A woman in her late 50’s who wants to look more rested. On examination she has prominent frown lines which make her appear stressed. She also has significant volume loss of the cheeks which makes her look older and more tired. The frown lines are present at rest, so it is helpful to fill them with restylane as well as weakening their overactivity with Botox. She is shown before and again, two weeks after placement of 15 units of botox to her frown muscles, as well as one cc of Restylane to the deep frown lines of the forehead and 3 cc of Restylane Lyft to the cheeks. I have avoided Botox to the upper forehead in her case to avoid dropping the medial brows and overarching the lateral brows ( a “Mephisto” look). Even with the small dose to the lower forehead she does get some nice arching of the lateral brows.
A woman in her late 40’s who is bothered by a tired appearance. Her diagnosis is volume loss of the midface, which gives her an aged appearance. Volume can be restored during surgery with fat grafting, but she is quite thin and does not have enough fat stores for adequate fat grafting. She elected for non-surgical treatment. I prefer the Non Animal Stabililized Hyaluronic Acid (NASHA) fillers such as Juvederm and Restylane, because they are reversible and can be dissolved if needed with an injectable enzyme called hyaluronidase, but have the benefit of lasting. In her case Juvederm Voluma was used, which can last up to 2 years in treatment studies. She has had Botox to the forehead and Juvederm Voluma to the cheeks. She has had a total of 7 syringes of Juvederm Voluma placed one or two at at time over a 3 month interval. And is shown one month after her last treatment. The red mark on her right cheek was an area of irritation from an ice pack that she had used at home.
A woman in her late 50’s who wanted fuller but still natural lips and improvement of some age related deflation of her cheeks. She had one cc of Juvederm Voluma split between her cheeks, and 2 cc of Juvederm Ultra to her lips. The lips were treated in two separate sessions with one cc placed at each session to avoid over augmentation of the lips- she did not want a “trout pout” look. She is shown one month after the second session.
A woman who wished to enhance her lips but did not want them to appear unnatural. She is shown 2 weeks after treatment with a single syringe of Juvederm Ultra. The upper edge of the lip (the white roll) is subtly filled but not overly so- we don’t want to see a “trout pout” which can look funny from across the room. The philtral columns ( the two ridges just above the middle of the upper lip) are subtly enhanced. And the pink portion of the lip ( the vermillion) is subtly filled to add shape to the lip.
A woman in her mid 70’s who is bothered by volume loss of her lips. She would like to have this corrected and have the lips fuller, but does not want “the trout pout”. It the lip roll is overly enhanced in a lip that has lost volume with age, it can look unnaturally prominent. But if one of the stiffer fillers is placed in the upper part of the lip it can look unnaturally prominent as well- the upper lip should have a natural concavity, not be prominent like a monkey’s lip.
The solution is to use one of the Non Animal Stabilized Hyaluronic Acid (NASHA) fillers that spreads out in the dermis such as Volbella or Restylane
Silk. In her case, 2 syringes of Restylane Silk were placed to the upper and lower lips. She is shown just before and again, 2 weeks later. This corrects the atrophy and volume loss of the white portion of the lip in a natural way and softly adds volume to the red portion of the lips as well. The lips no longer have the atrophy of aging and appear more youthful as well as slightly fuller.
Here is our patient that I used to demonstrate at the recent Allergan Master Class, given at the Seaport Hotel in Boston. She is in her late 50’s , and is bothered by drooping of her cheeks, volume loss of the lips with “bar code” vertical lines of the upper lip and well as decreased volume of her lips with age. The lower lip vermillion is “corrugated” from volume loss.
She had Botox to the frontalis muscle to shape and arch her eyebrows. She had Botox to the corrugator muscles to treat the frown lines, sometimes called “the 11’s”. She had Botox to the lateral orbicularis muscle to treat the “crow’s feet” lines. And Botox to the Procerus and Nasalis muscles to treat the “bunny lines”
Juvederm Voluma was placed over the upper cheeks to treat the volume loss in this area.
Juvederm Ultra was used to augment the lips along the lip roll, but also to add volume to the vermillion and evert the lower lip and fill the upper lip vermillion without looking “ducky”.
The Volbella is a new product and is similar to Restylane Silk and Belletoro in that it can be used as a superficial filler to treat the “bar code lines” of the upper lip. It was also threaded superficially below the vermillion of the lower lip to add smoothness and shininess to the lip vermillion- she feels that her lips look ok without lipstick now.
A man in his mid 50’s who has had lower lid blepharoplasty elsewhere and was told that he might eventually need some volume to the midface.
As we age, we are losing volume in our face- like a peach that’s been left on the counter too long. We can pull up skin that sags from volume loss with a face lift, but this doesn’t correct the volume loss. When the neck and jaw line is good, we can add volume back to give a more rested look. If we are in the operating room and a patient has enough fat we will use their own fat with fat grafting. But we can also add volume in the office. I prefer the non-animal stabilized hyaluronic acid (NASHA) fillers because they seem to give the best balance of the longest duration with the least chance of problems. And they can be reversed by dissolving them in the office with hyaluronidase, an enzyme, if they do have a rare problem.
I also prefer “slow and steady” with correction. The best results are slightly underdone-tnis still looks natural but slightly overdone looks funny from across the room. This patient is shown after a series of 3 injections done at 2 week intervals. A total of 5 cc of “Restylane Lift” (formerly called Perlane) was used. The plan now will be to wait 6months or so and then add a little more as needed to maintain his results.
A woman in her mid 20’s who is bothered by a hollow appearance of her lower eyelids and cheeks. She is shown before and 2 months after Restylane to the “tear trough” area and 1 month after Restylane Lift to her upper cheeks.
A woman in her mid to late 50’s who is bothered by an aged appearance of her face. She is interested in improvement without surgery. The first step in any consultation, after I find out what is bothering my patient is to make the diagnosis. There is a diagnosis with facial aging as in other areas of medicine. As we age, we lose volume in the face, through bone and fat resorption . She has significant loss of volume in her cheeks and middle face which makes her look older. She also has very active “crows feet” lines when she smiles, from activity of her lateral orbicularis muscles. Her brows are flat and give her a sad appearance. I have treated her with BOTOX to shape the brows, and weaken the lateral orbicularis muscles. Her brows have arched in a pleasing, but natural way. Her “crows feet” lines are markedly improved when she smiles. She has also had several treatments with non animal derived hyaluronic acid fillers (NASHA) including VOLUMA to her cheeks and the off label use of PERLANE to her cheeks. She has had RESTYLANE to improve the lines around her mouth. It is important to remember that this is not one treatment. The BOTOX is typically repeated in most patients every 4 months with a range of 3-6 months. The NASHA type fillers typically “last” 9 months with the first dose and 18 months with the subsequent doses. Allergan, the makers of VOLUMA reports that it lasts “up to 2 years” in the cheeks with full correction. I typically start with an improvement and then “tweak” the results as we go along. So over the past 18 months we have slowing enhanced her volume as she has returned to repeat her BOTOX. But of course, we want to stop short of creating a deformity with too much volume. “Slow and steady wins the race” and also helps us to achieve a natural result. I am grateful that she has allowed us to share her results with you.
Although she has not had surgery, and does not wish surgery, I perform the same analysis with every patient who is considering correction of the deformity of facial aging. After discussing the options available, I try and anticipate what options that a patient and myself are likely to be pleased with. She could have had a “face lift” to tighten the skin of her neck and jowls, but this alone would not have given her the same improvement as addressing the volume loss of her face, (unless we performed fat grafting at the same time, which is another discussion) Many patients come in and tell me that they “want a face lift” because they think that this will somehow magically address all of the signs of aging on the face. I have found it best to carefully analyze the signs of aging and address as many as possible to achieve a balanced improvement, without creating a deformity. So whether with or without surgery, it is best to make a careful diagnosis and then consider all of the options.