Friday, May 18, 2018

Dermal Fillers: The Risks to Eliminating Wrinkles

Kathleen Doheny
March 28, 2018

Dermal fillers such as Juvederm, Radiesse, and Sculptra can smooth ''laugh lines" and other wrinkles and restore a youthful appearance.
They can also make you look worse, as Cristino Estinal of Paterson, NJ, knows all too well.
When he was 49, he heard of a woman who offered dermal filler injections in her home. So he went, and she injected filler into his forehead, under his chin, and in the ''laugh lines'' around his mouth, recalls his wife, Natividad Reyes.

"A couple of days later, he had bumps on his face," Reyes says. He returned to the woman, who said she was a cosmetologist, and she injected more filler. That only made things worse, Reyes says. The bumps persisted, everywhere the injections had been done. He felt he looked so bad, his wife says, that he skipped family reunions and other social events.

That went on for 8 years. In late 2017, he sought help from Boris Paskhover, MD, a facial plastic and reconstructive surgeon at Rutgers New Jersey Medical School, Newark, who agreed to help him. He needed three surgeries to fix the botched work, Paskhover says. The filler had hardened so much, he says, that he had to surgically remove it and reconstruct the patient's face using nearby tissue.
"He fixed it, and he did a good job," Reyes says.

A Closer Look at Fillers

Dermal fillers have boomed in popularity. In 2016, more than 2.4 million filler procedures were done with one type alone, hyaluronic acid (Juvederm, Restylane), in the U.S. That's a 56% increase over the last decade.
In general, they are safe, Paskhover says. But there can be complications when they're used -- especially if someone isn't trained for it. Most of the problems aren't life-threatening, but in some cases, the fillers have been linked with strokes and blindness.
"It's rare, very rare. I am not saying this is common," Paskhover says of the serious outcomes.
In two recent but separate reports, Paskhover and Hani Rayess, MD, an otolaryngology resident at Wayne State University School of Medicine, analyzed how often complications happen and how serious they are.

Details of the 10-Year Report

Paskhover looked at reports from the FDA's Manufacturer and User Facility Device Experience (MAUDE) database from January 2007 through July 2017. The database receives hundreds of thousands of reports annually, Paskhover says.
Of the more than 5,000 reports of problems related to fillers during the decade studied, Paskhover found the most common were:
· Nodule (bump) formation
· Infection
· Inflammation
· Allergic complications
· Vascular complications
The most serious problems included 62 strokes or stroke-like events and 47 cases of blindness blamed on the fillers. Strokes can happen when an injection hits a blood vessel and blocks it. Blindness can occur when an injection near the eye blocks a blood vessel. Some blindness cases happened after shots into the cheeks and forehead.
The most common fillers linked with complications were:
· Juvederm Voluma XC (hyaluronic acid)
· Sculptra (poly-1-lactic acid)
· Radiesse (calcium hydroxylapatite)

Details of the 3-Year Study

Rayess used the same database but looked only at the years 2014 through 2016. He found nearly 1,750 reports of problems. The most common were:
· Swelling
· Infection
· Blindness (eight cases)
· Tissue death
The report looked at all the commonly used fillers, including Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill and Juvederm Voluma.
Blindness cases were linked with injections into the nose. Tissue death and blindness were strongly linked with Radiesse injections. Rayess found nine malpractice cases, with median awards of resolved cases at $262,000.
Researchers say the MAUDE database has limits. Although patients, doctors, and other health care professionals can file reports with MAUDE, no one follows up on the reports to verify their accuracy.

Outside Perspective

The research reflects reality, says Brent Moelleken, MD, a Beverly Hills plastic surgeon. He was not involved in the new research.
"I cannot tell you how many patients I have seen who have had very bad filler," says Moelleken, a clinical associate professor of surgery at UCLA's David Geffen School of Medicine.
The research, raises awareness that you can be ''one injection away from a disaster."
"Most problems with fillers are minor aesthetic problems," he says. Often, patients will have eyebrows that are too high, or lips a little too full -- and with time, because the fillers are temporary, their appearance will go back to how it was before. Other complications, though rare, can be serious, he says.
"These fillers are not benign," he says. "If they are injected into a blood vessel or injected too tightly into a tissue,'' there can be problems, such as the death of tissue in the tip of the nose or other tissue death.

Industry Response

In a statement, Allergan, the maker of Juvederm, says it "welcomes discussion that brings awareness of potential risks that have previously been identified to allow patients to make fully informed choices about their treatments."
Since all medical procedures are linked with potential side effects, ''Allergan encourages patients and their healthcare providers to discuss all potential benefits as well as risk when determining whether to opt for any medical intervention."
Allergan spokeswoman Lisa Brown acknowledges the limits of the MAUDE data.
She says research backs the safety of Allergan products. The company has done 23 clinical trials including 3,711 patients, Brown says.
Representatives from Sanofi, which makes Sculptra, and Merz Aesthetics, which makes Radiesse, did not respond to a request for comment.
Products are approved by the FDA for specific areas. For instance, Allergan's Juvederm Ultra XC is approved for the lips, its Voluma XC is for mid-face volume loss, and Juvederm is for folds and wrinkles such as the lines around the nose and mouth.
Caveats for Consumers
The best advice for those who want dermal fillers? "Don't take them lightly," Paskhover says.
Go to a doctor who is well-trained in the procedure and has done the fillers for some time, the experts agree.
Several different medical specialists can give you dermal fillers, including plastic surgeons, facial plastic surgeons, dermatologists, and ophthalmologists. But ''what matters more than specialty is experience," Rayess says.
Before injecting filler, a doctor should take time to understand each patient's concerns, asking what bothers them about their appearance and what change or improvement they are looking for, Paskhover says.


Boris Paskhover, MD, facial plastic and reconstructive surgeon, Rutgers New Jersey Medical School, Newark.
Cristino Estinal and Natividad Reyes, Paterson, NJ.
Brent Moelleken, MD, plastic surgeon, Beverly Hills; clinical associate professor of surgery, David Geffen School of Medicine, UCLA, Los Angeles.
Hani Rayess, MD, otolaryngology resident, Wayne State University School of Medicine, Detroit.

The American Journal of Cosmetic Surgery, February 9, 2018.
JAMA Facial Plastic Surgery, December 21, 2017.

Monday, May 7, 2018

Figure 1: Safe injection locations for neurotoxins. Injections ("x") 2.5 cm above the bony orbit (horizontal line), 1 cm lateral to and above the orbital rim (small dots) should avoid unwanted diffusion and paralysis

Monday, April 16, 2018

An Introduction to Injectable Complications

Dr Catherine Fairris provides an introduction to the types of complications that may occur after toxin and filler injections
Minimally invasive aesthetic techniques such as botulinum toxin injections and dermal fillers are often seen as a safe and cost effective aesthetic option. If performed by experienced, well-trained practitioners, the probability of complications occurring is relatively small; however, there are complications that patients can experience.
This article will discuss the common complications that may occur as a result of botulinum toxin and dermal filler treatments and will briefly state the routine management approaches. As this article is an introduction, it will not go into significant detail, but instead hopes to educate practitioners who are new to aesthetics.

Friday, March 30, 2018

Neuromuscular Toxins

Neuromuscular Toxins

The first option, which is most appropriate for active lines or age associated wrinkles that are just starting to appear, is to temporarily weaken or paralyze the muscle that is causing the wrinkle.  Botulinum Toxin type A is a family of neurotoxins that block nerve signals that cause muscles to contract.  The toxin works directly where it is placed, and thus can be artistically used to alter facial expressions.  Botox Cosmetic® is widely recognized, and was the first neurotoxin to be approved for cosmetic use in the United States.  Other manufactures are producing variant toxins that will likely be approved for use in the near future, including Reloxin and PurTox.  These toxins will be differentiated by their time to onset, duration of effect (the clinical effects of Botox Cosmetic® are typically 3 to 4 months), and the distance of effect from the injection site.  Risks include bruising at the injection site, rare chance of an infection, and the possibility of unintentionally affecting nearby muscle groups.  Specific risks should be discussed with your injector when considering treatment.muscle groups.  Specific risks should be discussed with your injector when considering treatment.

Soft Tissue Fillers

The second class of injectable treatments are the soft tissue fillers.  This group is rapidly expanding, and many options are available.  These injectables are more useful for treatment of firmly established wrinkles or larger lines of facial aging (such as the nasolabial folds).   Fillers restore volume to the face and can add structure as well.  Depending on the type of filler and the depth at which it is injected, you can smooth out fine lines on the surface of the skin, fill out deep lines (eg: nasolabial folds), augment soft tissues (such as the lips), or even effectively augment facial bone structure.  All of these injectable fillers are placed by an injection, so the group carries usual risks of bruising, lumpiness, redness, product specific adverse reactions, and in rare cases local infections.
Many options are available in the filler class, with clinical differences being predominantly governed by how long the effects last, as well as how the filler “feels”.  Generally speaking, very soft fillers (that are best for locations such as the lips) tend to have a shorter duration of effect, while fillers that last longer tend to have more structure and are better suited in regions where they will not be palpable (such as the nasolabial folds).  In the past, the most widely used fillers were based on collagen, with sources ranging from bovine to human.  For some collagen formulations, skin testing before injection is necessary to confirm that you will not have an allergic response to the filler.  Collagen based fillers tend to last 3 to 6 months, and for some indications have a very natural feel.

Wednesday, March 28, 2018

Botulinum Toxin Injections Between the Brows Produce Significant Patient Satisfaction Rates

Botulinum toxin type A injections are the most common cosmetic procedure performed in the United States. There were 4.3 million procedures performed in 2015 accounting for 42 percent of all cosmetic procedures in that year, based on the Cosmetic Surgery National Data Bank Statistics from the American Society for Aesthetic Plastic Surgery, (ASAPS). According to a 2016 study published in the Aesthetic Surgery Journal, the official publication of ASAPS, patient satisfaction with their overall facial appearance increased by 28 percent with injections to the so-called “11s” (the glabellar rhytids, which are the lines that appear between the brows as we age).
The satisfaction rate was determined based on participating patients’ completion of the FACE-Q survey, a newly developed and validated patient-reported outcome instrument that can be used for measuring a patient’s own perceptions of cosmetic facial procedures. The survey consists of 63 questions asking patients to evaluate their overall appearance, age appearance, and the appearance of cheeks, nasolabial folds, lower face and jawline, chin and neck.
Dr. Daniel C. Mills, president of ASAPS states, “The results of this study are not surprising and validate what we’ve suspected for quite some time. I see an ever-increasing influx of patients in my practice in Laguna Beach, California requesting botulinum toxin type A injections to the area between the brows and other areas on the face, like the crow’s feet and forehead as a preventative anti-aging or pre-aging measure from patients in their 20s up to their 70s. It’s a quick nonsurgical fix that packs a powerful punch. This new study reaffirms the efficacy of botulinum toxin type A and the satisfaction it brings to patients.”
The study’s authors examined 57 female patients who completed the FACE-Q survey. After the baseline survey, the patients received injections of one brand of botulinum toxin type A, (Botox, Dysport or Xeomin) in the region between the brows. Two weeks post-injection, the patients completed the FACE-Q survey again. The percentage changes in patient responses from the first to second surveys were assessed to determine how the injections affected patient satisfaction with their facial appearance.
Patients stated that they believe they look an average of 5.6 years younger post-injection with any of the botulinum toxin type A products. The average age of the 57 patients with pre- and post-neurotoxin FACE-Q responses was 49.6 years (range of 32-75 years old).
“This indicates that patients’ satisfaction with their overall facial appearance was statistically significantly greater after receiving the injections, and certainly accounts for the continued success of neurotoxin popularity to reduce the signs of aging,” states Dr. Ivona Percec, the study’s senior author.
To view the complete study, visit the Aesthetic Surgery Journal website,
The American Society for Aesthetic Plastic Surgery (ASAPS), is recognized as the world’s leading organization devoted entirely to aesthetic plastic surgery and cosmetic medicine of the face and body. ASAPS is comprised of more than 2,600 plastic surgeons; active members are certified by the American Board of Plastic Surgery (USA) or by the Royal College of Physicians and Surgeons of Canada and have extensive training in the complete spectrum of surgical and nonsurgical aesthetic procedures. International active members are certified by equivalent boards of their respective countries. All members worldwide adhere to a strict code of ethics and must meet stringent membership requirements.
Courtesy of The American Society for Aesthetic Plastic Surgery

Monday, March 12, 2018

Can Botox make you happy?

YouTube Lecture to Las Vegas Cosmetic Surgery Conference 2014 by Dr. Patrick Treacy regarding the effect of Botox on emotions, including both happiness and…

Wednesday, March 7, 2018

Rested and wrinkled? Oh, the irony

Are the facial wrinkles, lines and folds that happen with aging result purely from the expressions we make? While skin distortion from facial expressions causes many, if not most, of the wrinkles we see on our faces with age, a new study suggests there’s a wrinkle (ahem) in that line of thinking. It turns out, as many experts in facial aesthetics have long assumed, wrinkles also result from "mechanical distortion" during sleep.

Plastic surgeon and lead author Goesel Anson, M.D., clinical instructor of surgery at the School of Medicine, University of Nevada, Las Vegas, and colleagues report in the study published online June 21 in the Aesthetic Surgery Journal that compression, shear and stress force factors result in facial distortion when people sleep on their sides and stomach.
These sleep wrinkles tend to be perpendicular to expression lines and they don’t respond significantly to animation, according to Dr. Anson. Common sleep wrinkles include the lateral oblique forehead crease, radial orbital crease, lateral (vertical) malar crease, medial cheek crease, nasal/lip crease, corner lip crease, oblique marionette crease, preauricular crease and inferior vertical cheek crease, according to the study.

American Society for Aesthetic Plastic Surgery President Daniel C. Mills, M.D., a plastic surgeon in Laguna Beach, Calif., says he has long suggested to patients that some of their facial wrinkles come from sleep positions, especially when patients complain that they have more wrinkles on one side of the face than the other. He’ll ask them how they sleep at night, and often the light goes off in the patient’s mind that, yes, those wrinkles show up on the side of their favorite sleeping position, he says.
“So, these are things that we see on a daily basis, but it’s very nice for the doctors to have written an article about this, quantifying it,” Dr. Mills says.
The researchers not only looked at wrinkles from sleep, but also potential facial skin expansion. Based on available studies, they didn’t find a direct correlation between facial distortion during sleep and skin expansion, Dr. Anson says. However, it’s a logical conclusion to draw from basic science literature and more research needs to be done on the subject matter, she says.

Friday, March 2, 2018

Wrinkles A Quick Fix For Bunny Lines

Think about it: Which area of the face do you normally consider getting neurotoxin injections (better known as Botox, Dysport or Xeomin*)? Many women will tell you the crow's feet, forehead and even "the elevens," which are those pesky lines that form between the eyebrows. But you don't often hear about bunny lines, the wrinkles that form at the top of your nose when you scrunch it. That's likely because it's an area that many of us don't know can be treated because it hadn't occurred to us in the first place. 

Monday, February 26, 2018

Wednesday, February 21, 2018

5 reasons why Men should avoid Botox®

Botulinum Toxin type A injections, popularly known as Botox ® is the commonest cosmetic dermatology procedure performed worldwide. Botox relaxes facial muscles into which it is injected thereby reducing the facial lines resulting from muscle contraction. It is a relatively safe and easy procedure with very little downtime and the effect can last up-to 6 months. Of late there has been a considerable increase in the number of men opting for this procedure accounting for almost one tenth of all Botox clients. 
This consistent increase in its popularity even during this period of global economic slowdown is seen by many as an attempt by the young executives to project a “fresh and pleasing” look in the highly competitive job market. However I have seen several senior people taking Botox® to keep up with the younger sub-ordinates. I am yet to see a male client taking Botox to be more attractive to the spouse, though that is the prime concern for most women.
1. Forehead lines might be cool. Look at Brad Pitt, George Clooney and other very handsome men for examples.
2. Men's Eye Brows look best when they are flat and relatively low on the forehead. So no more brow lifts! Raised eyebrows are perceived as feminine.
3. The laugh lines around the eyes indicate a jovial personality. You don't want to appear aloof, do you?
4. The size of your nose represents personal power. It is not a good idea to meddle with it.
5. You may not be able to hide it from your partner. Maybe she visits the same dermatologist :)
[Read more about Botox® in Men |
 Read about this treatment in general: Part 1 : Part 2]
(Photo credit: AJC1)

Wednesday, January 31, 2018

What You Should Know About Wrinkle Fillers

Injectable wrinkle fillers can give you a more youthful look for a fraction of what a traditional face lift costs. Most will fill lines and wrinkles in less than 30 minutes with results that can last from four months to more than a year.
Injectable wrinkle fillers, unlike Botox injections that relax the muscle under a wrinkle, fill the line or crease with one of several different substances. As a result, the line or crease seems to have nearly disappeared.
wrinkle filler

Wrinkle fillers can also be used as "volumizers," plumping and lifting cheeks, filling out thin lips, and plumping sagging hands.
The treatment is fast and easy. But all wrinkle fillers have a downside, including the risk of allergic reaction and the formation of tiny bumps under the skin. In some cases, those bumps may be permanent. A bluish skin discoloration known as the Tyndall effect is also possible. The color change can last for several months, but there are treatments available. In very rare cases, skin cells may die if the wrinkle fillers are not used properly. Typically, the wrinkle fillers with longer-lasting effects are the ones more likely to cause side effects.
Not every wrinkle is right for every type of wrinkle filler. The least risks and best results come from using the right wrinkle filler correctly. That's one reason why you should only have wrinkle fillers injected by a board-certified dermatologist or plastic surgeon.
To help you discuss your options with your doctor, here is a breakdown of the wrinkle fillers currently available. It includes their basic ingredients, how they work, their risks and benefits, and the best areas for treatment. Your doctor can help you choose the right one for you.

Hyaluronic Acid Wrinkle Fillers

The most popular category of wrinkle fillers is hyaluronic acid. Each type of hyaluronic acid wrinkle filler works in a slightly different way with varying results.
Side effects are rare, but they can include redness, swelling, and bruising at the injection site. The filler may also be seen beneath the skin as tiny bumps. This is a problem that often improves over time.
How long the results last varies from several months to over a year. Some research shows that repeated injections may help stimulate the body's own natural production of collagen. That will help reduce the number of lines and wrinkles. There is also some evidence that less filler is needed over time to achieve the same look.

Friday, January 26, 2018

(Botulinum Toxin) & the Cosmetic Indications

The following four Botulinum toxins are available in EU and UK countries:
  1. Botox  (Serotype A-Toxin)
  2. Dysport (Serotype A-Toxin)
  3. Xeomin  (Serotype A-Toxin)
  4. Neurobloc (Serotype B-Toxin)

Wednesday, January 24, 2018

Replenish Volume. Restore Collagen. Refresh your Appearance with RADIESSE®

RADIESSE® acts as a scaffold under the skin, stimulating and providing a structure where your own natural collagen can grow. . Best of all, the natural-looking results are clinically proven to last a year or more in many patients. Over time your body absorbs these tiny microspheres and the gel and leaves behind only your own natural collagen.

Treatment with RADIESSE® is quick, comfortable and convenient, with immediately visible, long-lasting results. Experience what millions worldwide have and begin your journey towards a naturally, more refreshed you today.

Friday, January 12, 2018

Filler trouble? Hyaluronidase (and smarts) to the rescue

The filler crash cart that Ontario, Canada, plastic surgeon Claudio De Lorenzi, M.D., recommended years ago has narrowed significantly. Now, he says, physicians need only bovine testicular hyaluronidase (HYAL) and knowledge.
And the knowledge needed is less than in the past because providers don’t have to remember all the other stuff.
“[Knowledge about] hyperbaric oxygen, prostaglandins, eye of newt, toe of frog, wool of bat and tongue of dog. All unnecessary!” Dr. De Lorenzi jokes.
But seriously, physician injectors need to know how to stay out of trouble, as well as what to do when trouble happens, according to Dr. De Lorenzi, who presented “Injectables, anatomy and safety,” Tuesday at the Aesthetic Meeting of the American Society for Aesthetic Plastic Surgery (ASAPS) in Las Vegas.
“Avoidance is primary strategy, but if you get into trouble: HYAL and lots of it (about 450 IU per cubic inch of ischemic tissue). Rinse and repeat hourly until resolution,” Dr. De Lorenzi says. “Everything else is superfluous. We want HYAL flooding of the ischemic tissue."
According to Dr. De Lorenzi, dosing is 3 cc of 150iu/cc HYAL per cubic inch of ischemic tissue. The goal is to ensure that all the obstructed vessels are surrounded with a sufficient concentration of HYAL for a sufficient length of time to hydrolyze HA fillers inside the arteries. Flood the ischemic tissue and gently massage the area, he says.
“We want flooding because the HYAL has to pass through the vessel wall with enough local concentration to hydrolyze the HA filler inside the vessel — especially if the entire vessel is full, or if the initial HA bolus has broken up into smaller blobs that have subsequently passed into smaller vessels downstream,” he says.
And the bigger the area, the more HYAL. That’s because HYAL dosing is based on how much tissue one treats, according to Dr. De Lorenzi.
“Repeat treatment hourly until you have restored cutaneous perfusion,” he says. “It is the HYAL that dissolves the emboli…it is always intravascular embolus/emboli. It's never external compression….”
A couple of tips for staying out of trouble:
When doing filler treatments, cosmetic and plastic surgeons should use a small bolus technique (i.e. less than 0.1 mL per pass), according to Dr. De Lorenzi.
“High-volume intravascular events are far more difficult to treat and, more often, involve other systems (which can result in blindness, hearing loss, stroke, etc),” he says.
Finally, physician injectors should ensure they start with an adequate supply of HYAL. Having about 4500 IU immediately available is a reasonable start, according to Dr. De Lorenzi.
“How are you going to get more HYAL in an emergency?” he says. “Not a bad idea to think about that before it happens, especially in smaller, geographically isolated communities.”
Disclosure: Dr. Lorenzi is medical director for Allergan, Canada, and Merz, Canada. He is on the advisory board for Kythera Biopharmaceuticals, Suneva Medical and Valeant Pharmaceuticals.