of change have been quite satisfied.

A few points:

1. This is not a temporary fix. If you are happy with the effect using Radiesse (and for your purpose it is the only temporary filler on the market that will work well), you can transition to Artefill for a permanent correction. Rhinoplasty is not your only permanent option. Artefill will require several touch up sessions, but after that it is permanent. I have transitioned about 50 patients to Artefill so far and have had excellent results.

2. I'm not so sure that a Plastic Surgeon is the first person you should see. Most Plastic Surgeons do not perform this procedure or only do it once in a great while. You should get a consultation with a doctor who has significant experience with the non-surgical nose job procedure. That may be a Dermatologist or a Plastic Surgeon or a Facial Plastic Surgeon. This doctor can then give you an informed opinion about whether this is the right procedure for your needs.

3. It is actually easier to reach your individual aesthetic ideal non surgically than it is surgically. The non surgical procedure can achieve subtle, natural changes that do not completely alter how you look. Surgery is for big changes. Injection is for subtle alterations. The non surgical procedure is perfect for preserving ethnic individuality and avoiding the standard caucasian nose.

Hyaluronidase concerns

Dear Dr Rivkin

Can you tell me about this enzyme? Is it completely safe when used as an antidote to HA's? Does it distinguish between the synthetic HA's of eg Restylane and the natural HA's present in the body? Or can it dissolve those too? If it does affect the natural HA's, what are the consequences and will they replenish themselves?

Many thanks for your advice,

Anna


hi anna,
i have used this enzyme alot, but i use it in very small injections. i have never seen damage to the natural tissues, although i have heard of cases where it was suspected that hyaluronidase caused damage.
i inject the minimum possible and it works to just dissolve the synthetic HA. i then bring the patient back in a week to make sure that the hyaluronidase has had the desired effect.
hope that helps

Under eye Hyperpigmentation vs Tear Trough Depression

I have very dark circles underneath my eyes. I don't think that it is hyperpigmentation just heredity (I am white). Is there anything that might work to take some of the darkness away. I bought something called Dermalex but that didn't fade them at all. Would Vitamin K cream help reduce the darkness? I am so tired of people asking me if I am tired!

hi,
the first question i would have is whether its just color or if you have indentations in the tear trough area under the eyes. a tear trough depression looks like hyperpigmentation because a shadow falls into the depression. if there's a tear trough depression, it can be filled with juvederm and the results are quite dramatic. if its just color and the area under the eyes is flat, then your options are fairly limited. hydroquinone sometimes helps, but i would get the higher percentage creams - 8% or more. kojic acid sometimes helps as well.

Aging Lips - Lip Lines

Is there a way to improve the appearance of the aging of the lips or minimize the lines actually on the lips (not just the ones around the lips) without making the lips fuller?

hi,
sorry, i was on vacation for a few weeks.
yes, i would do very small amounts of botox to relax the muscles of the lips just a bit. 4 units per lip divided into 4 injections of 1 unit should smooth out the lines without disturbing your smile or affecting the way you speak or eat. this is usually my first line procedure. if the lines are still there after botox, i would suggest doing very small amounts of filler like juvederm in the lines.
hope that helps

Juvederm for Upper Eyelid Contour Irregularity

Hi Dr. Rivkin,

I have a higher crease and some fat loss in one upper eyelid after granuloma and suture cyst removal. I have been told it would be easy to correct with a filler such as restylane. What filler do you prefer for the upper eyelids?

My main hesitation is that I am concerned about safety. If I inject the eye with temporary fillers every 6 months or so, I may have some bad luck one day where the filler occludes the retinal artery. I have read this happens once in a great while when lids are injected with an anesthetic agent prior to surgery. Do you think this is a possibility, albeit remote, with with filler injections?

I have also thought of a fat graft rather than fat or other injections, as that would be a one-time operation, but I hear fat grafts do not always retain well. Thank you for any feedback on these issues.


hi,
the concerns that you raise are certainly valid.
first off, i prefer juvederm for the upper eye area - it is smoother than restylane. second, these fillers last considerably longer than 6 months in the eye area. when i inject the lower eyelid crease with juvederm, it usually lasts for a year and a half or more. so, i wouldn't worry too much about repeated injections - the filler stimulates collagen growth and so you may only need a few sessions to achieve fairly permanent results.
i would definitely never use any other filler aside from restylane or juvederm around the eyes.
lastly, you should go to a physician very experienced in filler injection first and injecting around the eyes second. just because someone is an opthamologist or an oculoplastic specialist does not mean that they are an experienced injector. don't be shy to ask specific questions.
i don't like fat that much, although i have seen good results with fat grafting. sometimes fat lasts for a long time, sometimes it lasts for 6 months. filler is so much easier that i do not see any reason to use fat.
in terms of artery embolism, i have injected about 700 patients under the eyes so far. i have never seen a problem and i do not expect to. i would not worry about it. the risk is very remote.

Active Fx vs Plasma in Combo with Thermage for Skin Tightening

Hi Dr Rivkin - do you feel the plasma treatment for the face is as
effective for fine lines as active fx or fraxel? I have also been told
that along with thermage it can tighten and take about 10 yrs off the
face. I am starting to see more info on this process.

Also - if I have had a series of polaris treatments (1 1/2 yrs agao) and I have continued to have a refresher treatment every 4-6 months would thermage be a waste of money? Or do you feel that thermage is now so superior
that I should opt for that treatment instead?

Thanks!


hi
sorry - i was on vacation
i like active fx for fine lines better than plasma. i think that it is somewhat safer and more effective. thermage can be used in combination with any technology - active fx, plasma - whatever. by the way, i think that fraxel is an inferior technology for fine lines.
i have seen that thermage is best for the tightening the jawline and under the chin, whereas active fx is best for under the eyes (not sure that plasma can be used under the eyes) and throughout the face for fine lines.
i do not think that there is a huge difference between thermage and polaris, but i do think that thermage is more intense these days and that can get you a better result.
by the way, i would be pretty sceptical of anyone who promises to take 10 years off. sometimes that happens, but not reliably.
hope that helps

Discoloration Under the Eyes After Juvederm

Hi,

I had juvederm in sept07 for some dark circles. Dr. told me to fill the hollow and it would get rid of the shadow. One month later there was an imperfection on one undeye(dent) so she talked me into filling it with restalyne. She hit a blood vessel on the l eye and I had a black eye for 5 wks. When it cleared, there was still a very dark mark where the black yey had been It did not get lighter and she said it was a hemosidirin stain and lets try to laser it. She laser it 2x and it helped lighten the bottom but there is still a discoloration I never had before. The other eye strated to get a discoloration under it also. It became worse than the other side. It looks like 2 dark lines that where drawn from my eye to the side ofthe nose. They are MUCH more noticable than any dark circles I used to worry about. They are VERY distinct in photos and I look like an exhausted mug shot. I reviewed all my photos prior to the injections and you cannot see any darkness or distortions under my eye. I guess the dark circles bothered me in the mirror but they were nothing compared to what I am dealing with now. I look terrible in photos and it is quite noticable in person. There is a slight bump on the right side but I can live with bumps. Its the discoloration (darkbrownish) that has me terrified. I am afraid I ruined my face. All over a little dark circles. I would give anything to have my face back. Any ideas? The 2 syringes of juv were 9/07 and the resty on top of it was 11/07.

Thank you for your help!


hi
sorry - i was on vacation
the discoloration that you are describing is a rare but really disturbing side effect of injecting restylane or juvederm under the eyes. i'm not sure why it happens - probably the filler becomes visible through the skin (it is clear, but looks blue under the skin). did your doctor inject deep, next to the bone? if she injected too superficially, it is possible that the filler becomes visible like this.
the filler is still there, so i would dissolve it with hyaluronidase enzyme if i were you. if your doctor is injecting under the eyes, she should be familiar with the enzyme. it will remove the filler and your eyes should go back to normal.
cheers