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Anti-Aging Blog

Coronavirus (COVID-19) Statement

Our country continues to face the ongoing threat from the coronavirus (COVID-19). As always, our #1 goal is patient care, and, in an effort, to ensure patient safety and the well-being of our staff, we are asking that you proactively reschedule your existing appointment if you are experiencing fever or flu-like symptoms in the last 14 days by dialing 757-437-8900.

As medical professionals, we are trained to place the well-being and safety of our patients above all else, and that commitment to your health and safety is driving every decision we are making during this challenging time. We are closely monitoring all developments related to the Coronavirus (COVID-19), and we are strictly adhering to all guidelines issued by the Center for Disease Control (CDC), World Health Organization (WHO), and our local and state governments.

As our offices are now seeing all appointment types, urgent and elective, and again offering cosmetic services, we encourage high-risk patients as listed by the CDC (as of 11/02/2020, see the full list of CDC high-risk patients below) to make informed decisions about their care.

CDC List of High-Risk Patients (as of 11/02/2020):

Adults aged 65 or older

Adults of any age with the following conditions are at increased risk of severe illness:

  • Cancer
  • Chronic kidney disease
  • COPD (chronic obstructive pulmonary disease)
  • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
  • Immunocompromised state (weakened immune system) from solid organ transplant
  • Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
  • Severe Obesity (BMI ≥ 40 kg/m2)
  • Pregnancy
  • Sickle cell disease
  • Smoking
  • Type 2 diabetes mellitus

Adults of any age with the following conditions might be at an increased risk for severe illness:

  • Asthma (moderate-to-severe)
  • Cerebrovascular disease (affects blood vessels and blood supply to the brain)
  • Cystic fibrosis
  • Hypertension or high blood pressure
  • Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
  • Neurologic conditions, such as dementia
  • Liver disease
  • Overweight (BMI > 25 kg/m2, but < 30 kg/m2)
  • Pulmonary fibrosis (having damaged or scarred lung tissues)
  • Thalassemia (a type of blood disorder)
  • Type 1 diabetes mellitus

Children with the following conditions might be at increased risk for severe illness:

  • Obesity
  • Medical complexity
  • Severe genetic disorders
  • Severe neurologic disorders
  • Inherited metabolic disorders
  • Sickle cell disease
  • Congenital heart disease
  • Diabetes
  • Chronic kidney disease
  • Asthma and other chronic lung disease
  • Immunosuppression due to malignancy
  • Those taking immune-weakening medications

These patients may still want to utilize our TeleHealth visits, which mimic an office visit with your provider and are covered by most insurance companies. If you don’t feel that the Telehealth visit is the right tool for your dermatological need, please call us at 757-437-8900 and we will book an in-office appointment and make special accommodations for any high-risk patient.

It has always been our standard practice to follow strict infection control measures at each of our clinic locations to prevent patients from being exposed to illness or infection. However, at this point in time, many additional infection control measures have been put into place. Below please find a link of some of these additional measures:

Steps We Are Taking To Protect Our Patients: Click Here.

COVID-19: General Information, Common Symptoms & Prevention Strategies: Click Here.

For Patients on Biologics or Other Immunosuppressive Medications: Click Here.

Posted in Services

Continued Steps We Are Taking To Protect Our Patients

As medical professionals, we are trained to place the well-being and safety of our patients above all else, and that commitment to your health and safety is driving every decision made during this challenging time. We are closely monitoring all developments related to the Coronavirus (COVID-19), and we are strictly adhering to all guidelines issued by the Center for Disease Control (CDC), World Health Organization (WHO), and our local and state governments.

Our pledge to patients is to be here for care you know is essential. Patients and practices are free to elect necessary medical services and procedures that may have been delayed. We will continue to provide a safe and comforting office experience for all patients needing dermatologic services.

Though restrictions are easing, we remain committed to ongoing safety and prevention of illness transmission. You need to know what our clinic sites are doing to protect everyone:

  • Everyone must wear a face mask. Patients may wear cloth masks and should have them on when they come into the office. Masks are required for adults and minor patients as outlined in executive orders from our governors. Wearing a mask may prevent the spread of small droplets, so please follow our lead and wear a mask throughout the visit whenever possible.
  • Everyone must wash hands or use hand sanitizer when entering and leaving the office. Please use the sanitizer provided, as you see our staff and providers doing. It is the most helpful prevention measure in the infection control arsenal! Hand sanitizer, tissues, and lined trash receptacles may be found in every waiting area and clinic room for use by our patients.
  • Patients must be screened at each visit for fever and flu symptoms. We perform the same screenings for every staff member, every day. Anyone with a fever or flu symptoms will be asked to reschedule the appointment. Patients with special risk, such as persons over 65 or persons with chronic health conditions, may wish to stay at home and use our convenient telehealth program.
  • Patients will notice posters at the office about COVID-19. These are meant to educate and advise about how to limit the spread of the virus. Every member of our staff has also received CDC generated written educational information about COVID-19, and about personal protective equipment. Policies and postings are changed as guidelines evolve.
  • Special physical distancing measures are now being taken, so please be patient with us when we do not get close to you or shake your hand. Please understand when we limit numbers in reception areas or we ask you to wait in the car to prevent office congestion. Please do not bring children under 12 or any others with you when you come for a visit. No one other than the patient and a required caregiver may be in the office. Sometimes these safety practices will add to the time it takes to complete your visit. Thanks for your understanding that our practices are meant to keep you safe and healthy.
    We have always prided ourselves on a clean, safe office environment. Now more than ever, cleaning and disinfection is of paramount importance. EPA registered cleaning materials are used frequently throughout the day on all surfaces in exam rooms, waiting areas, labs, and office spaces. High touch surfaces like door handles, exam chairs and tables, and restrooms are given special attention.
  • Our waiting areas no longer offer magazines, pamphlets, or children’s toys, since those items are difficult to clean and disinfect.

Be assured we remain fully prepared to evaluate and care for all of our patients, and we are taking all possible precautions to protect our patients, their families, our staff, and our communities. Thank you for your support and cooperation with these efforts as, together, we face this unprecedented public health challenge.

Posted in Services

July Flash Special – PicoSure

More youthful looking skin awaits. PicoSure activates your body’s natural skin cell process to reveal younger looking skin. No downtime. July only – $150 off of 1 treatment or Package of 4 for $2800 (saving $185/treatment)

A treatment for wrinkles & acne scars. No downtime. Contact us or call 757-437-8900.

*Offer may not combine with any other specials. Treatments must be medically indicated. Must receive treatment by July 31, 2019. (all packages must receive first treatment by this date).

Posted in PicoSure

RealSelf Ratings

Fillers and injectables are treatments that can be used on the face and different aspects of the body to reduce wrinkles and frown lines, plump up your lips or even reduce your double chin! These treatments are among the best of reducing signs of aging and each filler can target a different problem area. It can be overwhelming because there are so many but we put together this graphic that will helpfully narrow it down and show you how “worth it” they are based on ratings from realself.com. If you’re interested in learning more about these products, call us at (757) 437-8900 or schedule a consultation here!


Posted in Laser and Cosmetic

Freeze Fat Away with Coolsculpting

Dr. McDaniel has put together this educational visual on Coolsculpting, how it works and how it can benefit you! Take a look to learn more about the procedure and if you have any further questions, call us at 757-437-8900.

McDaniel - Coolsculpting-infographic

Posted in Laser and Cosmetic, News, Services

Voluma Infographic

Dr. McDaniel has put together a great educational visual on Voluma and how it can benefit you! Take a look and learn the basics of Voluma and if you have any further questions, call us at 757-437-8900.

 Juvederm Voluma | Virginia Beach

Posted in News

This Just In: Juvederm Voluma XC!

Dr. McDaniel has Juvederm Voluma XC

Dr. McDaniel is excited to be able to offer Juvéderm Voluma XC to his patients and wanted to share with you a picture of his first box of Voluma!

Posted in Laser and Cosmetic, News, Services

Juvéderm Voluma XC FAQ

What is Juvéderm Voluma XC?

Juvéderm Voluma XC is a gel that is injected into the cheek area to gently lift the skin and restore volume that is lost from aging. It is made from a modified form of hyaluronic acid which is a natural complex sugar that occurs within our bodies.

What is Juvéderm Voluma XC indicated for?

Juvéderm Voluma is the first and only FDA-approved non-surgical option to instantly correct age-related volume loss in the cheek area in patients 21 and older.  Juvéderm Voluma has been used in Europe since 2005 and approved in over 60 countries with over 500,000 syringes used.

How is Juvéderm Voluma XC actually used in treatment?

Juvéderm Voluma XC is typically used for restoring cheek or mid face volume loss and also to help restore a more youthful curve and position to the higher area of cheekbones in women (not men).
In Europe and Canada Juvéderm Voluma has been widely and very successfully used for off label FDA uses for lifting, volumizing and recontouring  the face and jawline.  Injection using little blunt microcannulas in addition to traditional small needles is also widely used for helping create a natural look while minimizing discomfort and bruising.

What makes Juvéderm Voluma XC different from other dermal fillers?

Juvéderm Voluma was specially designed to fill and lift the mid-face and cheeks.  It uses a new advanced technology from Allergan which is called Vycross that results in a smooth gel that flows easily and consistently and which can be nicely sculpted.  This special cross-linking technology not only produces the lift and fill that is unique to Voluma, but it also contributes to its long-lasting nature.

How long does Juvéderm Voluma last?

Up to two years with optimal correction.  There is evidence that hyaluronic acid fillers such as Juvéderm and Restylane actually help to stimulate the production of new collagen by your own body so that longer duration of improvement may be seen.  Also depending on various factors of your health, weight and body chemistry as well as the volume injected and the skill of the injector duration of correction may be shorter (or even longer) than two years.

Why use Juvéderm Voluma XC and not a wrinkle filler?Juvederm Voluma was recently approved by the FDA

While wrinkle fillers traditionally have been the mainstay of filler treatments and offer excellent results when properly used, Voluma opens up a whole new world of opportunities for rejuvenation. In particular, its ability to lift skin distant from where it is injected in the cheeks often reduces or may even eliminate the need for filling other lines and wrinkles – or at least decrease the amount of filler material needed.  This can be very important because the cost to add Voluma to your treatment plan may be significantly offset by the savings of not needing some  of the filler you may have needed in the past in the folds around the mouth.

What does the XC after Juvéderm Voluma XC mean?

XC means there is a small amount of lidocaine mixed with the Juvéderm which helps to numb the area during the treatment process.

Are the injections painful?

There is typically minimal discomfort during the treatment process.  Topical numbing cream may be applied before treatment to reduce discomfort – especially for sensitive areas such as fine lines around the mouth.  Numbing shots are normally not needed so that you do not have the long-lasting dental type numbing effects after you leave the office.  If you are being treated with the micro cannulas typically there is even less discomfort than with needles.

Is allergy testing needed?

No.  Allergy testing was once required in years past for other non-HA fillers, but not Juvéderm or other brands of hyaluronic acid fillers which are very safe.

How young can you be treated?

While we do not want to treat with fillers before they are really needed, the experience in Europe, Canada and elsewhere suggests that a relatively small amount of Juvéderm Voluma can produce a very pretty soft, natural look in younger patients who are showing early signs of aging or who have a tired look. Its actual FDA approval is for use over age 21.

Does it matter if I am 30, 40, 50 or older for treating or for the results I will see?

Yes it does. While you may benefit at any of these ages – as well as much older, there are potential differences. Younger women (and men) who do not have much skin laxity and who have primarily some early fat volume loss in their cheeks may see a relatively dramatic restoration of their youthful appearance before the fat loss occurred. Also the amount of volume of Juvéderm Voluma XC needed to produce these results may be relatively small – thus giving a really nice benefit for a relatively low cost. As time passes and more aging changes have occurred (especially for smokers or people who have severe sun damage or who may have had significant weight loss and other lifestyle and medical factors) the amount of Juvéderm Voluma XC required to produce optimal correction or restoration does increase and the costs also increase accordingly.  The results still will usually be impressive but may need to be combined with some other non-surgical procedures to create the most pleasing overall anti-aging effects.  However for people who have been receiving other fillers in the past, they may find improved results for less total volume of filler material and also with greater longevity.  Practically speaking there really are not so much absolute age limits for you to have very nice results with Juvéderm Voluma XC.  Some people are biologically much younger (or older) looking than their chronologic age and one of the really critical factors is for you to consult with an expert injector who has a good eye for the artistic natural look and also has the technical skills  and who is an experienced injector that understands Juvéderm Voluma well.  You really also would like to choose someone for your consultation who will listen to what your goals are and also your lifestyle factors and budget and try to give you an individualized and practical treatment plan designed just for you.

Can all skin types be treated?

Yes.  Juvéderm Voluma is excellent for all skin types.  People with darker skin of color usually do not wrinkle as much as lighter skin tones, but everyone experiences age-related volume loss in their cheeks.  Darker ethnic skin patients tend to be more likely to develop dull, ashy or unevenly pigmented skin which can be improved with skin brighteners (SkinMedica Lytera Cream is a product from the creators of Juvéderm Voluma which often works well for these darker skin patients also still experience sagging of the apex of the cheek with aging and this may appear at a relatively young age.  The cheek apex is what gives a youthful look to the face so restoring this can provide a very pleasing, natural and youthful look and typically this does not require much of the Juvéderm Voluma due to its unique filling and lifting ability problems).

Can men be treated?

Yes, however the technique is somewhat different especially for cheeks because what is optimal to create a younger male appearance differs from that needed for females.

How long does treatment take?

That depends on the extent of the areas being treated, the volume of Juvéderm Voluma being used and also the complexity of the treatment. Simple injections might take only 15 or 20 minutes, but treatment can require considerably more time depending on what is being treated.  For example full face sculpting may require using more of an artist’s pallet approach with the use of both needles and the European micro cannula technique and we sometimes need to blend the Voluma with additional lidocaine to customize treatment for non-cheek areas.  We may also use other forms of Juvéderm such as Juvéderm Ultra or Ultra Plus to treat residual smile lines or furrows (note that by lifting the cheek, Voluma often reduces or eliminates the need to treat nasolabial or nose-to-lip folds and smile lines).

So the more complete and creative the treatment the more treatment time is required. The artistry is a vital part of truly rejuvenating the whole face and that adds another dimension beyond just the technical skills for injecting. Juvéderm Voluma is a dramatic addition to our artist’s pallet and as cosmetic artists we want to create the most natural beautiful appearance we can.

Does Juvéderm Voluma require any special techniques or training?

Yes.  Because of the unique properties and long-lasting nature of Juvéderm Voluma some special training is required.  Allergan, the company who makes Juvéderm, requires some special training, but to achieve the full artistic potential that Voluma can provide requires experience Voluma as well as with facial sculpting and volumizing.  This is not your mother’s wrinkle filler!

The injection techniques that provide a very natural look have been refined in Europe, Canada, Brazil and many other countries over the last several years and using what we have learned from the leaders overseas really helps produce the best results.  Many Juvéderm Voluma experts use a mixture of both fine needles and micro cannulas.  Typically expert injectors may also combine with other forms of Juvéderm and sometimes blend in more local anesthetic or may combine with other products such as Botox to achieve the desired beautification.

What are micro cannulas and how do they work?

Micro cannulas are small, long, slightly flexible ‘needle-like’ devices which are blunt on the end and have a hole in the side where the filler exits. With the micro cannulas a small sharp needle is inserted  into the skin and then removed and the cannula is then inserted.  The needle creates a guide or entrance pinhole for the cannula – which is blunt and cannot by itself penetrate the skin – and then relatively large areas of the cheek can be injected and sculpted via this one tiny needle area.  It is less painful than a series of needle injections and also helps reduce bruising.  Note that micro cannula techniques require an experienced and skilled injector for optimal results.

Can you combine Juvéderm Voluma XC with other facial anti-aging treatments?

Yes that is a great question.  Often for optimal restoration of a youthful appearance more than one modality is needed.  So Juvéderm Voluma restores volume and can lift sagging skin. If the outside of the skin has chronic sun damage and is thinning from lost collagen then a fractional laser or IPL treatment may be useful.  Likewise, if spider veins dominate the landscape of your face, a blood vessel laser treatment may be helpful.

Lines of facial expression often will respond well to Botox and a particularly good combination is Botox and Juvéderm Voluma.  Eyes are important as well and sometimes a bit of a ‘lift’ can be achieve by either Botox or Juvéderm.  Eyelashes can be made longer, thicker and darker using Latisse. Topical skin products such as Retin A and antioxidants help to repair old damage as well as to protect your investment in some of these treatments.  Allergan, the creator of Juvéderm and Botox, also makes Skin Medica which is one of the leading science-based lines of anti-aging skin care products and their new Lytera creamhelps improve uneven skin pigment.  Many combinations are possible and should be customized to your skin, your lifestyle and budget.

Does it matter when you combine these treatments?

Yes.  It is thought that some combination of treatments – especially when treating the same anatomic area – may in most cases be better performed at different times.  This is especially true for some of the laser and light treatments or peels which can create swelling and possibly interface with the use of Botox at the same time. You should discuss with your physician because many treatments can be combined at the same treatment visit. Botox and Juvéderm for example are often a great combination at the same time, but there also are exceptions to this as well.

When can I return to work and resume my social life?

Juvéderm Voluma XC results are immediate and very natural looking, so typically you may return to work or social activities immediately.  However, sometimes transient side effects occur – in particular bruising – and mild swelling may develop by the next day, so you do need to consider this in your planning.  This is especially true if you have never been treated before or if you are taking things which might increase your risk or the severity of bruising like baby aspirin, blood thinners, fish oil, etc.  So discuss this with your physician.

What are the common side effects of Juvéderm Voluma XC?

Typically you might experience temporary bruising, tenderness, swelling, pain during injection or some redness or itching.  Lumps and bumps are possible but usually are easily massaged out either at the time of treatment or a few days later.  Depending on your facial anatomy sometimes asymmetry or unevenness from side-to-side might be experienced which can usually be easily corrected, however people commonly have some degree of natural asymmetry which may not be able to be perfectly matched.  Most of these are very transient but may in some cases last for a few weeks. Consult with your doctor about your particular situation.

What can be done to prevent bruising?

Bruising is one of the most common side effects.  Tiny bruises at the sites of needle entry may be very inconspicuous and easily covered, but larger or darker bruising that is visible and lasts for days or rarely longer can be rather unsightly.  Sometimes (if medically safe) people taking daily aspirin or other blood thinners may temporarily discontinue treatment (always consult your prescribing physician first if you are taking these for medical conditions).  Fish oil supplements may be discontinued for a week before treatment and then resumed.  If your injector has a pulsed dye laser or certain types of IPL you may be able to return within 24-48 hours for a quick zap.  These typically are very safe and speed the resolution of the bruising.

What if I don’t like the results – can Juvéderm Voluma XC be removed?

Yes all hyaluronic acid fillers can be ‘removed’ using a synthetic form of an enzyme that occurs naturally in our bodies called hyaluronidase.  Usually the filler can be removed in hours to a few days after injecting the appropriate amount of hyaluronidase.  All Juvéderm products including Voluma may be treated this way.  It is another important distinction between Juvéderm Voluma and some of the other longer-lasting fillers which are not hyaluronic acid because they often cannot be removed if you are unhappy.

How often can I be injected?

A better question is when do you need to be re-injected?  Since Juvéderm Voluma is very long-lasting filler you typically would not need to be treated again for a long time…up to two years or more.  However re-injection may be needed a few weeks after your initial injection if you need more volume or more lift.  Often it is better to be conservative and touch-up if needed. I personally see so many people who have been over-injected or overfilled and this is especially true I find for cheeks and lips.  While certain people in the entertainment business for example may with intentionally desire a bit more exaggerated look, I have a very strong commitment to creating a very natural, soft, rested appearance.  It is nearly always better in my opinion to remain natural and understated – especially if you have never been treated before.  Juvéderm Voluma does not require as much volume as other hyaluronic acid fillers to create the effect you want and so care must be taken for injectors who are not as experienced with Voluma to not overdo your treatment.

Allergan, the creator of Juvéderm Voluma XC has made exceptional efforts to provide proper training for Voluma and it really is very important that you have an experienced injector. I also suggest you ask to view photos of the actual injector who will be treating you so you can see their results and judge for yourself if that look ‘fits’ you.  Some of the best Juvéderm Voluma injectors in the world will tell you that optimal correction will give you the ‘best’ overall look and the longest duration.  To achieve this you may need to return for some touch-up or additional amount of Voluma to achieve this result…and that doing this typically then leads to the longest correction before you need injected again.  So your goal should be to ‘get it right’ and then to not need to be injected again until the results begin to fade.

How much does it cost?

That is a great question but it has a very individualized answer.  Because Juvéderm Voluma is such a ground-breaking filler it really is quite a bit different than you might be used to from your experience with previous fillers.  With Voluma we are now not only restoring volume but also providing lift and some indirect tightening.  So if you have been injected with fillers in the past you need to think more about ‘full face rejuvenation’ – and think less about ‘filling lines and wrinkles’.  Much of the filling of lines/wrinkles/ folds of the past will either not be needed – or the amount of filler needed will be significantly reduced.  There is still an important role for Juvéderm Ultra XC for example or Restylane if you have been using those but the volume of these fillers needed (and thus the number of syringes) likely will be reduced if not eliminated.

So again if you have had filler injected in the past, the total cost is not just the cost of the Voluma you need, but you need to factor in however much less you might need of the fillers you have used in the past.  You really need to think ‘total facial rejuvenation’ …this is very important.  With Juvéderm Voluma and other treatments like Botox, laser, etc. we now have the ability to create results non-surgically that truly will change the way facial aesthetic/cosmetic treatments are performed and the results you can expect.

I believe this is the wave of the future and you should think more about discussing with your cosmetic surgeon a ‘treatment plan’ for overall facial beautification and full rejuvenation and what the cost of that is.  Look at the cost over time as well.  For example if Juvéderm Voluma last twice as long but costs less than twice as much (not to mention that it probably produces better and more natural results and you have to come in less often) than what you have been doing then the cost over time may be less with Voluma.

So the old saying ‘less is more’ really does apply to Juvéderm Voluma because the same size syringe of Voluma can produce a significantly different (and typically greater) effect than the same size syringe of other hyaluronic acid fillers.  So you should ask your cosmetic surgeon to show you what can be done for the big overall picture – not just to fill a few lines and wrinkles and then compare fees….and compare the overall improvement in your appearance and how long that improvement lasts…that is a better way to look at fees.

Before and Afters

Click here to view more before and after photos of Juvéderm Voluma







Posted in Laser and Cosmetic, News

What are the differences among the various fillers?

Volume fillers were originally developed and introduced to fill in fine lines and wrinkles.  As the technology improved, it became possible to also fill in furrows and some folds.  The original dermal fillers were collagen (bovine, porcine, human), but there were various problems with these, including some people’s allergies to cow products. They tended to not last for a very long time and did not provide much bulk volume.

More modern fillers have become very popular and worldwide there are many more brands and forms available than there are in the USA.  The dominant filler is now HA (hyaluronic acid) which is a synthetically produced purified sterile product which comes in prefilled syringes for immediate injection.

We all have HA in our skin.  It plays a vital role in retaining moisture.  We also have HA in other critical areas such as joints. Our bodies also produce an enzyme called hyaluronidase which helps to degrade damaged or old HA and ‘recycle’ it within our bodies.   This is a continual, ongoing process in our skin and increases with some types of injuries to the skin.  The various brands and types of HA fillers have different lengths and cross linking (HA are long chain-like molecules).  The cross-linking and length profoundly impact key physical properties.  These physical properties, along with the amount of material injected, the location of the injection, and the technique of the injector determine what you will look like after your injections.

For those of you who are more technically inclined, the two key properties are called G’ (G Prime…and think of G’ as analogous to viscosity although that is an oversimplification) and the cohesiveness.  These determine how the material flows: is it still or silky? Does it lift or just flow? etc.  Popular brand names in the USA are Juvéderm Ultra®, Juvéderm Ultra Plus® and the soon to be FDA cleared Juvéderm Voluma® (out of the country there are more forms of Juvéderm) and other popular brands are Belotero Balance®, and Restylane®.  Likewise out of the country there are other forms of these as well.

Very generally speaking, Belotero works very well for fine lines like those on the upper lip from smoking. Restylane and Juvéderm Ultra perform well for all-purpose treatments from finer lines to deeper folds and furrows.  Perlane has a very high G’ and is often used where more lifting or filling is needed and has been thought to be perhaps preferable for this, although some recent studies indicate that Juvéderm Ultra Plus may actually be a bit superior or longer lasting. I believe this may be related to the higher cohesiveness of the Juvéderm Ultra Plus even though the Perlane has a significantly higher G’.  In any event, both perform very well when properly injected.

Juvéderm Voluma has proven to be a remarkable advance in both duration of activity (it may last as much as twice as long as the HA fillers above-up to 18 to 24 months) but also in its ability to ‘lift’ and to restore lost mid-face volume from fat loss. FYI, grafting your own fat remains also an option for volume filling but requires general anesthesia, more recovery time, and greater cost. Properly performed fat grafting can produce very long-lasting results for many years. Improperly done fat grafting is very difficult to reverse or correct.  One great thing about the HA fillers is that synthetic hyaluronidase comes in sterile vials that can be injected to hit the ‘undo button’ and ‘erase mistakes’ so that typically in a few hours or a few days the HA can be removed if need be.  That is not the case with non-HA fillers.

Another significant asset with Juvéderm Voluma is that it can be injected with blunt cannulas. These look like long needles but have no point and are slightly flexible with opening(s) on the side of the tip.  A ‘pilot hole’ has to be created with a tiny traditional needle which is then removed and the cannula is inserted and entire central cheek areas may be injected with only this one small needle entry.  There also appears to be less discomfort and bruising, and perhaps fewer complications than with traditional needles.  The cannula method is used very widely in Europe, Canada and other countries (Voluma has been available in Europe since 2005 and in over 60 countries) and it allows the injecting physician to maximize his or her artistic skills and truly ‘sculpt’ a very soft, natural youthful look.  Restoring mid-face volume loss is a major topic in itself we can cover another time.  Note: The mid-face volume loss is one of THE keys to rejuvenation of aging faces in a natural manner and may also be a critical component of traditional face lifts.

All the current fillers may also be injected using cannulas.  Several of these fillers come with lidocaine added (lidocaine is an older very safe anesthetic agent, although reactions may rarely occur).  The others may have lidocaine added just prior to injection using a sterile mixing apparatus.  Topical numbing may be used, and some people prefer to use nerve blocks similar to what a dentist uses. I prefer not to use nerve blocks as these add to the discomfort and, more importantly, may distort the skin contours.

Fillers can be (and often should be) used in conjunction with other procedures.  Your physician can advise which ones can be combined during the same visit and those which should be separated, but generally speaking the neuromodulators (e.g. Botox® Cosmetic, Xeomin® & Dysport® in the USA) make a great combination for same-time injection.  While we are on this subject, bruising is the primary temporary side effect for most patients and there are ways to minimize this, including injection techniques, needle size, ice packs, attention to fish oil and baby aspirin, and also by using certain lasers or IPL light treatments within the first day or two after treatment.  Discuss these with your physician for your specific situation.

Other popular NON-HA fillers in the USA include Radiesse® and Sculptra®.  These are both long lasting materials and when injected by a skilled injector can produce very nice results.  Radiesse has some limitations: for example, I typically use Radiesse for deeper folds and furrows in combination with HA fillers for finer lines, but there are a number of off-label uses which produce very nice results.  Sculptra is a collagen stimulator and also can produce very fine results particularly on the mid face. Sculptra often requires multiple injection sessions (often three) and results take time to appear as the body produces more collagen.  Full facial rejuvenation using Sculptra (often in combination with HA fillers) when seen several months after completion of injections and when performed by a very skilled injector can be quite impressive.   With Radiesse and Sculptra, however, patients should be aware that unlike the HA fillers and hyaluronidase discussed above, there is no ‘undo button’.  Once injected, they are there for a long time.

A few last thoughts.   All HA fillers (except possibly Belotero) may produce a faint blue-gray coloration in the skin.  This typically is seen in patients with very fair light skin tone and is caused by an effect called the Tyndall effect (similar to why the sky and ocean are blue; this has to do with the way light is scattered by the HA particles).  This can be annoying to some patients, especially if the HA is injected very superficially.  Radiesse is white in color and may show through the skin as well.  Sculptra does not have these properties.   All of these materials appear to stimulate production of your body’s own natural collagen to varying degrees.  Thus, when they wear off and are gone, some partial correction or improvement may persist long-term.  This is highly variable but can be a very nice effect as well.

The technique, technical skill, artistic eye, and experience of the injectors make a HUGE difference in the result.  It also may impact how many syringes of filler are needed. I often find I use half the number of syringes or less than a patient who is unhappy with prior treatment elsewhere has received, so truly the volume/number of syringes can matter greatly.  What I have found in traveling around the world is that all the great master luminary injectors have subtle differences in their techniques and also vary sometimes widely in their choice of fillers, but the final result on a patient will be very similar to what I would have envisioned using my techniques.  When we all get together at meetings and share our tips and ideas I think most of us agree that it is the end result and the safety that is critical and that each of us have slightly different ‘recipes’ for achieving a very similar outcome.  These are not skill sets that come overnight from a course or a DVD, although the quality and availability of excellent training materials produced by expert injectors has really increased in the last few years.  Not everyone is going to produce the same result, and price (high or low) is not necessarily a predictor of what you will look like after you are injected. There are some remarkably talented injectors of all ages and specialties, but there are many people poorly trained or who simply don’t have the technical skills or the artistic eye for fillers. Fillers are more difficult than neuromodulators such as Botox, Xeomin or Dysport, so if you are reading this, please choose your injector with care.  You might take in a photo of what you would like your lips to look like, or a photo of you when you were younger…and if you see a lobby full of ‘duck lips’ I would consider another injector!

Posted in Laser and Cosmetic

Juvéderm® for Frown Lines

The area between the eyebrows may develop vertical wrinkles or even deep creases (called glabellar frown lines or also referred to as ‘11s’). These are quite common and begin as lines of facial expression that appear when frowning or squinting (blue eyed people may have more light sensitive retinas and squint more as do some people who view computer screens all day). As time passes the repeated motion of these expressions causes the dynamic lines of motion to begin to etch into the skin surface lines which appear at rest 24/7. As more time passes some people develop very deep furrows with this crease in the middle as the muscles bulge upwards from all the ‘workout’ they are getting.

Neuromodulators such as Botox®, Xeomin®, and Dysport® relax the muscles so you cannot make the expression and thus the dynamic lines of motion do not appear. The etched in lines and the folds and furrows however that appear at rest without expression respond better to fillers as illustrated in this photo which were treated with only Juvéderm Ultra. For many people a combination of filler and neuromodulator may provide the best and longest-lasting improvement.

Posted in Laser and Cosmetic