Daily Skin Fix

Holiday Sale: 20% Off Botox, Juvederm and Skin Care

Join Dr Elaine Cook and staff at Advanced Skin Treatment Center, 2609 Wolflin Village, Amarillo to celebrate the start of the Holiday Season with an Open House on Thursday, November 17 from 8am to 8pm in conjunction with the annual Wolflin Village celebration. This is a sale you won’t want to miss!

In addition to offering 20% off on all Dr. Elaine’s® Advanced Skin Treatment Skin Care, we have reserved the entire day for patients wanting Botox® and Juvederm® treatments at 20% off! It doesn’t get much better than that. Most people want to look their best around friends and relatives during the holidays especially for holiday photos. With this special, you can ‘Lose Ten Years in Ten Minutes’ and save 20%!

Relax the wrinkles between your eye brows, across your forehead and the crows feet outside the eye area with Botox. With Juvedermyou can plump up the ‘parenthesis’ wrinkles between your nose and the outside corners of your mouth, plump up your lips and fill in the areas below the outside edges of your mouth to give your face a more youthful look. Whether you’re a veteran to these procedures or want to try them for the first time, you should call today to schedule your appointment because we expect the slots to fill up quickly!

Botox and Juvederm first come, first serve, by appointment only. Call 806-358-1117  or email us at skincare@skintreatment.com today to schedule your appointment.

One of the most common complaints I hear are about lipstick lines that radiate around the lips. This is usually followed by “and I never even smoked!” The causes of lipstick lines and loss of lip volume are several: loss of soft tissue and bone with chronologic aging, sun damage causing breakdown of elastic and collagen fibers, and repetitive muscle action. And, of course, smoking worsens all of these by both the direct toxin effect on the tissue and the habitual pursing of the lips.

The deeper the lines are around the mouth and the more the mouth sinks inward, the more aged you look. Additionally the muscle in the chin often becomes hyperactive and pushes the center of the lower lip upward and the corners downward. You see this most prominently in women with dentures but it occurs with most people as they age. Botox treats this very effectively with as little as 5 units per treatment.

Filler treatment of the lips can be very effective, but it is also the area where improperly done treatment has the potential to make you look worse. I used to get “don’t make me look like Goldie Hawn in First Wives Club”, then “don’t make me look like Angelina Jolie”, now “make me look like Angelina Jolie.” News flash–there is not enough filler on the planet to make you (or me) look like Angelina Jolie.

But there are some basic rules that should be followed. Remember these are IMHO, your doctor may feel differently:

• Lip augmentation should look as natural as possible. You are not a duck or a trout. You are not Angelina Jolie. You want your lips to look like they belong on your face, only a little fuller and with less lipstick lines.
• The outer corners of the lip should be filled to keep a youthful wide mouth. Don’t just fill the center and the lipstick lines.
• Turned down outer corners of the lips should be buttressed with filler so that they are either in neutral position or turn up.
• Most lipstick lines are best treated with filler in the red part of the lips themselves and in the junction of the red and skin, not just treated with filler in the skin above the lips. Sometimes a combination works best.
• Permanent implants in the lips are a bad idea. There may be some out there that don’t look bizarre but I have never seen them.
• The best fillers for lips are the hyaluronic acid fillers, Juvederm or Restylane. I usually use Juvederm Ultra  XC, as I think it looks and feels more natural and smooth. Thicker and more permanent fillers such as Sculptra, Artefill, Radiesse are not meant for use in the lips and may give lumps and stiffness.
• Your lips may feel stiff for 3-5 days after treatment with hyaluronic acid. This resolves.
• The ratio of the vertical dimension of the upper to lower lip should be 1:1.6. Your bottom lip should be more full than the upper lip. I often have requests to treat the upper lip lines and to not treat the lower lip because the patient would prefer to use the rest of the filler on the smile lines or elsewhere. Don’t do it if the upper lip becomes as large as or larger than the lower lip. You will look weird, especially in profile. Spring for another syringe if you need it.
• I don’t inject fat in lips because I don’t think it is as controllable and it is less predictable in terms of how much will last and how much will reabsorb. If you have fat injected into your lips, be prepared for significant swelling lasting at least 3 weeks, regardless of what you are told. Better to be pleasantly surprised than upset.

The best lip augmentations are those that no one knows you’ve had. It can be done. It does take an experienced physician injector, an aesthetic sensibility and the ability to know when to stop. Do it right or don’t do it at all.

Next: Cosmetic skin filler tips

Once again, these are the risks and instructions I discuss with my patients. If you are not my patient, you should listen to what your doctor tells you. I know you get tired of hearing this, but my lawyer doesn’t.

In general, the hyaluronic acid fillers last 1 year in the smile lines and lips; longer under the eyes, in the cheeks and temples. Sculptra lasts 2 years on average. Your filler may not last as long, or it may last longer. Results with Juvederm are seen immediately and settle in over a couple of weeks. Results with Sculptra are seen within 6 months.

I am always asked “do filler injections hurt?”  In our office we use a anesthetic cream. The hyaluronic acid fillers now have anesthetic in them. Sculptra is mixed with anesthetic. With the combination of anesthetic in the filler itself, and in a pre-treatment cream, most of our patients find the procedure very tolerable. If needed for lip treatment, additional anesthetic can be given in a dental block just like at the dentist. Now that Juvederm has anesthetic in it, only about 10% of our patients request a dental block. Before the anesthetic was added, 99.9% of our patients wanted a dental block.

There are risks with any medical procedure. The main risks with volume replacement and wrinkle treatment with cosmetic skin fillers are: bruising, infection, swelling, lumps, mild tenderness. Bruising is the most common problem after cosmetic dermal filler injections but can be reduced a great deal if you follow the instructions in my post “if you don’t want to look like I beat you with a stick, read this.” So read it.

Sculptra, or any of the longer lasting fillers, like Radiesse or Artefill, should not be used in the lips, or in the area immediately around the lips or eyes. If used in those areas, long lasting bumps under the skin can occur. Occasionally, they develop in other parts of the face. After Sculptra injections, our patients massage the treated area several times a day for 2 weeks to help prevent bumps under the skin.

Swelling after treatment is rarely a problem, the exception being fat injections in or around the lips, in which swelling may persist for weeks. Rarely unusual swelling occurs months to years after any of the fillers. It is more persistent with the longer lasting fillers Radiesse and Artefill.

Infection is rare but occasionally occurs. The risk is higher with the longer lasting fillers.

Compression of a blood vessel by the filler after injection very rarely occurs, but if not corrected, can cause death of the tissue overlying the occluded vessel. Symptoms include severe pain, gray discoloration (not the same as bruising), often with a light gray or white center, occurring within the first 24 hours after injection. It is most common on the cheeks or the area between the eyebrows. Immediate treatment is required to prevent ulceration of the tissue. If the hyaluronic acid fillers Juvederm or Restylane are involved, they are dissolved with a an injection of a medication, hyaluronidase. Compression of a blood vessel by the longer acting fillers, such as Radiesse, are more difficult to treat.

Occasionally, a patient either develops a lump, too much fullness in an area, or simply doesn’t like the result of treatment (usually lips–and we will talk about lip disasters later). One of the advantages of the hyaluronic acid fillers is that these can be reversed. I don’t know why some doctors don’t offer to reverse an area of filler if the patient is unhappy. I have seen patients, treated elsewhere how suffered with unsightly lips or other areas for a year. Not uncommonly they have seen the injecting doctor multiple times with their concerns, but were not offered reversal with hyaluronidase. So if that is you, know that there are options. In life, the ability to reverse a mistake is worth a lot.

There are quite a few fillers used that have not been approved by the FDA for use in the US. Yes, some doctors in the US use them anyway. Yes, some are used “all over the world.” Yes, some have good safety records. Some don’t. Just say no.

Next: Why you don’t want to look bizarre.

One of the hallmarks of youth and beauty is symmetry, i.e., one half is the mirror image of the other. When one eyebrow is up or down, when one eyelid droops and the other doesn’t, when one cheek is falling more than the other, the symmetry is marred and to our subconscious mind, the person is less attractive.

Classically, aesthetic facial beauty is characterized by the ‘rule of thirds’  in which the face is divided by three horizontal lines. The top third is from the hairline to between the inside ends of the eyebrow;  the middle third is from the inside ends of the eyebrows to immediately under end of the nose; and the lower third is from immediately  under the end of the nose to the tip of the chin.

Each third should be equal in vertical dimension, and each should appear equally dominant. When they are not, as demonstrated by someone with a very large forehead, large nose, or weak chin, again we subconsciously see that person as less attractive.

It’s my job as a cosmetic dermatologist to try to improve a patient’s symmetry and balance the thirds of their face.

Unfortunately, one of the things that I sometimes see are patients who either have had treatment elsewhere,  are Hollywood or Reality TV stars, or just people on the street, in whom the basic rules have not been applied. You have probably seen them too. Sometimes you just know that they are “off” but not entirely sure why.

The most common of these mistakes are augmenting the lips, smile lines, and corners of the mouth, without considering the cheeks, and temples. This is especially noticeable  on a thin individual with fat wasting of the cheeks and temples. They develop a “horsey” look with a prominent lower face, sunken cheeks and temples. The epitome of this look is the very diet conscious, compulsive exerciser, on Adderall and HCG, with a bunch of filler in her lips and smile lines in an attempt to compensate for her falling cheeks. Good thing that doesn’t describe me.

That’s why it is important to develop a plan with your cosmetic dermatologist, that addresses all of the areas of volume loss, to restore youthful symmetry and balance.

Then you won’t end up on TMZ as a “Don’t” with strangers commenting on your looks.

Next: Now the fine print

• Marionette lines and corners of the mouth—Juvederm Ultra XC or Juvederm Ultra Plus XC--1-2 syringes split both sides
• Lips–Juvederm Ultra XC-1 syringe
• Nasolabial folds (smile lines)—Juvederm Ultra XC or Juvederm Ultra Plus XC
• –1-2 syringes split both sides
• Under eye hollows–Restylane-L —1 syringe split both sides
• Cheeks–Juvederm Ultra Plus XC—2 syringes, one for each side.
• Temples–Juvederm Ultra Plus XC—1 syringe or Sculptra
• If doing overall “re-volumizing”-– Sculptra 2 vials per treatment, 3 treatments, (total 6 vials)

What do cosmetic skin fillers cost?

These are our current prices per syringe or vial for cosmetic skin fillers.

Of course they may change as our filler costs change.  We also have a lot of package discounts and intermittent specials on fillers. And the manufacturers offer rebates and discounts which help you out too.

Juvederm Ultra XC– $599

• Two or more syringes are $562.50
• Plus you get 5 units of Botox for chin free. This helps the turn down of the mouth and jowls.

Juvederm Ultra Plus XC– $625

• Two or more syringes are $587.50
• Plus you get 5 units of Botox for chin free. This helps the turn down of the mouth and jowls.

Sculptra Aesthetic– $899 per vial

• For a 3 treatment series, of 2 vials per treatment (total 6 vials)– $4999

When Juvederm Ultra XC and Juvederm Ultra Plus XC came out with anesthetic, our costs went up a substantial amount but we decided not to increase our prices for cosmetic filler. We thought it was important to hold costs down for our patients in this economy.

Are fillers expensive? I think that they are well worth the costs, because you really get a bang for the buck. When budget is an issue, our patients often start with one or two syringes and then add more later. And many patients only need one or two syringes to get the improvement they want. Also, at the time of retreatment, it is not unusual to not need as much treatment, as some of the results are lasting.

For more information on our current cosmetic procedures on sale and discounts check our web site.

Next: Don’t ignore the obvious

The first thing that I do when a patient comes in for a skin rejuvenation consultation is to try to determine whether they need volume correction, as that is likely to give them a big bang for the buck.  I look at all of the areas where volume loss causes aging changes and decide between a targeted filling of a few areas, reduction in specific wrinkles, or a broader volume restoration to larger areas of the face.

Cosmetic Skin Filler Evaluation:

1.    The first areas I look at are the corners of the mouth and the creases leading down from the corner of the mouth to the chin. These “marionette lines”,  that look make you look like a ventriloquist’s dummy, are the most aging changes. They appear to drag your face down and accentuates neck and jowl looseness. So the first thing I recommend is to fill those in.
2.    Then I look at the lips themselves. Often they have lost volume and have radiating lines. I like to plump the lips primarily to treat the lines around the mouth. If I just inject the radiating lines, often the patient will get a “Marge Simpson” upper lip with prominence of the area above the red part of the lip. We will talk more about lips later as they are the area that have potential to look bizarre if not done properly.
3.    Next are the nasolabial folds from the side of the end of the nose down to the mouth. If present, they cause a harsh appearance.
4.    The cheeks have usually lost volume, causing a flat face and pushing down on everything below them. This area is often neglected in filler treatments.
5.    If there are hollows under the eyes causing a tired look, we talk about fillers there.
6.    Last is the temples. After the other areas are corrected, if the temples look sunken then we need to address those.
7.    After I look at the entire face I decide whether we need to fill in certain areas, usually with a hyaluronic acid filler, or do a more complete, less targeted, overall filling with Sculptra.

There are a bunch of fillers available. These are the most commonly used:

• Hyaluronic Acid Fillers–Juvederm Ultra XC, Juvederm Ultra Plus XC, Restylane-L, Perlane-L
• Poly-L-Lactic acid (PLLA)– Sculptra Aesthetic
• Calcium hydroxyl apatite–Radiesse
• Fat injections
• Polymethylmethacrylate (PMMA) suspended in collagen–Artefill
• Surgical implants

I tend to stick with the hyaluronic acid fillers for targeted area and Sculptra Aesthetic for overall volume improvement. Hyaluronic acid fillers are reversible if needed, and Sculptra is great for overall volume improvement. Fat injections involve removing some of the patient’s fat and injecting it into the area to be filled. It is nice because most of us have a ready supply, but fat injections are more unpredictable with some of the fat not surviving transplantation. Also fat is less precise in placement, and causes a fair amount of swelling especially in the lips. I have seen major swelling last for 3 weeks or more. My patients won’t tolerate that. That said, some physicians do it very successfully.

Juvederm Ultra XC, and Restylane-L are for more superficial placements and Juvederm Ultra Plus XC and Perlane-L are for deeper filling. All 4 have a local anesthetic in them which decreases discomfort. All are sold by the syringe. The hyaluronic acid fillers give immediate improvement that lasts on average 1 year. At one year, more or less, we will do another treatment.

Sculptra Aesthetic is a powder that is mixed with an anesthetic and is for overall improvement. Sculptra is designed to be given over several (average of 3) treatments and lasts on average 2 years. At around 2 years most patients choose to do another treatment. Most patients do not need to do 3 treatments again at that time.

Sculptra (and to a lesser degree the hyaluronic acid fillers) are bio-stimulatory, meaning that they actually cause you to make more of your own collagen so some of the results are lasting. The improvement with Sculptra evolves over a 6 month time period so you gradually look better and better.

Fillers are my favorite procedure because they make such a difference and I enjoy the artistry of sculpting the face. I do all of the filler injections in my office. They are more difficult to get right than you might think. If you see someone and you think “wow, look at those bizarre lips” or if you can tell they have filler injections, they have not been served well. I always work to get a completely natural look, only better.

Sounds like a lot of filler injections. How much do we need?

Next: What is it going to take?

Cosmetic dermatologists achieve a youthful, aesthetically pleasing, attractive face by following the 5 R’s of anti-aging treatments: Repair, Relax, Restore, Resurface, Re-drape.

• Repair Sun Damage–Reduce Lines, Wrinkles, Spots, Sagging
• Relax Muscle Action–Reduce Lines
• Restore Volume–Reduce Lines, Give Youthful Fullness and Lift Sagging Skin
• Resurface Skin Texture–Reduce Lines, Wrinkles, Pore Size, Scars
• Re-drape Sagging Skin–Lift and Firm

Let’s go on to Anti-Aging Skin Rejuvenation Plan— –Step #3–Restore Volume

One of the most aging changes that happens over time is the loss of volume in the face. With age there is a loss of  fat, muscle and bone causing an aged, hollowed out, haggard appearance. In youth fat is under the eyeballs, in the cheeks, the temples, and the eyebrows. Over time this is reduced and drops which causes a “flat” face. This can be seen most dramatically in profile. Patients tell me “my face is melting.”

In youth the widest part of the face is the cheekbones, narrowing to the chin; called the “triangle of youth.”  With aging, volume is lost under the eyes leading to under eye bags,  hollows, and dark circles. The eyebrows fall when fat is lost, causing hooding of the eyelids. The high apple of the cheek falls. As the cheeks descend they cause deep lines from the side of the nose down past the corners of the mouth. These lines are like an arrow pointing downward, and appear to drag the face and neck downward.  The temples are hollowed, often with visible veins. The jaw line widens and the upper face narrows. The “triangle of youth” becomes the “pyramid of age.”  The skin’s “envelope” becomes loose over too little underlying structure leading to sagging, a flat and aged appearance and with jowls.

Adding to this is loss of volume in the lips as they become thinner and roll inward. Loss of bone around the mouth compounds the collapse of the mouth. Both cause a pinched and wrinkled mouth with radiating lines.

So basically, everything is falling. Cosmetic dermatologists call this deflation and descent.

And let’s not even talk about anything below the neck.

In the past, the looseness of the skin and the sagging was treated with a face lift alone, But that often lead to a gaunt, skeletonized, “caught in a wind-tunnel” look. The loss of volume needs to be corrected for a natural, rejuvenated appearance.

In any individual patient, either the volume loss or the looseness may predominate. But often it is a combination of both. If so, the problem of loss of volume and loose skin both need to be corrected. Although some patients certainly require a surgical face lift, we see many patients who successfully receive volume replacement only, or volume replacement combined with non-surgical tissue tightening with Thermage, sometimes called Therma-Fill. We will talk about this aesthetic option later.

Volume loss changes occur over time in us all, but may occur earlier in some than others. Of course, smoking or sun damage to collagen and elastic fibers cause the face to fall quicker and increases severity of facial lines. Individuals who have lost a great deal of weight, runners, and very thin individuals often show these changes earlier than others. I have a saying, “At a certain age, you have to choose between your face and your butt.” But actually you don’t– if you are willing to restore the lost fullness to your face.

So what on earth are we going to do?

Next: What we are going to do.

I love  dermal fillers for treating wrinkles and volume loss. Nothing drags your face down and makes you look older more than volume loss in the upper cheeks with aging. It changes the “triangle of youth” where the widest part of the face is the cheekbones into the “pyramid of age” where the central face is flat and the jowls are prominent.. As my patients often lament “my face is melting”.  Dermal fillers restore the lost volume   to the mid face, lifting the jowls–called “liquid lift”.

I use Juvederm XC, Restylane or Sculptra for my patients to restore the youthful volume. Patients love it, it looks and feels natural. But sometimes the injections cause bruising which may prevent a patient from getting treatment when they want it. This is what I tell them to do and it really seems to help. Of course that means you need to read this now and plan ahead. There are also a few other post dermal filler tips.

BEFORE TREATMENT TO REDUCE BRUISING FROM DERMAL FILLER

• For one week before, avoid aspirin, NSAIDs (Ibuprofen, Aleve, Motrin, etc.), St. John’s Wort, Vitamin E, Multivitamins, Fish Oils, Flaxseed Oils, Omega-3, Gingko, Ginseng, Garlic and Glucosamine.
• If you have frequent cold sores, contact us 3 days before treatment for medication.
• Go to store and buy a fresh pineapple. It can be cut up by the store but must be fresh not frozen or canned. Eat half of the pineapple the day before your treatment. Pineapple contains bromelain which is felt to help decrease bruising.

DAY OF TREATMENT TO REDUCE BRUISING FROM DERMAL FILLER

• Eat one quarter of the pineapple before you come in for treatment.
• Eat the final quarter of your pineapple after your treatment.
• You will receive Arnica gel to reduce bruising.  Apply 5 times a day for 2 days after treatment starting 30 min after treatment.
• We use GentleWaves^® LED treatment immediately after injection to reduce swelling and bruising.
• We use cold packs before and after treatment.

AFTER TREATMENT TO REDUCE BRUISING FROM DERMAL FILLER

• For two days after, avoid aspirin, NSAID’s (Ibuprofen, Aleve, Motrin, etc.), St. John’s Wort, Vitamin E (including multivitamins with Vitamin E), Fish Oils, Flaxseed Oils, Omega-3, Gingko, Ginseng, Garlic and Glucosamine.
• You may feel lumpy areas inside your mouth or on lips for a week. This is normal.
• Apply cold compresses for the first 8 hours to reduce swelling.
• Avoid touching the treated area within 6 hours after treatment, except to apply Arnica.  After that  gently wash with soap and water.  Foundation may be patted on.
• If the lips were treated do not put pressure on them with a straw, water bottle nozzle, etc., for one week.
• Do not put significant pressure on treated areas for one week (i.e. don’t lay face down on massage table cradle–I should be the one doing that).
• Bruising may be covered with makeup.  The most complete coverage is Dermablend Cover Cream (we get it at Ulta) although truthfully nothing covers it completely. Plan accordingly.
• Very occasionally an area will be too “puffy” and need an injection of medication to reduce the amount of filler. You don’t have to suffer with an unfortunate result (that you got elsewhere, of course)

Remember if you are not my patient don’t pay attention to what I tell you. Pay attention to what your doctor tells you.

Elaine Cook MD

Welcome to the SkinTreatment.com blog, opinions and observations of board certified cosmetic dermatologist and creator of  Dr Elaine’s Advanced Skin Treatment skin care line, Elaine Cook M.D.  I’ve been specializing in Dermatology for 27 years, the last 15 of which have been devoted to the practice of cosmetic dermatology, the development of my own skin care  line, and running SkinTreatment.com. This blog represents the summation of the knowledge and experience I have gathered over the years seeing countless patients and developing multiple prototypes for our skin care products. Some of the medical stories happen over and over again, some are more unusual. Some are purely cosmetic. Some are symptoms of underlying medical disease. All are important. All affect peoples lives.

I plan on discussing a variety of topics. Among them: the so-called “cosmetic” skin problems–acne, melasma, rosacea, aging skin, wrinkles, spider veins, cellulite, stretch marks, hair loss, age spots, sun spots, discoloration and more. I will also discuss the cosmetic procedures used to remedy these problems: Botox, Juvederm, Restylane, Sculptra, Laser, Fraxel  Laser, Intense Pulse Light Photorejuvenation (IPL), Thermage, Therma-Frax (also called Fraxage), Sclerotherapy, Chemical
Peels and the various other light-based treatments such as LED and blue light. Finally, I will be using my understanding of the skin in health and disease and my experience developing my own skin care line as a basis to discuss anything and everything about skin care products.

Basically, I will be discussing whatever I want on any given day.