Treatments to rejuvenate the face are ever evolving. Mr Rajiv Grover, Dr Nick Lowe, Dr Timothy Flynn and Dr Marina Landau offer their advice on technique, product selection and results
Mr Rajiv Grover: I’d like to ask you what new tip have you picked up in the last year, that has really been of practical value in your practice? It could even be something that you have decided not to do.
Dr Nick Lowe: To improve atrophic scars, fillers often need to be combined with other treatments. It makes no sense to start treating deeper atrophic scars with lasers or radiofrequency until you’ve used subcision for sub-dermal fibrosis. In deeper scars, use an appropriate filler such as Sculptra or an HA filler. After subcision and filler begin other procedures like Fraxel CO2, Fraxel Restore or micro-needle radiofrequency as skin tightening for the skin over and surrounding the atropic scars.
Mr Rajiv Grover: Recently it has been discussed that you can inject filler and massage it so it acts like a sticky patch. Could this be a way to lift or suspend the brow and keep it up? Or are you injecting primarily for volume?
Dr Timothy Flynn: I like simple things, and in the last year the thing that’s impressed me the most is vibration. Viration decreases the pain of the needle stick and also smooths out fillers—we have shown this in our clinic and similar results are which is also mirrored in the literature. For people who are pain sensitive, if you vibrate their skin beforehand with just a small ‘purse size’ vibrator, it will decrease the pain of the needle stick. Furthermore, for people who are receiving filler injections, there is a published study which shows if you vibrate the filler injections, there’s decreased pain associated with them.
We also dilute many of our fillers—particularly for deep injections such as with Radiesse, when injecting it deeply into the periosteum or around the deep fat pads—then we massage by hand and finish with a little vibration. I encourage you all to do this, particularly if you’re doing intra-dermal injections, because you’ll be amazed at the evenness. We only use Belotero for intra-dermal injections (diluted with a small amount of plain lidocaine) and it’ll smooth that right out.
Mr Rajiv Grover: There’s very good science behind this. A famous paper on pain relief, by Melzack and Wall, explains the gate theory of pain. If you are stimulating sensory fibres, within the nerve there are C fibres as opposed to AB. C fibres are pain, they’re slow, and you close the gate in the spinal neuron as a result of stimulation.
Dr Timothy Flynn: Of course, we struggled for years to try and call them something other than vibrators—medical stimulators, tissue devices—finally, in the end, we just threw in the towel and said, yes, it’s a vibrator.
Mr Rajiv Grover: Call a spade a spade. Marina—can you follow that?
Dr Marina Landau: I have started to dilute my fillers in the last year for a number of reasons. First of all, I do not dilute with lidocaine, I dilute with preserved saline which has anaesthetic qualities as well. I think that I get better cosmetic results, and it also creates a good anaesthesia.
Another remark, I have started to use the volumetric fillers and they give a good cosmetic result when the patients are at rest. When they smile, you can quite frequently see the demarcation between the filler and the untreated area. Therefore, by diluting the volumetric fillers, you can create smoother transition areas between the treated and untreated areas.
Secondly, a study done in Russia on calcium hydroxylapatite, showed very significant collagen stimulation by using hyper-diluted Radiesse. They used 1ml of Radiesse to 3ml of lidocaine. I use preserved saline, and this option allows me to treat non-facial skin, such as the neck, with no nodules or irregularities. It’s a very significant improvement. Hyper-diluted Radiesse is great filler for body skin.
Mr Rajiv Grover: I can imagine diluted Radiesse would work very well on the hands.
Dr Marina Landau: Yes. That is what you do with Radiesse on the hands—it creates better cosmetic results.
For the body, I use 1ml or 1.5ml Radiesse with 4.5ml preserved saline. You can add a 0.5ml of lidocaine first, then you need only 4ml saline, but preserved saline is an anaesthetic by itself, so it’s efficient for anaesthesia. For the hands, you don’t have to use hyper-diluted—you can dilute one to one.
Audience member: What’s the view on polycaprolactone and how does it compare to other available products?
Dr Marina Landau: It is considered to be a stimulatory filler, similar to Sculptra. I started to inject it very cautiously, as I do with every new filler. There is one study, which compared the efficacy of Ellansé against HA nasolabials. It showed less Ellansé was needed as compared to HA. I started with Ellansé S and according to the company claims, you need a small amount of filler—not more than 1ml, and again, diluted. I have limited experience, but you do have some stimulatory effect on collagen.
Dr Nick Lowe: Ellansé may prove to be useful, but I think all new dermal fillers need robust clinical safety studies.
Rajiv Grover: In your own practice, which filler is the one you use the most, and why have you chosen that particular brand of filler?
Dr Nick Lowe: Hyaluronic acid fillers combined with local anaesthetic have been my main fillers. The ones I currently use are the Emervel ‘family’ which I find very versatile and I can reduce or remove with Hyalase if needed. For diffuse atrophy of the cheeks I will often use Sculptra.
Mr Rajiv Grover: They talk about G prime and lifting capacity, do you think that these are an effect with some fillers?
Dr Nick Lowe: I think there are definitely different physical characteristics of the fillers. I think as important as that is how you inject them—the depth of injection and if you’re injecting onto the periosteum. These factors influence whether you’re getting lift, or as much lift as the next injection. It is related to technique as much as individual filler characteristics.
Dr Timothy Flynn: I end up doing a lot of very fine-line fillings that take a long time—the barcode on the lip, treating fine marionettes that have been under-treated, because nobody was doing the superficial lines efficiently. So Belotero is the only filler I use for this based on studies involving intradermal integration, and also Radiesse for deep filling. They work well together. I’m definitely using more Voluma, because of their longevity studies. We still use some of the Juvéderm family and also a little bit of Sculptra in the right people.
Dr Marina Landau: I don’t order all my fillers from one brand. I have one filler with lidocaine, which is Perlane—my workhorse. I then have one filler which is lidocaine-free called Princess, an Austrian filler. It is very similar to the original Juvéderm and I use it for any patient who claims to be lidocaine-sensitive.
Then I use Radiesse, for injecting in the lower face, and for my male patients. For volumising cheeks, I use either Voluma or Teosyal Pure Sense.
Mr Rajiv Grover: From a business perspective, what one top tip have you got from your practice—maybe a USP—that made you successful?
Dr Nick Lowe: Employ my wife as my business manager.
Dr Timothy Flynn: My tip is to always do the right thing for the patient—put yourself in their shoes. Here’s a simple example that actually happened to me: a patient came back after a filler session and said, “Dr Flynn, you can do better.” So I took a look at her and brought her in, and do you know what? I agreed with her. I could have done her fillers better. There were a couple of areas that I’d missed. She had some unevenness. The problem, I determined, was that she needed more volume replacement. I had a dissatisfied patient and I knew if I’d just used half a cc of, in this case, Juvéderm Ultra, I could fix the little depressed areas.
I didn’t charge her because I wanted to convert that unhappy patient, who’d already spend over $1,000 with me, into a happy patient. So I showed her I was going to take care of her, and do the right thing. That’s different to the person who comes in, three months after their botulinum toxin, and complains it’s not lasting that long—that’s clearly a person who’s working the system. I’m talking about something where you really agree with the dissatisfied patient and you want to help the patient because you’re disappointed in the results. Always do the right thing for the patient.
Dr Marina Landau: Do not compete on price—compete on quality. There will be always somebody who is cheaper than you are, so you deliver better treatment results.
Mr Rajiv Grover: Very good advice. Don’t compete on price; compete on quality. Do the right thing for the patient. Keep your overheads down and have a skeletal staff. And put your wife in charge of the practice.