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Should I get a chin implant or filler?

Chin augmentation can be very successful procedure for people who want more projection for their
chin.
It can also result in a more contoured facial profile, achieve a more chiseled look, or
extend or better define the jawline.
Chin augmentation be done with a cosmetic filler, a surgical implant, or a combination
of both.
I’ll discuss how I counsel my patients to help them make the best choice for their situation.
I’m Dr Amiya Prasad.
I’m a Board Certified Cosmetic Surgeon and Fellowship Trained Oculofacial Plastic & Reconstructive
Surgeon.
I’ve been in practice in Manhattan and Long Island for over 20 years.
For many years, facial implants such as chin implants have been a big part of my practice.
More recently, I’ve been using an advanced filler placement technique that reaches the
bone level of the facial structure, which has become a significant, non-surgical chin
augmentation treatment.
When it comes to chin augmentation, my patients will express wanting something that is safe,
long lasting, with immediate results, and minimal to no downtime.
Before choosing a solution, I first make an assessment.
I look at the relationship of chin projection with other parts of the face, such as the
nasal base, and the lips from a side view.
I measure these relationships using the established facial references such as Steiner’s Lines,
Ricketts’ Lines, and the Frankfort plane.
I also use the Golden Ratio, which is a natural proportion of beauty of 1.6 to 1 that we are
intrinsically drawn to as it occurs throughout nature.
When a patient is looking for a long term solution, I discuss chin implant surgery.
Chin implant surgery involves placing a silicone implant on top of the chin bone.
I typically do this procedure from just below and behind the chin, which heals very well
and is typically barely detectable.
This is a fairly straightforward procedure done in our office operating facility using
local anesthesia with LITE IV sedation.
The advantages of chin implants is they are long lasting.
It’s commonly assumed that implants are permanent, however the shape and size of the
face does change with age as bone, muscle and soft tissue of the face gradually diminishes.
Disadvantages of chin implant for the purpose of chin augmentation are the same as any implant
surgery.
The implant can shift, can become infected or need to be removed if the patient chooses
to do so because of dissatisfaction with the outcome which is additional surgery.
I’ve found that a significant percentage of patients who want chin enhancement are
not comfortable with having an implant.
This is where the modern and longer lasting fillers provide my patients a more attractive
option.
Cosmetic filler placement can be done in an exam room without surgery, and still get the
same results as a chin implant.
I would also add that the control I have in the precise placement of volume allows me
to even get better results.
Technique is critical to successful outcome.
I use a technique to place filler in the chin called Structural Volumizing.
Comparable to placement of an implant, I place the filler on top of the bone structure.
I use thicker and longer lasting fillers such as Juvederm Ultra Plus or Juvederm Voluma.
I perform this procedure using blunt cannulas instead of needles as the technique creates
less trauma to the skin, soft tissue and muscle.
While we can achieve results comparable to chin implant surgery with a the procedure
which is performed in minutes with patients usually returning to work the same day or
the next day.
Initial results can be seen immediately after the procedure and settles over several days.
I usually see patients in follow up after 2 weeks to review their results and compare
before and afters as well as assess if enhancement would be beneficial.
Result from placement of long lasting fillers can range from 1 to 2 years.
Should any issue occur which requires removal of filler, as opposed to surgery, the hyaluronic
acid filler may be dissolved in minutes with the enzyme hyaluronidase.
Hyaluronic acid, the substance that makes up fillers I prefer, including Juvederm Ultra
Plus and Juvederm Voluma, occurs naturally in the body, so these fillers are safely metabolized
by the body with time.
The choice of filler or implants for chin augmentation comes down to understanding your
priorities.
In my practice, I’ve seen a trend for more than 20 years toward a preference for minimally
invasive and minimal downtime procedures whether the procedure is surgical or nonsurgical.
I find that the acceptance of filler placement over surgical implant to be the basis for
continuous growth in structural volumizing for chin enhancement in my practice.
Thanks to the introduction of thicker, longer lasting fillers with the application of minimally
traumatic techniques for filler placement at the bone level, I find that I’m more
inclined to recommend filler for chin enhancement.
I find that the ability to make microadjustments at different levels from the bone outwards
allows me a type of control that cannot be done with an implant.
Oftentimes, patients also choose to have volume enhancement in other places such as the cheeks
and the lips to create better facial harmony and balance.
I hope you found this information helpful…thank you for your question.

Can I get upper and lower eyelid surgery done at the same time? Cosmetic upper and
lower eyelid surgery or blepharoplasty is a very popular procedure throughout
the world the goal of these procedures is to improve the aesthetics of the eyes
by addressing excess and sagging upper eyelid skin often associated with
genetics and aging as well as the appearance of puffy under eye bags other
issues which can be addressed in the eye area include upper and lower eyelid
hollowing wrinkles and dark circles which may be addressed non-surgically

I’m Dr. Amiya Prasad I’m a board-certified cosmetic surgeon and
fellowship trained oculofacial plastic and reconstructive surgeon I’ve been in
practice in Manhattan and Long Island for over 20 years as an oculoplastic
surgeon specializing in aesthetic procedures I perform a wide range of
cosmetic eyelid procedures I also treat complications of eyelid surgery
originally performed by other doctors I have throughout my career developed
several techniques in eyelid surgery to allow for minimal incisions save for
anesthesia and quicker recovery it’s important to understand some basic
principles in a younger person the skin quality tissue volume and bone structure
gives the upper eyelids a youthful appearance the supporting structures can
change due to genetics aging and medical issues the upper eyelid area can have
fat pockets prolapse forward hollowing and excess skin referred to as
dermatochalasis.

Under eye bags which are caused by lower eyelid fat prolapse is
often associated with genetics and if many young people under eye bags that
are also often seen with facial aging it’s common to see both sagging skin in
the upper eyelids as well as under eye bags at the same time another issue
affecting the upper eyelids which is commonly associated with aging is upper
eyelid ptosis ptosis means that the upper eyelid position is lower than it
should be and this position is unrelated to the physical weight of the upper
eyelid skin ptosis has to do with the muscle that raises the eyelid called the
levator muscle like the word elevator without the letter e the condition needs
to be identified before any cosmetic procedure so the muscle which lifts the
eyelid is addressed at the time the surgery is performed to get the best
outcome for many people the appearance of excess skin on the upper eyelids
puffiness in the upper eyelids and hooded eyes can be very frustrating many
of our patients note how it’s difficult to apply makeup to the upper eyelids
being perceived as older or lacking in energy is also a common complaint
expressed by patients during consultation in fact the appearance of
looking tired even when well-rested is one of the most common reasons for
inquiring about eyelid procedures these conditions affecting both the upper and
lower eyelids often occur concurrently so wanting to have both upper and lower
eyelids procedures done at the same time as a frequent request there are specific
procedures used to address hooded upper eyelids and puffy under eyes depending
on the underlying causes and the degree of severity
for example the appearance of hooded upper eyelids may be improved non
surgically I’ll be it temporarily with the procedure called Botox
brow lifts if the upper eyelid fullness is caused by eyebrow position
only if the eyebrow position has descended more significantly while
surgical brow lifting options may be considered as well if there is excess or
sagging skin over the eyes the more definitive and long-term solution is an
upper eyelid blepharoplasty an upper eyelid blepharoplasty is a procedure for
restoring the upper eyelids shape and contour creating a more rested and
refreshed appearance excess upper eyelid skin is carefully measured a design is
drawn to address the excess skin and additional tissue below the skin is
artistically contoured so the eyes look refreshed and natural afterwards gentle
handling of this delicate tissue with meticulous care allows for minimal
bruising and swelling after surgery resulting in quicker recovery as far as
under eye bags are concerned there are usually two approaches which are
considered these are the transcutaneous approach or the transconjunctival
approach the transcutaneous approach involves making an incision right below
the eyelashes to get to the fat pockets it typically leaves an external scar and
an approach that can be potentially lead to complications due to compromise of
lower eyelid support structures in addition unnecessary skin removal can
contribute to problems such as lower eyelid ectropion and lower eyelid
retraction for most of my patients regardless of age and ethnicity

I prefer the transconjunctival approach this procedure is considered technically more
complex but in my hands has proven to be safe with minimal risk of complications
patients find this approach particularly advantageous as I’m able to maintain the
natural shape of the eyes and avoid the rounded look which is seen all too
commonly after eyelid surgery preserving the shape of the eyes allows me to
provide my patients with the feeling of confidence about retaining their
character while looking more refreshed specialized procedures for upper eyelid
ptosis or drooping upper eyelids due to a weakened levator muscle can be
performed at the same time when addressing the excess upper eyelid skin
as well as under eye bags specialized surgery like ptosis correction is done
almost exclusively by oculoplastic or oculofacial plastic surgeons like myself
this is not usually done by general plastic surgeons or cosmetic surgeons

I routinely perform upper and lower eyelid surgery with any of the advanced or
additional procedures and necessary all at the same time all procedures are
performed using local anesthesia with light intravenous sedation which means
easier recovery and less downtime in comparison to eyelid surgery performed
under general anesthesia the upper eyelids heal extremely well and the area
where sutures are placed blends very well with the adjacent skin even when
the eyes are closed upper and lower eyelid surgery when performed together
usually takes less than two hours to perform minimal bruising and swelling
are typical after upper or lower eyelid surgery and my patients routinely go
back to work in one week upper and lower eyelid surgery can be performed at the
same time with minimal risk and quick recovery

I recommend meeting with qualified and experienced oculofacial plastic and
reconstructive surgeons who specialize in cosmetic eyelid surgery so you can
learn about your options I hope you found this information helpful thank you
for your question

How do I get fuller lips that still look natural?

Lip augmentation for fuller and
attractive lips is a very popular procedure which can be technically
performed in a few minutes when I discuss this procedure with my patients
they often expressed a concern about people they see with bloated and
unnatural looking lips these overdone lips create a negative perception of
cosmetic procedures especially so-called duck lips associated with celebrities
and other people in the media however when lip enhancement is
performed with artistry in experienced hands lip augmentation can be
beautifully proportional and balanced I’m Dr. Amiya Prasad I’m a
Board-certified cosmetic surgeon and fellowship trained oculofacial plastic
and reconstructive surgeon I’ve been in practice in Manhattan and Long Island
for over 20 years I perform a variety of facial cosmetic procedures such as
eyelid surgery facelift facial fillers facial implants as well as injectables
lasers and other skin treatments I can attest to the value of artistry with
years of experience performing surgical and non-surgical procedures in the face
providing a foundation and an advantage to treating specific areas like the lips
the key is balance when someone looks at you they look at an area within an
inverted triangle which includes the eyes cheeks lips and chin the importance
of lips aesthetically can be appreciated by the high level of interest in
cosmetics such as lipstick and lip liner billions of dollars are spent on
products which are sold to create the perception of full and youthful
lips the limitation is that no cosmetic product can enhance or restore lip
volume and definition before choosing fillers or neurotoxin like Botox or
Dysport for lip enhancement I take photos of your face from different
angles often my patients will show me how their lips looked when they were
younger to give me a sense of whether their lips
were naturally thin in the past or any other specific characteristics they want
to preserve some of our younger patients bring photos to show an ideal lip
appearance that they would like their lips to resemble in addition I review
some important principles which guide my approach to lip aesthetics I begin with
looking at the front view of the lips with some ethnic specific exceptions I
apply the golden ratio also known as Phi which is a ratio underlying Beauty seen
throughout nature the ratio of 1 to 1.6 applies to proportions in the face
including the volume and size of the lips a proportion which also applies to
the lips is one-third to two-thirds which means that the balance is
one-third for the upper lip to two thirds for the lower lip I also look at
the projection of the lips from the side in relation to the chin and other
guidelines using specific measurements refer to Ricketts and Steiner lines I
look in detail at specific aspects of lips such as the philtrum, Cupid’s bow
the vermilion border the lip body the G and K points and the orientation of the
outer corners of the lips I look at the skin quality around the lips such as the
presence of vertical lines and skin discolorations objective measures and
proportions guide the artistry to determine how the lips will fit with the
rest of the facial features I think it’s important to recognize some concepts we
go enhancement of the lips when patients
who are younger come in there are two common situations the first is the
younger person who feels their lips are genetically thin or they feel that the
upper lip is too thin in proportion to the volume of the lower lip the second
situation is when a younger person has proportional volume in their lips and
want to further enhance or beautify their lips for people who are noticing
aging changes in their face such as loss of volume where the lips have become
dinner with loss of definition of the Vermilion border as well as some or many
vertical lines the purpose is to restore or correct the lip volume and definition
I would also note that more men are coming in than in previous years for lip
enhancement regardless of age every patient wants their lips to look natural
and not overdone they are also concerned about how they will look immediately
after any procedure done to enhance the lips in particular the risks of
significant swelling or bruising I discuss a strategy with my patients
based on their specific concerns as well as the techniques I apply to allow them
to have minimal swelling or bruising lip enhancement can include the use of
neurotoxins such as Botox or Dysport for vertical lines outer corner lip lift and
for the upper border the lip to turn slightly upward often referred to as a
lip flip the other part of lip enhancement involves a restoration or
augmentation of volume this is where I use different fillers from the
hyaluronic acid family such as Restylane and Juvederm hyaluronic acid exists
naturally in the body and the filler material is slowly metabolized and
usually lasts about 4 to 6 months I use different fillers to fill fine lines and
volume in the lips there is a lot of artistry in lip filler placement
the challenge is to place the filler with minimal trauma repeated injections
with needles can result in swelling which makes accurate placement more
difficult I routinely use blunt cannulas to minimize needle related trauma to the
lips and patients are often surprised as to how little discomfort they
experienced my approach in comparison to having lip procedures done elsewhere
naturally less swelling and the absence of bruising allows my patients to return
to their regular activities sooner than they would have with more traditional
approaches many people come in last-minute needing to look good in a
few days generally speaking this is achievable
I do routinely see all my injectable patients after two weeks to see how
things have settled and to see if additional filler would be beneficial
there is no question that the appearance of lips is very important to facial
appearance artistically performed lip enhancement can create a remarkable
effect on facial balance and appearance the popularity of lip enhancement
procedures makes choosing the right practitioner challenging understanding
that the ideal experience requires a combination of detailed analysis and
planning with maximal comfort and minimal trauma I hope you found this
information helpful thank you for your question

How do you cover bruises from lip filler injections? The desire to have attractive
lips is the reason why cosmetic brands sells so much lipstick lip gloss
and lip liner in my practice I find that a lot of my patients both men and women
who come in for cosmetic eyelid rejuvenation such as enhancement for
hooded eyes or puffy under eye bags as well as for injectables for cheekbone
chin and jaw enhancement appreciate how the lips are also affected by aging when
we discuss lip enhancement with fillers two major concerns come up one the fear
of looking like a duck – the fear of bruising I assure them that the fear of
looking like a duck or the list of people in the media they mentioned whose
lips look too big is something I’m confident that will not happen when I
perform their lip enhancement my goal is to make the lips look appropriate for
the individuals facial features so the lips don’t look out of place as far as
bruising is concerned they often mention a friend or several friends who had
bruises and swelling which was so significant it prevented them from going
to work again I assured them by explaining that as a surgeon who’s
performed a wide range of lip procedures long before the popularity of injectable
fillers I have my own approach to enhance the lips and consistently avoid
bruising I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and
Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in
practice in Manhattan and Long Island for over 20 years
bruising occurs when there is bleeding when bruising happens during or after
lip filler injection it’s due to the needle piercing a blood vessel the more
times a needle pokes the lips the more likely a bruise will occur this also
increases the numbers of bruises I begin any lip enhancement with first and
analysis of the aspect of the lips which would benefit from additional volume
this allows me to consider strategically how to use the least number of points of
placement to achieve the desired outcome I routinely use blunt cannulas instead
of needles to place filler by using blunt cannulas there is less of a chance
of piercing a blood vessel in contrast to a needle for lips I use a range of
hyaluronic acid fillers such as Restylane-L, Restylane Silk, Juvederm XC
and Juvederm Voluma I find these softer fillers ideal for the natural soft
quality of the lips this allows for the lips to move naturally with talking
smiling eating and kissing I prefer hyaluronic acid fillers over other
options such as fat grafting or implants I’m able to place these fillers with
fine precision to address volume and contour asymmetries these materials are
metabolized naturally because hyaluronic acid occurs naturally in the body
unfortunately disproportionate lips and bruising strikes fear in the hearts of
men and women considering lip enhancement as with general health
prevention is the best approach although excessive swelling and bruising from lip
augmentation can be common both issues can be addressed with optimal technique
I feel that there is a particular value for a lot of patients who come in and
wear lipstick in a way where they literally draw the lips they wish they
had this means that the lipstick goes well outside of the borders of the lips
essentially there is a potential space where the lip volume has diminished
typically associated with aging that can be enhanced as I often discuss during
consultation lips play a very important part in your facial appearance minimally
traumatic and artistically placed volume can have a tremendous impact on your
appearance don’t let the fear of swelling or bruising stop you from
enjoying the benefits of naturally full lips I hope you found this information
helpful thank you for your question

How can I minimize scars from a hair transplant?
Prior to establishing the nonsurgical treatment for thinning hair which we call Trichostem®
Hair Regeneration, minimizing the scars from hair transplant surgery was one of the most
significant challenges I faced when performing hair transplant.
I’ll discuss my perspective on how hair loss is optimally managed including hair transplant
surgery as well as nonsurgical hair loss treatment.
I’m Dr. Amiya Prasad, I’m a Board Certified Cosmetic Surgeon and Fellowship Trained Oculofacial
Plastic & Reconstructive Surgeon.
I’ve been in practice in Manhattan and Long Island for over 20 years.
I performed surgical hair transplant throughout my career with most of my experience being
with FUT which is an abbreviation for “follicular unit transplantation” also known as “strip
surgery”.
The “strip” refers to the strip of hair bearing skin that I would remove to use for
hair grafts.
As a Cosmetic Surgeon who routinely performs facial procedures such as facelift and brow
lift, I focused on how to attain a well-healed minimally perceptible scar.
One of the tools I used in this effort was extracellular matrix by ACell.
This material enhances wound healing through the activation of your own adult stem cells.
I routinely used this material to optimize healing for facelift incisions as well as
for reconstructive procedures.
This strategy worked out very well as I found the strip incisions to heal faster with overall
better long-term results.
I also used the same material to enhance the healing of the hair grafts.
A major frustration with hair transplant surgery is that a percentage of hair grafts will not
survive ranging from 10% to as high as over 90%.
I found that with acellular matrix that the hair grafts healed much better and the survival
rate of the grafts went up considerably.
I also noticed that after one year that thinning hair located outside of the transplanted area
actually increased in number and became thicker.
This was the inspiration for my developing a system of treating thinning hair without
surgery.
Around the same time, the popularity of strip surgery was being overtaken by a different
approach called FUE or follicular unit extraction.
This was essentially because of the frustration felt by people who had hair transplant surgery
with what was referred to as “ugly strip scars”.
In my opinion the so called “ugly strip scars” was the result of an aggressive single
procedure or multiple strip harvesting creating significant skin shortage and tension resulting
in suboptimal healing.
I would also assert that many people were being operated on who were not good candidates
for hair transplant surgery, which resulted in poor healing of the donor area incision.
In many instances, if the patient had straight or wavy hair, these scars could be hidden.
During this time it became a popular trend, particularly for younger people to wear their
hair very short making the strip scar less desirable.
This resulted in a growing demand for FUE surgery, which was being marketed as “scar-less
surgery”.
The term “scar-less” surgery is inaccurate.
The grafts are harvested in a much larger area than FUT surgery with small round skin
punches.
There needs to be a minimal distance between these punches, which results in a wide area
of hair bearing skin to be harvested from.
This area is way outside of the true permanent hair zone.
Further, the claim of scar-less surgery is far from accurate.
In actuality, there’s considerably more scar tissue in comparison to an FUT or strip
surgery.
The more significant issue is the survival rate of hair grafts.
In FUE surgery, it is generally understood that about 30% of grafts are transected which
means there is no root when the hair graft is placed.
In addition, due to the limited amount of tissue in each graft, the graft survival rate
is lower in comparison to FUT or strip surgery.
I find that when the question of minimizing scarring in hair transplant surgery is raised,
it is predicated on an assumption that hair transplant surgery is the best option for
your hair loss.
This may not be the case.
During the many years I performed hair transplant, I found that most people who come in for consultation
for hair transplant are men and women with thinning hair.
Typically, they would come in when they felt that their hair loss was getting much worse.
Frequently, the perception was that their hair loss was progressing much faster than
it was over the past few years.
The fact is that hair transplant surgery does nothing for hair thinning.
As mentioned earlier, I developed TrichoStem® Hair Regeneration in part because I recognized
that there was a potential to get results which could be better than surgical hair transplant.
How could that be possible?
Since most people coming in for consultation had thinning hair, I recognized that the density
of their existing hair was much better than the density that would be created with a hair
transplant.
Native hairs exist naturally more close to each other than a hair transplant can safely
achieve.
The density of your native hair even when thinning can be 50-100 hairs per square centimeter,
while a transplant is typically about 20 grafts per square centimeter.
This means that reactivating hair that is not growing and thickening of your thinning
hair can result in better coverage than hair transplant surgery.
I worked everyday on dosing and delivery methods for optimal results using Acellular matrix
and PRP or platelet rich plasma.
I followed my patients closely with high resolution digital photography and microscopy every three
to six months for years.
It became clear that my hypothesis was right.
Contrary to the assumptions of hair transplant surgeons for whom the first line for hair
thinning is surgery, TrichoStem® Hair Regeneration provided more effective scalp coverage than
even 2 hair transplant surgeries.
In fact, the success of this system of hair loss inspired to me to build a freestanding
center in Northern Virginia, to help make our system accessible to more people.
One variable that is relevant, particularly for people with good density is that during
hair transplant, much of the existing thin hairs are permanently lost because of direct
trauma during surgery as well as vascular compromise and inflammation.
This has always been well known as so called; ”collateral loss” with the rationale being
that the thin native hairs were going to go away eventually and thicker hair were being
transplanted.
When someone has already lost a lot of hair and they are losing their hair at a fast rate,
hair transplant surgery cannot keep up with this degree of loss.
Each surgery after the first typically has less hair to harvest for grafts.
More surgery, means more scars.
I regularly see people who had several hair transplants over the course of 5 to 10 years
and still they don’t appear to have much hair.
Now, with TrichoStem® Hair Regeneration this approach of performing multiple surgeries
to keep up with progressive hair loss is no longer the first line of therapy for thinning
hair.
I feel that the only indication for hair transplant is to place hair in an area toward the front
where the skin is smooth and bald for many years.
For everyone else, since 2011, TrichoStem® Hair Regeneration has been the optimal system
for men and women with thinning hair in my practice.
There are of course limitations.
Hair loss is not cured, hair loss is managed.
Medical therapy such as DHT blockers and hormonal replacement can potentially optimize the longevity
of hair growth.
Hair loss is still going to progress.
However, the option to improve your scalp coverage with one to two treatments performed
over a 2 year period with longevity of benefit being typically 3 to 5 years and in many situations
even longer is far more accessible, convenient, less risky and more economical than surgical
hair transplantation.
Since 2011, I observed the hair loss profiles of a wide range of patients who came from
around the world and developed a classification system for hair loss for men and women.
This classification is used to create customized treatment plans based on gender, age, age
of onset of hair loss, rate of progression, degree of hair loss and other medical variables.
I find that during consultation, I generally suggest hair transplant to be something to
consider as a last option after achieving the full results of TrichoStem® Hair Regeneration.
99 plus percent of my patients don’t pursue hair transplant after TrichoStem® Hair Regeneration.
I’ve observed that most people look for a hair loss solution after they’ve passed
a certain threshold of hair loss.
This motivates them to pursue a solution.
I find that once there is a significant improvement and a stable appearance for several years,
they feel better and less anxious about their hair.
In fact, many people who’ve undergone hair transplant come for TrichoStem® Hair Regeneration.
As mentioned earlier, since hair transplant does nothing for hair loss progression, many
people who’ve had hair transplant have come to manage their thinning hair rather than
undergo a second hair transplant operation.
In addition, we’ve treated many people who want to optimize their hair transplant results
by coming in within the first three months after their surgery.
The benefits of improving the hair transplant healing process coupled with the reactivation
and thickening of existing hair helps to optimize scalp coverage after surgery.
In conclusion, the best way to minimize hair transplant scars is to not have a hair transplant
at all.
If hair transplant is going to be necessary, then I would suggest considering non-surgical
options to maximize the coverage and longevity of your existing hair before considering hair
transplant surgery.
For people who want hair in a smooth and bald area, if there is hair present in the mid
scalp and crown, a procedure like TrichoStem Hair Regeneration can improve the total scalp
coverage so you won’t need to be as aggressive with surgical hair transplant.
I hope you found this information helpful, thank you for your question.

Is Kybella® a good procedure for double chins? There’s been a lot of excitement
about the product Kybella® after introduction to the market in 2015
Allergan the company behind Kybella® obtained FDA approval for the
non-surgical dissolution or dissolving of fact under the chin also known as a
double chin or medically referred to as submental fat there was often a lot of
buzz for any new non-surgical treatment as an alternative to surgery
so is Kybella® a more effective and convenient treatment for people looking
to address their double chin in comparison to a surgical procedure I’ll
discuss how I looked at kybella as an option in my practice I’m Dr. Amiya
Prasad I’m a Board-certified cosmetic surgeon and Fellowship-trained
oculofacial plastic and reconstructive surgeon I’ve been in practice in
Manhattan and Long Island for over 20 years I have been treating the double
chin or submental fat area throughout my career using different methods of
liposuction or facial liposculpture as well as non-surgical long pulsed 1064
yaga laser although I’m trained and practiced as a surgeon I routinely
integrate non-surgical procedures in my practice to help my patients in the best
way I can I’ve always pursued my training and
ongoing education by integrating information and experience from multiple
specialties to do what matters most helping my patients in the safest most
predictable and beneficial way being in practice for so long I’ve witnessed such
hypocritical self-interest and Inter specialty rivalry
has resulted in an erosion of the general public’s trust in the medical
profession every physicians single mission should simply be to put the
patient’s best interest above everything so let’s take a look at kybella the
active ingredient in Kybella® is a chemical called deoxycholic acid deoxycholic acid
naturally exists in your bile which is stored in your gallbladder and is used
for the digestion of fat it makes sense that the same chemical for fat digestion
in your intestines can be used for fat dissolving under the skin people who
want to improve the appearance of double chin are understandably excited
about being able to have their double chin improve without surgery the catch
is that kybella can take up to six treatment sessions to achieve the
desired result which means you have to have multiple injections over multiple
sessions these injections typically cause swelling as well as skin
discoloration for extended periods of time the ability to control the amount
of fat being dissolved is difficult with Kybella® since a liquid injected under
your skin can spread to areas where you don’t want it to go this is a problem
because a certain layer of fat directly below your skin is beneficial for
healthy as well as youthful looking skin as mentioned earlier my objective is to
help my patients by recommending procedures which are safe highly
predictable and allow for quick recovery many people are afraid of the word
surgery and many non surgeons as well as non physicians unethically take
advantage of this fear for their own financial benefit I’ve helped many
patients who are apprehensive about surgery come to understand some basic
prints one entering the skin with a needle is
an invasive procedure subject to many of the same complications as surgery to a
surgical procedure performed under general anesthesia can be safer and more
predictable than a non-surgical alternative by using local anesthesia in
my practice I routinely reduce fat under the chin and jowls with local anesthesia
and LITE IV sedation as per the patient’s preference I’m able to sculpt
the fat which means being able to protect the skin and allow the retention
of the healthy layer of fat needed for smooth looking skin the procedure takes
little time to perform and the benefits are appreciated in real time the
patients can go back to work within a few days and they don’t typically need
any additional sessions the highly aggressive marketing of kybella
by both the company and the practitioners hoping to profit from
another cosmetic retail service has resulted in everyone concerned about the
appearance of their neck to think that Kybella® is the way to go there are some
limits to both facial liposculpture and Kybella® if you are significantly
overweight for example it’s important to understand through a proper evaluation
how much of the appearance of the under chin and neck area is related to fat
that is accessible and how much fat is in the deeper tissue which is not
accessible optimally a treatment like facial liposculpture is done for
stubborn fat not diminishing in spite of you being close to your ideal body
weight loose skin under the neck is not due to fat but from skin and soft tissue
sagging associated with age or from significant weight loss generally this
needs to be addressed by some type of lifting
procedure floating the excision or removal of redundant skin for example if
the loose skin is due to aging then a neck lifting procedure may be
appropriate for people with moderate skin laxity a minimally invasive suture
suspension neck lifts may be performed without the need for more extensive
surgery if there is a small amount of fat and skin laxity a non-surgical gel
lift procedure such as a long pulsed nd-yag laser treatment can both reduce
fat and contract the skin to create better jawline definition another issue
which is not addressed by facial liposculpture and Kybella® is the
appearance of platysmal bands the platysma muscle starts at the base of
the neck and runs up to the sides of the neck all the way to the chin lattissima
bands can be addressed with the neurotoxins such as botulinum toxins in
Botox Dysport Xeomin and Jeuveau if there is also significant skin laxity
then a neck lift is also an option the appearance of excess volume under the
chin can also be caused by the natural anatomy of having a low hyoid bone the
hyoid bone is responsible for the angle between the chin and the neck a low
hyoid bone can create the perception of having a double chin loose skin under
the chin can also be associated with the deficiency in the bone structure which
can be caused by genetics aging or a combination of the two I perform a
procedure called Structural Volumizing where I place long-lasting hyaluronic
acid fillers such as Juvederm Ultra Plus and Juvederm Voluma in a way which is
comparable to the placement of facial implants by enhancing the bone structure
of the cheeks the chin and jaw angle and neck skin the elevated neck skin and the
facial proportions can look significantly better while having a
non-surgical treatment to improve the appearance of a double chin may be
attractive it’s important to recognize that there are many different anatomic
issues which can all be described as a double chin this means that a proper
examination by a doctor without any bias is the first step to your understanding
what treatment strategy is best for you if you have fat under the chin and you
are in a healthy weight range with good skin tone the question is which is a
better option Kybella® or facial liposculpture in my opinion I am serving
my patients better by performing facial liposculpture with local anesthesia
rather than having them come in for multiple sessions with less
predictability and more total recovery time using Kybella®
I hope you found this information helpful thank you for your question

Is facial stem cell therapy a good treatment?
The term stem cells have many people excited about their potential as the
secret to the Fountain of Youth I couldn’t believe my eyes when several
years ago I saw board-certified dermatologists selling stem cell creams
on late night infomercials late night infomercials are of course where the
most authentic science is broadcast currently the term stem cell is being
used for so many products and treatments that the actual scientific foundation
for this term is lost in all of this marketing noise it’s understandable why
there is confusion about the term stem cells I’ll discuss my perspective on the
general topic of stem cell based therapy for facial rejuvenation in my practice
I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and
Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in
practice in Manhattan and Long Island for over 20 years in the aesthetic field
a few years ago procedures refer to as stem cell facelift began to appear and
patients would inquire about these procedures first of all like many
marketing misnomers none of these procedures were actual surgical
facelifts in that there were no incisions or actual vertical lifting of
the skin they appear to be harvesting fat and then processing the fat with the
claim that a higher concentration of fat or adipose derived stem cells were being
injected under the skin for the purpose of improving volume loss and skin
quality so what are stem cells stem cells are types of cells which have
the ability to become more specialized cells in the body for example stem cells
in the bone marrow can turn into different types of specialized blood
cells such as red blood cells and white blood cells unfortunately many people
have been harmed by unethical practitioners offering stem cell
products to the point where the US FDA has taken action to stop the use of stem
cell products not approved by the FDA this is a quote from the FDA the only
stem cell based products that are FDA approved for use in the United States
consists of blood-forming stem cells hematopoietic progenitor cells derived
from cord blood so an adult stem cell is thought to be an undifferentiated or not
specialized cell found among differentiated or specialized cells in a
tissue or organ the adult stem cell can renew itself and can differentiate to
yield some or all of the major specialized cell types of the tissue or
organ this means that we can perform therapies which helped you through
activation of your own adult stem cells inside your body for example I use PRP
or platelet-rich plasma as well as acellular matrix both of which activate
your body’s adult stem cells so the FDA statement does not apply to treatments
where your stem cells are being harvested or activated and used in
certain clinical situations several of my colleagues myself included feel that
the term stem cell facelift is typically being used to rebrand fat grafting with
a higher price tag as has become the rule more than the exception
the marketing message is claiming benefit
which in my opinion are exaggerated at the most basic level there are three
questions both practitioners and consumers should ask 1 indications
what are the indications which make someone a candidate for a stem-cell
facelift 2 benefits what benefit does the stem cell facelift provide and are
the benefits superior to other options including fat grafting
3 predictability how predictable are the results of a stem-cell facelift there
are of course many more questions but let’s start with the question about
indications one indication for this procedure is facial volume loss since
this procedure is limited to adding volume below the skin
I see no advantage over any injectable filler or fat grafting since this type
of procedure is used to help people experiencing volume loss from facial
aging there is an inherent flaw in this treatment strategy age-related facial
volume loss is proportionally much greater at the bone level than it is at
the level below the skin whether a deficiency in facial bone structure is
due to genetics aging or a combination restoring volume at the bone level will
be more impactful than any material placed just below the skin I perform a
procedure called structural volumizing where I place a long-lasting hyaluronic
acid filler such as Juvederm Ultra Plus and Juvederm Voluma at the bone level
restoring volume at the bone level in the cheeks chin jaw angle and jaw line
creates facial balance which can be appreciated immediately and predictably
if anything Structural Volumizing or the Y lift results can Pier as if someone
actually had a surgical facelift in terms of benefits and predictability
differentiating the benefits stem-cell facelift have over fat grafting remains
unclear scientific hypotheses can be made to support the potential benefits
of fat or adipose derived stem cells but do clinical results substantiate these
hypotheses it appears that clinical results do not
support benefits and predictability of so-called stem cell “facelift” as
advantageous over fat grafting that’s a problem since fat grafting is fairly
unpredictable in that 30 to 70 percent of the volume placed doesn’t survive in
addition there’s a high incidence of lumps and irregularities
not to mention asymmetry procedures which are highly predictable safe and
effective tend to stand the test of time I can personally attest to this
firsthand when I first went into practice more than 20 years ago I
questioned the need for general anesthesia for many cosmetic surgical
procedures so I developed my own approach to performing procedures such
as eyelid surgery facelift surgery as well as body procedures using local
anesthesia at the time I received a lot of backlash from many surgeons some of
those same surgeons today have incorporated my approach into their
practice close to 10 years ago I recognized the potential benefit of PRP
with a cell or a cellular matrix for the non-surgical treatment of male and
female pattern hair loss in spite of my showing so many successful outcomes hair
transplant surgeons and dermatologists were dismissive and openly derogatory
about both PRP and a cell so what happened the system I developed was
effective for hundreds of patients coming to me every year from around the
world that in the last two years many doctors decide to just start trying to
use PRP and PRP with a cell for hair loss treatment they’re not so dismissive
anymore the same can be said when I started using PRP for skin rejuvenation
and scar treatment more than 10 years ago the German philosopher Arthur
Schopenhauer said, “All truth passes through three stages first it is
ridiculed second it is violently opposed third it’s accepted as being
self-evident” having experienced Schopenhauer’s observation throughout my
career I won’t dismiss the concept of stem cell facelift as not having a
potential future the value from harvesting fat and using the adult stem
cells in fact for skin quality improvement is a good concept however
unless the procedure can meet my standard for safety predictability and
quick recovery I will continue to employ other strategies for my patients who
would have been potential stem cell facelift candidates again working from
the inside out for bone volume loss and minimal skin sagging I perform
Structural Volumizing meaning are placed long lasting hyaluronic acid fillers at
the bone level to enhance the cheekbones chin jaw angle and jawline it’s
important for consumers to understand that achieving this outcome is very much
technique dependent I routinely see people who had filler placement in their
cheeks and they know that they have more volume but they don’t feel like they
look like themselves this is because the filler is really in this soft tissue
under the skin and spread around creating a rounded
appearance for the purpose of skin quality improvement below the skin
within the fatty layers of the skin I use platelet-rich plasma or PRP PRP has
been studied extensively and has been shown to improve many of the elements
which contribute to good skin quality including blood supply and the vitality
of the fat cells below the skin I have helped several patients whose skin was
compromised from multiple infections scarring and surgical trauma with PRP as
well as through combining PRP with a cellular matrix in fact several studies
have shown improved fat graft survivability when PRP was used I use
PRP below the skin and I combined PRP with hyaluronic acid to enhance the
backbone of the skin called the dermis using a specialized device we refer to
this as skin boosting superficial or epidermal skin management is customized
but broadly speaking for pigmentation vessels and skin quality I use both non
ablative lasers like a Q switch YAG laser and a blade of lasers like
fractional and erbium or co2 laser for general epidermal management I use
hydro facial which is a water-based microdermabrasion with active
ingredients such as glycolic acid I have throughout my career pursued and
advocated innovation I continue to be optimistic about the future of stem cell
technology as far as stem cell facelifts thread lifts and thermal heating devices
claiming to lift faces without surgery or concerned it’s important that you
make an informed decision about the risks benefits and I cannot
stress this enough the alternatives of a proposed revolutionary procedure similar
to pharmaceutical advertising the marketing of aesthetic devices and
services is so persuasive that the general public is essentially being
trained to want these products without the benefit of unbiased and objective
professional guidance more than ever it is invaluable for you to have a
specialized physician on your side to help you understand what is
appropriate for your individual concerns I see so many people every year who
decided to respond to an ad for some aesthetic deal only for them to have to
deal with the consequences of their decision and become consumed with regret
this is followed up by them spending an inordinate amount of time pursuing a
solution unfortunately you can’t hit a reset button I hope you found this
information helpful thank you for your question

Is non-incisional Asian double eyelid surgery right for me?
Double eyelid surgery or eyelid crease surgery is a popular request from patients of Asian ethnicity who see me in consultation.
They often expressed a preference for non-incisional double eyelid procedure. This is based on a belief that the non-incisional procedure is a less invasive or minimally invasive procedure. If I get to the surgery sometimes of course non-incisional approach creation eyelid surgery or double eyelid surgery is still a surgical procedure and it can be affected. I’ll discuss how i determine during the consultation and examination wheather you’re a good candidate for the non-incisional Asian eyelid surgery. I’m doctor Amiya Prasad I’m a board-certified cosmetic surgeon and fellowship trained occulofacial plastic and reconstructive surgeon. I’ve been practicing in New York city and Long Island for over 25 years. As a cosmetic eyelid surgery specialist i would deal primarily and revision surgery procedures performed by other doctors. For example I help people improve their appearance of their hooded eyelids and under eye bags. I also performed advance eyelid surgery for conditions like eyelid ptosis or eyelid retraction and eyelid ectropion. I’m also become well-known for my approached to performing ethnic specific eyelid surgery for people with darker skin as well as Asian double eyelid surgery. Its well known that double eyelid surgery is a popular treatment worldwide among people of Asian descent.

It’s estimated that about 50 percent of Asians such as those Koreans, Chinese or Japanese lineage are born with an eyelid crease also known as double eyelid. The other 50% either have no eyelid crease or what refers to monolid or don’t have a deep or defined crease. Rather a single shallow crease or multiple shallow creases. The purpose of Asian double eyelid surgery in general is to create a defined eyelid crease when there wasn’t one there before. Or to create a more defined crease where there where previously more shallow crease or multiple undefined creases. An eyelid crease made surgically by creating a connection between the eyelid skin and the muscle that lift the eyelid called levator muscle. The word levator was like the word elevator but without the letter e. A surgical connection is made by passing the suture through the skin and levator muscle in both non-incisional and incisional approaches to Asian double eyelid surgery.
The point where the skin and muscle are suture together is where the eyelid skin folds in when the eyes are open. I perform incisional Asian eyelid surgery in situations whether maybe excess skin, excess fat or combination of both.

This is a situation that is commonly seen in older people where the fat may have pushed forward due to aging can prevent from securing proper connection between the skin and levator muscle to create a stable and well defined crease. Older patients generally have stretched or redundant skin which needs to be tailored in order to create a well defined eyelid crease. Since younger people haven’t yet experience skin laxity due to aging and often lil to no fat upper eyelid where it can be a problem. There are often time candidate for non-incisional approach to Asian eyelid surgery. I also perform non-incisional eyelid procedure for patients who had previous excisional surgery where skin and fat had been removed.

I’ve observed that the definition of the eyelid crease can be improved in the situation using this non-incisional approach. During the incisional asian eyelid surgery i create a connection between the skin and the levetor muscle using limited small openings located on the skin where i intend to crease. During consultation I show my patients a very accurate approximation of how their eyelids will appear after surgery.

I do this by using an instrument or a q-tip to stabilize the eyelid skin in a way such that in sutures will be placed during a non incisional procedure. I would performed both the incisional and non-incisional double eyelid surgery using local anesthesia with LITE IV sedation in my office operating facilities. My patient are relaxed, just sleeping without having to go the risk and complications that are associated with general anesthesia. My patients usually get back to work in a few days with minimum swelling.
So to answer the question of whether the non-incisional approach is right for you, it depends on your individual anatomy. Ultimately you should be comfortable with your surgeons familiarity and experience with Asian anatomy and the eyelid surgery. And hopefully you found this information helpful. Thank you for your question.

How can I minimize the appearance of facelift scars?

A surgical facelift is a highly effective way to lift sagging cheeks and jowls to create a more
youthful appearance one of the most common concerns expressed during a
consultation when I discuss face lifts as part of a facial rejuvenation plan is
the potential visibility of the facelifts scar which is located at the
sides by the ears my approach to cosmetic procedures
whether it’s facelift eyelid rejuvenation and non-surgical procedures
such as injectables is to retain my patients unique facial character while
achieving a naturally refreshed look generally speaking the people who I care
for like looking like the best and natural versions of themselves at any
age I’ll share how I’m in amaizing appearance of facelift incisions in my
practice I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and
Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in
practice in New York City and Long Island for over 25 years I perform all
types of facelifts such as short scar mini lifts deep plane facelift and
extensive face and neck lifts I’m also called upon to help people who have
undesirable faces of scars from other doctors this is due in part to my having
developed my own adult stem cell based regenerative healing strategies for
tissue loss surgical incisions and scar revision there are several factors that
affect the appearance of facelift incisions these factors include the
placement of the incision the tension on the incision after
closure and the way the tissue heals over the next several months after
surgery I cannot stress enough some basic strategies which I employ that I
believe are critical to optimal results for any surgery for example in my
practice I spend a lot of time with my patients in my exam room with them
sitting up the for surgery so I can place my markings for the incisions
strategically I examine my patients face and neck skin and soft-tissue to
determine the optimal direction of elevation and to determine the potential
level of tension there will be after the skin is trimmed and the sutures are
placed this is a critical part of the artistry and for me to visualize the
results I expect to achieve since I have my own facilities i allocate and factor
in additional time to allow me to never be rushed during surgery this is
something that many of my patients understand that by investing their
resources and time and having this level of attention they able to get better
outcomes I’ve seen many patients who were operated on by high volume low cost
doctors who claim to be the number one plastic surgeon wherever they are this
type of doctor rushes through surgery to make up for the money they need to make
in order to charge such low prices and they end up doing unintentionally subpar
work I’ve also seen poor outcomes in patients of doctors who claim to be the
best and charge a lot but end up taking on too much work and the patients don’t
get the quality results they otherwise could have once again I decided to treat
each patient so that there’s no time pressure and I have my schedule managed
accordingly if you think about it like an athlete a surgeon has a timeframe of
peak performance in any given day as far as how placement of the face
that incisions affect visibility or the potential of a telltale sign of having
had surgery I factored in the skin texture the color and contrast with the
skin at the opening of the ear and the characteristics of the sideburn for a
more extensive face and neck lift where the incision goes around the earlobe and
extends upward behind the ear and back towards the hair I designed the
placement so if a woman wants to pull her hair back the incision will be well
hidden skin shortage and tension at the earlobe can result in downward
displacement to the earlobe which is referred to as a pixie ear deformity
when this occurs the earlobe appears attached and elongated
as opposed to detached and freely mobile I have helped people who have come to me
with this problem by detaching and redirecting the position of the earlobe
attachment I have seen many patients who’ve had wide scars in front of their
ears due to excess skin tension one reason for this is simply removing too
much skin and relying on the skin alone to lift the face this is not as
effective as lifting the underlying tissue called the SMAS or superficial
musculo aponeurotic system as the foundation for the skin to be supported
by poor artistry or execution of the skin trimming is another reason for
stretching of the scar by the ear as I stated earlier it takes time and
artistic vision to plan as well as surgical skill and experience to achieve
optimal results I feel that my experience allows me to better predict
the potential issues that can occur so I can take the appropriate steps to
optimize my patients healing is it possible for well performed surgery to
have issues with incision visibility related to how the skin heals afterwards
the answer is yes it’s possible I approach this part of the healing after
surgery by using advanced wound healing technology to expedite the processes
that occur during wound healing I use materials such as extracellular matrix
by a cell which has been used to regenerate a wide range of tissue in the
body for example extracellular matrix was used to regenerate an entire
fingertip including the fingernail and even the fingerprint after a traumatic
amputation injury I often combine extracellular matrix of platelet-rich
plasma or PRP which is derived from your own blood as a catalyst for this process
I have successfully used this strategy with facelift incisions which appear to
be virtually invisible in as little as one month after surgery aftercare by the
patient and close monitoring by myself and the staff is a very important part
of a strategy to achieve optimal results while not directly associated with
facelift scars I attribute part of the faster facelift recovery my patients
experienced by my performing the procedure using local anesthesia with
LITE IV sedation instead of general anesthesia general anesthesia requires
the patient to be paralyzed and the patient needs to be on a respirator in
order to breathe the face can be distorted by the presence of breathing
tubes and other medical apparatus needed when you have general anesthesia since I
use local anesthesia with Lite IV sedation the patient is comfortable and
in a twilight state of consciousness my patient’s face is in a more natural
state and I have the ability to be much more precise my patients go home the
same day a surgery without suffering the side-effects of general anesthesia or
needing to be in a facility for monitoring for
when face ups are performed with general anesthesia patients generally need to
stay in an overnight facility often with drains and extensive facial bandaging
the side effects of general anesthesia can linger for about a week and even
delay the progress of surgical recovery in contrast my patients undergoing the
procedure with local anesthesia typically only require a light facial
dressing and return to work in about a week
for example many years ago I actually performed upper and lower eyelid surgery
as well as a facelift for a lady who wanted to look good for her son’s
wedding which transpired 10 days later she did very well but I would recommend
a little more time before a significant event where you are getting a
significant amount of attention while no incision can be completely invisible a
face lift incision can be virtually imperceptible with a combination of
minimal tension optimal placement advanced healing and proper aftercare
your facelift results start with the judgement experience and expertise of
your surgeon I often perform face lifts with other rejuvenating procedures
including eyelid surgery and facial filler placement as I said earlier I
believe in taking a lot of time to plan and design each patient surgery before
they go into the operating room in the operating room I allocate extra time to
allow me to perform my patients procedure without any time related
pressures every step matters my strategy is also flexible and I make the
adjustments as the results of the procedure I’m performing materializing
meticulous suture placement is also critical for optimal healing which of
course takes time my patients understand the value of investing their resources
and time to have the level of care they need in order to get
the natural results that they want my patients are with me for the long term
and I continue to be their beauty doctor for injectables laser and skin
rejuvenation for years after I performed their facelift surgery
I believe that surgeons whose practices are geared toward volume cannot provide
quality because of limited time and being rushed and unable to focus this
statistically can lead to a higher rate of undesirable scars and other avoidable
complications I hope you found this information helpful thank you for your
question

What can I do if the fillers in my face haven’t gone away?

Hyaluronic acid fillers such as in the
Restylane and Juvederm family of fillers have made a
radical shift in how fillers are used in aesthetics
since the mid-2000s in comparison to previous fillers
hyaluronic acid fillers are safer more convenient
and easily metabolized hyaluronic acid exists
naturally in the body in areas such as in the joint spaces the skin and even
the eye there are some instances where
hyaluronic acid filler remains longer in the body than would be
expected i’ll discuss the reasons why this can
happen and how i manage patients with this
problem in my practice I’m Dr Amiya Prasad
i’m a Board-certified cosmetic surgeon and Fellowship-trained
oculofacial plastic and reconstructive surgeon
i’ve been in practice in New York City and Long Island
for over 25 years i perform hyaluronic acid filler
placement for my patients every day in my practice i routinely
help people improve the appearance of the lips under
eye hollows and the smile lines or parentheses lines i also use thicker
hyaluronic acid fillers for the purposes of restoring the volume
at foundational level of the bone in areas such as the
cheeks chin jaw angle and jawline i’m also frequently consulted to reverse
hyaluronic acid filler and to even surgically remove permanent
and semi-permanent fillers originally
performed by other doctors generally the longevity of a hyaluronic
acid filler is related to its thickness and its
viscosity for example a thicker filler such as
Juvederm Voluma would be placed in areas where there is
less movement and there is a need for more projection
such as the cheek area a filler like Juvederm
Voluma can last up to two years i generally use softer
hyaluronic acid fillers in facial areas where there is a lot of movement
such as the lips and the under eye area i routinely use fillers such as
Restylane-L and Juvederm Vobella for these areas
it’s generally expected that these hyaluronic acid fillers
will be gradually metabolized by the body
although hyaluronic acid exists naturally in the body
there are times when there is a response by the body to treat the filler
like a foreign material it remains undetermined
whether this response is related to the material itself
or the presence of any surface bacteria that is transferred into the skin at the
time of placement nonetheless the response of the body is
to create a capsule around the material
when the filler material is surrounded by a capsule
the natural breakdown of the hyaluronic acid
is actually prevented although this may sound like
an added benefit a lot of times the appearance
is less than ideal this leads to patients
wanting to find a way to remove the hyaluronic acid filler
fortunately the treatment for encapsulated hyaluronic acid filler
involves a strategy to dissolve the filler
as opposed to needing surgical removal which would be necessary for
semi-permanent or permanent fillers in order to dissolve hyaluronic acid i
used the enzyme hyaluronidase hyaluronidase is sold
under brand names like Vitrase and Hylenex hyaluronidase exists
naturally in your body as part of the normal metabolic processes
in the production and turnover of your body’s
own hyaluronic acid the technical challenge is to be able to
place the hyaluronidase inside the encapsulated hyaluronic acid
once the hyaluronidase contacts the filler material
the material dissolves immediately i’ve had several patients who had been
getting hyaluronic acid fillers for many years
in areas such as the soft tissue of the cheeks and around their eyes
i found that as i dissolved the areas where the filler was more superficial
the patient and i came to realize that there was even more
filler present in the deeper tissues which needed
additional treatment this simply meant
that more sessions were needed until we reached the point
that the original normal anatomy was restored sometimes patients are
surprised to find that the filler they had placed in one area
had migrated to an adjacent area for example
filler placed in the temple to treat hollowing
can migrate to the brow making the brow appear
swollen a common location where filler migration occurs
is the nasolabial fold many practitioners try to soften the
nasolabial fold by trying to place the filler directly
under the line due to the anatomy of the nasolabial
fold the filler can be displaced upward toward the cheek and
downward toward the lip encapsulation of the filler can still
occur when the filler has migrated to an area that it was
not originally intended for as mentioned earlier bacteria that
typically is present naturally on the skin
surface can end up on the surface of the injected filler
resulting in a type of infection called biofilm
in addition to encapsulation biofilm infection is characterized by periodic
episodes of swelling and inflammation biofilm is known to occur in different
areas of medicine related to any kind of foreign material
that is placed past the skin barrier such as an iv
catheter or a breast implant the issue with biofilm is that your own
immune system is unable to respond to the bacteria
effectively due to the absence of blood supply within the foreign material
the standard approach to any infection like this is to remove the foreign
material such as would be the case in the removal
of a breast implant in the case of biofilm associated with
hyaluronic acid filler the strategy is to use
hyaluronidase to completely dissolve the hyaluronic
acid where the biofilm is residing
the challenge with biofilm is often making the diagnosis
biofilm is sometimes diagnosed as an immune mediated issue so that the
patient gets treated with anti-inflammatory medications as well as
antibiotics once again the absence of blood supply
makes these strategies challenging and often frustrating
a lot of my patients who come in for hyaluronidase
treatment will report that they had hyaluronidase injection performed
unsuccessfully by the doctor who had originally
performed their filler injection i find that many doctors and
non-physicians who perform injectables are not familiar with the tissue anatomy
of the area they’re treating at the level that a
surgeon who performs surgery in the same area would be
this is particularly relevant around the eyes
patients are often surprised to learn that an oculofacial
plastic surgeon such as myself who trained in the early 90s in
ophthalmology during that time i was using
hyaluronidase routinely as part of the anesthetic procedure
before cataract surgery i used hyaluronidase to
improve local anesthetic absorption when
injecting local anesthetic around and behind the
eye this was called a retro bulbar injection
as an oculoplastic surgeon i have extensive experience in performing
surgery around the eye including the bones and the anatomical
spaces around the eye this means that my knowledge and
familiarity in this area is very different
from someone who’s never done work like this
since hyaluronic acid can migrate or be injected into the space deeper
than the superficial skin layers my knowledge and experience
in this area has been helpful for people who have had
hyaluronic acid injected around their eyes
a common fear is that hyaluronidase injection
use will affect the native hyaluronic acid
that would be dissolved in addition to the filler
potentially resulting in hollow appearance
in my clinical experience of performing hyaluronidase injections for a wide
range of patients for many years i have not observed any
significant issue with hollowing after treatment
since the body’s natural hyaluronic acid is continuously replenished
there is really no issue in the long term
in summary if there is a long-standing hyaluronic acid filler present
which needs to be removed the treating physician
should have the knowledge and experience with both the anatomic spaces
and the precise application of hyaluronidase
to achieve the best outcome i hope you found this information
helpful thank you for your question