What fillers do I use in the LIPS for injections and why?

Lip Injections by Calvin Lee, MD, My thoughts in 2020

This question is a bit like asking what type of how do I like to use for playing the violin. Sometimes it depends on my mood and sometimes it depends on what type of mood I’m trying to create. It also depends on what type of technical challenges I’m up against.

This discussion is limited to the syringes I have at my office.

Image may contain: 13 people, inclu

Above collage are lip before and after pictures of my patients in the 4 weeks leading up to today 9/13/20. Pictures posted with permission. Bottom right pictures are of the Surgical Artistry team.

Dumbells vs Fillers?

Oh another analogy: Picking a filler might be a little bit like picking which kind/type of dumbells one might use for working out. There are different brands of dumbells and different weights.

Juvederm Volbella

Often I choose Juvederm Volbella XC to inject into the lips. The syringe itself is very ergonomic and has a good responsive feel when I inject it when attached to a 32 gauge needle. This needle gives me enough resistence so I don’t just pour it all out in one spot.

It is a soft filler (not very thick – or it has a lower G prime) made of smaller Hyaluronic Acid molecules. The molecules stack on top of each other very smoothly. So if I’m looking for a subtle and more smoother look, I choose Volbella. Many younger patients who have a nice vermillion border and philtral column do very well with Volbella but many times we need two syringes of Volbella for the younger lip. Volbella also has less swelling due to the vycross technology and uses a smaller needle which is a 32 gauge needle. In the older patient, Juvederm Volbella sometimes looks the most natural with softer edges for the lips. The tissue integration of this product is rapid and thus there would be less movement of the product after injection. This is a great filler for patients with thin skin for their lips. Volbella is also a relatively long lasting filler syringe wtih longer duration compared to Ultra and Ultra plus.

This product also doesn’t look too blue under the skin and thus can be used very nicely for those smoker’s lines. This is one of my favorite products to inject into smokers lines.

I recommend this Volbella syringe to the more extremes of age – youngest patients and oldest patients – and in patients who only want a very subtle change but want long lasting results.

Volbella is a medium-high cost syringe in the lineup of Juvederm products.

Juvederm Ultra

This is my most commonly used filler for lips. I have been doing lip fillers since 2008 and this filler just feels very comfortable to me in my hand. I like the way the filler syringe feels and I like the feel extrusion force. This filler is attached to a 30 gauge needle.

This is a filler that makes great borders of the lips, and I like to inject it close to the vermillion border, and use it for philtral column support. The results are beautiful and this tool is in my comfort zone due to my experience with this product. This filler however tends to swell afterwards.

This filler is also very good for lines around the mouth. I will sometimes take a second syringe of Juvederm Ultra and use it for perioral support and reduction of the lip lines. Sometimes patients don’t want fillers in the red part of the lip, they just want the perioral support and lip line reduction (smokers lines – or bar codes).

This is the lowest cost product of the Juvederm lineup of products. I don’t choose it based on cost, but I choose it because in my hands, I feel that the results are predictable and it creates beautiful borders with the versatility of creating a fuller, plumper lip. Overall, I feel that Juvederm Ultra is the most versatile filler product in my hands. It can create a nice body to the lip along with a nice border to the lip.

Juvederm Ultra Plus

I sometimes use this syringe for lip augmentation. I am not entirely used to the light extrusion force when attached to the native 27g needle. The syringe itself is a wonderful tool as with all the other Juvederm products, with rubberized grips in the right places.

This Juvederm Ultra Plus filler is good for creating volume. But in my opinion not that good for creating the borders and many times in my observation it seems to extrude out of the borders. This is a thicker filler like a thick jelly and isn’t great for the fine borders or philtral columns but is good for creating a stiffer and thicker body to the lip.

Juvederm Ultra Plus is the same price point as Juvederm Ultra – they are both on the low end of the price scale.

Juvederm Vollure

The extrusion force is on the lighter side, but I can definitely get used to it. I’m so glad it comes on a 30 g needle so that it is less traumatic to the lip. I love the ergonomics of this syringe. It has a nice violet color to the syringe that lets me know that I’m using the right syringe.

The Vollure Lip procedure is becoming one of my favorites for building a fluffy body to the lip. Vollure is a very spreadable smooth filler that has the Juvederm vycross technology which allows the filler to last longer. This isn’t a great filler for sharpening the borders or defining the filtral column but it is wonderful for volumizing the lip, and giving it a bigger look and having great mobility of the lip without looking stiff. This filler works great going through a cannula as well.

Juvederm Vollure is very versatile and may work well alternating or alongside Juvederm Ultra. Using Vollure for creating a fuller body and using Juvederm Ultra for creating the definition. The swelling is less for this filler than a Juvederm Ultra filler procedure.

This product also integrates quickly into the lip and doesn’t move or swell much afterwards.

Vollure is a medium-high price for the syringe.

Juvederm Voluma

I’ve used this for lips a few times, mostly at patient request. This is for someone who wants a stiff large lip which can sometimes look a bit wider. I usually use this syringe in the cheeks for a stiff filler. This is the stiffest filler in the lineup of Juvederms at this moment in 2020.

This syringe is not good at creating borders, but it is good for creating a stiffer, wider, and fuller look and feel.

Juvederm Voluma is the highest priced syringe in the Juvederm line up at this moment. It is also very long lasting.

Restylane Silk

This Restylane Silk is an incredible syringe for the lips. It creates a very soft look and feel and rarely forms bumps. It does unfortunately create a good deal of swelling afterwards. I like this syringe very much for helping with the lip lines around the mouth. This product also does not look very blue under the skin.

Restylane Kysse

I’ve only injected this filler syringe a few times. I do not have good motor memory with the use of the syringe. I’m not entirely used to the markings on the syringe itself – to give me a visual feedback of how much I’ve injected. This is mainly due to the fact that I’ve injected thousands of Juvederm fillers and very few Restylane Kysse syringes in comparison

The lip filler seems to be a very nice filler which isn’t the best in my hands for creating borders, but it is decent. Not bad for creating philtral column definition, but perhaps a bit thick. It is good at creating a nice fluffy body of the lip and many patients like the results. This product has a lot of potential. I think the thickness falls between Juvederm Ultra and Juvederm Ultra Plus.

Restylane Refyne

This is a lightweight filler that creates a soft change to the lip with flexibility. It is very popular with some of the patients and is asked for by name. I think it is very versatile.

Restylane Defyne

This is the thicker version of Refyne. This is a very versatile syringe and creates a result thicker than Kysse in my limited opinion. The lineup seems to be from thinnest to thickest: Restylane Refyne, Restylane Kysse, and Restylane Defyne. My patients who have gotten Refyne and Defyne for their lips seem to think that Kysse is better and just right for their lips.

Restylane L

This was my original lip filler syringe that I used back around 2006-2008. This syringe is still one of my favorites to use. It creates nice borders and stiffens and lifts the body of the lip. I like the feel of the syringe and it fits into my smaller hand very easily.

Restylane Lyft

I’ve actually not tried this in the lip, but I think it would be similar to my Juvederm Voluma Experience

Belotero

This Belotero syringe does a very nice subtle change to the lip very similar to the Silk and Volbella changes, but the duration is pretty short. I only used it when it first came out, and it doesn’t have lidocaine built inside like all the other syringes mentioned earlier..

In Summary of Fillers for the Lips – how do I choose?

I choose based on familiarity – can I inject it with my eyes closed type of concept.

I choose the filler based on the physical syringe itself – can I visually see what ratios I’ve created easily, and will the syringe fall out of my hand? And when I push the product, will I get good tactile feedback regarding how much I’ve actually pushed? This is somewhat like the gas pedal of our cars. Some have a stiffer pedal and others, you might floor it without knowing – zoom! A lot of this is also based on familiarity too and some of it based on purposeful design.

I choose this based on age of the lip, thickness of the skin, and desired outcome.

For a patient who wants a very stiff thick lip – then Juvederm Voluma.

For patients who wants everything – nice borders, flexibility, more fullness – but is willing to be a little bit on the smaller size and knows that we can just add more syringes of the same product or other products to get a bigger size: then it’s my usual Juvederm Ultra. We can add more in a few months to get to the right size.

For patients who want a subtle change with long duration with less recovery: Juvederm Volbella

For patients who already have a nice vermillion border who knows they want a bigger lip but only wants to do one syringe with longevity then I choose Juvederm Vollure. This syringe creates more of a visual change as seen in pictures.

For my patients whom I’ve had from 2008 and have liked their lip results with Restylane, I continue on the Restylane track. The same for new patients who want to try something new or came from other practices who use more Restylane than I do. Restylane is a fine set of fillers.

There is a new filler which can be used in the lips which is RHA 2 and RHA 3. New to the USA. I’ve tried RHA 3 and it seems very nice too.

My most common to least common ranking of lip fillers used in my own practice:

Most common on top:

  1. Juvederm Ultra
  2. Juvederm Volbella
  3. Juvederm Vollure
  4. Juvederm Ultra with Volbella combination
  5. Juvederm Vollure with Ultra combination
  6. Juvederm Ultra Plus
  7. Restylane Kysse
  8. Restylane Silk
  9. Restylane Refyne
  10. Restylane Defyne
  11. Belotero

In the end, it comes down to four things when I pick a filler to inject lips.

  1. Injector factors – injector’s personal preference, familiarity, predictability of giving the right outcome, reliability and responsiveness of the filler company.
  2. Patient factors – thin skin, age of lip, lack of border, patient desires.
  3. Friends and family factors – what do they prefer when they look at your lips and does it matter to you?
  4. Financial factors – cost to the patient and cost to the injector. Many fillers can give a similar look but can I as the injector make that desired outcome with the least amount of product? I call this efficient use of product.

Feel free to find me for a consultation regarding lip fillers in Modesto, CA: 209-551-1888.

Before Lip injection – answer this one question

The one thing I need to know before doing your lip injection

So the topic today is: The one thing I need to know before doing your lip filler injections with Juvederm or Restylane.

Have you ever had cold sores on the outside of your lips?

What is a cold sore? It is caused by the herpes simplex virus.  I know now we’re all worried about some other virus right now – the coronavirus, but I still worry about an “older” virus.  Cold sores are caused by the herpes simplex virus.  There are 2 types and type 1 is the usual cause of the cold sores around the mouth.  At least half of all adults are infected with herpes simplex virus type 1 which spreads easily from person to person.  Once you have the infection, you have it permanently.  The virus lies dormant inside the nerves causing no symptoms most of the time.  But it can be woken up by triggers such as stress, sunburn, hormonal changes, exhaustion, fever – this is why they are sometimes called fever blisters, and any trauma around the area where the herpes simplex virus lives.  An example of trauma would be needle trauma from lip injection procedure.

By knowing your history of cold sores and how easily you get them, we can have a plan of possibly pre-treating your risk of a flare up by having you take a prescription medication called acyclovir right before your lip procedure or even a few days before your procedure if you are really prone to cold sores.  I have pills of acyclovir available in my office and you can take a tablet right before your procedure while numbing up those lips with topical numbing cream.  Totally optional and we offer it for free.    I joke with my patients when they try to chug down the pill of acyclovir while their lips are getting numb from my special formula numbing cream.  When the water drips down the floor because you can’t feel your lips, I pretty much will say, “I see you have a drinking problem!”

I would also write you a prescription for acyclovir tablets to take at home to prevent the flare up.

On another note, cannulas for lip augmentation is something I also do if the risk of swelling and cold sores is severe.

The risk of flare ups with patients who have had previous coldsores is relatively low, but I think it may be 1 in 5 procedures and with pretreatment, perhaps we lower that risk to 1 in 20 procedures.  So I would rather have a lower risk, because cold sores are unsightly and can lead sometimes to scars, and sometimes it can even push our lip filler off to the side.

The lip filler experience can be a bit of a roller coaster ride afterwards because of the swelling, and if we can eliminate the added aggravation of having a cold sore – that would be a good thing.

Also if you have a history of swelling a lot with hyaluronic acid fillers such as Juvederm and Restylane, it would be good for me to know too because we can consider an antihistamines or a prescription prednisone series of pills.  Prednisone is a steroid which is like a big “off” switch for the body and part of what it can do is turn off the swelling mechanisms. So prednisone, antihistamine (like Zyrtec), and cannulas are options for patients with extreme risk of swelling and cold sores.

But in summary, I will ask before your filler appointment if you have a history of cold sores – mainly because it’s somewhat of a risk with lip fillers, but we can lessen that risk by being prepared. Come visit me for lip fillers in Modesto, CA.

Hyperdilute Radiesse

Hyper-Dilute Radiesse, written by Calvin Lee, MD / Surgical Artistry
(209) 551-1888

What is Radiesse / Hyper-dilute Radiesse?

Radiesse is made of calcium hydroxyapatite, which you also normally have in your body.  Radiesse is a filler that has been around for many years.  We took the Radiesse and diluted it down so it’s not as thick.  We sometimes take one syringe of Radiesse and add sterile saline to turn it into 2 or 3 syringes.  This is the process of diluting it and sometimes we call it hyper-dilute Radiesse.

Why do hyper-dilute Radiesse?

The purpose is to stimulate the growth of collagen and have the skin improve in texture, thickness and tightness.  Subtle wrinkles can improve as can skin texture including.  The skin can tighten a bit too.  Hyper-dilute Radiesse works great for temples (side of forehead), lower cheek, neck, chest, buttocks, knees, arms – basically anywhere skin could use some improvement with stimulated collagen.

How often to do hyper-dilute Radiesse?

Growth phase: Consider 2-4 times the first year (spaced 2-4 months apart).
Maintenance phase: Consider 1 time a year.

How many syringes for each session?

Depends on the area.  For the lower cheeks – 1 syringe.  For the neck – 1 syringe.  For the chest – 1-2 syringes.  For the Buttocks – 2-10 syringes.  For the Arms –  1-2 syringes.

When can you see results?

Immediately you see some changes because Radiesse is a filler.  You will see some thickening of the area filled.  But the main results that I’m excited about takes about 2-3 months to see when the collagen starts to enhance.  In some patients it would be subtle and others more noticeable.  Collagen growth is dependent on one’s health, diet, stress level, and many other factors like smoking (smoking is bad for collagen growth / eating lots of fruits and vegetables is good for collagen growth).  Patients have seen continued results of collagen growth even after 6 months and perhaps even after 9 months.

How long do the results last?

In general I think patients will want to repeat the procedure every year.  The collagen stimulated to grow is your own collagen which you could keep for many years – hard to say specifically how long.  But I recommend once a year for maintenance and perhaps even more if one wants to keep improving the area injected.

What to expect afterwards?

I use numbing medicine to help in the comfort of the procedure.  The numbing medicine can temporarily cause a lopsided smile for a few hours after the procedure.  Some patients have a bit of dull ache in the area injected for about 1 week.  Some patients get some swelling which can last 1-3 weeks after the procedure.  After a few days, the saline gets absorbed and the swelling goes down.  The saline is 50-75% of what we injected.  No pain medicine is needed afterwards, but one is welcome to take over the counter medications used for headaches if needed, or apply ice to the areas injected.

Where to get Hyperdilute Radiesse?

At my office: Calvin Lee, MD – Surgical Artistry with Dr. Tammy Wu plastic surgeon. 4754 Dale Road, Modesto, CA 95356. (209) 551-1888.

Hand Rejuvenation FAQ with RADIESSE

Patient Questions for Hand Rejuvenation

How is this procedure performed?

I have been doing this procedure successfully with a blunt tipped micro-cannula.  Most patients are relaxed and having a conversation with me while I’m doing the procedure, and are pleasantly surprised when I’m done because it didn’t take as long or hurt as much as they expected.  The procedure is done in our procedure room at Surgical Artistry – the same room where we do most of our Botox injections.  Care is taken to make sure the procedure is safe and comfortable.  I make it a priority to use the Radiesse filler efficiently with no wasted product.  Radiesse is carefully injected into the back of the hands to plump up that area to restore a youthful fullness to that area.

Is it painful?

Most of our patients say that this procedure isn’t very painful.  We do use a numbing injection and mix numbing medicine into the filler syringe of Radiesse.  I can usually do the procedure with one entry site – much like laparoscopic surgery.

How does it work?

Radiesse is a filler that is able to plump up the skin and subcutaneous space on the back of the hands and as an added bonus – promote collagen production.  Thinning of the back of the hands reveals veins and edges of bones which can be a sign of aging.  By thickening this area, the veins and bony appearance lessons as does the signs of aging.

How much does it cost?

There is a special going on at Surgical Artistry at the moment which is $1000 for two syringes of Radiesse, specifically reserved for the back of the hands.  This is a significant discount.  We normally charge $750 for a syringe of Volume Advantage Radiesse.  This is the large sized Radisse syringe.  There exists a smaller syringe, but we don’t carry that syringe currently at Surgical Artistry.

How soon will I see results, and how long will they last?

You will see the results right away.  At first there may be some mild swelling, but after about 7-10 days the slight swelling resolves.

Will I need the same amount of filler the next time I get this procedure after the first round has worn off?

In my opinion, most patients will need the same amount of filler the next time.  But because there is the possibility of collagen growth, it is entirely possible to get the same results with fewer syringes.  I believe that most patients need 2 syringes, and some need three.

What are the side effects?

The side effects are minimal and mostly related to bruising, mild swelling, mild redness, and some mild dull ache for about a day or two afterwards.  The active ingredients of Radiesse are naturally occurring substances in the body. Thus, the risk of allergic reaction is very small.

Who is this treatment for?

This treatment is for patients who are concerned about the thinning of the back of their hands due to aging.

Is there anyone who should not get this treatment?

I wouldn’t recommend this procedure in patients who have an active infection on the back of their hands.  I also wouldn’t recommend filler procedures on patients who are pregnant or breastfeeding.  Furthermore, I wouldn’t recommend this procedure on patients whom I feel are not appropriate candidates due to extremely thin skin or patients who don’t seem to need the procedure based on my assessment.

What filler is used for this procedure and what is it made of?

Radiesse is the filler I like to use for this procedure.  The active ingredient is calcium hydroxylapatite which is a naturally occuring substance in our body

What is the recovery like?

Most patients go back to normal activities.  But there is most likely some mild dull ache for the next day or two after the procedure.  There is numbing medicine which I add to the syringe which can last up to 4 hours of numbness after injection.

Is there swelling after treatment and if so, how long does the swelling last?

Yes, there is some swelling after the procedure.  For most patients it is for about 1-2 days.  But I have heard up to a week for some patients as well.  But the swelling is mild and just about all the patients go right back to work.

If I work with my hands, will I still be able to immediately after treatment?

For many things, such as typing, it is possible to go back to work immediately after treatment.  But the numbing medicine might slow you down for the next 4 hours or feel a bit awkward.  Furthermore, many report a very slight dull ache, which might affect performance a bit when it comes to lifting or working out, but most patients go right back to work after the procedure.  In general, most patients consider this procedure a “lunch time” procedure where they take an hour off of work and then return immediately.

 

 

Questions written and thought up by Hannah, and answers written by Calvin Lee, MD, Botox Surgeon at Surgical Artistry.

What is it like to be a doctor?

dr-calvin-lee-cropI was recently asked to answer these questions as part of a student’s assignment for school.  She wanted a surgeon to interview.  I have elected to answer these questions as the surgeon that I am today which is different from a decade ago when I was a trauma/general surgeon.  Now I am a surgeon who does acupuncture and cosmetic injections (Botox, Fillers, Kybella – neck, Asclera – veins).  For more information, consider visiting my other webpages www.InjectionArtistry.com and www.SurgeryToday.com 

  • Describe your work environment.

I am a surgeon with additional training with acupuncture and cosmetic injections.   I have worked as a general surgeon and trauma surgeon.   In 2006, I decided that I was going to dedicate my surgical skills to working with needles for the majority of my work as a doctor.  I became an acupuncturist and learned cosmetic surgery from my wife, Dr. Tammy Wu, who is a plastic surgeon.  Our practice is Surgical Artistry, and one of the main focuses of the practice is cosmetic surgery.  About once or twice a month, I have days where I assist the entire day in surgeries with Dr. Wu or other surgeons in our area.  For the most part, I am now mostly an office based doctor – as opposed to one who sees patients in the hospital.  I use three different acupuncture rooms to see patients with varying problems ranging from back pain, neck pain, headaches, athletic injuries to fertility acupuncture.  And then I have one large procedure room where I see my cosmetic injection patients.  The lighting and space design is different in each of these rooms based on the procedure intended for the room.  Surgical Artistry has two physicians – myself and my wife, and at this time 4 full time employees.  We like to keep our work environment clean and neat and be a sanctuary for health and wellness.  It has an open feel to the environment for our employees as we want to foster good communication with our team.  We believe in having our patients be beautiful both with health and appearance.

  • What’s a typical day at work like?

As a surgeon who focuses on acupuncture and cosmetic injections, I see patients from 8am-5pm.  I try to start on time as much as possible and I try to stick to the schedule.  I dislike having patients wait.  Half of my usual day is dedicated to acupuncture and the other half to cosmetic injections.  I go from room to room with no break in between.  I find time for my “breaks” when patients don’t show up or are late to the office.  That is when I prepare a batch of Botox, catch up on emails, enjoy some facebook (my facebook page), maybe even grab a quick bite.  I don’t take a formal lunch break.  I usually work till about 5:05pm.  That’s when I start to have time to write my office medical charts which are important to document the day’s work.  This allows me to record for future medical use when the patients come back, and thus, I can improve on their care.  The medical charting usually takes me about 1-3 hours.  Then I go home.  But sometimes I have to take care of business matters especially since Surgical Artistry is my business.  Sometimes there are employee matters, bills that need to be paid, or leaking roof issues.  So at times I don’t go home till 1am in the morning.   This is pretty much most of my days Monday-Friday.  There are a few days per month which I reserve for surgery assisting where I give my staff a break from my daily grind; I am not at the office on that day, I would spend my day at the hospital going from surgery to surgery.  And my staff spends that day catching up on their paperwork in the office.  The hospital and my office are not connected.  I think there are some lucky doctors who have an office inside a hospital.  Or maybe they consider themselves unlucky because they never get out of that work environment.  Regardless, I have to drive to the hospital from my office and I work at a handful of hospitals such as Stanislaus Surgical Hospital, Doctors Medical Center in Modesto, and Sutter Memorial Hospital in Memorial.  on Stanislaus Surgical Hospital’s home page, they actually have a picture of me as the operating surgeon on their header!

  • What are the three most important responsibilities of your job?

First most important responsibility is getting the patient the best results that I can.  Second most important responsibility is to do this as safely as I can.  This involves good technique and good knowledge.  The third most important responsibility is managing patient expectations – which means that I should spend the time communicating well with the patient and letting the patient ask questions, and I should try to think of questions that the patient might not have thought of himself/herself.

  • What technical skills do you need to do your job?

A tremendous amount of technical skills are required.  Skills involved in navigating around anatomy so that needles are placed accurate.  Steady hands are involved to insure precise delivery of Botox or filler.  Plus there is technique involved which help prevent injury to the patient if the patient were to flinch.  And there are techniques involved which ensures a sense of 3D space and tactile feedback at the tip of each finger.  These are skills which I think take many years to develop and I’m still trying each day to get better.  I became a surgeon because I am attracted to technical skills with my hands.  I received my MD degree in 1997 and every day since then, I’ve been continually trying to improve.

  • What people skills do you need to do your job?

To be a surgeon, acupuncturist, or cosmetic physician.  One has to love people and have a passion for other people’s health.  We are teachers to begin with and we need to teach patients about their current state of health and teach them how to improve upon it.  We have to be convincing as well to help steer them in paths which may not be apparent or easy to them – such as quitting smoking or eating more veggies.  We have to have people skills to communicate well.  And we have to have people skills to not only manage expectations, we have to manage our complications.  Surgeons are only as good as the complications that we’ve managed.  But those complications doesn’t just involve technical skill, they involve all sorts of people skills;  We have to listen, empathize, have compassion, instill confidence, communicate effectively, and most of all have patience.

  • Describe a recent problem on the job and how you solved it.

There are always problems, but by being a cosmetic physician and acupuncturist, my problems may not be as life threatening as a trauma surgeon’s problems.  I realize that it is somewhat less stressful for me since 2006.  But I have the same passion for making sure I focus completely on patient problems.  I’ll just describe something from yesterday’s line of work.  I had a patient come into the office for what seemed to be a routine cosmetic mole removal.  However, on examination and further questioning, it was revealed to me that it was a vascular type of lesion which had a history of bleeding.  The patient was worried that it was going to bleed further because when it did bleed, it was very severe.  I decided that I had to postpone some of my patients for a bit of time and take care of this bleeding mole like structure right away.  I first fired a vascular laser at the base of this lesion and then removed it like a mole and found the bleeding artery – which continued to bleed – but I was able to place an old fashioned figure of eight stitch around the bleeding artery and closed the skin incision which I purposely made.  We sent the mole like structure to pathology to rule out the possibility of cancer.  I discussed with the patient that if this lesion continues to bleed at home that he was to call me on my cell phone and I would meet him immediately at my office even if it was the middle of the night.  It bled more than the usual skin lesion removal because this lesion was in my opinion mostly vascular in nature.

I had anticipated this problem and thought the laser would stop the bleeding before I even began, made a decision to act on it right away, and encountered more bleeding which I had a plan which was my old fashioned stitching.  Then, I made plans for aftercare and in case other problems arise after he leaves (having the patient contact me and meet me at the office).  I’m glad I have a background in trauma surgery and bleeding is really not a big deal to me.

  • What kinds of information do you need use, analyze, and/or stay up to date on how to do your job efficiently?

There are medical journals pertaining to acupuncture and cosmetic injections which I read from time to time.  There are also national/international meetings on acupuncture and cosmetic surgery which I attend regularly.  There’s the collective wisdom of many doctors who can share experiences and ideas which will help my patients in Modesto.  Having the latest info helps me with another aspect of being a doctor – advising my patients on alternatives, even alternatives which I do not have.

  • How do you think your job will change over the next 10 years? Why?

I think for the most part the acupuncture will stay the same and perhaps become more popular with patients.  More and more people in the world seem to be exposed to acupuncture and the idea of healing with less side effects.  The art of acupuncture began about 5000 years ago, and I think much of the practice of acupuncture will stay the same.  But I do think that more points will be discovered as physicians are now more open about sharing.  Regarding cosmetic injections.  I think they will become more popular in the next 10 years as patients are looking for quicker procedures, less invasive and less downtime.

  • What technology and special tools are used by you and others at your workplace?

As a acupuncturist, I don’t think I have any special tools except my hands and a collection of acupuncture needles.  For the cosmetic side, there are many tools such as lasers which help with little red veins on the face, etc.  However, in my own preference of what I do at work, I try to rely mostly on my hands connected to instruments which do not require too much technology, except for the technology which rendered the instruments.  I like special needles for all of my work in acupuncture and cosmetic injections.  There is a lot to the property of a needle.  It is very much like a violin bow.  Needles may all look alike, but they have different characteristics – weight, flexibility, length, angle, sharpness, consistency from one batch to another, and the ability to stay sharp throughout the procedure.

  • What written materials are used at the workplace?

We have written materials on the safety of chemicals at the workplace.  We also have written protocols which I follow for some of the procedures that I perform.  Plus we like checklists.

  • What impact dose the workplace have on the local and global communities?

I particularly like it when I get patients who come from other cities and then get to spend some time enjoying our local economy here in Modesto.  For example, I had a patient from San Francisco, who said that she did all her Christmas shopping in Modesto and got to enjoy our lower sales tax rate.

In general, I think I am here to mainly help our patients in Modesto get the best care that they can.  Globally, I don’t think I’ll have much of an impact unless others want to learn my techniques.

  • What academic skills do you need for your job?

The most important academic skill is the ability to keep learning and improving.  My knowledge of the human body and experience with operating on the human body are at play every day in my work.

  • What are at least two ways you apply mathematics at the workplace?

One way is when I have to calculate the cost and dosage of Botox every day.  This is simple addition and subtraction.  But it is in play all the time.  Even when drawing Botox out of the bottle.  Then there’s the mathematics of injecting it out of the syringe.  You have to make sure you push and stop your thumb at the right moment and that’s math.  Botox arrives as a powder and precise but simple math skills are used to convert that powder into a liquid.  I also use math skills to determine how to best use 1 syringe of filler in a patients face.  The filler is a limited resource and we have a job to do which involves symmetry.   Then there’s more abstract and intuitive math which involves angles – especially when using a long needle.  Then there’s the mathematics of getting the procedures done under the price budget laid out by the cosmetic patient.

  • What are at least two ways you apply communication skills at the work place?

I like to have a detailed conversation with the patient in trying to understand their vision of beauty.  I have my vision, and many times the patient has their beauty.  I need to spend time understanding if my vision and their vision align.  If not, I need to really try harder to understand.  Then I have to communicate what I am capable of doing – which sometimes may not be enough for the patient.  And if I get the feeling that I can’t get my message across, or I can’t understand the patient, then I need to communicate that I am not the right person for the job.

  • What are at least two ways you apply scientific principles or social studies concepts in your work?

In cosmetic medicine, there’s the economical social studies concept of meeting the patient’s budget, and dealing with the supply and demand of Botox/fillers.  We also have to deal with the history of the patients responses to various treatments.  In the end, I want to have high yielding efficient results for the patients which they can afford.

We live in a world of science.  And medicine is the artful application of that science.  So I would say that all that I do as a doctor has a foundation in science which ultimately is an explanation of how things are in the universe.  However what we know of science at this point is just small window into how things are in the universe and sometimes we are misled of what we know of science.  But I would say that science is the best of what we know at this time.  As a surgeon, our main science disciplines is the science of anatomy, the science of physiology, and the science of physics.  The anatomy is the science of having identified body parts.  Naming these parts allows us to communicate efficiently with others.  physiology is the science of how these body parts function.  And as for physics, it is the nature of the interaction between surgeon, instrument, anatomy, and its impact on physiology.

  • What opportunities are there to use creativity or art in your job?

There is always creativity and art in my world of acupuncture, surgery, and cosmetic injections.  Every human being is different and every problem is somewhat unique.  Thus almost every solution for a patient requires creativity and art.  This is why I’ve called my medical practice: “Surgical Artistry.”  There are so many different instruments to use, so many different fillers, different needles, different angles, different locations.  Plus with limited budgets for cosmetic procedures, we have to think creatively to get the work done.  Compromises need to be thought of, but always without sacrificing safety.

As for Acupuncture. There are creativity needed in picking effective points for the patient.  Each problem has a unique set of problems.  Back pain patients sometimes even have the problem of not being able to lay on the table a certain way.  So we have to think of ways to get the patient comfortable – perhaps in a chair or perhaps with rolls under their knees, etc.

  • How long were you in school?

First 12 years got me past high school.  Then I did 4 years of college.  Then I did 4 years of medical school.  At this point I got my MD degree – but that’s without any formal surgery training.  Thus to continue on to become a surgeon,  I did 1 year of surgery internship, then I did 5 additional years of surgery residency.  At this point I became a board-eligible Surgeon.  As for acupuncture, I did 1 additional year after all the surgery training.  I think I took the short route compared to other surgeons.  There are many surgeons who spent more years in school.  I consider all those years to be formal schooling for me.  But in many ways I am still in “school” as my patients are my teachers.

  • How does your job affect your life?

My job is my life.  I think I don’t really have much of a life outside of my job.  It was much more this way when I was doing trauma surgery, but I got in the habit of living the job – always.  I married a surgeon too and we love what we do.  I initially picked surgery because I wanted to live that way of life.  Surgery isn’t a job, it’s a way of life.  But I think I need to start learning to live my life in a different way.  Perhaps it isn’t the healthiest way of life for me – I’m starting to realize that and I’m almost 50 years old.  In fact, I don’t really respond to my first name – which is really part of a person’s normal life.  I respond more to “Dr. Lee.”  As that’s who I am and the majority of my life I’ve been called “Dr. Lee.”  I know many people go through customer service and say that people feel comfortable when they hear their first names.  Not so much in my case… it’s usually my parents or my wife who call me by my first name, and usually if they are using my name, it might mean that I was in trouble.  But hopefully as I change my lifestyle and have a life outside of the medical world, I’ll regain my recognition for my first name again.

  • Why did you want this job?

I was drawn to the world of surgery.  I believe it was some sort of calling.  I think I liked it because it requires great responsibility and the capacity to make others happy.  Perhaps also, it was the ability to fix a problem rather quickly.  I also feel that I have a gift of using my hands and wanted to use my gift.  In addition, I was drawn to the world of acupuncture because I wanted to have medical solutions with low cost in terms of side effects – I wasn’t happy with some of the side effects created by medications.  But in the end, I came to realize that acupuncture is just another branch of Surgery.  Blade or needle, either way, we heal with steel.

 

 

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.

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What I love about Belotero Balance

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.

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