JUVEDERM, the “new-and-improved” RESTYLANE

There is some confusion about when Botox is used and when a filler is used.  Botox paralyzes muscles that produce a wrinkle.  A filler can be put in a wrinkle but it will lift it up some, which is generally not satisfactory.  Fillers are best used to enlarge and define (contour) the lips, make nasolabial folds less deep, or to get rid of the sunken cheek look that comes from fat loss below the cheek bones. 

For the lips, I use Juvederm Ultra Plus, sort of a “new and improved” Restylane.  This is a filler, most often used to “contour” the upper lip and fill in lines.  Begin using Botox at the same time and after about two years you usually won’t need Restylane to fill lines.I put in a dental type anesthetic (nerve block) that makes the injection painless.  There is some swelling afterwards that temporarily exaggerates the effect.  This peaks at three days and is barely noticeable by five days.  Bruising is extremely rare, and infection is extremely rare.  I give antibiotics for a day because this is a foreign object being placed (I supply them; you don’t need to fill a prescription before your visit.)  Treatment ranges from $265 to $465 and lasts about a year.  Most of the time I inject 0.3 to 0.4 ml.  0.8 ml would be a fashion statement.  Most or all of that quantity goes into the upper lip, but sometimes I put an injection front to back in the lower lip to push it out a bit, or less often a couple injections side-to-side in the center third of the lower lip.

FAT TRANSFER

The main use for fat transfer is to fill the nasolabial folds (between nose and cheek), and the face below the cheekbones. Intact fat cells transferred into muscle have a high rate of survival, but not many fat cells can be collected intact.  Unlike the lip, the nasolabial folds can be over-filled.  Then even with only 20% of the transferred cells surviving, two treatments four to six months apart usually produce a lasting and satisfactory result.  $600 for nasolabial folds, $300 extra to fill the area below the cheekbones.  I usually collect the fat from the flanks where the fat cells are smaller and less likely killed during harvest; I think I also get some collagen-producing cells from the flanks as they are quite fibrous.  If fat transfer is done at the time of liposuction, fees are 50%.  Juvederm can be injected more superficially than fat, which is why I prefer it for the lips.  In addition, lips bruise easily (Juvederm uses a much smaller needle and almost never bruises), and uneven survival of fat can be very obvious in the lips.

Marionette lines, the folds coming straight down from the corners of the mouth, are best treated by liposuction of the area directly posterior to them (jowls), along with chin/neck liposuction and a lower face lift

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