Being Consistent with Botox Prevents Wrinkles Even with Less Frequent Dosing

According to recent research from Oregon Health Sciences University, consistent treatments with Botox or Dysport have a wrinkle preventing—or prophylactic—effect.  Patients who begin receiving injections every 3-4 months while in their 30's, 40's, and 50's are able to prevent wrinkles from forming and eliminate many existing wrinkles.

Moreover, after 2 years of treatment at 3-4-month intervals, patients can potentially cut the frequency of their Botox or Dysport treatments by half.  After patients receive Botox or Dysport every 3-4 months for 2 years, the frequency of the the injections can be changed to every 6 months and still achieve good results.

So what should the average person think about this study?

• Younger patients, even in their 30s, should consider starting Botox or Dysport to prevent hyperdynamic wrinkles.
• Patients should try to be consistent (every 3-4 months) for the first 2 years when using either Botox or Dysport.  While such frequent treatment may deter some patients from starting a regimen, eventually they should be able to achieve good results with broader treatment schedules and ultimately at a lower overall treatment cost.

Botox for Marionette Lines? Nope. Choose a Filler Instead

Hi, Dr. Pickart.  I was talking with someone about getting rid of marionette lines, and she was given Botox for that area.  Does that sound right to you?

Anyway, I was going to tell her about Sculptra.  Do you think that 1 vial may be enough for that area?

-Janet F.

Dear Janet,

Actually, the best treatment for marionette lines is NOT Botox.  I do sometimes use Botox to turn up the corners of the mouth, but Botox has NO EFFECT on the marionette lines themselves.
 
I would recommend a filler for marionette lines.  Sculptra is my favorite because it lasts the longest (at least 2-4 years).
 
Regarding how much Sculptra, it depends upon...

• the depth of the marionette lines - Shallow will obviously require less than deep.
• the patient's response to Sculptra - Younger patients respond more vigorously, with more collagen production, compared to older patients.

So, how many vials?  A young patient with mild folds and with a vigorous response to Sculptra might need just 1 vial.  However, an older patient with deeper lines and with less brisk collagen production might need 3-6 vials.  Make sense?
 
Sincerely,
Mike Pickart

Tissue Glue Rather Than Drains (?!)

There is an old surgical adage:

If a surgeon thinks that the patient might benefit from a drain, he should put it in.  A surgeon never regrets placing a drain.

Patients, however, hate drains.  They are a post-operative nuisance.  Most patients grudgingly accept drains because they minimize fluid collections (called seromata) and infections.

Since drains are so uncomfortable, there have been a number of products and techniques developed to obviate the need for drains....

• Quilting sutures beneath tissue flaps to minimize "dead space"
• Tissue glues

Biological tissues glues are particularly exciting because they are quick, effective, and precise.  Unfortunately, there have been no specific research studies which have rigorously documented the safety and efficacy of biological glues for plastic surgery.  A study published in Plastic and Reconstructive Surgery in 2008 proved the success of tissue glues in a canine abdominoplasty ("tummy tuck") model; however, dog and human tissues do respond differently, and the results of an animal model can not necessarily be generalized to human beings.

To investigate human plastic surgery patients' response to biological glues, Cohera Medical, Inc., has just enrolled its first few patients in a study of its TissuGlu.  The clinical investigation is a prospective, open-label, randomized study to investigate the safety of TissuGlu, its effect on wound drainage, and its relationship to complications.  The study will compare 40 abdominoplasty patients in Bonn, Frankfurt, and Freiburg, Germany, who will undergo...

standard wound closure techniques versus

standard wound closure techniques plus the application of TissuGlu

Currently, patients who undergo abdominoplasties require the insertion of one or more drains to remove fluids that accumulate under the skin at the surgical site.  (The old surgical adage remains true in tummy tucks!)  However, TissuGlu will hopefully adhere the flaps created during the procedure to reduce fluid accumulation, and, ultimately, the duration of use of surgical drains.  With the use of TissuGlu, patients may experience a reduction in fluid accumulation, a more comfortable recovery, and a quicker return to normal activity.

If the European trial goes favorably, Cohera will apply for a larger U.S.-based trial later this year.  Let's say our prayers that TissuGlu works!...

The Nefertiti Lift with Sculptra Aesthetic Rather than Botox

About one year ago, I reviewed a published article considering the "Nefertiti Lift" (http://www.pickartplasticsurgeryblog.com/2008/12/the-nefertiti-lift-can-botox-tighten-an-aging-jaw-line.html).  The Nefertiti Lift is a technique for using Botox to rejuvenate the aging jawline and neck.

• My immediate conclusion was...  "I'm skeptical."
• My conclusion one year later, after having tried the Nefertiti Lift on a number of patients:  "Bogus."

However, I have since discovered that Nefertiti Lifts are possible with certain non-surgical techniques.  Botox just isn't the right product.  Sculptra Aesthetic can--non-surgically--rejuvenate some poorly defined jawlines, baggy jowls, and loose neck skin.

Sculptra works by stimulating a patient's body to make collagen.  The manufactured collagen provides volume.  The subsequent inflation helps the patient's tissues stand up at attention.  To some degree, the face and neck are, therefore, lifted.

I have grown more and more pleased with the results from Sculptra.  Nevertheless, I am not throwing out my scalpel.  For most "waddles," the surgical face/neck lift is still the gold standard.

Dr. Pickart To Host More Training Sessions for Sculptra Aesthetic

Dr. Pickart is the only Board Certified Plastic Surgeon in Southern California who trains other physicians on the appropriate techniques for Sculptra Aesthetic.  He has recently returned from...

• Denver, Colorado
• Lawrence, Kansas
• Oklahoma City, Oklahoma
• Houston, Texas
• Galveston, Texas
• Lake Charles, Louisiana
• Lafayette, Louisiana
• Los Angeles, California
• Beverly Hills, California
• Burbank, California
• Encino, California
• Rancho Mirage, California
• Newport Beach, California
• Huntington Beach, California
• Pasadena, California

He will be hosting additional training sessions for physicians in his office in Ventura, California.  Please call if you would like to be included:  (805) 648-4567.

Is Artefill Back?

Artefill is the only permanent soft-tissue filler approved by the FDA.  Owing to corporate over-expansion and to the recession, Artefill's parent company, Artes Medical, filed for bankruptcy in December 2008.  So, Artefill has been unavailable for the past 9 months.

I am not a business person, and I certainly don't understand corporate finances and accounting.  Nevertheless, it appears clear that Artes Medical's problems were not a result of a bad product.  On the contrary, Artefill had been safely and effectively used in thousand of patients.

It's therefore exciting that Suneva Medical will soon re-launch Artefill.  Its competition is...

• Juvederm Ultra/Juvederm Ultra Plus:  6-9 month duration
• Restylane/Perlane:  6-9 month duration
• Elevess/Hydrelle:  6-9 month duration
• Prevelle Silk:  3-6 month duration
• Evolence/Evolence Breeze:  6-9 month duration
• Radiesse:  8-16 month duration
• Sculptra Aesthetic:  > 2-3 year duration

All of the above fillers are eventually absorbed.  (Sculptra is the lone exception.  Because the collagen produced by Sculptra is a patient's own, perhaps some of Sculptra's effects will be permanent too.)

Artefill stands out because it will not be degraded.  The FDA will allow it to be marketed as the only permanent device for correction of nasolabial folds--the creases between the nostrils and the corners of the mouth.

Of course, patients will continue to age, so even Artefill's smoothing effects will not truly be permanent.  At least, perhaps, Artefill injections can be limited to once every 5-10 years.

I think that Artefill will have a place in my armamentarium.  There certainly are patients who have "injection fatigue."  While the procedure for Juvederm or Restylane is not painful, the bruising and swelling are never fun.

Cost may be an issue.  An Artefill treatment will likely cost twice as much as the other products' treatments.  Of course, in the long run, Artefill should be cheaper, but it remains to be seen whether patients in our difficult economy will be willing to spend $2000 for a single session of injectables.

Under Eye Bags Caused by Muscle Hypertrophy

Hi, This has been a problem since I was a little girl.  Now I'm 40 and want to improve the appearance of my under-eye bags, whether it is with surgery or fillers.

I look tired all the time and my bags just keep getting bigger as I age. I went to another consultation for blepharoplasty (eyelid surgery).

The doctor told me there's nothing that can be done, because it's all muscle and not fat. Could I have hypertrophy?  What can I do?  I can't stand to look at myself or have others look at me.  If there is surgery for this, what is it called?

-Shellee

 

Dear Shellee,

Find an experienced Botox injector.  Ask for 1 unit of Botox in the roll under each eyelid.  This might solve your problem without surgery.

(If your plastic surgeon is up on the latest treatments, 2.5 units of Dysport would also work.  Dysport is probably equivalent to Botox.)

Do be aware that this is a tricky use of Botox/Dysport.  There are a few potential (albeit unlikely) risks...

• Lowering the lower eyelid margin (so that you see white beneath your green irises)
• Loosening the tension on the fat beneath the eyes, such that bags really do become apparent (I agree with your current analysis.  You do not have fat bags, just excess muscle.)
• Causing your eyes to become dry and scratchy

I highly doubt that you will have problems, but other plastic surgeons might be hesitant to give my suggestion a try.  This is definitely a Botox/Dysport use for experienced injectors only.

If the Botox/Dysport is unsuccessful, the injector could try more.  Or, a little filler in the upper cheeks (at the infraorbital rims--the bony rim beneath the eyes) can smooth the area out.  My favorite is Sculptra.

(By the way, the world's 2nd most beautiful woman--Angelina Jolie--also has muscular rolls beneath her lower eyelids.  Shellee, you're in good company.)

(Who's the world's most beautiful lady?  My wife, of course!!)

Sincerely,

Mike Pickart

Hydrelle: Elevess Has Been Re-Named

A promising dermal filler has been re-named.  Elevess has been re-christened as Hydrelle.

• Like Restylane and Juvederm, Hydrelle is a hyaluronic acid-based product.  This is a type of dermal filler that has a long track record of safety and success.
• Like Restylane and Juvederm, Hydrelle should last between 6 and 12 months.
• What makes Hydrelle different (and potentially superior) is that it contains a local anesthetic (specifically, lidocaine).  (Restylane and Juvederm do not.)
• Even with numbing creams and dental-type anesthetic shots, injecting certain areas of the face can still be uncomfortable.  With lidocaine, Hydrelle should have even less pain and discomfort at the point of injections.
• Could Hydrelle became the injectable of choice for needle-averse patients?!

The Lifestyle Lift Company Fined for Fake Online Reviews

I have blogged before how I am not necessarily a fan of the lifestyle lift (http://www.pickartplasticsurgeryblog.com/2008/01/lifestyle-lifts.html).  It's just a mini-facelift, and it's no different than what every plastic surgeon has been doing for the past 10-15 year.

Yet, I have always been amazed that this mediocre operation could create so much positive buzz.

Now I know how.  New York Attorney General Andrew Cuomo announced last month that the cosmetic surgery company that promotes the Lifestyle Lift has agreed to a settlement over fake online reviews.  As part of the settlement, the company has agreed to stop publishing anonymous reviews of its offerings and to pay $300,000 in penalties to the state.

Apparently, Lifestyle Lift paid its employees to write positive reviews about the company on various websites.  These employees also apparently "attacked" legitimate internet posters who criticized its services, and even tried to get those reviews removed.  Cuomo's office says that its investigators came across internal e-mails that specifically instructed employees on what actions to take.

While $300,000 might be just a slap on the wrist, I hope that this story generates at least a little bad buzz about the Lifestyle Lift.  Could karmic justice be for real?

Package Deals in Plastic Surgery: Why They Make Sense

I have increasingly seen advertisements for plastic surgery "packages":

• New mommy makeovers:
  • Breast enhancement
  • Tummy tuck
  • Liposuction

• Surgical facial rejuvenation:
  • Browlift
  • Eyelids
  • Facelift
  • Necklift

• Non-surgical anti-aging:
  • Fotofacial/intense pulsed light lasers
  • Botox or Dysport
  • Fillers (like Juvederm, Restylane, Radiesse, or Sculptra)

My wife has been skeptical.  "Aren't those packages just gimmicks to sell additional services?"

Yes, but that's a good thing.  These bundled procedures do work well together.  Combining services can lead to results that are greater than the sum of their individual parts.

Consider the "new mommy makeover."  All women know that pregnancies and breast feeding cause both the breasts and the abdomen to swell.  In many women, the skin never snaps back to its pre-pregnancy elasticity.  Lifting or augmenting the breasts makes the chest look great.  However, the whole torso is not balanced until the tummy is also flattened and tightened.  So, combining breast enhancement with a tummy tuck does produce the best proportions.

Non-surgical solutions can also be performed concurrently to optimize results.  For example, the "11's" between the eyebrows will usually respond to Botox or Dysport; a 60-80% improvement is typical.  However, for some patients, 60-80% is not good enough; they want 90% erasure of the wrinkle.  So, adding a little bit of filler beneath the relaxed wrinkles (such as with Restylane or Juvederm) can nearly eradicate the 11's.

Fillers can even be used to enhance a surgery.  Everybody knows that a face/neck lift can improve the cheeks, jowls, jaw line, and neckline.  However, the area around the mouth is usually not rejuvenated.  So, I will often recommend Restylane or Juvederm to minimize the "smoker's lines" radiating from the lips.  Combining these fillers with the face/neck lift can produce the most harmonious result.