Ethnic Botox for my Asian patients

I attended a Botox lecture yesterday in Fresno that included a small section on ethnic differences in use of Botox, fillers, and Kybella.

This made me think of my Asian patients.  I live in an area of California where there aren’t a huge population of Asian patients, but I have a good handful of Asian patients coming in for Botox and fillers.

Botox differences that I’ve observed

Compared to caucasian patients, our Asian patients are asking more for Botox for slimming the face, and there is more of a preference placed on crows feet botox over glabellar botox.  Glabellar area is the “11’s” between the eyes.  I’ve noticed that my Chinese patients are usually requested a lower dose for the glabellar botox, but the opposite is true for my Indian patients who frequently request or need more glabellar botox for the same effect.

I’ve also seen much more request from Asian patients regarding jaw slimming botox procedures.

Filler differences – Voluma

I’ve actually learned a few things from my Asian Botox / Filler patients who have received cosmetic injectables in Asia.  They tell me and teach me about rounding out the glabella and forehead and filling up the bridge of the nose.  This has helped me observe that this area tends to flatten with age in some Asians.  Also most of the cheek augmentation tends to be in the anterior direction more than in the lateral direction.  Thus the apple cheek result is what they are asking for with Juvederm Voluma injection – rather than more of an angle with the zygomatic arch.

Well, that’s what I’ve observed so far, and I hope to observe and learn more from my patients and I hope to continue to improve.


Cosmetic Annual Growth by patient visits

Acupuncture, Botox, Juvederm, vein annual growth for Calvin Lee, MD

I am very thankful and proud. In 2006, I reinvented myself from General/Trauma surgeon to Acupuncture/Cosmetic Surgeon. In the operating room, I have been assisting in Tummy Tucks, Face-Lifts & breast surgeries done by my wife, THE Plastic Surgeon for the past 10 yrs. This graph shows the growth of what I do OUTSIDE the operating room, in our SURGICAL ARTISTRY office: Acupuncture & Cosmetic Injections. I use hundreds of needles per day. I started my practice with only 58 office visits in 2006. Last year I exploded to 3371 visits with one of the highest retention rates of patients in the country according to Allergan. I am so grateful to my patients for trusting me. I am also so grateful to my supportive parents, Dr. Tammy Wu, her parents/brothers and to those who have directly helped me grow this new world for me:

Jeannine M, Andrew M, Ken T, Christine Donham Landrum, Jacquie A,Jessica Vargas, Annabeth Ghiglia Allan, Lorena Redula, Katherine Ruth,Karla A Valente, Lynne C, Sarah S, Lea S.

Surgical Artistry Modesto Marathon, Heidi Ryan, Karen Kopecki Hodges Lozano, Vickie Chu-Hermis

Sutter Gould Medical Foundation, McHenry Medical Group (First Choice Physicians), Doctors Medical Center, Memorial Medical Center

Alyssa Petrino, Chris W, Jeran Wadlow, Suleika Bauer, Tadra Rex, Nicholas Eichhorn, Jennifer M, Brooke Cramer, Joe K, Jenny D, Tom Z, Cherise P.,Bree Alexander

Kempton Stephens, Katherine Barton, Paul B, Charles Cherrie Suntra,Enoch Choi

It has been a tremendous first 10 years at Surgical Artistry and I’m looking forward to the next 10.

Number of patients seen per year Calvin Lee - text - Botox


a botox 2015 statistics sign IMG_1370 - 4th version

a botox what we do sign IMG_1370Botox Retention Analysis

cumulative botox 2014 2015 with title

cosmetic acupuncture botox bar graph

quarterly comparison of botox units 2014-2015 - with frame

a shadow IMG_1036 - with text


Plumped up Cheeks with Botox or Filler?

Another Botox question in a public forum:

Fluffy cheeks with botox or filler?

Hello i am 37 years of age. I want my cheeks become fluffly as i was used to look in young age. Which treatment would b better botox or filler ? And how much is cost? Thanks.

My Botox Answer:

I get this type of question of Botox or Fillers every single day – so it’s a great question.


​Last month I had the honor of treating 127 patients with Botox, and 31 patients with a dermal filler.  I think 1/4 of these patients wondered about the differences between Botox and Fillers.  And in my practice, the usage of Botox is a lot more than the usage of fillers.


​I came up with this explanation for my patients and perhaps it will help others.  First imagine our face as having a landscape.  We have mountains and valleys in our face.  The valleys being the wrinkles which are usually surrounded by mountains on either side.  I have told my patients that Botox weakens muscles and thus it will give the appears of lowering the mountains on our face.  But Fillers, will help to fill up the valleys.  Thus if we want an even surface – a combination approach might be needed: we might have to lower the mountains with Botox (those bulging muscles!) and we might have to raise the level of the valleys/wrinkles with Fillers.


The filling/raising of a structure on the face requires a Filler.  Thus for bigger, fluffier cheeks, we need a filler.


​There are many fillers.  The filler that is very popular in the cheek is Juvederm Voluma.  But I still consider off-label FDA choices of other fillers in the cheeks for my desired appearance or a combination of fillers.  I use Belotero, Juvederm ultra plus XC, Juvederm ultra XC​, and Radiesse in the cheeks.  I also use thinned out versions of Juvederm by purposely diluting the products.  All this is considered off-label FDA, but this helps me get the results I envision along with my patient’s goals.

​My plastic surgeon wife who is in practice with me has certain permanent implants which she can use in surgery.  But that would be a totally different topic which I’ll let her explain.


​What is used for making bigger cheeks Filler or Botox? The answer is Filler.  I try to explain that Botox actually shaves down the appearance of bumps in the face, and filler raises lowered areas on the face.  But if we want to raise a bump (mountain) on the face – that would also be fillers.  Naturally the next question might be which filler would we choose.  I think my go-to filler right now is Voluma for the cheek.

​Thank you for your question. Without having seen you in person, I’m answering the best I can without physical examination info. My comments are meant for a general public discussion to help others who may have similar concerns. I’m also using my answers to build up library of information for my own patients and also to see how my answers compare with other doctors. There is always much for us to learn from each other. My answers are generalized medical information only, not directed medical advice. For medical advice please see your doctor/surgeon in person.

​Calvin Lee, MD
​Botox and Juvederm in Modesto, California

Modesto Surgeons at work

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