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

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.

ATX-101: FDA Approval for Dissolving Fat (?!)

Maybe, I shouldn't have been so quick to disparage injection lipolysis.  Kythera Pharmaceutical's ATX-101 just might prove me wrong.

Back in November 2009, I called attention to the farce of injection lipolysis and mesotherapy, also known as...

• LipoZap
• Lipostabil
• Flabjab
• Lipomelt
• Lipodissolve
• Fat-Away

http://www.pickartplasticsurgeryblog.com/2009/11/whatever-happened-to-lipozap.html

Mesotherapy, injection lipolysis, LipoZap, etc., involved injecting bile acids beneath the skin to melt fat--or at least that was the hope.  Compelling advertising enabled LipoZap centers to spring up throughout the United States and Europe.  As is so often the case, clever marketing preceded any clever science.  Without appropriate testing for safety and efficacy, many patients were swindled, and some were seriously harmed.

Enter Kythera Pharmaceuticals.  Led by executives and researchers from the established biotechnology industry (such as Amgen and Allergan), Kythera seems grounded in science and safety.  ATX-101 is Kythera's fat buster.  Preliminary trials have been completed for dissolving lipomas--benign fatty tumors, affecting 2% of the population, which can be painful and cosmetically displeasing.

The traditional treatment for lipomas has always been surgical excision.  However, surgery always entails risks, such as scarring, infection, damage to critical structures like nerves, etc.  The hope is that ATX-101 will significantly reduce the size or eliminate lipomas without the need for surgery.

If ATX-101 were to work on lipomas, then I don't see why it shouldn't work on those stubborn fat deposits that we have inherited from our parents.  Analogous to current lipoma treatments, stubborn fat is now removed with surgery--liposuction.  Wouldn't it be nice to sign up for a few injections rather than a surgical procedure (albeit a minor one)?

Evolence Discontinued

The economic downturn continues to particularly hurt "cosmoceutical" companies.  Evolence is the latest victim.  Ortho Dermatologics (a division of Ortho-McNeil-Janssen Pharmaceuticals, which is itself a division of Johnson & Johnson) has discontinued Evolence.

What is (was) Evolence?

• A soft-tissue filler based upon porcine collagen (from a pig)
• Excellent safety record:  Unlike bovine collagen (from a cow) which caused multiple allergies, Evolence was never associated with a single allergy.
• FDA approved on June 30, 2008:  The federal government was satisfied with its safety and efficacy.
• It has been used similarly to Juvederm and Restylane, especially at the nasolabial folds (connecting the nostrils to the corners of the mouth).
• Less swelling and bruising than Juvederm and Restylane
• Similar longevity as Juvederm and Restylane

If Evolence was similar to Juvederm and Restylane (and with less bruising), why wasn't it more popular?

Lumpiness.  A number of my patients noted that Evolence was not as soft or smooth at its competitors.  While the lumps were never visible, they were palpable (and apparently annoying).

My mother loved Evolence.  Women in their 60s and 70s have thinner skin, which tends to bruise significantly (with all of the injectable products).  When my mother had requested Juvederm, Restylane, Elevess/Hydrelle, or Radiesse, the subsequent bruising had persisted as long as two weeks.  However, with Evolence, the black-and-blue marks were smaller and resolved within a few days.

Evolence has filled a niche in my practice:  It is useful in patients who would like to minimize bruising...

• because they have a big event tonight!
• because they are older.
• because they naturally have thin blood.
• because they are on blood thinners (like Coumadin, Plavix, or aspirin).

What will be the new anti-bruising injectable filler?  In this economy, I don't know.  I certainly hope that Evolence is soon replaced.

The Boob Jab: Enlarging Breasts Via Injections Rather Than Implants

In Ventura, and elsewhere in Southern California, breast augmentations are the most popular cosmetic surgery.  Placing a prosthesis (filled either with saline/salt water or with silicone) beneath the breast increases its size and improves its shape.

Despite the relative safety of breast surgery, many patients fear "going under the knife."  Others are not looking for a pneumatic change in their silhouette; just enough to fill up B cups, please!  What to do if you fear operating rooms, or if you're after a more discreet enhancement?

Enter the boob jab.

Yes, you read right.  Jab, not job.  Some of the injectable products, which have revolutionized the way plastic surgeons treat aging faces, may be good not only for filling in sunken cheeks but also for subtle breast enhancement...

• in the office
• not in the operating room
• with local anesthesia
• no IV
• no general anesthesia

Macrolane injections--the boob jab--are currently available in Europe.  A few thousand women have now undergone treatments, and they can expect their results to last for 18 months.

It is unlikely that boob jabs will be available in the US in 2009 or 2010.  We can only hope that Macrolane (manufactured by the same people who have brought us the wildly popular Restylane and Perlane) makes it to our shores soon.  It could be another option for women seeking breast enhancement.

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.

Belotero Balance: Another Hyaluronic Acid Filler on the Way?

The FDA will review Merz Pharmaceuticals' premarket approval application for Belotero Balance.

Belotero Balance is another hyaluronic-acid-based dermal filler that will likely be FDA approved for injection into the mid-to-deep dermis for correction of moderate to severe facial wrinkles and folds.

There are already a truckload of popular, non-animal-stabilized hyaluronic acid fillers in the USA:

• Restylane
• Perlane
• Juvederm Ultra
• Juvederm Ultra Plus
• Hydrelle (formerly, Elevess)
• Prevelle Silk
• Captique

How will Belotero be different?

• Restylane, Perlane, and Juvederm last about 6-9 months.  Will Belotero stick around that long?
• (By the way, don't believe the marketing that Restylane, Perlane, and Juvederm last 12 months or longer.  Exaggerations!  These products NEVER last 1 year.)
• Will Belotero be as easy to use as Restylane, Perlane, Juvederm, and Hydrelle?  These are easily administered in the office without the needs for pre-treatment allergy testing and extensive post-treatment care.
• Safety?  I have never had a major complication with Restylane, Perlane, Juvederm, or Hydrelle.  Zero complications is a pretty high standard!
• Price?  Might Merz distinguish Belotero by offering it at a more competitive price point?

I'll keep you informed!

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?!