Juvederm for Upper Eyelid Contour Irregularity

Hi Dr. Rivkin,

I have a higher crease and some fat loss in one upper eyelid after granuloma and suture cyst removal. I have been told it would be easy to correct with a filler such as restylane. What filler do you prefer for the upper eyelids?

My main hesitation is that I am concerned about safety. If I inject the eye with temporary fillers every 6 months or so, I may have some bad luck one day where the filler occludes the retinal artery. I have read this happens once in a great while when lids are injected with an anesthetic agent prior to surgery. Do you think this is a possibility, albeit remote, with with filler injections?

I have also thought of a fat graft rather than fat or other injections, as that would be a one-time operation, but I hear fat grafts do not always retain well. Thank you for any feedback on these issues.


hi,
the concerns that you raise are certainly valid.
first off, i prefer juvederm for the upper eye area - it is smoother than restylane. second, these fillers last considerably longer than 6 months in the eye area. when i inject the lower eyelid crease with juvederm, it usually lasts for a year and a half or more. so, i wouldn't worry too much about repeated injections - the filler stimulates collagen growth and so you may only need a few sessions to achieve fairly permanent results.
i would definitely never use any other filler aside from restylane or juvederm around the eyes.
lastly, you should go to a physician very experienced in filler injection first and injecting around the eyes second. just because someone is an opthamologist or an oculoplastic specialist does not mean that they are an experienced injector. don't be shy to ask specific questions.
i don't like fat that much, although i have seen good results with fat grafting. sometimes fat lasts for a long time, sometimes it lasts for 6 months. filler is so much easier that i do not see any reason to use fat.
in terms of artery embolism, i have injected about 700 patients under the eyes so far. i have never seen a problem and i do not expect to. i would not worry about it. the risk is very remote.

Active Fx vs Plasma in Combo with Thermage for Skin Tightening

Hi Dr Rivkin - do you feel the plasma treatment for the face is as
effective for fine lines as active fx or fraxel? I have also been told
that along with thermage it can tighten and take about 10 yrs off the
face. I am starting to see more info on this process.

Also - if I have had a series of polaris treatments (1 1/2 yrs agao) and I have continued to have a refresher treatment every 4-6 months would thermage be a waste of money? Or do you feel that thermage is now so superior
that I should opt for that treatment instead?

Thanks!


hi
sorry - i was on vacation
i like active fx for fine lines better than plasma. i think that it is somewhat safer and more effective. thermage can be used in combination with any technology - active fx, plasma - whatever. by the way, i think that fraxel is an inferior technology for fine lines.
i have seen that thermage is best for the tightening the jawline and under the chin, whereas active fx is best for under the eyes (not sure that plasma can be used under the eyes) and throughout the face for fine lines.
i do not think that there is a huge difference between thermage and polaris, but i do think that thermage is more intense these days and that can get you a better result.
by the way, i would be pretty sceptical of anyone who promises to take 10 years off. sometimes that happens, but not reliably.
hope that helps

Discoloration Under the Eyes After Juvederm

Hi,

I had juvederm in sept07 for some dark circles. Dr. told me to fill the hollow and it would get rid of the shadow. One month later there was an imperfection on one undeye(dent) so she talked me into filling it with restalyne. She hit a blood vessel on the l eye and I had a black eye for 5 wks. When it cleared, there was still a very dark mark where the black yey had been It did not get lighter and she said it was a hemosidirin stain and lets try to laser it. She laser it 2x and it helped lighten the bottom but there is still a discoloration I never had before. The other eye strated to get a discoloration under it also. It became worse than the other side. It looks like 2 dark lines that where drawn from my eye to the side ofthe nose. They are MUCH more noticable than any dark circles I used to worry about. They are VERY distinct in photos and I look like an exhausted mug shot. I reviewed all my photos prior to the injections and you cannot see any darkness or distortions under my eye. I guess the dark circles bothered me in the mirror but they were nothing compared to what I am dealing with now. I look terrible in photos and it is quite noticable in person. There is a slight bump on the right side but I can live with bumps. Its the discoloration (darkbrownish) that has me terrified. I am afraid I ruined my face. All over a little dark circles. I would give anything to have my face back. Any ideas? The 2 syringes of juv were 9/07 and the resty on top of it was 11/07.

Thank you for your help!


hi
sorry - i was on vacation
the discoloration that you are describing is a rare but really disturbing side effect of injecting restylane or juvederm under the eyes. i'm not sure why it happens - probably the filler becomes visible through the skin (it is clear, but looks blue under the skin). did your doctor inject deep, next to the bone? if she injected too superficially, it is possible that the filler becomes visible like this.
the filler is still there, so i would dissolve it with hyaluronidase enzyme if i were you. if your doctor is injecting under the eyes, she should be familiar with the enzyme. it will remove the filler and your eyes should go back to normal.
cheers

Radiesse vs Artefill for Jawline Contouring

Dr. Rivkin,

I have had great experience with Radiesse in scuplting the jawline, especially the jaw angles. Up to now, it has been thre most reliable filler for creating a sharp jaw angle. It has great thickness much like paste, but doesn't seem to last long enough.

I have heard that you are a fan of Artefill.

However, in an earlier post on here, you mention that for BONE CONTOURING, such as the jawline, jaw angles, or cheek bones, you prefer RADIESSE ?? Is this true, in terms of your opinion ?

The reason ARTEFILL seems interesting is that it's permanent. Can it match or surpass RADIESSE in terms of CONTOURING of the BONE STRUCTURE in the face, in areas such as the jawline, jaw angle, and cheek bone / malar area ?



hi
yeah, i've used both radiesse and artefill for the jawline and i have better results with radiesse. the line is sharper and the effect is more predictable with radiesse. i think that you should continue with radiesse for now, until a better permanent filler comes on the market (which should be within the next 6 months or so).
in a pinch, i will use artefill for these areas, but i will make sure that the patient knows that i cannot get the same sharpness, and they will have to come back for multiple touch up sessions as the artefill builds up.
hope that helps

Nasolabial Folds Improve with Cheek Augmentation

Hi Dr. Rivkin,
I had Restylane injections on the nasolabial lines one year ago. I was not very happy with the results. First, I did not notice a major difference and it felt lumpy to the point I could not wait for it to wear off. The other problem I have is that besides the lines the area is also depressed. I am wondering if another kind of filler is better for me and...............is there anything that can be done for the depressed area? And.........what about the little spider lines that come off the nasolabial lines.........can something be done with them? Thanks


hi,
it sounds like you have deep nasolabial folds, not just wrinkles. sometimes just pumping up the depressed area does not work. some people have a loss of volume above the fold - in the front portion of the cheek. this volume loss accentuates the depth of the fold. if you fill the cheek, though, the fold improves - it looks much less prominent and the midface regains some of the lost volume. a full midface area is very important to prevent the "saggy," tired appearance that comes from loss of cheek volume.
i would also not use restylane - it is a filler for more superficial lines. you should be using a thicker filler that goes deep, like radiesse. it will also last you alot longer as well.
in terms of the spider veins, i just got a new device called veinwave that works really well. it is a needle with a current. you put it on the vein and it destroys it. works well for small facial vessels.
hope that helps

Active Fx, Nose Job Steroids and Velasmooth vs Thermage

Hi Dr. Rivkin - thanks for your thoughts on active fx and body tightening procedures. Why do you feel active fx is a better treatment vs fraxel - would love your opinion!

Also - had a wonderful corrective nose job (he cleaned up the problems by another dr) by a great surgeon in Beverly Hills -it was my third nose surgery and it looks amazing. I am 1/2 armenian - thicker skin so I do have a little bit of scar tissue between the skin and cartialage so the refinement is a little off - would you recommend steroid injections to improve? It's been a couple of years since the surgery and am super happy with overall result!

Sorry - one last question for you! You mentioned that thermage for back area of leg is not that great but vela smooth is good. I am an avid runner - do pilates and yoga so in really good overall shape. I don't have any cellulite but am getting older (46 yrs) so notice the skin isn't as firm -it's muscular but a few lines on the back of my thigh area. I am also pretty small - 5 ft 4 and about 110 lbs - would you still recommend vela smooth vs thermage for that area??? I"ve always had really good legs and want to keep them firm firm firm!!!

Thanks - you are so helpful and still need to come in for a visit next time I'm in LA!


hi,
well, i have both fraxel and active fx. the active fx is a co2 laser, as opposed to erbium for the fraxel. what that means for you is that the effect is more intense with the active fx. it goes deeper and the healing response is more intense. so, one active fx treatment is equivalent to about 3 fraxels. but you get it over with all at once, instead of going through downtime 3 times. also, for problems such as deep acne scars, the fraxel just does not get the results that the active fx does, as far as i have seen.
i don't know if i would suggest an intervention if you are happy with the result of your surgery - there's always a risk whenever you do anything. so, if you're really happy, maybe leave it alone. steroids do work for that kind of refinement, though. so, if you want to, it would work.
for your legs, i would try the vela first - its alot cheaper than the thermage and it may be good enough. if not, then perhaps thermage would be a good idea.

Jawline Definition using Radiesse

Hello dr. Rivkin,
Do you know what filler is normally used to give that smooth fuller look to the jawline and chin? my jawline has lost some volume and therefore it's thinner than before. have you done this procedure before? and approximately, how much does it costs?

Thank you:)


hi,
well, the price depends on how much filler one uses.
i usually prefer radiesse for the jawline because it lasts a while and it goes deep, for a smoother effect. duration of effect is about 10 to 12 months.
i have tried to use artefill after someone has been satisfied with the effect of radiese, but its difficult to get the contour with artefill as well as you can with radiesse. i would probably suggest sticking to temporary fillers at this point. preferrably radiesse until something better comes out.
cost of radiesse is about $800 per syringe, and you will need at least 2 syringes, probably 3 or 4. when it is multiple syringes like that, i give people a significant price break - it can get expensive. for 4 i would probably charge about $2400 (1 free). for 3 i would charge about $1900.
hope that helps