The Aesthetic Clinique
Steven F. Weiner, MD
Making 30A, Destin, & Panama City More Beautiful

Blog

3/27/2018 3:00:42 AM

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor  and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

  1. Know the major vascular structures and their landmarks
  2. Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
  3. Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
  4. Use cannulas whenever feasible, preferably 25/23g or larger
  5. Avoid boluses, small linear threads are safer
  6. Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
  7. A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
  8. Injection onto periosteum is safest but does not guarantee a vascular free injection
  9. Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
  10. Retrograde injections are safer than anterograde injections
  11. Dermal injections should be relatively safe
  12. Avoid deep injections in the lips. Stay superficial to the muscles
  13. An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
  14. Have on hand 6-8 vials of Hylenex
  15. Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.



2/16/2018 3:03:52 AM

Nefertiti was recognized for her crisp jawline and smooth neck. Her bust is one of the most famous of the ancient Egyptian sculptures. A razor sharp jawline and well defined ascending ramus (or gonial angle) are hallmarks of beauty, both male and female. Jowling, submental fullness, blunting of the gonial angle, and an irregular jawline are all signs of aging.

While there are many commonalities between the sexes of what constitutes an attractive jawline, there are fundamental differences as well.

Males:

  • Broad/wide rami of mandible leading to a near vertical appearance on frontal projection
  • Approximately a 110-115 degree gonial angle (more acute than female)
  • Significant height of the body of the mandible
  • Wide defined, projected chin

Females:

  • V-shaped rami of mandible on frontal projection. A more masculine (vertical) ramus is also considered beautiful in some women (Such as Alessandra Ambrosio)
  • A more obtuse gonial angle of approximately 135 degrees
  • Shorter height along the body of the mandible
  • Pointed, less projected chin

There are considerable age related changes of the mandible.

  • Loss of bone along the body of mandible leading to loss of vertical height. This change is accelerated in an edentulous patient
  • Blunting of the gonial angle eventually leading to a curvilinear jawline
  • Narrowing of the male chin and widening of the female chin
  • Deepening of the gonial notch

The age related mandibular changes lead to loss of support of the soft tissue in the lower face – falling forward and downward. Jowling and submental fat is exaggerated. The upper neck skin shows more laxity as facial skin drops into the neck.

Correction of age related jawline changes with fillers- reJAWvenation

Dr. Weiner has perfected a correction using dermal fillers which he has coined “reJAWvenation”. It is based on restoring the age related loss of bone and leads to support of the lower face soft tissues. Filler is placed along the inferior border of the mandible as well as filling the gonial notch. The gonial angle is recreated. The lower aspect of the jowl is considered the new baseline and filling is made on either side to “camouflage” the jowl. Filler is also placed along the posterior aspect of the ascending ramus. The prejowl sulcus is filled, with emphasis to include the space beneath the inferior mandibular border. The chin must also be corrected to the male/female appropriate projection and shape.

reJAWvenation offers a quick (10-15 minute) correction of the age related changes to the jawline. Improvements in jowls, upper neck, jawline, and chin can be expected. There is minimal or no downtime. Even with facelifts, jawline volume is not typically addressed and needs to be corrected either during the procedure with fat grafting, or in the office, after healing, with fillers.

 



1/23/2018 3:27:24 AM

On October 12, 2017, Galderma was notified by the FDA that Restylane Silk was approved to be administered using blunt microcannulas. Galderma deserves a huge “high 5” for stepping out of the box in recognizing the improved patient outcomes and safety benefits of cannulas. No other dermal filler in the US has been approved for use with cannulas, it is a “First for Fillers”. Galderma is researching other areas for cannula use and expect approval in 2018 for another 1 or 2 indications.

What’s the big deal with cannulas?

The traditional method to administer dermal fillers is using a needle. Unfortunately, there are many side effects and risks using needles. These include:

  1. Bruising – sticking a needle into a highly vascular organ, skin, will lead to bruising a majority of the time. This is corroborated by the FDA studies for all the US approved fillers.
  2. Pain – needles require multiple entry points to deposit the filler. Pain fibers are most prevalent in the dermis.
  3. Vascular Occlusion Risk – when a blood vessel is cannulated with a needle and the filler is injected directly into the vessel, occlusion of the vessel occurs. The sequelae of such event can result in skin necrosis, eye injury, or even blindness.

Cannulas have a blunted, rounded tip which is less likely to injure blood vessels than a needle is. When the cannula brushes up against a vessel, it is deflected away, in distinction to a needle which will often pierce the vessel. When a vessel is traumatized, a bruise will occur.

To use cannulas, a small pilot hole using a needle is required. Unfortunately, completely eliminating needles is not possible. However, after that entry is performed, the cannula can be placed through the dermis and into the subcutaneous tissue or deeper fat compartments.  The areas below the skin surface are generally less innervated and are more comfortable to place filler.

The most important quality of cannulas is their safety. By design, they are much less likely to result in placement of filler within the lumen of a blood vessel. The rounded tip eludes lumens of blood vessels whereas needles don’t offer that protection. Although vascular occlusion is possible with cannulas, it is much less likely when compared to the risks associated with needles.

Dr. Weiner has been an advocate of injecting dermal fillers with cannulas for the past 6 years, since 2012. He has become one of the most experienced cannula users in the US. He has been chosen by Galderma to use his cannula experience to “Train the Trainers” in the use of cannulas for Restylane Silk in the lips.



12/16/2017 11:34:34 PM

Lutronic has added a new laser to it’s armamentarium and it is called the Action II. There are several different applications for this laser which include: fractional laser resurfacing, the “Shining” laser peel, skin lesion ablations, and the “Bella V” procedure for vaginal rejuvenation.

Erbium lasers are ablative lasers, they cause ablation of the tissue treated. This means that there will be vaporization of the treated skin. The Action II is a fractional laser, so only a “fraction” of the area treated will be ablated. Studies show that fractional lasers are safer and provide improved recovery times when compared to total (100%) ablative lasers. Comparing an erbium laser to a CO2 laser (which is also ablative), the erbium will have less coagulation of the tissue – less heat is transmitted to the surrounding tissues. The clinical result is that there is less crusting, less wound care, and faster healing with the erbium vs the CO2 laser.

  • Fractional Laser Resurfacing: The Action II uses a stamping handpiece that has approximately 15% coverage (15% of the skin is ablated) per pass. Depths are controlled by varying the energy as well as the pulse stacking. Typically patients will receive between 1-2 passes. The procedure takes about 30 minutes to complete. Only topical anesthetic is needed and patients are very comfortable throughout the procedure. Wound care which includes soaks and specialized creams is required for about 4 days. There is minimal to no crusting with this laser. More than one treatment might be needed to get optimal results.
    • Indications: Treating deep wrinkles, sun damaged skin, pigmentation, and laxity
  • Shining Peel: This is a very superficial laser resurfacing with minimal depth and can be done without topical numbing creams. It takes about 15 minutes and is meant to have almost no downtime. It causes a rejuvenation of the skin
    • Indications: Treat superficial wrinkles, minor pigmentation, enlarged pores
  • Surgical Handpiece: This is a microfocused beam to treat very small skin lesions. No anesthetic is needed.
    • Indications: Treat sebaceous hyperplasia, seborrheic keratosis, actinic keratosis, benign nevus, skin tags, warts
  • Bella V: This handpiece/procedure is used for vaginal rejuvenation and stress incontinence. The handpiece is insert to the vagina. It has a unique 360 degree treatment zone as the laser is pulsed. There are 2 pulses, a shorter ablative or subablative pulse, followed by a longer nonablative (heating) pulse. The handpiece is gradually withdrawn about 0.5cm and another pulse is fired. The is done throughout the entire vagina and introitus and then repeated. If there is a component of stress incontinence, the area of the tissue around the urethra is treated more aggressively. The entire procedure takes about 10-15 minutes and no topical anesthetics are required. (At this time, external vaginal treatments are performed using the ThermiVa at the Aesthetic Clinique.)
    • Indications: vaginal laxity, vaginal atrophy, decreased moisture, stress incontinence



12/10/2017 2:48:52 PM

“A picture is worth a thousand words”. It’s true, seeing a great before and after speaks volumes for a certain physician’s or practitioner’s abilities. Unfortunately, there are some deceptive practices that can trick the eyes into believing results are better than they are really are.  Instagram is a showcase for the aesthetic industry, but there is no oversight as to the claims made on the photos displayed. The bullet points below will help one to develop a critical eye to discern the truth from the “fictional results”.

  1. Lightening must be the same in both pictures. A common misleading practice is to have a dark before picture and a light after picture. In the lighter picture, wrinkles and shadows are going to be less, and fool the observing into thinking these were related to the procedure.
  2. Angle of the neck/head must be the same in both pictures. Take a look at the nose and jaw to see if the head is in the exact same position. If the head is tilted more upward in the after picture, the neck will appear to have less fullness, less wrinkles, and be firmer. This is particularly popular in the Kybella before and after photos.
  3. The expression must be the same in both pictures. If a patients is partially smiling in the before and not in the after, the wrinkles around the mouth and cheek will appear falsely improved.
  4. Sculptra pictures should have at least a 3-6 month interval. Sculptra is always mixed with water or saline for reconstitution. The immediate results after injection reflect merely the effects of the water/saline and not that of Sculptra. The collagen stimulation from Sculptra will take at least 3 months to appreciate, with 6-9 months being even a better gauge of results.
  5. Using company photos or other physician’s photos without noting this or giving the appropriate credit on their websites or posts is also a common practice.
  6. If make-up is used, it must be similar in both photos. Too often the before has none and the after has make-up.

Perfect before and after photos are very challenging. Even when results are extraordinaire, there are often difficulties trying to capture these changes with the camera. However, purposely trying to “enhance” photos with the practices above must be pointed out to the practitioners.

 



11/13/2017 11:58:51 PM

In surgery, sterile technique is “the law”. Any break in sterility places the patient at risk for a potentially life threatening infection. It is the duty for the surgeon(s), scrub tech, and circulating nurse to self report or call out any suspected or potential contamination risk. Immediate actions are taken to remedy the situation and to limit the risk to patient.

Why should dermal fillers be treated as anything differently? They shouldn’t! Fillers are semipermanent or permanent implants, and they must be administered in aseptic technique. The majority of injectors are not trained as surgeons and therefore don’t fully comprehend what sterile technique entails. Granulomas, one of the more serious complications from fillers, have now been traced to biofilms. Biofilms are latent bacteria that somehow get activated and present as infection or granulomas, months to years after the initial injection. Most often biofilms are deposited in the tissues during the initial injection procedure. Clearing infections or granulomas takes weeks or months to clear and often entails antibiotics, steroids, 5 FU, and hyaluronidase (if a hyaluronic acid was used).

The following guidelines should serve as a reference for physicians and nurses to minimize infectious complications during dermal filler injections.

  1. The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
  2. Never inject someone with a current/ongoing infection. Even if the infection is not in the area of the dermal filler, bacteria can seed the filler from distant areas through the bloodstream (bactermia).
  3. If a patient is in the process of getting dental work or even dental cleanings, hold off on injections until after the work has been completed. Bactermia is well documented during dental cleanings. It is recommended to wait at least 2 weeks after fillers to get dental cleanings. The areas of filler placement will initially have increased blood flow (hyperemia) so it is best to wait until this settles down.
  4. Skin should be prepped for injection with chlorhexidine, with Hibiclens being the preferred form by the author. Although isopropyl alcohol (70%) is effective in killing bacteria and fungus, it is only effective for seconds and becomes ineffective as soon as it evaporates. Hibiclens kills germs on contact and will give persistent bactericidal effects for at least 6 hours, and up to 24 hours. It will bond with the skin even after washing to give continued killing effects. Isopropyl alcohol doesn’t give this lasting bactericidal effect, so anytime after the initial cleaning that an unsterile glove touches the skin, that area is now contaminated. (Hibiclens must be kept out of the eyes because it can burn the cornea). Technicare is also a great antiseptic but the author doesn’t have experience with it. Too many patients are allergic to Betadine for it to be used routinely.
  5. Do not use tap water when applying Hibiclens or to clean the face after completion of the injections. There are several bacteria, fungi, as well as mycobacterium in water which can seep through the injection ports and cause infection.
  6. If the filler is prepared by mixing lidocaine or saline, this must be done in a sterile fashion. The female/female connector used to connect the 2 syringes together must not be reused. It can only be used for the current patient and cannot be sterilized for use on other patients. The tops of all the solutions used must be wiped with an alcohol wipe. Routine use of blending fillers opens up more avenues for filler contamination and must be done with the strictest of sterile technique. If any of the solution vials becomes unsterile, all future filler patients using that vial will become infected.
  7. Blunt tip cannulas can be used for multiple injection sites ON THE SAME PATIENT and are not intended to be used for multiple patients. When changing the cannulas between syringes, they should be recapped first. It is not sterile technique to lay the cannula on an unsterile tray or even a sterile drape when uncapped. After a syringe of filler is removed from its sterile packaging, the areas touched with the exam gloves become “contaminated”. Therefore, the sterile drape is not a sterile field anymore, once the syringes is placed on it. Best practice is to cap the syringe every time it is laid down.
  8. Blunt cannulas are much longer than needles and must be kept sterile throughout their entire length. The cannula is contaminated if anywhere along its length it touches non sterilized skin, gloves, or hair.
  9. It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
  10. The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
  11. Unless the gauze used during the procedure is specifically labeled as sterile, it is not, and introduces another route of contamination. Gauze that comes in sealed pull away packs and labeled as sterile is best to use. The author will take unsterile gauze, place in autoclave packs, and place in the autoclave to obtain sterility.
  12. Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
  13. If ice or devices for vibration are used to control discomfort, these should be cleansed with Hibiclens prior to applying to the skin. In addition, the areas where these were applied should be “re-sterilized” prior to injections.
  14. When the procedure is complete, sterile water or saline on sterile gauze should be used to clean the patient. Again, if tap water is used, this can seep through the injection ports and lead to infection. Also, when soaking the gauze, best practice is to pour the water/saline over the sink onto the sterile gauze so as to keep the remaining fluid in the container sterile. By tipping the water/saline onto gauze that is covering the top, there is risk of contamination going back into the container.
  15. Make-up should not be applied to the skin until the morning. At this point, the injection ports have all healed and there is no risk of contamination.
  16. Dental procedures, even cleanings, should be postponed for at least 2 weeks.

Although the details above are fairly lengthy, any break from any step will lead to a possible source of granuloma or infection in the future. Strict sterile technique will lead to better outcomes and happier patients,



10/2/2017 12:49:38 AM

A couple years ago, I wrote a blog that stated deep injections along the periostium using Sculptra were the best way to enhance temples suffering from volume loss. I would like to update everyone to a newer technique I have perfected that gives better results.

Although the Sculptra temple injections are safe and long lasting, there were deficiencies:

  1. Multiple treatments were required – 3 or more
  2. Results take weeks or months to occur
  3. Final results still showed volume loss in the temporal fusion line and supraorbital area
  4. Significant volumes of Sculptra were required
  5. Needle injections inherently lead to more bruising than cannulas

The temporal fossae is a very large space and when Sculptra is injected in this area, there is tremendous spread of the product due to its watery consistency.  In addition, the deep temporal fascia is a thick and unyielding tissue plane that resists lateral movement from filler placed deeply.

My current preference for volumizing the temples uses large (23g) cannulas and a diluted HA (Refyne) dermal filler. I use large cannulas because they are safer than the smaller cannulas and needles for preventing vascular occlusion. I have found that the larger cannulas navigate the numerous veins in the temples well with minimal discomfort.  My entry point is the zygomatic arch, about 1 cm posterior to the brow. The plane of injection is between the superficial temporal fascia and the deep temporal fascia. This is the exact area where the temporal fat pad is situated and where fat loss occurs.  Surrounding areas such as the superior orbital rim, supraorbital area, forehead, and hairline can all be injected from the temporal approach. By diluting the Restylane Refyne with 1cc of saline and 1cc of lidocaine 1%, the thinner product is able to distribute very evenly throughout the plane of injection. Refyne’s high tissue integration and low swelling properties makes this the optimal filler for this area. I have found that a total of 1-2 syringes of the filler is needed to achieve correction in most patients. Massaging at the time of injection and periodically afterwards by the patient will give the smoothest results. A follow up in 3 weeks is typically made to make final touch ups if needed.

Techniques must constantly be re-evaluated and refined to achieve the optimal and safest results for our patients.

 



9/24/2017 7:47:38 PM

Aesthetic physicians are constantly striving to find the best procedure/device to turn back time. This time, it is actually a procedure which has been used for decades, but with some modifications. Fat grafting is a procedure that harvests fat from one part of the body and then injects the fat into another area. It has been used to volumize the aging face, hands, and even breasts. Benefits of fat grafting in repairing slowing healing wounds and radiated tissue have shown there are additional qualities to this procedure other than just volume. It turns out that fat contains stem cells and growth factors, more than any other tissue in the body, even more than bone marrow. The component of the fat that contains the stem cells and growth factors is called the “stromal vascular fraction”, also know as SVF.

When digging down into the research, an interesting finding has been discovered. It turns out that most of the fat cells injected don’t actually survive. What actually happens is that the stems cells (Adipose Derived Stem Cells – ADSC) injected along with the fat cells (SVF) leads to new fat cell production.

So here’s the new modification of the procedure. There is new a way to separate the SVF from the fat, without affecting the viability of the stem cells. This process creates the so called Nanofat, a highly concentrated solution of stem cells and growth factors.

It is a process of using filters and screens which takes less than 15 minutes to perform. It turns out that fat cells make up about 80% of the volume of the fat extracted during the harvest. The filtration system leads to destruction of the fat cells (which don’t live anyways) and leads to a much thinner solution which can be injected using smaller cannulas or needles than typical fat grafting procedures.

It turns out that Nanofat actually contains little to no viable fat but is the popular term for the SVF derived from fat. To even further “energize” the Nanofat injections, PRP or PRF is mixed with the solution. This process gives additional growth factors which benefit in the fat production and overall repair and rejuvenation of the areas treated.

Nanofat injections are often combined with fat grafting which is modified from the classical method. It has been found that the inconsistent “take” and lumpiness of fat grafting is related to large size and nonuniformity of the fat harvested. To overcome these hurdles, the harvesting process is now done with smaller cannulas and the fat is pushed thru filters to make uniformly smaller sized fat globules.

Nanofat is useful to treat:

  1. Crepey skin around the eyes
  2. Superficial lines and wrinkles
  3. Smoker’s lip lines
  4. Thin, atrophied skin
  5. Severely sun damaged skin (in combination with other procedures)

The use of Nanofat, with or without fat grafting, requires a minor liposuction procedure to harvest the cells. This is done completely under local anesthesia. Only syringes are used as suction and the cannulas used are much smaller than typical liposuction. There will be some downtime of swelling, bruising, and redness, that typically lasts a few days or up to a week (longer in a minority of patients). Full results require about 9 months to fully appreciate – the time required for new fat and skin cells to be generated.

We now have a completely natural way to rejuvenate and reverse the affects of aging, using stem cells derived from fat cells – Nanofat. The process of isolation of the stem cells and growth factors from fat has become an extremely viable option with a 90 minute procedure.



7/3/2017 1:42:19 AM

The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.

There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.

The reasons to dissolve HA filler are:

  1. Poorly placed filler giving an aesthetically poor result
  2. Where too much filler was placed
  3. Filler that is infected
  4. Filler is forming a granuloma
  5. Filler is causing ischemia/vascular occlusion
  6. Filler is causing visual changes or blindness

The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.

It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours. 

Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.



6/21/2017 12:23:48 AM

The nonsurgical aesthetic industry has finally hit an important milestone. Using a combination of techniques, cosmetic physicians are now able to halt, and even reverse, the age-related changes which occur to one’s face. In the past, technologies would allow for turning back time for a few years but eventually, the inevitable and undeniable signs of aging would occur. As lasers, radiofrequency (RF), filler and neuromodulator techniques have improved, the aging face is a thing of the past. The concept of “age freezing”, keeping ones looks for a decade or more, is not merely a dream, but reality. More importantly, this all can be done without surgery!

Not everyone is a candidate for “Age Freezing” unfortunately. The stipulations are:

  1. Must be a nonsmoker – There are several significant skin and health issues associated with smoker which can’t be overcome. Many procedures require healing and collagen stimulation which are inhibited by smoking.
  2. Free of chronic debilitating disease – There are tolls long term diseases take on the body which lead to premature aging, cellular changes.
  3. Stable weight – As Katherine Deneuve once stated, at the age of 40, you must decide between your ass or your face. If you lose too much weight, fat is lost from your face. In most instances, this can be overcome but not always. However, in patients with significant weight gains, there can be some difficulties maintaining the same look one had in the years prior.
  4. Alcohol consumption in moderation – Alcohol can take a toll on the body in the long run when taken in excess. 1-2 drinks per day is the recommended maximum intake that the author recommends.
  5. Healthy lifestyle and diet – Although this topic overlaps some of the previously mentioned necessities, a good exercise regime is also required. The benefits of exercise on weight, hormones, circulation all benefit the facial appearance. Obviously, a well-rounded diet full of antioxidants, vitamins, and nutrients is beneficial too. There is research to support telomere lengthening with these measures as well.

The requisite procedures for “Age Freezing” are:

  1. Neurotoxins on a regular basis. Relaxing the hyperdynamic muscles of the face with either Dysport or Botox needs to be performed at least 3 times per year. The regularity is needed to keep the muscles weak and prohibiting them from regaining strength.
  2. Dermal Fillers for lost volume. Fillers are the epicenter of the whole “Age Freezing” concept. Beginning in the mid 30’s, at least a cc of volume is lost per year. This is the result of fat, bone, and muscle loss. Replacing and keeping up with this process is tantamount to looking young. Large volumes are best replaced with using Sculptra, a collagen stimulating filler. It is best to recreate the foundation with Sculptra. Superficial fine tuning is best performed with a hyaluronic acid filler, such as Restylane. New techniques using blunt cannulas permitted safer, less downtime procedures. A comprehensive understanding of the aging process has enlightened our specialty as to what needs to be corrected for accomplishing age reversal.
  3. Skin Tightening to reverse gravity. The constant downward pull due to gravity leads to skin laxity, above and beyond what is attributable to volume loss. Devices that heat up the dermis will stimulate collagen and tissue contraction. Devices vary in their ability to tighten, often with a tradeoff of more downtime/discomfort/risk for more results. Ablative lasers, CO2 and Erbium, will give the most tightening for lasers. Radiofrequency can also be used, with the microneedling RF, such as Infini, giving the best results. A new procedure called JPlasma, looks like it may have promise in significant tightening, but does have about 14 days of downtime and a month of redness.
  4. Skin Resurfacing to improve pigmentation, fine lines, and thicken the dermis. The aging process, primarily due to sun exposure, causes skin to thin with loss of collagen and elastin. Dyspigmentation, pigmentation problems, occurs as well. Renewing the surface of the skin can be accomplished using lasers, such as the Fraxel Dual, or chemical peels. Microneedling can thicken the skin by producing small injuries in the dermis with very little downtime or risks. There may be benefit to adding PRP, platelet rich plasma, to the skin, but the jury is still out.
  5. Skin Care is essential to achieve the optimal results from any of the above mention procedures as well as to improve one’s skin health. Retin A or Retinol should be a staple in one’s nightly regime. These products stimulate skin turnover, reversal of pigmentation problems, better hydration with hyaluronic acid stimulation, and collagen production. Blemishes/Acne breakouts are improved with these products as well.
  6. Oral Supplements are key to good, healthy skin. Oxidants are the source of disease, cancer, aging, and skin damage. To neutralize the oxidative stress, strong anti-oxidant supplement(s) are necessary. Examples include: superoxide dismutase, fish oils, resveratrol, Polypodium leucotomos, turmeric, and glutathione. In addition, the antiaging benefits of Metformin are hard to dismiss with the current research published. Lengthening one’s telomeres with TA65 is probably beneficial as well.

One must understand that the “Age Freezing” concept is a process. It is a lifestyle, a choice. It is not a “one and done” procedure. It consists of regular visits to an aesthetic physician. There are big steps and little steps along the way. The author has dozens of “Age Freezing” patients whom look younger and better, 10 or more years after initiating treatments. “Age Freezing” will eliminated the need for future cosmetic surgery.



6/17/2017 10:38:51 PM

It’s been touted for years by the aesthetic physicians – “Prejuvenation” – starting maintenance treatments in one’s late teens or early twenties.  The Kardashians have popularized these minor cosmetic tweaks to stay youthful and refreshed with visits to their Beverly Hills physician, documented regularly on “Keeping Up with the Kardashians”. There is increasing pressure to get that perfect selfie for Instagram or to look cool and attractive on a “Snap”. Unfortunately filters don’t work well with videos unless you want to look like a cute puppy. Doctors are in agreement (for any disease process) that it is much easier to treat problems in their early stages than to reverse them after they have spiraled out of control. Small preventative treatments early on, can maintain and even enhance one’s looks for many years and avoid invasive surgical procedures in the future.  The question is, which procedures should be considered for Prejuevenation?

Neuromodulators: These wrinkle improving injections take less than 5 minutes and have no downtime. Millions of these procedures are done each year and it is the most popular cosmetic procedure performed worldwide. Most often these are used in the younger population in the frown lines (glabella), forehead lines, and crows feet. Treating these areas before the lines set in at rest, known as “etched in” lines, is one of the fundamental concepts of Prejuvenation. (Suggestions: Dysport, Botox)

Dermal Fillers: Dermal fillers made from hyaluronic acid (HA) are used to improve the minor volume loss which occurs with age. In the more athletic patients, fat loss can be appreciated in the face as well as throughout the body. Supple enhancements can be added to the mid cheek and around the eye to stave off this premature volume loss. HA fillers are also used to plump up the lips to create a youthful appearance. (Suggestions: Restylane Refyne, Restylane L, Restylane Lyft, Sculptra)

Chemical Peels: To keep the skin in top notch shape and to reverse early sun damage, chemical peels can exfoliate the superficial layers of skin. This renews the texture and pigmentation and leaves a youthful and glowing quality to the skin. (Suggestions: Illuminize, Vitalize, ZO 3 Step Peel)

Skin care: Great skin care is the basis for good looking skin. Most would agree that some type of Retin A or Retinol is essential for maintaining youthful skin. These products lead to increased turnover of the skin cells, improve dyspigmentation (pigmentation problems), thicken the skin, and create a more hydrated skin. Sun protection with an SPF should be part of one’s daily regime. It is also highly recommended to apply growth factors to the skin to reverse the aging process. (Suggestions: ZO Skin Health, Lifeline Stem Cell Skincare)

Prejuvenation is a trend that is here to stay. Preventative maintenance will prolong the need for more aggressive corrections in the later years. With short, no downtime procedures such as neuromodulators, chemical peels, fillers, and a good skin care regime, youthful, natural appearances will persist for years. Stay ahead of the curve with Prejuvenation.



6/16/2017 1:48:18 AM

 

Acne affects millions of people in the US, and is the most common reason to seek medical attention from a Dermatologist. Billions of dollars are spent on medications to control the disease, both over the counter and prescription. Medications have potential side effects, and compliance is difficult. Even with aggressive medical therapy, acne can be difficult to control, which leads to frustration by patients, parents, and physicians. With prolonged cases of acne, scarring can set in, creating an even more difficult problem to treat.

It’s the early teen years, as one is experiencing puberty, when acne usually starts.  This period coincides with high school, selfies, and an interest in dating. Acne can negatively impact social interactions and lead to depression, moodiness, negative self-worth, and isolation. Controlling acne is a top priority for large number of teenagers in the US.

A cascade of events leads to acne:

  1. A trigger: hormonal, emotional, stress, metabolic
  2. Increased sebum (oil) production from sebaceous glands
  3. Plugging of the follicles by the sebum
  4. Infection of the sebum by bacteria
  5. Inflammation related to the infection/immune response

Treating acne with lasers is not a new concept, but the Aerolase has made the process more effective and safer. Even the wavelength, 1064nm YAG laser, is not novel to the Aerolase. However, having a pulse width of 650 microseconds is unique. The Aerolase sits in the middle of the prior lasers used to treat acne, the Q Switched (nanosecond) and the Excel V/VBeam (millisecond). It has been shown that this pulse width is better tolerated than faster and slower lasers, and therefore more pulses and even stacking can occur. Deeper and more broadly-based heating occurs with the Aerolase. With the increased heating of the acne, the laser becomes more effective in its eradication. The 1064 wavelength is safe for all skin types, but settings are reduced for the darker skin patients. The Aerolase laser treats acne by:

  1. Heating up and shrinking the sebaceous glands leading to lower sebum output
  2. Killing the acne bacteria
  3. Reducing the redness associated with the acne
  4. Improving early scarring
  5. Reducing the inflammatory component of acne

Typically, a series of treatments are needed, 4-6, about a week or two apart. Touch ups are needed every 1-3 months. Flairs should be treated acutely, so they are controlled quickly. Continues use of topical therapy is usually recommended, such as Retin A and benzyl peroxide. The Aerolase gives patients a unique, no downtime, near painless 10-minute procedure to help control even the most difficult cystic acne.

“Get rid of that Instagram filter and show your true selfie.”



5/28/2017 2:24:27 PM

Coolsculpting’s original FDA approval was in 2009 and it was initially cleared to cool skin prior to dermal procedures. It was later in 2010 that the FDA approved Coolsculpting for fat reduction in the flanks (love handles). Over the next several years, the procedure has been approved for abdomen, thighs – both inner and outer with various sized handpieces to treat every body type.

What’s new is that there are 2 new indications for Coolsculpting treatment. The submental fat (double chin) can now be treated with the Cool Mini handpiece. Depending on the needs of the patient, one or two applications are needed. Treatment times are 45 minutes. There is no downtime as is customary with all Coolsculpting procedures. A 2nd treatment is needed in some patients who need larger corrections. Another exciting area of recently approved treatment is the underarm area. This is where the new Cool Petite handpiece is used. Loose skin is not going to improve but that annoying “bat wing” can be reduced with these treatments.

In 2016, there was a significant change to the handpieces used for treatment called the CoolAdvantage Handpieces. (Not all practices have upgraded to these, so patients must inquire). The difference is that these handpieces are more shallow – the amount of suction witl therefore be less. The cooling plate is continuous rather than just the sides. The area treated is now more uniformly cooled than with the prior handpieces. These changes result in:

  • More comfortable treatments
  • Treatment times of 35 minutes vs the usual 60 minutes
  • Faster onset of results – as little as 3 weeks
  • Less bruising and post procedure pain

Soon after Coolsculpting’s approval it had been noted that manual massage post treatment led to improved results. About a couple years ago it was found that using the Zimmer Z Wave in place of the massage yielded even better results. It was found that adding the Z Wave increased the treatment efficacy by 68-100%. The Z Wave uses Acoustic Pulsed Technology, which sends shock waves through the skin and fat. It is a painless 5-10 minute procedure. These shock waves further injure the fat cells leading to a better result. After the Coolsculpting treatment, there are fat cells which are killed, some unaffected, and some which are “on the fence” as to whether they will survive or die. The Z Wave pushes some of these “undecided” cells over the brink. Z Wave has also been shown to lead to less post procedure discomfort.

“If one is good, two is better”. In some practices, a second Coolsculpting machine has been purchased. This allows for “DualSculpting”, treating 2 areas simultaneously. Treatment times are then cut in half using this technique.

Comparing the DualSculpting to  treatments 1 year ago, two areas can now be treated in about one quarter of the time when adding the benefits of the CoolAdvantage Handpieces.

The Aesthetic Clinique has been one of the pioneers in Coolsculpting treatments. Its first machine was obtained in 2009, being one of the first 25 in the country, even before the formal FDA approval for fat reduction. All the latest handpieces are available including the CoolAdvantage, Cool Mini, and Cool Petite. The Zimmer Z Wave is a complementary service added to all Coolsculpting treatments. A second machine has just been purchased, so DualSculpting is now available at The Aesthetic Clinique.

Recent advances have made Coolsculpting significantly faster, more comfortable, and more effective. It is a great noninvasive procedure for reducing unwanted fat without downtime.



3/14/2017 9:00:28 PM

(Dr. Weiner is one of the most experienced users of Restylane Refyne and Restylane Defyne in the US and has trained multiple physicians on his injection techniques of these new products.)

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Restylane Defyne Treatment Radial Cheek Lines – Dr. Steven F Weiner

Late 2016, two new dermal fillers, Restylane Refyne and Restylane Defyne were FDA approved. Although new to the US, these fillers had approval in Europe in 2010  and in Canada in 2015 under the name Emervel. The announcement flew mostly under the radar and it wasn’t until early 2017 that Galderma officially launched the new fillers. Although these fillers are similar in composition, hyaluronic acid (HA), to many of the other fillers on the market, it is the technology behind them that set them apart from the rest.

Restylane Refyne and Defyne are made with XpresHAn technology which adds flexibility to the fillers – “think honey” – and makes them perfect for treating areas of expression. (Other Restylane fillers are based on NASHA technology, and are particulate in nature – “think sugar”.) Additionally, Refyne/Defyne have high crosslinking that lends to their ability to stretch and recoil. Refyne has less links, so it can stretch more, while Defyne is more tightly bound.

The clinical outcomes of using Refyne and Defyne are unique and directly related to their manufacturing process. With placement in the dermis using small aliquots (a different technique than other fillers) in areas of high muscle movement (expression), the filler will support the skin and soft tissue in unparalleled ways. In fact, muscle strain around the mouth was tested before and after Refyne/Defyne placement and was shown to revert a 55 year old’s profile to one similar to a 30 year old on average. The hyperactivity of the muscles was “constrained” by the filler, just as Botox or Dysport does in the glabella and crows feet. The previously difficult to treat radial cheeks lines (smile lines) can now be improved significantly with the new Restylane Refyne/Defyne fillers. Other fillers used to treat this area are more apparent and obvious due to their lacking the XpresHAn technology, and don’t look as natural with movements. Adding bulk/volume to the lower face is usually not desired because beautiful and youthful faces are V or heart shaped. The unique placement of Refyne/Defyne in the dermis does not add fullness in the lower face during corrections of the marionette lines, prejowl sulcus, and smile lines in Dr. Weiner’s experience.

Cohesiveness is the ability of a filler to “stick to itself” and integrate with the surrounding tissues. Both Refyne and Defyne have a high cohesivity. This equates to more blending of the filler with the tissues, and a more natural appearance. In clinical use, these new fillers can be injected into the mid/deep dermis (a dermal filler actually being injected in the dermis!) and still go unnoticed, without nodules or lumps.

One final highlight of Refyne/Defyne is their low degree of swelling associated with injections. This is beneficial for areas such as lips and tear troughs, where swelling can lead to social downtime, precluding some clients from doing these procedures. When comparing all the HA fillers available in the US, it’s been Dr. Weiner’s experience that Refyne/Defyne have the least amount of swelling.

Restylane Refyne and Defyne open up a new treatment paradigm for the perioral smile lines (radial cheek lines) where previous corrections were usually suboptimal.  This area is often overlooked or discouraged, but is a frequent concern for a majority of dermal filler clients. The satisfaction rate with these corrections have been extremely high in Dr. Weiner’s experience. With the additional benefits of high conhesiveness and low swelling, Restylane Refyne and Defyne are a great addition to the filler armamentarium of the advanced injector.

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3/12/2017 4:21:05 PM

The value of volume replacement in the aging face is now universally recognized as one of the most beneficial procedures to restore youthfulness. The combination of sun exposure, aging, and genetics leads to collagen, fat, muscle, and bone loss. Reinflating the cheeks, lips, and tear troughs are routinely done by physicians across the world on a daily basis. Most of these patients will have a week or more of downtime – swelling, bruising, discomfort – but that doesn’t have to be. Blunt cannulas can minimize most of these side effects associated with filler injections and has become standard practice for Dr. Weiner for the past 6 years.

The benefits of blunt cannlas are:

  1. There is only one insertion point to treat multiple areas. This equates to less intrusions through the skin and therefore a more comfortable procedure.
  2. The tip is rounded and blunted. This very fact accounts for less bruising/swelling. When a blood vessel is encountered with the end of the cannula, the vessel is more likely to be gently displaced rather than punctured.
  3. There is increased safety. A phenomenon termed “vascular occlusion” occurs when a filler is injected into a blood vessel. The filler then blocks the blood flow and can lead to necrosis (death of skin) or even blindness. It is much less likely to occur with blunt cannulas, particularly larger cannulas (23 or 25 guage), because they don’t enter blood vessels as easy as needles do.
  4. Allows treatment in areas otherwise not easily accessible. Due to the safety of the cannulas, there are now areas of the face which are more easily treated. The superficial temporal area, supraorbital, forehead, piriform, periocular and lower eyelid are now routinely treated with cannulas whereas with needles, these areas were very precarious to inject.
  5. Downtime is minimize. As a result of all the benefits listed above, most patients have significantly less healing time and are much happier after receiving their filler treatments with blunt “safety” cannulas.

If blunt cannulas have so much benefits, why are only 5% of the providers using them for dermal fillers? The art of using cannulas is not an easy one. Patience is required because directing the tip to the exact spot it is needed is not always easy. Remember, when the tip encounters an obstruction (vessel, ligament, collagen), it will need to traverse around it and not pierce it (as needles would do). This can be frustrating and lead to longer and less satisfactory results for the inexperienced cannula injector.

Dr. Weiner is one of the leading authorities on cannula injections of dermal fillers and has used them for over 6 years for nearly all of his injections. The cannulas provide a safe, comfortable, minimal downtime technique for volumizing the aging face, even with multiple syringes being used simultaneously.



1/25/2017 2:46:54 PM

Tattoo removal is most effectively performed with lasers. The mechanism by which the laser works is by breaking up the larger ink granules into smaller particles. The body is unable to clear the larger particles but when smaller, the immune system is capable of clearing the ink. Successful clearance of a tattoo is dependent on several factors which will be highlighted in the remainder of the blog. While the experience of the physician performing the tattoo removal can’t be ignored, he/she is limited by the laser  being used.

There are 3 aspects that need to be considered in a tattoo laser. They are power (and spot size), wavelengths, and pulse durations.

Power

Power is a measure of how much energy can be delivered to the skin. What’s more important is how much is getting to the level of tattoo. It remains obvious, the more power delivered to a tattoo, the better clearance there should be. This is limited by the damage to the skin and surrounding soft tissue. Excessive energy to the superficial skin can lead to blistering, prolonged healing, scarring, and pigmentation changes. High-power lasers are able to use large spot sizes (10-15mm) to deliver the energy to the tattoo. Larger spot sizes give deeper penetration of energy and a safer treatment. Under-powered lasers need smaller spot sizes to get enough energy into the skin to cause an effect on the tattoo. This leads to the superficial skin heating up and potential for blistering/scarring.

depth

When comparing energies between lasers, most companies measure the output from the laser. What is not discussed is how much the energy is diminished while going through the arms, mirrors, and handpiece. This can account for 20-30% less energy at the skin than what is the measured output of the laser in the lab. (The energy measured by the Piqo4 system is to the skin while all other systems is output from laser.)

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compare-tattoo2

Wavelength

The wavelength of a tattoo laser determines what colors it can treat. The most common color in tattoos is black. The best wavelength for treating black inks is 1064nm. This wavelength also is the safest for darker skin type. Even if the tattoo doesn’t look like it has black ink, over 95% have some component of black ink. It is imperative that the laser chosen for tattoo removal has a 1064 wavelength. The next most common ink is red. This is best treated with a 532 wavelength. Almost always, the 532 and 1064 wavelengths are packaged together in the same laser. It requires a doubling of the frequency to go from 1064 to 532 (double frequency means halving wavelength). The remaining colors require a variety of wavelengths so it is essential to have multiple wavelengths to treat colored tattoos. The lighter the color – pink, yellow, white, light blue – the harder it is to treat.

compare-tattoo

Pulse Duration

The lasers for tattoo removal are much faster than lasers used for hair removal, photofacials, telangiectasias, and leg veins. Where as the typical pulse duration is measured in milliseconds for the dermal treatments, tattoo lasers are measured in either nanoseconds or picoseconds (1000x – 1,000,000x). These extremely short pulses lead to extremely high energies being placed into the tattoo. This energy leads to a shock wave hitting the ink and breaking it up. The faster the pulse, the higher the energy and the more directed the energy is to the ink and less to the surrounding tissues. The longer the pulse, the more time the energy has to spread to the tissues. In the author’s opinion, initial treatments for tattoos are best performed with nanosecond pulses (to break up the larger ink particles) while the later treatments need picosecond pulses to clear the remaining ink particles which are smaller in size. It is most effective to have a laser with both nano and picosecond capabilities for treating tattoos.

The Best Laser for Tattoo Removal

After understanding the important qualities required in a laser for optimal treatment of a tattoo, it becomes fairly easy to see the obvious best laser. The Piqo4 has the highest energy (to the skin) of all nano/picosecond lasers. As a corollary, it has the largest spot sizes on the market – meaning safer, deeper, and faster treatments. With it’s 4 wavelengths, it has the capabilities to treat the 9 most common colors. It has 4 different pulse durations – 2 and 8 nanosecond and 600 and 800 picosecond. In conclusion, the Piqo4 combines high power, 4 wavelengths, and multiple pulse durations to enable it’s lasers to be the most effective option available on the market.

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1/22/2017 4:40:52 PM

Melanocytes are the cells responsible for the pigmentation in the skin. Their activity can be increased in response to inflammation. When skin becomes hyperpigmented from an injury, it is called “post inflammatory hyperpigmentation” or PIH. This is particularly prevalent in darker skin individuals, where there is more melanocytic activity, but can occur in lighter skin individuals as well.

The widely accepted scale for skin pigmentation types is the Fitzpatrick Scale. The Fitzpatrick Skin Type 1 are extremely light skinned, have blue eyes, and burn extremely rapidly with sun exposure. Type 6 individuals have very dark skin, dark eyes, and tolerate prolonged sun exposure without burning. In general, the type 4-6 skin types are the ones at risk for PIH.

PIH is possible after the following:

  1. Laser procedures (mainly laser resurfacing)
  2. Acne
  3. Surgical incisions
  4. Chemical peels
  5. Burns
  6. Infections
  7. Radiofrequency (Infini is low risk)

The best way to treat PIH is prevention, if possible. Prevention consists of calming down the melanocyte metabolism. The standard recommendations are Retin A and hydroquinones. If there is a procedure a darker skin individual is planning that has risks of PIH, this regime should be started at 3 weeks prior to the procedure. It should be continued at least a month and up to 3 months afterwards. These 2 topicals are also standard therapy for patients with PIH.

Prolonged inflammation after a procedure (more than a week) in a darker skin individual, is a risk for PIH. The practitioner needs to recognize this and treat the inflammation appropriately. If there is prolonged redness of the skin, steroids and/or vascular lasers are needed to reduce this. If infection suspected, antibiotics are needed. Calming the skin is essential to prevent PIH.

The timing of PIH is very predictable. It almost always occurs about 3 weeks after a “at risk” procedure is performed.

If there is already PIH, treatments which can be used are:

  1. Topicals such as Retin A, hydroquinone, and steroids; Triluma contains all 3
  2. Chemical Peels
  3. Gentle laser treatments with a 1064 laser (nanosecond or picosecond)
  4. Possibly PRP with microneedling (experimental but minimal risk)
  5. Antibiotics for ongoing infections
  6. Laser hair removal for PIH associated with folliculitis

In general, PIH is best prevented then trying to treat after it occurs. Recognizing risk factors with certain procedures is the key to success. Treating prolonged redness is often overlooked and must be treated aggressively rather than taking a “wait and see” approach.



1/8/2017 5:51:10 PM

The concept of applying radiofrequency energy into the skin has changed in the past few years. The “older” methods use a process called “bulk heating” to apply the energy to the surface of the skin which will diffuse to the deeper layers of the dermis. The deficiencies of this method are:

  1. The heating is not precise, with the depths unknown.
  2. The epidermis is at risk for too much heat, leading to potential for scarring or pigmentation issues.
  3. Subdermal fat is at risk if the heating goes too deep.
  4. The heating is bulk and not fractional, so safety is less.
  5. The highest temperature achieved is about 45 degrees, enough to minimally stimulate collagen.

The progression of technology with RF heating of the skin has evolved to a process that is more precise. Using microneedles, RF energy is able to be placed at desired depths in the dermis. The deeper, fractional heating is much higher than if placed on the skin surface. It enables the temperatures to get to 65-70 degrees C, enough cause coagulation. Coagulation leads to maximal collagen stimulation and tissue contraction. In regards to the microneedles, there are 2 types of needles used: Insulated and Noninsulated. The noninsulated needles deliver energy only at the exposed tips, completely bypassing the more sensitive epidermis. On the other hand, noninsulated needles allow the energy to transmit along the entire length of the needle, creating a wound that includes the epidermis. When the epidermis is heated to point of coagulation, there is wound care and potential for pigmentation and scarring. The only way these uncoated needles get around potential safety problems is by delivering less energy. The advantages of microneedling insulated delivery of RF are:

  1. More precise level of RF energy delivery.
  2. Fractional heating of dermis, which is safer than bulk heating.
  3. Bypassing the epidermis so darker skin types are more safely treated.
  4. Higher energies can be placed leading to coagulation and better collagen stimulation.
  5. Insulation leads to better epidermal protection, less downtime, and potentially higher energies.

The main devices that deliver RF through microneedles with insulated needles are Infini and Profound. There are actually significant differences that might not be apparent to even the most informed providers.

  1. Infini uses 49 needles while Profound uses 10 needles.
  2. Infini can treat at 0.25 mm incremental depths between 0.1 – 3.5 mm while Profound has just 2 possible depths.
  3. Infini’s pulse durations are up to 500 milleseconds while Profound’s pulses are 3-5 seconds.
  4. Infini uses multiple passes to create thousands of coagulation zones whereas Profound uses only one pass.

What does this all mean? It means that the coagulation wounds placed with the Profound are less in number but much larger in size. The downside to larger wounds is that there is longer healing times because the unaffected tissue which is needed to assist in healing is further from the center of coagulation. With smaller coagulation zones as in the Infini, the wound healing is shorter in duration. In addition, the healing in the desired fashion (without scarring) is easier to control with multiple smaller wounds than it is for fewer, larger wounds. The concept of fractional ablation being safer and with less downtime (popularized by the Fraxel laser) loses it advantage as the wounds get larger.

It boils down to: The Infini creates smaller and many more coagulation zones than the Profound which creates larger and fewer zones. Safety and recovery are improved with the more plentiful, smaller coagulation zones of the Infini.



12/23/2016 8:49:41 PM

The ideal facial shaped has been described as “heart shaped”, “V shaped”, or “Upside Down Egg”. A youthful face draws attention to the upper face and eyes. With aging, the lower face becomes “heavier” and more dominant, as laxity and volume loss set it. Instead of round or oval, the shape of the face becomes closer to square. The underlying cause for these changes is primarily loss of fat, muscle, and bone.

The upper face’s width is determined primary by the temples. Fat pads in this area are particularly susceptible to atrophy associated with aging and exercise. To reestablish the youthful facial shape, it is essential to reflate the temples. There is a contiguous fat pad in the preauricular area which follows similar volume loss as the temples and should be volumized simultaneously. When the lateral cheeks are given filler, the temporal deficits become exaggerated and more obvious. Patients must be counseled on their temples whenever cheeks injected.

Besides the overall facial shape change, the benefits of filling the temples are the lift given to the surrounding tissues. The brow, and upper eyelid will be elevated with temporal filler. Placement of filler along the orbital rim and lower forehead further enhances this effect. The ideal temple should be convex in a women and slightly concave in the male.

The filling of the temples is reserved for the experienced injector. Dr. Weiner’s choice for this area is Sculptra because of its safety and natural appearance. The only downside to Sculptra is that when placed along the bone in the deepest aspect of the temporal fossa, a large volume of product is needed for complete correction. To finish corrections after the deep Sculptra placement, a superficial layer of HA filler (Restylane, Juvederm) can be safely placed using large bore cannulas. The filler is placed immediately below the dermis in the subcutaneous layer or just below the superficial layer of the temporalis fascia.

To reverse the signs of aging and restore the upper face dominance, temple volumization is required. It must be considered for patients that have brow and eyelid heaviness as well. This is an area that is difficult to treat with higher than average safety risks, and should be reserved for the most experienced injectors.

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11/11/2016 6:52:46 PM

 

There are now several procedures to make those private moments even better. There is no downtime and minimal discomfort with these procedures and they should boost your self confidence.

  1. Botox for sweating: Most people are familiar with Botox for wrinkles. What most don’t know is that it also stops sweating. It works by inhibiting the nerves to the apocrine and eccrine glands from secreting sweat. Botox can be injected in the pubic area to improve the sweat and the odor associated with it. It can be done in less than 5 minutes and should last 4-6 months. Dr. Weiner has developed a technique that makes it go faster and gives less discomfort than standard injections. The results are apparent about 3-4 days after treatment. Men and women can benefit from this procedure.
  2. Fillers for the labia: Just as with the face, as we age, the labia (majora) loses fat. This can easily be improved with fillers. Dr. Weiner uses cannulas for this so the amount of insertion points is either 1 or 2 per side maximum. All the fillers can be used here but Radiesse and Sculptra are the preferred choice.
  3. ThermiVa for rejuvenation: ThermVa is able to improve multiple different problems with a series of painless 45 minute procedures. It uses a temperature controlled wand that cause collagen stimulation, tissue contraction, and rejuvenation of the vaginal mucosa. The treatment improves: dryness, laxity, labial (minora) hypertrophy, urinary incontinence, and in some cases, orgasmic dysfunction.

Build you confidence and pleasure under the sheets with these 3 easy procedures. Downtime, side effects, and discomfort are minimal.  These are procedures both you and your partner can enjoy.

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11/9/2016 11:07:01 PM

It doesn’t matter how long you spend in the gym. Most women still want a more rounded, lifted buttocks and legs with less cellulite. Wouldn’t it be nice if both of these could be improved with just injections?

There is a new procedure that uses a long term filler for a new purpose. Sculptra has been FDA approved since 2004 for use in the face for volume loss. It works by stimulating one’s own body to produce collagen in response to the PLLA (Poly L Lactic Acid), it’s main component. It takes 2-3 months to appreciate the correction from Sculptra. The result of Sculptra should last years because newly formed collagen lasts 7 years in other areas of the body.

How the procedure works is by filling in the dimples and creases associated with the cellulite with injections. The correction is seen immediately but that subsides rather quickly because it is mostly saline. Over the next several weeks, collagen is gradually built up from the PLLA injected, and the cellulite appearance improv es. Severe laxity and “cottage cheese” of the skin is not correctable.

Creating a Brazilian Butt Lift with Sculptra is an extremely easy procedure to get done. There is no liposuction required, no healing/soreness from fat harvest, no need to sit on donuts or in some cases “avoid sitting at all costs”. It can be done in 15 minutes and is nearly painless. Dr. Weiner prefers to do the procedure in a series of 3-4 treatments. Each injection is done using cannulas for minimal bruising and discomfort. Approximately 4 vials are used per treatments. Long lasting improvements in lifting and fullness should be expected from Sculptra which appears gradually over several months.

Having a minimally invasive alternative to these traditionally difficult to treat “problems” is a breakthrough for those patients “on the go”.  In contrast, a formal BBL requires weeks to recover, restrictions on exercise/sitting and sometimes need “redos”. These Sculptra injections can be done in about 15 minutes and have no downtime except for bruising, with results lasting for years.

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11/6/2016 5:44:14 PM

Some of the fastest growing and most popular procedures in the Aesthetic Industry are radiofrequency and laser procedures. The most sighted obstacle for patients doing these procedures is pain. Dr. Weiner has develop and perfected a method to numb the face fairly thoroughly that is fairly quick and simple. The “Superficial Skin Block” takes about 3 minutes to administer for the entire face. It requires no knowledge of neural anatomy and is less invasive/more comfortable than nerve blocks. The anesthesia kicks in within minutes and will last at least a couple hours. It is ideal for improving comfort when undergoing the Infini, CO2, Erbium, or Fraxel laser resurfacing. Dr. Weiner’s mixture for injection is:

  1. Lidocaine 1% with 1:100,000 Epinephrine (Standard premixed from most medical suppliers)- 5cc
  2. Bacteriostatic 0.9% Sodium Chloride with Preservative – 5cc
  3. 8.4% Sodium Bicarbonate – 1cc
  4. All this is drawn up in a 10cc syringe

The “Superficial Skin Block” starts with placement of topical numbing cream. Dr. Weiner uses “Lipothene” from Central Avenue Pharmacy which contains 23% Lidocaine and 7% Tetracaine. It is left on the face for at least 1 hour. Do not place on face and neck simultaneously. This is too large a surface area for the topical. The neck doesn’t require this strong a topical in Dr. Weiner’s experience.

The injection requires a mesotherapy apparatus from Mesoram.com. The exact device used is found at: Dr. Weiner’s Preferred Mesoram Needles .  The needles are 4mm, 30g and the plate is circular with 7 needle connectors. Plates can also be purchased without needles and 32g needles can be purchased from the site and attached manually.

The topical is wiped off and the face is cleaned with alcohol and hibiclens. The injection is started on the cheeks with 0.5 ml aliquots placed in each injection. The areas injected are slightly overlapped. A small amount of the mixture is placed above the upper lip with a needle that is removed from the device. A few minutes are allowed before starting the procedure to allow for the small blebs to diffuse into the skin tissues. You will notice areas injected become pale and this is the epinephrine effect. This helps in controlling bleeding and bruising.

Dr. Weiner’s Superficial Skin Block has been used by multiple practitioners with great success. It’s effectiveness, ease of use, and limited downside make it perfect for many aesthetic procedures, particularly Infini and laser resurfacing.

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11/4/2016 8:22:29 PM

Until recently, the dreaded double chin has been fairly difficult to treat. Liposuction was the mainstay of treatment. This can be performed under local anesthetic, but there is downtime, bruising, need to wear a chin strap, and some risks. Now, there are 3 non surgical options to treat this area and along the jawline (with 2 of them) which have no or minimal downtime.

Kybella is a bile salt (deoxycholic acid) that is found in the gallbladder. It is natural secreted to assist the body in digesting consumed fat. It is now available in an injection form and can be used in the submental area to permanently reduce fat. It typically requires 1-2 vials per session, and about 2-4 session. This is all dependent on the amount of fat in this area. 1 month to 6 weeks in the recommended period between treatments. The procedure takes about 15 minutes. There is very minimal pain at first. It then starts burning and this lasts for up t0 30 minutes. Swelling occurs for the first 3 days that is significant. Most of the swelling is gone by a week. All swelling is gone by about 3-4 weeks and results are seen at this time. Areas other than the submental area are being investigated

Pros: short procedure, effective for submental area, long lasting results

Cons: swelling, can’t be used along lateral neck – only central portion, multiple treatments

CoolMini from Coolsculpting is a new handpiece that is designed to treat the upper neck area. At this point, most people have heard of Coolsculpting. This technology cools fat down to a certain temperature to where it will partial die, but leave the other structures intact. The CoolMini is a newer technology from Coolsculpting that uses more uniform cooling, and doesn’t require the full one hour to get treated. It’s suction grabs onto the fatty area and stays attached for the 45 minute cycle. It can be used to the central and lateral portions of the neck. If there are large areas needing treatment, more than one session is needed and more than one attachment is needed per session.

Pros: minimal or no downtime, can treat lateral as well as submental fat, proven technology that is permanent

Cons: treatment times are 45 min per application, might need more than one application and more than one session

Infini uses high intensity radiofrequency to treat excessive fat in the neck. It gets to the fat by use of the microneedling delivery system. It can go up to 3.5 mm which is into the superficial layer of fat. By adjusting the power and pulse duration, fat along the jawline, jowls, and submental areat can be treated. It is usually a series of 3 treatments, spaced about 4-6 weeks apart.

Pros: can treat all areas of fat in the neck and jowls, tightens skin as well and improves wrinkles

Cons: requires topical anesthetic (more painful than others), requires 3 treatments usually, mild redness and swelling afterwards for a couple days

There are now a few ways to treat the neck and double chin area. Which one is best for you is based on your desires, lifestyle, and anatomy. All are effective with minimal or non invasive techniques.

 

 

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10/19/2016 6:58:15 PM

Coolsculpting has established itself as the worlds #1 noninvasive fat reduction treatment. It has over 3 million treatments worldwide and has been found to be a safe, well tolerated, and reliable procedure. It was FDA approved to cool skin to allow for anesthesia in 2009 and later in 2010, it was given the permanent fat reduction approval.

Coolsculpting treatments involve attaching a handpiece to the area of desired fat removal. There are various sizes of handpieces to assist in reaching all the different areas of the body where there is excessive fat. Most of these handpieces use a suction to pull/draw the tissue and fat into the handpiece, so a requirement (except for the outer thigh where a flat handpiece is used) is that there is “pinchable” fat. These handpieces gradually cool the area treated to the optimal temperature where the fat is killed but the surrounding tissues (skin, blood vessels, nerves) are kept safe. The attachment duration has been 1 hour until recently. It has been proven that about 25% of the fat treated will be removed during this process. It has also been shown that massaging the area treated immediately after handpiece removal improved the outcomes too. There was more fat loss and less post procedure discomfort.

There was a study last year that showed the Zimmer Z Wave treatment, done in place of the massage, lead to a 65-100% improvement in outcomes. In large volume practices, including Dr. Weiner’s office, this is now routinely performed on all Coolsculpting patients immediately when the handpieces are removed. The Z Wave uses radio pulsed technology that send shock waves through the tissues. When these waves bump against newly frozen fat cells, the already compromised cell is further damaged. This increases the amount of fat cell death from the Coolsculpting treatment. Another way to explain how it works is that with Coolsculpting, there are cells that are killed, cells that aren’t, and cells that are undecided. The Z Wave pushes some of these undecided cells to the point that they will die.

A recent advancement in the handpiece technology has been developed. This is the found in the CoolAdvantage and CoolMini handpiece. The changes consist of a more uniform cooling of the area treated. Older handpieces had cooling elements only on the sides of the handpiece cup but the newer has cooling throughout. What does this do to change the treatments? It lowers the treatment time from 1 hour to 35 minutes (45 min with the CoolMini). The newer handpieces have less depth, so more fibrous, less flexible skin areas can now be treated. This also translate into a much more comfortable treatment because there is less pulling in of the tissues. It has been found that post treatment discomfort is also less. There are reports that these handpieces are more effective because there are no longer fat pockets that might not get to the critical temperature need for death.

With the addition of CoolAdvantage technology and the Zimmer Z Wave, Coolsculpting treatment times are almost cut in half, treatments are more comfortable (during and after), and most importantly, the procedure is significantly more efficacious. When researching providers, make sure they use these new technologies.

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10/16/2016 2:57:37 PM

It’s been a little over 3 years since the Infini was introduced in the United States in August, 2013 by Lutronic. It was developed in Korea, and had been used in the prior 2 years in Asia and Europe. Infini brought a significant evolutionary change to treating the skin with radiofrequency (RF). Although RF has an over 50 year history of medical uses, Lutronic’s Infini innovations has elevated the precision in which the RF energy is delivered to an entirely new level.

It been long established that heating skin causes an inflammatory response that results in collagen stimulation, tissue contraction, and skin rejuvenation. While 42-45 C (denaturing) has shown to be enough to create this cascade, 65-70 C (coagulation) has been shown to lead to maximum collagen deposition. Radiofrequency devices which push their energy through the skin without penetration are limited to temperatures of 45 C because of the risk of harming the skin surface (blisters/scarring). Bypassing the surface with microneedles, as Infini does, temperatures can go up to the coagulation point with very little risk. In addition, Infini can place this energy at the “sweet spot” of the skin, the mid to deep dermis. The depth of most of the predecessor RF devices was always in question, and was often too deep (fat necrosis risk).

Over the last several months, there have been significant treatment innovations with Infini. With diligent research and histological evaluations, optimal settings were further enhanced. These settings lead to larger zones of coagulation during each pulse. This translates into fewer pulses needed (shorter treatment times), and better results. In addition, the treatment tip was modified to allow for a more even distribution of energy, which also leads to better outcomes. The “price to pay” for these innovations is slightly more prolonged redness, possibly up to a week. Also, “microdots”, the grid-like white marks from the needle tips, might last for more than a couple weeks. These have always resolved without scarring or complications.

Dr. Weiner has performed approximately 1000 cases in the past 3 years with Infini. (Cases = areas treated, i.e face, neck, chest).  A summary of his findings:

  1. There have been no long term complications in his patients. There have been no incidences of scarring, unwanted fat loss, or pigmentation issues.
  2. Infini is safe to use on all skin types.
  3. Infini is the most effective device available for acne scarring when compared to ablative, non ablative lasers, and other RF devices.
  4. Significant improvements can be established in the neck wrinkles, necklace lines, and creepy skin of the neck.
  5. Superficial fine lines on the face are well treated.
  6. Jawline and submental definition are improved in most cases. Purposeful fat loss is possible in these areas with deeper, more aggressive settings.
  7. Infini is an option for axillary hyperhidrosis with proven long term results.
  8. Infini can be safely used all over the body but the small footplate limits treatments on large surface areas.
  9. Treatment of stretchmarks is only mildly effective. Further refinements in settings and combination therapies are still being researched.
  10. Treatment of malar festoons (fat pads) is moderately effective with Infini (and will soon be even better with new protocols).
  11. Over 95% of patients can be treated with only topical anesthesia. With the addition of the Superficial Skin Block, treatments are extremely well tolerated by the remaining patients.
  12. For optimal results, some patients need volumization and Sculptra can be done simultaneously with Infini treatments.

Infini has already established itself as a low risk, low downtime, skin tightening procedure. Expect better results, less number of treatments needed, and new indications in the future. Significant resources at Lutronic will build upon the Infini platform to maintain its market dominance in the Aesthetic RF market.

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8/28/2016 5:03:45 PM

 

There are currently 2 dermal fillers FDA approved for enhancing the cheeks – Voluma and Restylane Lyft. These are both HA (Hyaluronic acid) fillers which are injected into the deeper tissues of the cheek to volumize and lift the cheeks. By lifting the cheeks, the entire lower face is lifted as well, including the jowl area, nasolabial folds, and jawline. It is well known that for an aging face with volume loss, the mainstay of treatment starts with the cheek area.

There are 2 main distinctions between Voluma and Lyft. The first is G prime, which is a measure of resistance of a fluid to flow. What this translates into when injected into the body is it’s “lifting ability”.  There is huge difference between the 2 with Lyft at 531 and Voluma at almost 1/2 of Lyft at 274. Although this is not important according to Allergan, the makers of Voluma, this was found to be significant in our challenge. The other factor is cohesivity. This has only been popularized since Voluma was introduced and it the pressure needed to “flatten” the filler. What this translate in the body is the amount of spreading of the filler in the body. Voluma is higher in this category (less spreading) when compared to Lyft, but it’s importance is not known.

When Voluma was introduced to the market, there was significant marketing on it’s “2 year duration”. What wasn’t discussed was how this FDA designation was obtained. Most people in the study were injected at 2 different times. Also, the average amount of filler injected was over 6 syringes. Lastly, only a minority of subjects had evidence of some correction at the end of 2 years. These important details are left out of most discussions with physicians, and certainly not what the public understands about Voluma. In addition, Voluma’s pricing is much higher than all the other fillers on the market, but justifies these prices due to it’s longer duration.

The “Cheek Challenge” was performed by Dr. Weiner to try to vet out whether there are significant differences between Restylane Lyft and Voluma. To try to keep the study similar to the FDA study, a total of 6cc was injected, 3 of Lyft on the right cheek, and 3 of Voluma on the left cheek. Follow ups and photos were taken at 1-2 month intervals for 1 year. There was no secondary injections because this is what most closely represents a real patient’s experience. Keep in mind this is only one patient but Dr. Weiner did challenge other physicians to do the same, similar to the “Ice Bucket Challenge”. There were about 4-5 other physicians which have also done the “Cheek Challenge”. Their findings have been similar per private discussions with them.

The Results:

  1. Duration of improvement was the same. AT 12 MONTHS, THERE WAS NO DIFFERENCE BETWEEN THE RESTYLANE LYFT AND VOLUMA TREATED SIDES AND THE BASELINE PRE PROCEDURE PICTURES.
  2. During the year, the patient noted that the Restylane Lyft cheek felt higher than the Voluma side.
  3. During the year, the patient felt that the Voluma cheek dropped slighted.
  4. During the first 1-2 weeks, more swelling was noted on the Lyft side.
  5. There was no difference in pain between the 2 sides.
  6. Noted improvements were seen in jowls, jawline, NLF, cheeks, and periocular area on both sides of face.

Although this is only a single patient, these results support multiple clinicians findings that Voluma’s duration is very similar to other HA products. Even with the use of 6 syringes, which is rarely used in a single patient, the duration did not exceed 12 months. Patients need to be counseled that 12  months is what can be expected for Voluma’s longevity. Less expensive and higher G prime filler, Restylane Lyft, seems to be a better choice for volumizing the cheek complex.

Video of patient at end of 1 year with discussion and pictures.

 



6/28/2016 9:40:45 AM

There is an increasing recognition of the power of PRP (Platelet Rich Plasma). Platelets contain a high concentration of growth factors and immune modulators which have been shown to improve wound healing, improve hair growth, and possibly rejuvenate skin and other areas of the body. The “Vampire Facial and Facelift” have become popular procedures in medspas and refers to applying PRP into the skin surface with microneedling devices (facial) or more deeply with injections (facelift). Wound care centers have great success at expediting healing in chronic would which have failed conventional therapy. Many orthopedic joint problems have been improved or resolved with PRP injections into the joint area. Cardiac surgeons have noted a significant drop in wound problems by using preventative treatments with PRP. Hair growth has been documented with PRP scalp injections and improvement in hair transplant results are found by bathing the follicles in PRP prior to implantation has been noted. Laser resurfacing has been shown to heal faster when PRP is applied immediately to the skin. It is clear, PRP has significant benefits for multiple medical ailments.

What’s even better news is that using PRP is extremely safe! Essentially what PRP consists of is using your own blood and isolating a concentrated portion of it, the platelets. This is where the lack of regulation can be abused. Since the FDA has considered PRP to be “minimal manipulation” of taking something out of the body and then placing it back, there is no FDA approval needed and oversight is minimal. The problem then becomes that there is tremendous variation is what one office considers PRP versus another office and concentrations of platelets can be all over the map.

Blood is essentially 2 components – Red blood cells (RBC) and plasma. In normal individuals, RBC’s make up about 40% of the blood (hemoglobin of 40). Plasma is serum and platelets, the other 60%. So in a 10 cc blood sample, about 5cc can be considered useful for making PRP. Through a process of centrifugation, the RBC’s can be removed, and the concentration of platelets can be increased. It has been shown by studies, that the “sweet spot” for PRP is a platelet concentration of 6X (1.5 milllion/ml) the normal value found in blood. Higher concentrations have been shown in some studies to actually be counter productive and lead to more inflammation, and lower concentrations have less improvements.

So, doing the math, if only a 10cc tube of blood is drawn, only about 1cc of useful PRP is obtainable if shooting for the 6X goal. A cc of PRP is 1/5 of a teaspoon…not much. Much higher volumes are needed to get an adequate amount of PRP to be useful (the author uses 60-120cc blood volumes). There was one study presented at the IMCAS conference in Paris over 2 years ago (which the author attended) which looked at the concentration of platelets using 14 different devices. In about half the devices, the platelets weren’t even concentrated more than what is found in normal blood. Only half the remaining were in the therapeutic “sweet spot” of 6X concentration.

Bottom Line: If only 10-20cc of blood are being drawn, then the final product is either not the ideal concentration of PRP (6X) or the volume of PRP is too small to be useful!

There is no doubt that there are clear benefits to PRP in the areas of wound healing, orthopedics, and hair restoration. However, with the lack of FDA oversight, many patients who think they are receiving therapeutic doses of PRP, are actually getting suboptimal doses or just plain plasma, which has little to no benefits. When seeking out PRP treatments, make sure that provider knows the concentration of platelets that his/her device is producing, and the math makes sense.

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4/3/2016 7:46:47 PM

There have been hundreds of potions, lotions, and procedures claiming the end to cellulite. All have basically failed…until now. Finally, there is a way to cure those cellulite dimples on the buttocks and posterior/lateral thigh. The procedure is called Cellfina, and at the ASLMS in April, 2016, there was data presented showing 3 years of persistent improvements. One presenter suggested that the very early test subjects from 5 years ago had similarly persistent results.

Cellfina is done in the office using just local anesthesia. Start to finish, it takes about 1 1/4 hours, and patients are able to drive themselves home. There is very mild discomfort during the procedure (4/10) and is associated with the numbing of the areas to be treated. Afterwards, no pain medication is required, and some go back to work immediately afterwards. Most will take the remainder of the day off and head back to work the following day. Physical activity can resume after 1 or 2 days. Bruising is the most common side effect, but can be treated at the Aesthetic Clinique with the Excel V to cut down the duration to a couple days. There have been no long term side effects noted in any of the study patients.

The procedure starts with pictures and identification of the dimples that need treated. These are only able to be treated on the back part of the thighs and buttocks.  After marking the sites, the patient lays prone on the table and the areas are cleaned/prepped. The Cellfina suction plate is placed over the marked areas and controlled injection of tumescent anesthetia is placed. After about 15 minutes, the same suction apparatus is placed on the sites again, and a motorized reciprocating needle-like device is inserted. This device releases the fibrous bands which are pulling the skin down. By releasing the bands, the skin elevates and viola… gone dimple. This process is continued until all the areas marked are treated. Pads are placed on the treated areas because there may be some leaking of the tumescent fluid for the next day or so.

Results begin to appear within a few days. Results are stable after a couple months for years to come.

With years of research behind Cellfina, it appears that there is finally a long term solution for correcting the nagging dimples associated with cellulite. With minimal side effects and downtime, it seems likely to be a very popular procedure, given that over 85% of females over adolescence have some degree of cellulite.

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3/15/2016 3:50:31 PM

There is so much information available on the internet that is becomes extremely confusing to the average person as to what is the right thing for them to do. While genetics, race, and lifestyle play a role in how one ages, there are many universal features of the aging face which are inescapable. While it is common to be asked “should I do this or that”, the best results are always a combination of several different procedures.

  1. Wrinkles:  Botox/Dysport relax hyperdynamic muscles which cause wrinkles with movement. There’s a reason this is the most popular cosmetic procedure in the world. It is quick, extremely effective, very little downtime, minimally painful, and with a high satisfaction rate. Common areas treated are the “11’s” or frown lines, crows feet, and forehead lines. Duration of effect is about 3-4 months.  Early preventative treatment is effective in delaying lines which appear at rest (etched in lines).
  2. Loss of Volume: Volume loss is inevitable. The aging process in combination with sun exposure causes the face to lose fat, bone, muscle, and collagen. Starting at the age of about 32, a cc or 2 of volume is lost per year. It begins to become visible at about age 38-40. This is called the “tipping point” in women, about the time when fertility starts to drops off. Sun protection and darker skin types will delay this lost volume up to 10 or 15 years. Replacing lost volume is done with fillers. The most common fillers are made with Hyaluronic Acid (HA) which is a natural component of skin. Examples of HA fillers include Juvederm, Restylane, and Voluma. Longer lasting fillers are Sculptra and Bellafill.
  3. Pigmentation/Redness: Inevitably, skin gets exposed to the sun and “sun damage” occurs. The sun is responsible for destroying collagen in the skin, causing it to thin, and lose elasticity and hydration. Another effect is causing vascular fragility leading to visible vessels and redness. Melanin is produced as the body makes an effort to protect the skin resulting in “sun spots” or hyperpigmentation. Lasers are effective in treating these conditions near painlessly. For reds, VBeam or Excel V Lasers are the gold standards. Up to 3 treatments might be needed. For a few small patches of pigment, a Q Switched Laser or Excel V is used. For more diffuse patches of pigmentation, laser resurfacing (Fraxel) or IPL are good options.
  4. Skin Laxity/Sagging: The combination of gravity and loss of skin elasticity can result in the need for skin tightening. Surgery will give the most aggressive result for this. Alternative treatments with less downtime, less risks are Infini, Thermitight, or Ablative Lasers.
  5.  Fat Accumlation: Aging leads to changes in metabolism and fat storage. Patients develop fatty collections which become difficult to diminish despite aggressive workout routines and diets. There are now multiple noninvasive approaches to removing fat permanently with no downtime. Larger more diffuse areas require a technology called Vanquish ME. Smaller areas can be spot treated with either Coolsculpting, Sculpsure, Ultrashape, or Liposonix. In the submental area, fat can be reduced with an injection called Kybella, a new handpiece from Coolsculpting (CoolMini) or with Thermitight. Of course surgery including liposuction or tummy tuck has been the gold standard for decades and is the best option for those desiring the most aggressive approach.

Drum roll please….The top picks from the 5 categories (Dr. Weiner’s Choices):

Dysport, Sculptra, Excel V, Infini, Coolsculpting (CoolMini)



1/23/2016 5:48:07 PM

Thread lifting is not a new concept. It was first developed in 1999 by Dr. Sulamanidze in Russia. APTOS Threads (a non absorbable suture made of polypropylene) were used for lifting and tightening skin without surgery. Contour threads of similar make up were introduced in the US in the early 2000’s. There were problems with these procedures. Placement was fairly complicated, requiring deep fixation points with hooks on the suture. The downtime was several days, skin redundancy was frequent, and sutures extruded or needed to be removed. Complications rates were very high and by 2007, the Contour threads were taken off the market. Thread lifting was not ready for “prime time” at this point.

After heading “back to the drawing board”, a simpler, less invasive, less risk thread was developed, PDO Threads. PDO (also known as PDS) sutures have over 30 years of safety use in Cardiothoracic, Plastic, OB Gyn, and Trauma surgical procedures. This material (polydioxanon) is highly flexible, elastic, strong, and absorbable. It is hydrophobic (does not absorb water) so swelling is kept to a minimum. Gradually over 4-6 months, the suture is degraded by the body’s immune system and replaced with collagen. Patients with immune system diseases, on immunosuppressants, or smokers are not good candidates for threads.

The placement of these PDO sutures is done with minimal discomfort (somewhat similar to filler placed with a cannula). They are placed just underneath the surface of the skin and don’t require the deep fixation that the prior threads needed. Downtime is minimal, with only possible bruising holding you back from social events. The risks and complications have been significantly reduced as well. It is extremely rare that a thread needs to be removed because they are much smaller (therefore less noticeable) than prior threads and because they can be dissolved with using heat (most often RF energy). The ability for the threads to dissolve over time increases the comfort level of all involved in PDO Threads. Results can last from 12-18 months, depending on the area treated (lip area is maximum 4-6 months). Only about 30% of the full result is seen immediately. It takes about 3-4 months to see the final result as the body reacts to the thread.

There are 4 design variants of the PDO Threads:

  1. Smooth threads: these are used in areas where collagen stimulation (dermal thickening) is needed. Often they are placed in a cross-hatched pattern. They are commonly placed in areas of superficial wrinkles or crepey skin. Common areas used are: cheeks, neck, marionette lines, glabella, temples, forehead, lip lines, lips.
  2. Twisted threads: these are smooth threads which are coiled. They give more collagen production than the smooth. These are used mainly in the nasolabial folds and marionette areas.
  3. Single Barbed threads: these threads have barb on them (cut with a laser) to lift and tighten sagging skin. Once they are placed, the physician runs his hand over the thread to engage the barbs to help pull the skin up or back. The ideal areas for these threads are the mid/lower face, jowls, and upper neck. Keep in mind these can be used anywhere on the body and some physicians are using these in the knee area, chest, and breast area. Think of these threads as “creating a collagenous tendon” as the body breaks the PDO down and replaces it with collagen.
  4. Double Barbed threads: similar to the single barbs but they have 2 sets of barbs going in opposite directions. They are placed slightly differently and require an exit point as well. Once the suture is in position and engaged, both ends are cut at the level just below the skin. These are used in similar areas as the single barbed threads when cheek fullness is desired or additional lifting is needed.

PDO threads aren’t for everyone. Severe skin laxity won’t be improved with these. It is important that patients are volumized to their fullest prior to or during the procedure. It is vitally important that patients and physicians have realistic expectations for threads. The results won’t be comparable to surgery but will offer improvements which might push surgery out for a few years. The great thing about the threads is that more can be added down the road to maintain or get additional correction.

Dr. Weiner is a physician trainer for PDO Treads (Nova Threads) and was one of the earliest adopters of this new procedure in the US.

Blog: https://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Facebook: http://www.facebook.com/TheAestheticClinique/

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