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Treatment for Wrinkles Around Mouth

So we have this preparation we’re doing with Belotero filler. There’s 1 milliliter that’s delivered in syringes and even though this has a lower chance of Tyndall effect, according to the studies and even acknowledged by some company executives from the competitive companies, I still like to bring the solution down to around 5 milligrams per deciliter.

So I’m taking basically our connector here and I’m going to put the… connect this and put the Belotero HA into roughly 3 milliliters which is gonna be one part product, 4 parts solution, if you will, and I have four milliliters… dividing that by 4 gives us 22.5 milligrams divided by 4 is in the 5 milligram per deciliter range which is where I feel like it’s optimal and then I’m just simply putting this in the solution. I don’t think you can do this too much. In fact, I’ll often have my assistant sort of sitting in the background doing this sort of mixing between the two syringes and making sure I don’t have any parts of the HA that are more concentrated.

And then I’m simply drawing it into my delivery syringe, it’s too hard in a big 5 milliliter syringe, and a 30 gauge needle which is really the key for fine lines. And these two little components been very successful for us in the absence of the Cosmoderm product which I think was obviously the ideal product for fine lines and I’m just going to draw this up in to the syringe. And the I’ll often have my assistant, actually, will just take a 1 milliliter BD syringe that’s got a screwed vessel for the needle on it, a locking vessel.

The key is getting intradermal. I should see a little wheel developing in the skin surface which is an indication that I am intradermal, and the more intradermal we are, the better effacement of the line it is. If I am sub-dermal or even deep dermal, what I’m going to do is push the line towards the surface and not really treat the line itself. And if it develops a little superficial wheel, I’m okay with that but as long as the line is effaced, that is the important thing. And so I’m just doing this with serial point.

Linear threading sounds appealing but it is so hard to do this with linear threading. And I think anybody that remembers the Cosmoderm days, knows that this serial point injection is a far superior way of treating a fine line. And then the patient themselves will massage this when we’re done. If there’s a little swelling, that’s not a problem. If you start near the top of the lip, it’s helpful because the indentation comes from the top. Ultimately in a lip like this you’re pretty much laying down a layer along the entire upper lip surface intradermally, and that effaces all the lines.

The hydrating affect of the HA is also a large benefit and it really comes down to, in the end, how smoothly you can lay these products down with serial point injections. So I think the more optimal treatment for this is either serial fractional laser resurfacing or full laser resurfacing, which actually works much faster but has longer recovery time. But in the end, this sort of ultra-dilution method and mixing of an HA filler is what I find to me the optimal treatment methodology for perioral and other fine lines frankly. It doesn’t have to be just in the perioral area for people who want to do this over being treated with some resurfacing method, all of which I think work very well. Peels, laser, even dermabrasion would work.


Upper Eyelid Surgery Excerpts

We carefully marked the patient's eyelid and we measured the height of her eyelid. It's at seven millimeters. I can go as high as about twelve on a woman. Her natural crease is seven to eight millimeters. I've got eight millimeters and then I compare her symmetry.

Taking the muscle strip is a different strategy than taking the skin and muscle flaps so I'm controlling this muscle strip… this is like forty millimeters in length. We could see the fat pad clearly by turning her head a little bit and applying low pressure. This is the fat pad that bulges on patients. I use a needle-point cautery he and that takes care of all the little spots of bleeding. There's a very limited amount of bleeding but if we're careful with this, people have really minimal bruising.

I did a little orbicularis myotomy to help with the crow's feet. Her eyes are going to be beautiful… Hallelujah.

We drape the extra skin so we can see how much extra skin is here for this patient. This is where I am able to carefully estimate how much skin incision we'll need. If we drape it, we'll never take more than needed. Obviously taking too much skin results in the inability to close the eyelids completely. We want to see only a millimeter of lagophthalmos while laying on the table and that gives us the proper amount of eyelid.

Skin excision on the eyelid… a millimeter is a good target goal. This is really all we want. We used 6-0 absorbable suture so we don't have to technically take them out but we can take them out at day three. Eyelids heal so quickly. I'm going to do this in segments because I feel like I have taken a little more than I want in terms of my estimate incision. I can always close it as a V to Y closure. This lateral aspect is where one can be more aggressive and pick up the skin without risking lagophthalmos.

I always save the skin… we mark and save the skin as excess if we were ever to need… if we felt like there was too much excision, we could always use the skin as a graft to make sure there is sufficient eyelid closure. That's a rare event but certainly it is a strategic way of doing surgery. We make sure that we're always safe and obtaining the safest and best outcomes. It's a very gentle procedure and not very long at all. Very nice eyelid closure is still achieved and I'm going to put a nice cool ice pack on there and we're going to move on over to the left side.

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