Will Botox Help lift my inner eyelid? (public forum question)

Will Botox help lift my inner eyelid?

Another public forum question I attempted to answer.  This question comes from Corona, California.  A photo was attached, but it isn’t entirely clear from the non-moving 2D photo – the goals and wishes of the patient.  But I did my best to try to answer the question.

 

Here’s my answer which all the other doctors don’t seem to understand what I’m writing:

Lateral and Medial Pretarsal Obicularis Botox micro injections

What we’re discussing is consider off-label FDA use of Botox.  In my experience, I have treated only 3 patients for eye lid raising with Botox.  The injections are extremely tricky.

I would inject the lateral and/or medial aspects of the pretarsal obicularis (which is the eyelid muscle) – taking extreme care to avoid the middle part of that muscle which is connected to the levator (which lifts the eyelid).  I would inject about 0.5 to 1 unit with each shot.  I don’t want to go into too much detail because this is a discussion you need to have with your injector.  The basic theory is that if we weaken a depressor (which are the sides of the eyelid), we help the levator become more dominant.

For mild imbalances in appearance, I would leave it alone.  It’s possible for us to make things worse with our decisions and injections.  With my only 3 patient trial of this method – this doesn’t make me the expert on this topic.  It’s a very rare request.

Basically if your question was an academic style question, I would say that it could be done if I understood your question correctly.  But in reality – check with your Botox injector!

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.

Best wishes.

Calvin Lee, MD
Modesto Botox Injector, California

Lip swelling after Juvederm Question

Another public forum question that I attempted to answer:

I had Juvederm 2 wks ago and my top lip is protruding like a duck bill. Will it go away or should I have it dissolved?

I had juvederm ultra plus done 2 weeks ago in my lips and the top is still protruding outward like a duck bill. Will this go away or should I get Hyaluronidase to dissolve it and if I do use Hyaluronidase in the lips will it dissolve it completely and evenly?

 

My Answer:

Perhaps more filler for the bottom lip but first consider waiting 3 weeks?

It is sometimes possible that the upper lip swells more than the lower lip with Juvederm. In my hands – that happens often because there are just so many more components in the upper lip – thus I have to manipulate the needle and filler in that area more.

Sometimes the swelling could be present for a month after injections, but that is somewhat unusual in my humble opinion. But consider waiting till 3 weeks before deciding to do something different. And if that’s the case – you may just need more filler on the bottom and then you could have the results you wanted in the first place.

Lip fillers are a difficult project for me. I do it every day, but I am still humbled by the artistry and difficulty of the procedure. Best of luck to you.

Here’s my disclaimer:
Thank you for your question. Without having seen you in person, I’m answering the best I can without physical examination info and a one-on-one dialogue. 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.

Thanks for reading.

Calvin Lee, MD
Cosmetic Injections in Modesto, California

a natural beauty logo

Pimples after Botox

I attempt to answer another public forum question about Botox.  This question comes closer to my office in Modesto, California – it is from San Jose, California!

Why do I break out since having Botox?

In the exact same area where the injection was; is where i break out. As if causing a “man made pore” from the needle which then does not close up and gets filled causing an ongoing blemish effect. I ONLY break out now where I’ve had the injections. But why??

My Pimples and Botox Answer:

Wonderful question.  I’ve encountered this question about having breakouts in the area of Botox injections in my own practice in Modesto, California about 3 times.  So this is rare.  The world of medicine is complex, and sometimes it seems strange.  I have not had a case of the “man made pore” – so I can’t address that question except to speculate that it may be a scar of sorts or somehow related to a cyst?   I’ve had an experience where there was a reddish – pimple like reaction to only one of my needle pokes.  I suspect in that patient that there was an underlying infection in that area – such a pimple – which then got exacerbated when I decided to inject Botox too close to that area.  Botox injections are tricky, we want our injections to be in strategic places, but sometimes in our patients, blemishes and veins get in the way of an ideal placement – and thus I have to compromise in my decision and Botox strategy.

​Regarding the break-outs in the Botox areas.  For some of my patients, I’ve come to realize that they are sensitive to some of the antiseptic methods I use to help prevent infections from the Botox procedure.  Sometimes they are allergic to the antiseptic.  There are various ones available out there and perhaps switching to a different antiseptic could help.  Meaning, having your injector/surgeon/doctor/nurse switch to a different agent.  And there’s the possibility that the actual needle poke – which is a very mild form of skin trauma – could incite a inflammatory process.

​Ironically (to your question of why does Botox cause more blemishes), I’ve found most of the time that Botox helps calm down inflammation in an area of skin. This may be due to reduced sweating or a direct effect on rashes and pimples by Botox.  Also, Botox sometimes shrinks pores as with what we’ve seen with meso-Botox.

​Thank you for your question, I’m just answer from my own personal experience as a Botox injector. 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.

​I hope this discussion is somewhat helpful.

​Calvin Lee, MD – Botox Surgeon
Botox injections ​Modesto, California

surgical artistry full page ad never boring

BOTOX for Hyperhidrosis

A pubic forum questions which I decided to answer using my own experience in Modesto, California as an injector of Botox for this problem of excessive sweating in the axilla (arpits).  The question comes from Kansas City, MO.

Is it uncommon for botox for hyperhidrosis to not work the first time?

I’ve had hyperhidrosis since age 13. I finally had botox treatments about three weeks ago, and was sure that this would be my answer. The sweating has improved some, but I still get sweat marks. Which, for the price I had to pay, is incredibly disappointing. I don’t know if it’s worth it to try again or not. My dermatologist’s office said insurance wouldn’t even allow me to get another treatment until it had been 4-6 months. They also said nobody had ever had the botox NOT work for them. Help!

My Botox and Hyperhidrosis Answer

A great question.  I can only speak from my own experience as an injector of Botox for my Modesto hyperhidrosis patients.  I have had a few patients where the sweating has reduced somewhat after 50U of Botox injected in each axilla (arm pit area).  But then they needed more.  A carefully planned approach to the remaining excessive sweat areas by using a starch test or even just observation, could help direct perhaps another 25 units of Botox into each side.  That’s what I’ve done with some success in my own practice in Modesto California where it does get over 100 degrees F in the summers.  I think that 1 in 5 of my patients would benefit from a higher amount.  I’ve also worked with excessive sweating in the palms/feet which can be a lot higher in Botox dose.

​You’ve shown that it works with the reduction you noticed, and now it just needs more – probably because everyone is different.  And perhaps if you had to wait 6 months – it might work even better because I think there would be some overlap of the Botox injections.

​My practice doesn’t accept insurances, so I totally understand that the cost can be a concern.  But many of my patients think that it is “a new lease on life” as some of my patients claim.
​​
​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.

​I hope my own experience as an injector helps.

Calvin Lee, MD

two surgeons working at the same time - Crop
Dr. Tammy Wu and Dr. Calvin Lee operating together in Oakdale, California

 

Botox doesn’t work as well anymore – what to do?

I’ve decided to tackle on another question in a public forum about Botox.

I’m a Botox user but over the last 3 – 4 times I’ve had Botox it hasn’t worked as well. What unit of Botox would I ideally want?

I’ve been getting Botox for a few years,recently its not worked as well ,getting top ups is a hassel, especially when it doesn’t work again.i asked my doctor what units he used, what type and the dilution solution , ‘ Azzalure which is the same as Dysport. Diluted with bacteriostatic saline solution to produce 200 Speywood units per ml. ‘frown 50-60units’ is this good? I’m thinking of changing doctors, what would the best thing to ask them?how many units do i want injected if this didnt work?

My Answer:

There are so many different ways to inject a neuromodulator and there are so many possibilities for a neuromodulator injection to work less effectively.  I’m going to use the word neuromodulator to describe Botox, Dysport, or Xeomin.  I agree that Dysport is sometimes called Azzalure.

​WHAT CAUSES VARIANCES IN OUR RESULTS?

​Patient factors

  • ​Is the patient Zinc deficient?  Zinc seems to play a role in neuromodulator
  • Did the patient develop antibodies to the product?
  • How long ago was the patients previous neuromodulator treatment.  Often, when the treatments are close enough together, there’s a synergistic effect of the previous injection along with the new injection.  Thus don’t wait too long between injections where to facial muscles have gained back all their strength.

Product factors

  • ​Dilution of the product.  Was it diluted appropriately.
  • Age of product.  How long has it been on the shelf?  Shelf life can matter.
  • Which product?  I feel that the neuromodulators are somewhat different from each other.  The units cannot be interchanged very easily.  It’s sort of like asking – how many tangerines does it take to make a washing navel orange?  Similar, yet different for the discriminating injector/patient.

Injector factors

  • ​Where were the injections made?
  • Was there waste of product?
  • Was the measurements accurate?
  • Three dimensional injection, was the neuromodulator placed within the muscle or right under the skin, or right above the bone?
  • How many injection points were chosen?

​I’m probably forgetting a few variables.  But you can see that there’s so much going on here.

THE ANTIBODY QUESTION:  Try more Dysport and/or go back to Botox.

​Consider going back to your injector and asking for a higher dose of Dysport.  If that still doesn’t work, then consider asking your injector to switch back to your original – Botox – which seemed to work for you.  If both the higher dose and switching back to Botox – this might point to an antibody problem.  This will degrade the product faster.  This is a very rare possibility.  I think in the past, this happened more because of the higher percentage of albumin mixed in with the Botox.  But it’s a much lower amount of albumin used now and thus the antibody reactions are much rarer.  If antibody reactions occur, I believe that you’d be forming reactions to all Botulinum Toxin Type A’s:  Xeomin, Dysport, and Botox.  These are the ones available in the USA.

​SWITCHING INJECTORS​

​But if you have doubt about your injector.  You can switch.  Neuromodulator injection styles are incredibly different – this might be what you’re looking for – something different.  And hopefully better results.  I think you have a good idea on this one.


OR SPEND MORE TIME DISCUSSING THE PROBLEM
​​
​Consider spending even more time talking to your injector.  Perhaps he/she will come up with a comprehensive plan of figuring out what’s happening with your new dissatisfaction.  Above is just my own plan of what I do with my patients who present with such a scenario.  But most of the time, it’s because I’ve gotten patients who have decided to switch to me due to dissatisfaction with results from another injector.

IDEAL BOTOX UNITS FOR THE GLABELLA:

​How many units of Botox for frown lines?  I call these lines glabellar lines.  I usually inject anywhere from 10-36 units of Botox for this one area.  Every person is different, but usually I am sticking to the same general amount of units for each treatment session.  Thus if a patient is a 36 unit user – they tend to be a 36 unit user for a few years.  I have found that they can usually space the treatments further apart though as they keep using Botox.

​On average, I use 20 units of Botox for the glabellar complex.  The numbers written above in the question are probably Dysport units which could be about 3 times more than the Botox units to achieve a similar (not same) result.  I’m not entirely sure because I am nearly 100% Botox in my own practice.  My experience with Dysport spans only about 3 months in my practice.  I was pretty happy with the Dysport results, but my patients seem to want Botox more, so I caved into consumer demand.  I am happy with both products.  But I do not use the terms Botox, Xeomin, and Dysport interchangeably.  They are different products and have different effects and require different care.
​​​
​Thank you for your question. Without having seen you in person, I’m answering the best I can without physical examination info and a one-on-one dialogue. 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 injections Modesto, California

surgical artistry full page ad never boring

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.

​BOTOX IS MORE PREVALENT

​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.

​BOTOX AND FILLERS EXPLAINED AS MOUNTAINS AND VALLEYS.

​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.

​WHAT IF WE WANT TO RAISE A CHEEK?

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

​WHAT CHOICES OF FILLERS DO WE HAVE?

​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.

​OTHER POSSIBILITIES – PERMANENT IMPLANTS:
​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.

​SUMMARY:

​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.

​DISCLAIMER:
​​
​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

Botox for slimming the jaw

Another Botox question on a public forum:

Botox for reduction of masseter. How many units are required for a noticeable difference?

How many units is required for a noticeable difference? Or is it entirely dependent on the individual? I’ve visited a few clinics and I’ve been quoted either 15 or 25 units. I was told by one doctor that with Botox, only a small amount is needed for a difference to be seen. But some clinics recommended a higher dosage as the cost was paid for per unit. Could anyone provide some information on this and what dosage they recommend?

An excellent question.  I’ve wondered this myself and I continue to wonder about what others think about jaw slimming with Botox.  The masseter is the main muscle which can give us a square-ish box-like face.

​I don’t get this opportunity to do this procedure very much.  I’ve only had about 20 patients come in for this issue.   And about 16 patients who come in repeatedly for this feature of Botox at this time.  But I’ve had many more (probably 60 patients) who have had TMJ dysfunction/pain issues which required Botox in the Masseter muscle.

​My worst case scenario is a male patient who had TMJ pain which eventually resolved when we eventually came to the conclusion that 50 Units of Botox on each side helped.  I usually like to do my Botox procedures in a staged fashion where we do a little bit at a time and thus we eventually find the lowest dose that does the right job for us.  He did get jaw slimming features, but that actually was more evident after his third round of 50U of Botox on each side.

​My experience with TMJ masseter muscle Botox helped me come to the realization that masseter/jaw muscle slimming Botox usually has it’s most dramatic effect after the 3rd Botox treatment – assuming no large gaps between treatments.  So this is almost 10 months later.

​Thus for patients coming directly to me for Jaw slimming Botox (cosmetic only).  I try to assess how much of a “rush” patients are in for this to happen.  If they are OK with best results in 10 months.  I usually suggest about 16U-20U on each side to start.  And repeat this process in 3-4 months.  If a person is in a “rush” to get this result, I might start with a higher dose – such as 24-30U and then gradually lower this dose with each subsequent treatment – so I don’t over-correct and get a sunken in jaw look – which in my opinion is not a youthful appearance at all.

​Summary:  Quick answer:  12-50 units per masseter muscle.  Long answer:  It’s not the number of units per session – it might be the number of units done over time that matters most.  I’ve come to realize that the best appearances for masseter muscle slimming is obtained after repeated treatments to this area.  I tell my patients to be patient and wait for the appearance after the 3rd Botox treatment to the masseter area.  Everything in medicine should be individualized – especially Botox!

​Calvin Lee, MD
​Botox injections in Modesto, California

Calvin Lee at Desk smiling ss DSC01401
​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.

Botox for changing eye size

Here’s another public forum cosmetic Botox question.

Can I use Botox for my cheek pushing up on eye when I smile, making it look smaller than other?

I have had 2 ptosis surgeries On my upper eyelid it has been about 4 weeks since my 2nd. the 1st 1 was an over-correction. Now I don’t think it is so much my top eyelid. It is raised a little more than before any surgeries. I’m still not happy with my eyes. If you notice when I smile it really goes to one side. And I’m okay with that. But when I smile only 1 cheek pushes up on my eye and makes it look smaller. i don’t want to do anymore surgeries. Could Botox fix my check from coming up?

My Answer:

What a great question!  I have to break up my answer into several parts

​BOTOX FOR CROWS FEET

​Botox is FDA approved for treatment lateral canthus lines (crows feet).  These are the lines on the side of the eyes which become more pronounced when we smile.  Through our experience treating these crows feet, we’ve found that we can affect eye size, brow lifting, and even cheek elevation.

FULL vs. PARTIAL TREATMENT of CROWS FEET
​​
​In a situation where one just wants the cheek to elevate less with smiling, a full treat of crows feet might be too much.  However, if one is bothered by the potential of crows feet (meaning that BOTOX can prevent crows feet as well as treat crows feet), the a full treatment could work on both sides, and may even out the appearance.  I can envision a possible treatment of the lower crows feet on the side with the cheek elevation “problem.”  I can also see a potential patient of mine benefiting from full treatment on both sides and with added Botox to the “problem” side.

​TREATING THIS PROBLEM IN STAGES

​If I had a patient coming in for this issue, I would consider treating this issue in stages.  Starting with a low dose targeting the lower crows feet area (obicularis oculi muscle) and bringing the dose higher perhaps separated by about 2 weeks.  And maybe even considering treatment on both sides to keep up with symmetry issues.  With good note taking, we could figure out the optimum solution if possible.

MOUTH MUSCLES MIGHT GET IN THE WAY

​Cheek elevation is also caused by muscles that affect the smile of your mouth – Zygomaticus Major and Zygomaticus Minor muscles.  These muscles, if targeted too strongly with Botox will affect the symmetry of your mouth.  Thus if the bulk of your cheek is formed from these muscles, Botox may not be able to give you your 100% desired result.  But I still think that your desired effect is possible without injecting Botox into muscles that affect your mouth.  Fortunately with a gradual staged approach, you might gradually find a solution.  If a solution isn’t possible, I would say that it’s because of the mouth muscles and the amount of natural fat pads we have on each side of the face which can compress and change shape on animation of our face (ie. smiling).

​THE QUEST FOR SYMMETRY

​I understand that symmetry is important. However, we should keep in mind that it isn’t human to be exact mirror images of our selves on each side.  We are usually strong on one side – for example, being right handed.  This contributes somewhat to our facial muscles as well.  The natural asymmetries in a person’s face can be considered a strength and add flair.  Thus, sometimes, it’s ok to go with the idea that the sides of our faces are like siblings, not genetic clones.

​IN SUMMARY

​Botox can possibly solve this problem of smaller-eye, higher-cheek.  If one is interested in wrinkle treatment or prevention – it makes using Botox even better.  Consider partial or full treatment of crows feet or even heavier application on the elevated-cheek side.  But keep in mind that Botox can make other parts of our face appear asymmetrical – like the mouth or the eyebrows – so be careful, and good luck!

​Calvin Lee, MD
Botox injections in Modesto, California​

SurgicalArtistry_womanlogo - original

​Thank you for your question. Without having seen you in person, I’m answering the best I can without physical examination info and a one-on-one dialogue. 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.

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

obagi-blue-peel-radiance-modesto-california-dr-lee-holding-fan - Copy

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.

logo_bag