How to dissolve Belotero?

Another public forum question which I attempt to answer for fun.

Blue puffy bags after Belotero in tear trough + older Juviderm on inner orbit rim. Will Vitrase dissolve both at the same time?? Had bad reaction to Vitrase 2 years ago but can’t wait it out…it’s appalling.

Thank you for asking your question. My answer is just an academic exercise in producing a discussion regarding a hypothetical situation. My answer is not directed medical advice. Please see your doctor in person for medical advice.

So how do we dissolve Belotero and Juvederm which caused blue puffy bags in the tear trough under the eyes?

About the sensitivity to Vitrase issue:

Vitrase isn’t the only hyaluronidase available in the USA. I believe that other formulations are Hydase, Wydase, Amphadase and Hylenex. All of them are animal derived hyaluronidase products except for Hylenex which is derived synthetically from recombinant human product produced by genetically engineered Hamster Ovary cells in a laboratory. Because it is not derived from an animal and it is the human form of hyluronidase, there would be less reactions from it. Consider using Hylenex. This is what is available in my office. For a patient with previous Vitrase reaction, I would try Hylenex.

About dissolving both Juvederm and Belotero at the same time:

Yes, Juvederm and Belotero are both hyaluronic acid fillers and will be affected by Vitrase, Hylenex, or other hyaluronidase products. However, Juvederm will be a bit more resistant to dissolving. Thus if a very small amount of hyaluronidase is use, the Belotero would dissolve first.

Regarding the Bluish tint = Tyndall effect:

That is probably from the Juvederm. I have had the same problem before when using Juvederm in the tear trough. But I still use Juvederm in that location but only for patients with thicker skin or darker skin. I had to learn from some of these problems which I’ve also had. I have only had one patient who reported a Tyndall effect with Belotero and thus I consider the Tyndall effect to be very rare with Belotero.

Another possible suggestion – using dilute Hylenex:

Much of what we do as doctors are considered off-label FDA use. Much of what we are discussing here is off-label FDA use. For some of my Hylenex cases, I dilute the Hylenex with Saline. My formula varies with the application, and thus I have been able to thin out the problem to an appropriate degree and thus have a happy outcome without having to reinject filler or to have a complete loss of filler in a particular area. This is a tricky process, and I sometimes manage this in a staged approach – meaning multiple sessions.

Calvin Lee, MD
Modesto, California Belotero Injector

Voluma Disappeared over a Month?

Another public forum question which I will attempt to answer.

Almost total Voluma absorption after only 5 weeks? What caused and does that mean hyaluronic products a no-go for me?

I had 1 vial of voluma–split between both facial cheeks and eye areas, and one perlayne split between both marionette areas 5 weeks ago and already the sunkeness around my eyes is returning–voluma should last at least a year–any suggestions as to why this happened? Does this mean I’m not a good candidate for any hyaluronic acid products? My injections performed by a very experienced plastic surgeon–little bruising, redness or after discomfort; immediate happy results. )-: thank you!

My Voluma Answer:

I will attempt to answer your question from a community discussion standpoint. Please see your own doctors in person for personalized medical advice.

Much of what an injector does with fillers is an art, thus the amount, the products, the location, and the method of placement is all different.

I am currently mostly a cannula injector when it comes to Juvederm Voluma and I still prefer the threading methods. And for me, Voluma is not the only filler I use in the cheek. I have found myself layering with Juvederm Ultra Plus XC, and also Belotero when needed for additional superficial shaping. I used to inject this differently – using droplets of filler. But my style changes from time to time and from patient to patient. Thus I am speaking only from my experience, and my methods and thought process could be completely different from your plastic surgeon. Please keep in contact with your plastic surgeon. I think he/she would appreciate an open dialogue. I am answering this question as a public academic exercise for myself to see how my answer compares to others and to personally build up information sheets for my own patients. Thank you for giving me the opportunity to participate.

Your comment about Voluma disappearing in about a month’s period of time is a comment I hear from my own patients in my practice. Much of the time, it isn’t because they were fast metabolizers of Juvederm Voluma. But most of the time it is due to at least these four factors:

1. The Juvederm Voluma softened over that time and lost some of it’s original projection. This almost always happens in what I’ve seen. Then the Voluma spreads out and becomes more of a diffuse appearance – more rounded / less angular. this is what I mean from the title – the Juvederm Voluma evolves over the first few weeks.

2. The Juvederm Voluma, with gravity, sometimes shifts downwards. Thus, it might get somewhat “lost” in the hollows of the cheek. This is what I also mean from the title – the Juvederm Voluma evolves over the first few weeks.

3. Some of the original swelling has gone down from the procedure itself (needles/cannulas/massaging), and thus it appears that some of the material is lost – but in fact the only thing lost is the swelling.

4. Our patients sometimes gets used to the new look and had pleasantly “forgotten” the “before” look. Thus the changes don’t seem as dramatic.

With all those four factors, additional Juvederm Voluma injections might solve the problem. I have found that one syringe is useful in youthful patients with tight skin over their cheek bones. But for most of my other patients, two syringes of Voluma helps me achieve the look (and duration) I want for my patients. It is not uncommon for me to consider 3 or 4 syringes.

You also mentioned in your question about Perlane. The active ingredient in both Voluma and Perlane is hyaluronic acid. If the Perlane results are still evident, this means that you are unlikely to be a rapid metabolizer of hyaluronic acid. It sounds like from your question that you are satisfied with your Perlane results. This means to me, even more so, that another syringe of Voluma might be your best solution before thinking of switching to a different material such as Radiesse or giving up on future Voluma injections.

Calvin Lee, MD
Modesto, California Juvederm Voluma Injections

Disclaimer: some of the discussion above involves off-label FDA usage of fillers. And none of what I mentioned above is meant to be personalized medical advice. I am just discussing a hypothetical situation posed by a person I have not examined. Without a personalized examination, I am only guessing at possible solutions which I present above. I am also assuming that the mention of 1 “vial” = 1 syringe.

Bulging Vein after Voluma Injections

I copied this question from Real Self. I think it would be a good intellectual exercise to pretend that these questions come from my own patients and I try to formulate my own answers then compare to the answers of other doctors. Of course, I’ll probably be biased and think that my own answer is the best.

Disclaimer: This is just generalized medical information. Any medical discussion here is not meant to be medical advice. Please see your doctor in person.

Here’s the Voluma question:

I had Voluma a week ago and I have this bulging vein/artery on the side of my temple now that has two branches stemming from it. It is ugly and really noticeable. I really don’t know how to correct it or who to go to next. Can more fill disguise it or will that just make it worse? Is it dangerous to get it ligated? Or should I just get the filler dissolved?

Here’s my Voluma Problem answer:

Thank you for your question. Without a personal examination of the problem, my thoughts will only be a generalized discussion.

I have to make the assumption that your question regarding Voluma is an injection at the side of the face by the cheek. There are off-label FDA injections of Voluma elsewhere but the FDA indication is for the cheeks. Thus, the problem described is bulging vessels in the temple (probably a vein) 1 week after Voluma injections in the cheek.

It is possible that the venous outflow is somewhat limited due to the mass-effect created by the added volume of the filler (Voluma) and the very likely added swelling from the physical nature of the procedure. (Meaning that the flow of blood is a bit squished from the filler itself and swelling due to the procedure.) When the swelling subsides, the venous outflow would become less obstructed. In my opinion it may take 3 weeks for the swelling to disappear. Perhaps at that time, the veins would become less distended.

During this time, if you were my patient, I would appreciate knowing about your situation and concerns. Together we could discuss further therapy – such as those that you mentioned such as dissolving the filler or ligation of the vein. Ligation of a facial vein is possible but it would be an extreme measure in my opinion. Sometimes the hardest therapy to endure is a tincture of time. But many times, that is the best option along with watchful expertise from your injector.

If you haven’t contacted your injector, please do so as your top priority. You mentioned “who to go to next.” Your injector should help guide you in that decision if you feel another level of expertise is needed. Best of luck to you.

Calvin Lee, MD
Modesto Voluma Injections, California

Botox Parties – are you available?

Botox parties?

I got this extremely nice request today. I always have a hard time saying “no”. I truly like to make everyone happy. But I had a chance to think about this many years ago, and I’ve come to the conclusion that I’m just not good enough to inject at Botox parties.

Here’s my response:

Hi! Thank you for writing to me. I don’t do Botox parties – I’m so sorry. Thank you again for thinking of me. I don’t know a lot about Botox parties, but I don’t think I’m good enough to inject in a place which doesn’t resemble a doctors office or an operating room. Oddly, those are my locations of comfort! There’s controlled lighting and controlled height adjustments of exam tables. I think I’m too old fashioned. I like to control every element that I can – including the method of refrigeration of the Botox. So if I was at a “party” I think I wouldn’t be injecting very well. Plus, I get somewhat distracted if more than one person is talking to me at a time. I don’t inject too well when I’m distracted. So it’s my preference to just see one patient at a time at the office. There are probably more than 42 other injectors of Botox in Modesto and the surrounding areas.

Thank you so much for thinking of me for the opportunity. I am truly honored.

Dysport vs. BOTOX comment on FaceBook

Personally in my hands, I like BOTOX

Today, I received on FaceBook, a question regarding a comment regarding Dysport vs. Botox. I was invited to give my personal thoughts and I would like to share them. For the most part, I disagree with what’s written in the screen capture below:

My response to the question:

I like all of them! Botox, Dysport, and Xeomin

Dysport is excellent. So is Xeomin. Dysport, Xeomin, and Botox are neuromodulators. In my opinion they work very similarly. I have personally injected all three products and have personally received injections of Botox and Dysport. I have come to the conclusion when using the products, much of the differences come down to four things:

1. How much was used.

2. Who is the injector.

3. What precise 3-D location was it injected (muscle/fascia all have depth).

4. How was it injected.

How to Compare? pound for pound?

I’m not certain that you can convert one unit of one product to another unit of another product. For example, how many Hondas equal one Toyota? Would it be 1.5 Hondas is the equivalent of 1 Toyota because of horse power rating or based on gas mileage – or the other way around. I have owned both Hondas and Toyotas – and I like both.

So that’s the first problem when comparing neuromodulator. Do we really know if we have equivalency? Is 2.5U of Dysport really the same as 1U of Botox? Or have we now changed it to 2.9U of Dysport to equal 1 U of Botox. I jumped at the chance to try Dysport in January 2013. I think the results were great. But I think that in my own hands, the results of Botox was better.

I agree that Dysport spreads more. But for me, I see that as a disadvantage. The way I inject, I like a bit more pin-point accuracy. But then again, that’s my personal way of injecting. I like planning my injection sites whenever possible – thus I’m not looking for a wide diffusion pattern of the neuromodulator.

There will be people who say that a Toyota is better than Honda – or the other way around. I think both are good car companies. But I would say that currently for me, I drive my own Honda a lot better than I would drive a Toyota because that’s what I drive every day.

Botox is my Violin

Schindler’s List Played by Calvin Lee, MD, guest concertmaster Taipei, Taiwan

Yep, that’s me and my violin.

I have been a violinist most of my life. I frequently say that Botox is my violin. When I’m using my violin, I can create results more predictably. My Violin is what I prefer when I concertize. I would be a bit timid when using a different violin. But this is not to say that other violins are inferior. But I have confidence to say that I would make other violins sound quite good!

Thus said in a different way. I prefer to inject BOTOX because I’m comfortable with it and I can predict the outcome better. But if I had to use Dysport or Xeomin, I would still get great outcomes, but I would have some uncertainties with it because I don’t use it every day.

Many of my patients and my entire staff prefer their BOTOX results over other products.

Their reasons are multifactorial. Perhaps in another entry of my BOTOX blog, they can chime in.

I leave you with one more thought: The injector plays the biggest role in the outcome.

It’s the violinist that makes the sound, not the violin. Just like it’s the surgeon that makes the surgery, not the scalpel. Thus we can debate on and on regarding which violin to use or which scalpel to use. As long as the violin is of high quality and the scalpel is too, then the results lay on the shoulders of the artist.

Here’s a quote from master violinist, Jascha Heifetz:

After a concert, a member of the audience went up to Jascha Heifetz. He said, “Wow, your violin sounds really great.” Heifetz then held the violin up close to his ear and replied, “Funny, I don’t hear anything.”

About Me, About My Botox practice

I thought I needed to try to write something recent about myself at Surgical Artistry. This is what I came up with:

Botox, Juvederm, Voluma, Belotero injections – my goal is to provide cosmetic injections at the highest level. I value quality surgical level outcomes, patient safety, comfort & communication.

My Modesto Botox Page

I am a Board Certified General Surgeon with a past trauma career who assists in plastic surgeries and spinal cord stimulator / spinal pain pump surgeries. I am also an Acupuncturist who injects Botox as an extension of Acupuncture. Many of my Botox point selections are related Acupuncture points for migraine headaches and wrinkle prevention. 40% of my clinical time is spent at work is spent on Acupuncture, and 50% of my time is spent with cosmetic injections for Botox, Fillers, and Veins, and 10% of my time is spent assisting in surgeries. In a clinic day, it is common for me to use 200 units of Botox, 4 syringes of dermal fillers, and see about 6 acupuncture patients.

Outside of my clinical time, I also spend a great deal of time as an administrator of Surgical Artistry – the combined medical office for myself and my wife, Dr. Tammy Wu, Board Certified Plastic Surgeon. We have been surgeons in Modesto since 2003. My wife and I met while we were students at Brown University.

I am an author for MedicalSpaMD a resource for plastic surgeons, dermatologists, and aesthetic physicians. I’m also a member of the marketing department of the Cooperative of American Physicians based in Los Angeles. My hobbies include piano, violin, marathon running, being vegan, creating websites and social media.

Mother’s Day Special May 2015

Give mom the gift of great skin with the special we have available from Obagi. They gave us a great deal and we wanted to pass this along. It’s Elastiderm Eye cream plus hydrate or hydrate luxe (your choice) and get a free cosmetics bag. There is also a Latisse BOGO, buy one get one free in the mail. Specifically it is buy one 5.0 mL Latisse and get one 3.0 mL Latisse free with mail in rebate.

Elastiderm eye cream is great for around the eyes including under and over the eyes. And it’s a great complement with Botox treatments. Hydrate is a moisturizer that has extended release characteristics. Hydrate Luxe is a thicker version of Hydrate plus some anti-aging peptides!!

Both of these are in limited quantities. So act soon!

see this page for details

www.injectionartistry.com/mom

Mother’s Day Skin Care and Eye Lash Care Specials

What I love about Belotero Balance

I have been an avid user of Belotero Balance for a few years in my cosmetic injection practice. Last month, April 2015, I injected about 4640 units of Botox and 75 syringes of fillers. 20% of the fillers I use is Belotero Balance. Much of what I do with Belotero is considered off-label FDA use. I am a frequent user of cannulas in my filler practice which includes the spectrum of Juvederm available in America and Radiesse. Juvederm dermal fillers in my Modesto practice include: Juvederm ultra, Juvederm ultra plus, Juvederm ultra xc, Juvederm ultra plus xc, Juvederm Voluma xc.

Briefly about my Modesto Practice

I spend half of my clinical time personally performing cosmetic injections. I think I would be a bit busier if I spent more time on the Botox/filler side of the practice but I have plastic surgery assisting duties (my wife is a plastic surgeon, I am a general surgeon with trauma experience), a small cosmetic vein practice, and I also have an acupuncture practice which I love. After clinical hours, I am an administrator for our plastic surgery practice. I feel that I spend about 80 hours per week on our practice clinical+administrative. Of course there is room for me to be more efficient.

Belotero is great for

Belotero is great for tear troughs and around the eyes
I use a cannula and lay down Belotero for tear troughs. It works well for many tear troughs, and flows very well through a cannula. I’ve learned over the years to tell the patients that the duration in that area seems to average about 6 months. Of course this varies from patient to patient. I was a Juvederm user for almost all tear troughs before and ran into some trouble with swelling for a few patients. I still run into some swelling issues with Belotero but it is much less. It also works well for building up a little bit of the cheek above the zygoma laterally.

Great for forehead lines
Some fine forehead lines are amenable to Belotero filling. It is especially useful for those patients who want a smoother forehead with less brow drooping which can happen with overzealous Botox use on the forehead. It is also great for those wrinkles in the eyebrows.

Great for a touch up on the oral commissures
Belotero is wonderful just as a small touch to a slight downturn in the oral commissure. I’m not talking about the entire marionette line, but just the corner of the mouth and injected superficially.

Great for crows feet
I need to be careful with the bruising in this area but it works well for some of the fine crows feet lines. It works well with Botox to battle those light static lines.

Great for neck lines
Those horizontal lines – belotero becomes very labor intensive but well worth it. The patients get a bit of bumpy look for the first 2-3 weeks, but it settles and the Belotero works well to integrate into the skin.

Great for chest
Or some call it decollatage area. These crinkles thicken up well, with belotero for many patients, I have to bend the needle to get the angle I need. It really does look like it integrate into the skin after two weeks.

Serial Puncture method
Yes, this is useful, and can at times reduce bruising because the needle doesn’t go in very deep. A wrinkle is injected several times about 2 mm apart and the needle just barely goes into the skin. For most of what I like to do with Belotero, except for the tear troughs, I am injecting very superficially. If I’m threading the needle through (ie, in neck lines), I can see the needle through the skin. This superficial needling probably has an added collagen induction characteristic for the patients – similar to microneedling.

Superficial injections for longer lasting effect
Superficial injections lead to longer lasting effect. I have found that deeper injections in areas with movement seem to eat up the Belotero in 3 months. But 5-6 months can be derived from superficial injections.

I would recommend Belotero to other injectors
I like Belotero and would recommend it as part of our creative set of tools for beauty. It’s like a very thin paintbrush. And Belotero works well with other fillers in a layered approach.