That doesn’t sound good. What exactly is “fat atrophy”?

There are pockets, pockets in the face, when people are younger ... once again this is a younger face versus an older face ... and these pockets in the face help keep people youthful. Now, if you ever go to the mall or you have a friend that has a kid, look at their face, look at the difference. Look how puffy their cheeks are. Look at a 15-year old's face versus an 80-year old face and you will really see that a lot of this fat will start to kind of follow gravity and go down. 

I like to say people, when they're younger, they kind of have, have a funnel. So, their face looks more like this. However, as they get older, their face starts to get more square. And what that's from is, basically, in this area and that cheek area, that fat is slowly starting to go down.

And the last is going to be collagen. 

I’ve heard of collagen. How does that work in the equation?

Collagen is the younger skin versus the older skin. 

I like to look at collagen kind of like a pillow case. So, if you think about it, everyone has their favorite pillows. Whether its your favorite pillow now or when you were a kid, it's your love. You slept on it every single night. And the pillow started to have spots in them where it wasn't as full as it used to be or wasn't as thick as it used to be. 

And there's two ways to fix that pillow. 

Number one is we can cut it and make the pillow smaller, squeeze all the fluff that's in there together. 

Way number two is, basically, to fill it. So, we refill it with more fillers and kind of blow it back up. It's kind of the two options that we have when trying to make someone look younger. To go in and fill it is, basically, us choosing fillers or Sculptra, or something like that. As far as cutting, that probably would be more like a face lift. So, those are kind of the two options to really get you looking a lot younger. 

If “fillers” are an option to a facelift, how do they work?

All right, so this kind of does a segue into ... what do we use for what. 

So, when do we use Dysport or Botox, verses fillers, verses Sculptra? 

Some people say, "I need Botox down here. I need it up here," and they don't really understand it, which is, you know, most people don’t. 

So, Botox is mostly going to be used up on the forehead or kind of around the eyes and it's going to be for small lines. It's going to be lines from this muscle constantly squeezing called the frontalis muscle. You can have lines over here as well. What the Botox does is its ... basically stops that muscle contraction. When you stop that muscle contraction, over time, we stop the lines.

How is Botox different than other fillers?

Number two is going to be fillers, and fillers have two kinds of options. 

Using filers, option one is if people have really deep lines. If people have really deep lines, we can go in and inject another type of filler into the line if Botox isnʻt enough. 

Option two is, sometimes it takes multiple modalities to really get people to where they want. We can also increase the volume in those areas we talked about before - in the cheek, in the jaw. 

Option three is going to be the Sculptra product. The Sculptra product is very unique in that it can pose as any of the three things that we talked about. It can pose as collagen. It can pose as bone and as fat. So, it really works as a really good filler when trying to fill out those areas.

So fillers help create more of our own collagen?

This is kind of the science behind how it works. What collagen does is it goes in and it's ... or Sculptra does ... it's a collagen, kind of binder. So, it goes in andactually helps to create more collagen in your body. 

How long can I expect the effects to last?

The reason Sculptra works longer than most fillers is, I don't know how many of you guys have had fillers, but if you've had fillers, the second that the filler's gone, the wrinkle comes back. The lines come back. The fullness is gone. This actually works to kind of bind to make more collagen, so that it's not gone in 6-months to a year.

Sculptra has been shown to last longer; two-years in a lot of people. The big thing is that binding you see of the collagen. 

When you come in, what we'll do is do one vial on each side. Six to eight weeks later we'll do one vial on each side. 

And we'll continue until you’re wherever you want to be. Some people want to be fuller. Some people don't want to be as full. Once you get to the point you want, it’s very easy to maintain. Usually we can maintain at just one vial per year. But to get to that point, sometimes, takes a little longer. 

Do you have before and after photos to see how it worked for others?

We have before and after photos of fillers on our main website here. 

Here is our gallery of images for the Botox procedures.

How do we maintain the look? 

The important thing to know that ahead of time is that you do want to massage the Sculptra five times a day for five minutes a day for five days. That's to help make sure the product stays distributed evenly through your tissues. 

One of the prior concerns with Sculptra was palpable nodules in the skin from too much collagen being stimulated in one area versus other areas in the skin. 

Iʻll be honest, I actually used this product a few years ago and then, briefly, stopped using it. But the company reformulated the way they mixed the product, the way itʻs injected, and I have had none of those issues since Iʻve restarted using the product. 

Like I said, Iʻve used the product myself. So, it’s just as important to be aware of that sensation as it is to know that youʻre going to be able to massage these areas and know that youʻre going to have to do that after the procedure. 

[ photo to come? ]  This is actually a patient who had a face lift and really thought she looked a little too pulled, and a little too tight. And just by adding the appropriate amount of volume it just softens the result and just makes her look more refreshed and well rested.

What if I wanted to focus on just my neck?

For that we suggest injectables, specifically, Dysport. 

Although, occasionally, you can get an indirect effect because if youʻre volumizing this area we happen to inject right above the jaw bone. It can decrease some of the looseness. Probably not so much for this central portion.

Dysport, which is one of the neuromuscular modulators, in cases where a lot of that pull down is due to the muscle ... thereʻs a muscle on the neck called the platysma that pulls down ... in some patients, injecting just along that muscle can help it relax and smooth out so its not pulling away from the neck. If indeed itʻs skin, and stretchiness of the tissues over time. 

When that muscleʻs been so stretched out that and tightened that it canʻt relax with a neuromuscular modulator, then surgery is really the only answer we have at this time. But some patients do try, you know, some patients it works great for. I actually use it in the neck procedures I do, because Iʻm trying to prevent all this stuff from happening to myself.

And I have many patients who get, you know, eight or, twelve injections just along the muscle line and have very good results. Some patients donʻt see as much of a result.

And Dysport in NOT a filler, right?

Correct. 

We talked about neuromuscular modulators, fillers, and collagen simulators. Um, neuromuscular modulators, Dysport is made by the same company that makes Sculptra. And thereʻs Botox and thereʻs actually a new one called Xeomin. I hadnʻt had as good a success with that so I donʻt currently carry it. 

And fillers are...

The fillers are going to be more of the ones that most people have heard about. Thereʻs a huge class called hyaluronic acid. Itʻs Restylane, Juvederm, Juvederm Ultra Plus, Voluma. Those are all hyaluronic acids. 

There is another filler called Radiesse on the market which is part hyaluronic acid, part collagen stimulator. Sculptra is truly the only collagen stimulator thatʻs indicated for use in all of these areas on the face for general volumizing.

How often is plastic surgery required when fillers and neuromuscular modulators DON’T work?

It’s true, many times we would do both. 

I think in this day and age many patients might feel like weʻd be doing them a disservice if we just offered skin tightening without revolumizing. So, itʻs my strong opinion that volumizing should be done in conjunction with any kind of surgery. 

And if weʻre on the fence about whether you need a surgery I really think doing the injectables and revolumizing first gives us the best chance of really assessing whether you need something. Because some patients find that they get enough of a teeny bit of brow lift and eye opening with injection, and fillers, and, and Sculptra to the temple area. 

With Sculptra, you might be able to avoid a brow lift for a few years or, you know, avoid a face lift for a few years. But, you know, I definitely thinkrevolumizing first is the way to go because then youʻre assured that youʻre going to look as soft and natural as possible after a surgery.

I have an issue with my eyelids. Can injectables work for that?

It can help, but itʻs not a replacement for lower eyelid surgery. Nor is it a replacement for face lift surgery, if you truly got enough laxity in the tissues and loosenessthat it helps to reposition. 

However, that said, really volumizing through the cheeks helps push them up in a way that it camouflages that junction between the eyelid and the cheek.

Lips. I want to hear about how to make my lips look better.

Many patients that ask me to fill their folds around their lips. So Iʻm now offering to fill the cheeks and revolumize the upper face because its just a more natural way of addressing that fold. 

Eight-year olds have folds. Twenty-year olds have folds. It is not natural to have no fold. So, just addressing aging around here with fillers is really not going to give you the best look possible. 

So this is what I wanted to point out. You can see a youthful shape to the face and, with youth, you have these fat pads that abut right against each other. 

With age, they not only descend but they also shrink so that all of a sudden youʻre seeing this junction. What youʻre seeing is your muscles connecting to the eye

socket and the bone. And, in fact, youʻre losing bone too. So, everything recesses and there's ... it seems like there's too much skin for the area because it's not filled out.

Like the pillow case analogy: if it's too big: tighten it. But, it's a better approach sometimes to, to re-stuff and to re-fluff. And by putting a lot of volume back to the cheeks many people can hide that lid cheek junction and look and get a lot younger without surgery. 

I was quoted in an article “Is a 'Lip Lift' the Permanent Fix for a Prettier Smile?” Check it out to learn more.

All these injections sound painful. Are they?

If you’re sensitive, sometimes we will prescribe patients one pill of Valium or Ativan or something to take before the procedure.

Most of the time anesthesia's not that beneficial for these filler products because the anesthesia causes some dilation of the blood vessels. When we do surgery we often inject epinephrine in the tissues, which will counteract that. 

With fillers, you don't want to inject extra substances into the tissues most of of the time. So, I find patients just get a lot more bruising when I combine it with another surgery or do it under anesthesia. 

It’s also best to be sitting up. And most patients ... with the topical numbing cream we have and, you know, with dental blocks for around the mouth if they’re needed, really do well at tolerating the procedures. I have patients that say, "I can't tolerate anything. I'm such a baby!" And they tolerate it.

Are there other restrictions to consider?

Not so much age, as lifestyle and health. There are some patients that, because of nutrition or other factors in their lives, are not as capable of producing collagen. So, there are some patients that will not get as great a result with this treatment. For patients who I feel are at high nutritional risks, we'll start a multivitamin regimen and do some supplements with protein shakes and some other nutritional products to help that process. 

Generally, younger people may need two or four vials; usually, it is four.  Older patients may need six, or seven, or eight before they get the result they're looking for. And then, yearly, it's just one or two to kind of maintain that look because, you've got that collagen and you're going to continue to simulate it.

How long is the healing process? Is there much bruising?

Actually, there's usually very little bruising if any. 

Because we inject the product, and it’s mixed with saline, you would get 6-milliliters of fluid injected into the various parts of the face. So, actually, a lot of patients like the way they look right after because they're a little puffy and its kind of simulates what the result's going to look like. But within two, three, days, all that puffiness is gone. 

Then you will wait at least for maybe six weeks before you start to feel and see the difference in your tissues. And that's when we do the second treatment session. 

What is the cost?

It varies, but generally, the cost is $750 per vial. 

We generally do two vials per treatment because we do one vial for each half of the face. Very few patients will respond to two vials alone.

Although, I have a few patients who have said, "I just want to do the temples," and weʻll split one vial between them. There are situations like that. But most patients are going to use two to four vials.

What’s the difference between the lactic acid, the stimulator, and Juvederm, the filler?

Polylactic acid is similar to the material they use to make absorbable sutures. So, essentially, itʻs a complex sugar. And its role is to stimulate your bodyʻs collagen production. 

So, itʻs injected in the very general areas mixed with saline so it spreads throughout the tissue and stimulates the tissue. Fillers, like Juvederm and Restylane, are hyaluronic acids. Theyʻre a gel, but not a suspension of particles in a fluid. The gel is meant to be injected exactly where you want that volume. 

When you see a hollow spot, you inject it right there. You see a wrinkle, you inject it right in the wrinkle, usually right in the deep layer of the skin.

When do you use the stimulator instead of the filler?

Depends on the patient and what particular area they want to address. 

If a patient says "I donʻt care about the rest of my face. I just want this area addressed." sometimes weʻll still do a filler. 

With lips we always do a filler. If you have enough volume in your cheeks and you still have this line around your mouth, some of those fillers will be appropriate. A lot of times its kind of a “both" response. 

Do you do fillers?

Absolutely! And the fine lines around the mouth it may effect the lip a little bit but its not going to directly effect the lip. So sometimes we do resurfacing and other fillers and surgery. Sculptraʻs not the only product we use, it just happens to be pretty unique and does apply to a wide range of patients. Thereʻs patients in their 30ʻs and 80ʻs that both get a benefit from the same product. 

Can you “mix and match” different injectables?

We have patients who have used both Sculptra and Voluma in their faces.

Theyʻre different products, so they do address slightly different areas of the face. We did a training session for Voluma so, and I thought, "Why the heck not?" And, "Iʻll put some in where it needed to be.” So you’re right: theyʻre very mix-and-match.

Some patients have twenty-one fat pockets in the face.  Everybody loses them at a different rate. And some people even lose them at a different rate on each side of the face. 

Sometimes if you do Sculptra and stimulate collagen evenly, you may have a little less symmetry. You can either choose to do one vial extra in those spots or you get a little of Restylane or whatever filler and you just pop that area.

I have deep lines, so do I need some type of filler?

Yes, when you move, your muscles and skin actually bend, and just like a credit card if you bend it in the same spot over and over again it breaks down and weakens. 

Youʻre breaking down collagen in those areas. So, if you, if you do the Dysport or Botox, your body will have a chance, without that muscle movement, to rebuild collagen in that area.

For some patients who have deeper wrinkles, sometimes you need to get that treatment for eight-months or a year, which could be two or three sessions of the treatment, to really let your body fully recover. 

Occasionally, we have patients that still have lines even after that time period and we do use filler. But, if you say, OK, now Iʻve got the filler, I donʻt see the line, Iʻm going to stop doing the modulator treatment ... unfortunately, your body is still going to be breaking down your own collagen. Youʻre just not going to see it because you have that plumper in there to kind of hide the fact.

So I do still recommend getting Dysport to weaken those muscles even if you require a filler. Just maintain it that way youʻre not breaking down further collagen in those areas.

If this is deep now, imagine how deep it would be in twenty years without once going.

So using injectables now will actually prevent deep lines down the road?

Dysport and the Botox will also help to prevent aging. 

But they can only prevent collagen breakdown thatʻs due to muscle motion in particular areas. Itʻs a very narrow spectrum of what it addresses. 

This product will rebuild product in your tissues essentially all over your face. There are a few areas we donʻt inject it, the nose, the lips, basically, the central portion of the face. The eyes. But everywhere else, the cheeks, the temples, the chin, youʻre building collagen in those ares so, it is making your skin younger. 

But does it also give you a fat face?

Good question!

I remember one of the physicians that trained me showed this picture of this guyʻs before photo, and I thought, "There is no way this guy needs Sculptra!” Full cheeks, big face, he mustʻve weighed three-hundred pounds. 

However, afterwards, he just looked better. He looked like a college linebacker instead of some fat dude when he was finished with the injections, because he had the volume here to balance out the fullness that he had in the rest of the face. 

Iʻve had many patients that are concerned with any filler, let alone Sculptra, because they think theyʻre going to look fat. Youʻre putting volume where you need volume in the face where your bone structure used to be, where you can lose it as you age. So, it wonʻt make you look fat, it's just going to make your face shape more youthful or make you look more like you did ten, twenty years ago.

Doesn’t Botox paralyze you facial muscles?

Correct.

However, if you do your maintainenance, and you get either Botox or Dsyport religiously every three to five months or whenever it wears off. You donʻt want it to wear off completely and start wrinkling again. As soon as you notice that muscle movement, or on a scheduled basis, even before you really notice it. 

If you maintain those treatments, your body will build new collagen and you may not need maintain your lines. Its just a matter of being regular with it. 

I’ve seen people who LOOK like they’ve had too many injectables done.

Thatʻs too much filler and a little drastic. 

And just so everybody knows: traditional fillers, like those hyaluronic acid fillers that are usually used in the lips and sometimes the tear troughs, can be dissolved. 

Sculptra cannot be dissolved. 

But, since we do it by session, if you feel that you have enough fullness after the first two vials, after one session, you stop. If you feel like after two sessions you have enough volume, you stop. 

And none of these products are permanent. So, youʻre going to continue to lose volume as you age and these products will continue to slowly break down. So, you donʻt have to be concerned about over volumizing as long as youʻre communicating clearly with me what you want. I donʻt tend to make people overly plump.