Juvederm Voluma: The new kid on the block

If you are reading my blog, that means you know what a dermal filler is.  

A quick recap: Dermal fillers are used to plump up areas or add volume underneath the skin. The dermal fillers I use are typically composed of hyaluronic acid (made synthetically, but is a natural occurring substance in our bodies and dissolves over time). Once any of these fillers are placed they soak up water in the area over the next week or so and expand in size. 

These fillers are typically used to: 

• increase lip size
• decrease facial wrinkles 
• decrease size of lines from the nose to the mouth
• fill in smokers lines
• improve under eye volume loss (leading to the "sunken" look)

The new "Big dog" on the market comes from Allergan, the same company that makes Botox and regular Juvederm. The new product is called Juvederm Voluma. It is a hyaluronic acid filler that is aimed at "re-volumizing" the face. As we age we tend to lose our fat pads in the cheek area resulting in a more hollow faced appearance. Juvederm Voluma is an out patient procedure injection that places this "plumper/volumizer" in the cheek and causes a lifting effect to the entire cheek and face. These results last 1-2 years! The best part, if you are unsatisfied with it, this particular filler can be dissolved!

Results are very subtle and a bit pricey, but 1-2 years!! That is pretty darn good!

More to come on fillers soon, alternative uses and more about Belotero for tear trough defects (undereyes).

Dr. B
www.symmetrymedicine.com

The secrets behind Retin-A and Retinol: The cornerstone of anti aging treatments

All trans retinoic acid, commonly known as Retin-A, is truly the cornerstone of cosmetic medicine and should be included in most, if not all cosmetic treatment regimens. As many of my patients know, a skin conditioning regimen that you can stick to is so very important. With at home skin conditioning, maintenance procedures, and corrective procedures, it is very possible to slow down the aging process or reverse signs of aging by up to 10 years!

Later in the blog series we will discuss what components are in a skin conditioning regimen and why some patients need more than just moisturizer.

Retin-A (a vitamin A derivative) is truly the backbone to the field of anti-aging. The anti-aging revolution was started with this product. Retin-A forces the skin to slowly start making more new collagen. Yes, you read that correctly, new collagen. New collagen equals less fine lines! 

It's important to stick to a few guidelines with Retin-A products:

• Always wear sunscreen (you can burn easier when using Retin-A)
• Be consistent: skin needs time to adjust, your skin will likely be dry, flakey, and irritated for two weeks while the pH of your skin adjust to its new regimen
• Use a good moisturizer, dry skin looks good on nobody
• Apply every evening and take a "holiday" a couple times a year. Just stop using the cream for 2-3 weeks
• If you cant tolerate the strength there are great alternatives: Adapalene and Retinol

I like using skinceuticals skincare products who sell a great Retinol.

Hope this helps everyone know some more about a great product.


Dr. B
www.symmetrymedicine.com

Acne Scars: New inexpensive treatments that work!

Acne is a disease that plagues many people through their teens and some into the late 20's and 30's. Recall those gruesome days in high school? Well, if not, consider yourself lucky. Unfortunately numerous people are left with unsightly acne scars resulting from from the uncontrolled inflammation and damage to the skin resulting in irregular collagen formation.

Typically acne scars come in 3 types: 

• boxcar 
• icepick
• rolling

The type of acne scars that exist will likely depict the response to treatment. Fortunately, most patients have mixed presentation of acne scars and all can be improved or resolved with combination treatments. 

Typical treatment in previous years has consisted of peels, laser/light therapy, and surgical removal. Unfortunately many of these procedures have an increased risk of hyper or hypopigmentation (lightening and darkening of the skin) and can carry a heft price tag. In New York City a full series of acne scar removal with laser therapy may run upwards of $3,000. 

Introducing percutaneous microneedling collagen induction therapy, trademarked as Dermapen and many other competitors. This technology uses high-speed vibrating handheld devices to make micro-injury (controlled injury) to the skin allowing numerous growth factors and collagen synthesis to occur in an organized fashion. 

Over the course of 10 weeks your skin will begin to smoothen out and acne scars will be come less noticeable and some will completely resolve. For acne scaring, I typically recommend patients to have 4-6 treatments, each treatment a month or so apart.

The treatments are painless thanks to topical numbing cream and the vibrations of the device. The device makes tiny microscopic almost pinpoint needle tip penetrations of up to 1,000 times per second! These little mirco-wounds are at a controlled depth by the physician and differ on each spot of your face.

The results are spectacular. The risks, little to none... Can't beat that, and to top it off most sessions start at $200/session with multisession discounts (beats that hefty $3,000 Laser price tag, with equivalent results).

What about downtime? With any procedure, different skin reacts different ways, but in my experience people are ready to go back to work in less than 24 hours. Granted you may peel a little like a sunburn over the next week or so, but nothing as drastic as laser. The technique causes less damage to the surface layer than laser, hence... shorter downtime!

It is very important to follow a post procedure skin care regimen that your doctor can prescribe.

Don't forget this treatment is not just for Acne marks.

It works well for: fine lines, smokers lines, skin tightening, skin complexion, pigmentation issues, skin texture, stretch marks (anywhere on the body), and even scars. 

This device is soon to become a very popular treatment due to its cost, effectiveness, and low risk. Happy skin needling!

Dr. B

www.symmetrymedicine.com

 

Is it to early to start BOTOX? The secrets on when to start this magic medicine.

With the commercialization of BOTOX patients come to me younger and younger for consultation on prevention and correction of fine lines and wrinkles. Often I will be asked, "At what age should I start Botox?"

This is a highly scrutinized topic in the cosmetic medical society. Many "oldschool "physicians believe BOTOX should be used for cosmetic purposes to correct existing damage, while other fast thinking physicians have discovered the use to prevent formation of lines and smooth out skin.

The Brilliant idea: if some (not all) wrinkles are caused by excessive and constant facial movement, then relaxing the muscle temporarily from making these movements should result in less wrinkles down the road..

So how young is too young? I have heard of some physicians treating patients younger than 21 with BOTOX but I usually do not recommend this to patients under 21 (for purely cosmetic reasons). Sunscreen and proper skin hygiene will help prevent skin damage very well up to this point. Don't forget 90% of our sun damage is done during our teenage years!

Ages 21-30 reasons for consultation
- Prevention of aging signs
- The "Resting B*tch Face" (Yes, I get this complaint a lot!)
- Fine lines
- Skin conditioning regimen

Ages 31-40
- Correction of fine lines and wrinkles
- Prevention of fine lines and wrinkles
- The "Resting B*tch Face"

Ages 41 and up
- Botox works great to a certain point and then usually cosmetic surgery and/or a change in Botox technique is needed due to changes in facial architecture and sagging of skin.
- With early and continued use of Botox, this may be avoided or prolonged. The verdict is still out since Botox for prevention of aging is a relatively new technique.

In summary,  Consultations are usually free. Check with your doctor about what options are right for your aesthetic needs. I personally do not start anyone with Botox younger than 21.

Again, it is always important to see a well trained injector, as many different off label techniques can be used to achieve the results you are looking for.

Until next time,

Dr. B

Top 6 BOTOX Side effects you need to know right now

Back to my favorite injectable drug... BOTOX and it's not so long a list of side effects.

BOTOX is increasingly safe and has been around for decades, with first documented use for cosmetic purposes in 1989.

With any injectable procedure you should think about possible side effects.

#1 - Bruising

Relatively common (after all, you need a needle to get the injection completed). In my experience, the location of the injection plays an important role. Injections around the eye tend to have a higher chance of bruising, although the bruise can occur anywhere a needle is used. So how do you decrease the chances of a bruise?

• no alcohol 5 days prior to the procedure
• no NSAIDS (Ibuprofen, Advil, Aleve) 5 days prior to procedure - Tylenol is ok
• no retin-a type creams or vitamin E creams 3 days prior to procedure
• Use ice during the procedure
• Arnica cream before and after the procedure
• most importantly try not to have the injections right before an important event. Bruises can be bad sometimes!

#2 - Asymmetry | Uneven Results

Typically BOTOX is used to treat the forehead. The forehead controls our eyebrow height and architecture. When these muscles are relaxed with injections the results can sometimes be seen in the eyebrows. The undesired effect of asymmetry is not common, but does occur. Most faces have resting asymmetry (sorry I just knocked your self esteem down a notch). BOTOX when improperly placed (or even when properly placed) can result in exaggeration or new asymmetry. This is easily fixed with a second time 1 or 2 spots of injection of a few 'extra units' to even out the undesired effect.

#3 - Under treatment | Over treatment

Under treatment - not getting the desired effect of BOTOX can occur and is easily fixed with additional units. Some patients do require more units in order to get the look they want or any effect at all. You can work with your injector to better understand how many units you need.

Over treatment - Too much BOTOX can cause the "frozen appearance" or ptosis (see #5). It is always easier to add more BOTOX, you cannot take it away!

#4 - Spock Brow | Jack Nicholson Brow

When treating the forehead, injectors are extra careful to prevent eyelid drooping (which can happen, see #5). To do this injectors tend to concentrate on the central forehead (more commonly in women). This can sometimes lead to eyebrow arching, some patients request this look, others do not like it. The BOTOX works by relaxing the forehead muscle and if the outer part of your forehead is still very strong it can pick up the eyebrow into an arched shape sometimes. Thankfully this is usually easily corrected with a couple extra units of properly placed injections.  

 #5 - Eyelid drooping | Brow Drooping | Double vision

Thankfully rather rare, but does occur. The more aggressive your treatment is and your injector is, the higher the likelihood of ptosis or eyelid drooping. This is not a fun side-effect but can happen. This is the result of the forehead usually being too heavily treated on the outside. There are special eye drops your injector can likely provide that can help increase your recovery rate to about 2 weeks.

#6 - Headache and flu like symptoms

 A very common side effect is Headache. They are usually short in duration and a results of the BOTOX itself or the needle from the injection. The good news is, BOTOX will usually help you get less headaches over the course of its 3-4 months of action. Tylenol and or a muscle relaxer can help with this short term headache. Flu symptoms are uncommon but do occur and last for up to 3 days.

Do not fret, side effects are usually short lived. Your injector can help facilitate any adverse effects you have and give you an estimated timeline.

More to come..

Dr. B

P.S. Don't jump to conclusions, injections usually take 3-7 days to start working!

Melted Money: The impact on emergent and urgent healthcare of the ice bucket challenge.

The ice bucket challenge has swept the nation and has brought a lot of attention to one of many diseases that truly needed the attention, Amyotrophic lateral sclerosis. ALS and many other progressive spinal cord & neurologic diseases have in no doubt benefited from the selfless donations of numerous Americans over the last few months in thanks to the ice bucket challenge.

If you are unaware, in short. The ice bucket challenge is a viral marketing sensation, mostly on Facebook, of "nominees" usually while pledging a donation dumping a bucket of ice water on their heads and nominating three additional pledgers. I must admit, sounds like a nice summer treat.

From sources close to the ALS foundation I have heard upwards of 22 million dollars in donations to this point, which is fantastic. My growing concern is for the ice bucket challenge "fails". As with any viral phenomenon, nominees want to one-up one another over and over and over again. This has resulted in more "unique" ways to preform the simple task of dumping a bucket of ice water on ones head.

As you may have found out (Google 'ice bucket challenge fail'). People dumping absurdly large buckets of ice from heights that are unsafe and in conditions that are unsafe onto peoples heads. This has resulted in multiple injuries including fractures, lacerations, concussions, eye damage, cardiogenic shock, multiple contusions, and a plethora of other injuries.

The lesser of these injuries in an emergency room likely costs between $600 - $1000, while the more serious can result in surgery, hospital admission, and short-to-long term disability (although I have not seen or heard of any to this point) could run in the five to six digit range.

The economic impact on the healthcare system will likely be minute from these injuries. The challenge has done a wonderful thing pulling awareness for this cause. The point of my article is to bring awareness to the general public on safety.

We have all acted purely on impulse before, all done things we know we should not have. Just try to think before you act during the ice bucket challenge and donate as much as you can to help improve outcomes for ALS.

Happy Icing

How many units do I really need?! BOTOX

This post is for BOTOX newbies and BOTOX veterans.
BOTOX is a very complicated medication to grasp the concept of. I usually explain concept multiple times per day. My goal in this article is to give you a little insight into BOTOX and the dosing.
 

First off:

BOTOX is a trademarked name by Allergan. Kind of like, er..um.. Kleenex.

Good with your analogies?

BOTOX is to botulinum toxin as Kleenex is to tissue paper. Got it?

 

 

Ok lets move on....

 

There are two other alternatives that are FDA approved at the current time of writing (2014): Dysport and Xeomin. They can be used interchangeably with BOTOX and usually have very similar results. Dysport is a completely different dosage and pricing will vary accordingly in most offices.

 

 
 

Females | Typical Areas of Injection

11 lines (Glabellar complex): 20 units on average to start

Horizontal lines of the forehead (furrows): 10 units on average to start

Crows Feet (lateral canthal lines): 10 units per eye on average

 

Males | Typical Areas of Injection

11 lines (Glabellar complex): 20 - 40 units on average depending on muscle bulk

Horizontal lines of forehead (furrows): 10 - 20 units on average depending on muscle bulk

Crows Feet (lateral canthal lines): 10 units per eye on average

 

 

Rarely patients develop antibodies to botulinum toxin and need additional dosing. About 30% of injections need "touch-ups" or follow up in order to achieve the desired results. Do not forget, BOTOX injection are not without complications (thankfully all short term). Talk with you injector in detail to get an idea of what to expect and possible complications. 

 

 

I hope this sheds some light on how many units you are getting or are planning to get. Remember to seek out a qualified injector and be wary of "too good to be true" deals. You get what you pay for!

 

More to come on my favorite injectable med.

Next: Common complications

 

Dr. Alexander Blinski