Which filler would you recommend and which is more effective between Botox, Dysport, and Xeomin?

Dr. Dean Kane Q & A. 

Q. Right now in my life for being 43 years old I feel great and I think I look pretty good but, of course, we all have things we"d like to change. The thing that bothers me most is the tear trough area, and the upper eyelid. I know in the near future I will be getting an upper and lower eyelid lift, along with a face/neck lift. Until then can I get a filler that will last in the tear trough area, and botox/dysport in the upper eyelid area to lift a little. Is this possible without surgery?

A.  ​​​​Every patient is unique. Your bony and soft tissues, their symmetry and aging, your personal and perceived appearance and how it bothers you are just a few of the factors to review with a well experienced, Board Certified Plastic Surgeon or Facial ENT Surgeon who offers ALL these and other options.

​Since the effects of aging, weathering, sun-damage, ethnic background affects everyone differently, you may consider filler for the tear trough and Botox for the brow elevation and / or stage your surgery at this time when healing is better, scars will usually be smaller and skin elasticity is at its best.
​
​Consider more than one well experienced, Board Certified surgeons for evaluation as you may find that their Botox and Filler skills as well as their surgical skills and results will vary.
​
​One consideration come to mind and that is you may wish to have the upper and lower lids improved at the same time. Using access gained by both incisions, a mid-face lift may rejuvenate your cheeks, eliminate the tear trough, possibly elevate your jowls and bring you a longer duration of satisfaction.
​
​If you are a candidate for a short scar face lift (or MACS lift and other named procedures) you may improve the jowling and upper neck while younger and gain more youthful appearing years.
​
​Regarding which Fillers or Muscle Relaxers; the options are getting so numerous that each filler or muscle relaxers have their own peculiar niche of use.
​
​I happen to like Botox in the brow area for precision and Dysport in the lips for a softer relaxation.

​Hyaluronic Gel fillers such as the Restylane Family or Juvederm Family each have their nuances. Depending on each gels production and artificial molecular linking will determine:

1. ​their duration,
2. ​their projection,
3. ​their volumization (ie. water attraction).

​This determines where they provide the best "fill" you desire.
​
​Noting your tear trough example, some injectors have only superficial injector skills and will inject immediately under or within the skin (ie. dermis). Others, may feel comfortable injecting under the deeper muscles of the cheek next to the bone with a variety of techniques.

1. ​You may wish to use Restylane or Juvederm superficially but it has the side-effect of radiating a "tindel" bluish coloration or lumpiness on eyelid skin.
2. ​Silk in this location superficially may swell the tissues too much.
3. ​I achieve my best appearance under and over the deep muscles of the cheek with a more linked, longer duration filler such as Voluma or Perlane.

Yes, the possibilities are endless today and so you must find and trust a surgeon with a lot of experience using each option selected for your anatomy, concerns and budget.

​I hope this has been helpful. All the best!

Would you recommend Botox, Juvederm, or both for eye area?

Dr. Dean Kane Q & A.

Q. I was initially considering Botox for my crow's feet but now I'm thinking that Juvederm may be a better option for the under eye area. Or should I consider both - Botox for the crow's feet and Juvederm for the under eye area? What would you suggest and how much do you think would be needed?

A.  ​​​​While:

1. Botox for dynamic lines (such as the crows feet), and
2. ​Fillers for folds (such as tear troughs)

is not 100% true, it is a guideline.
​
​Dynamic lines are those created by active underlying muscles such as those around the eyes. Botox is great for crows feet relaxation but will not fully erase the etched dermal skin lines and a fine filler such as Silk works well synergistically with Botox at this site.

​Botox for the lines along the lower lid should be used very judiciously. Relaxing these muscles will soften the lines but eventually weaken the lower lid tone, "rounding" the eyelid.

​Separation of the soft tissues and muscles between the cheek and eyelid creates the tear trough. This passive process will not be helped with a muscle relaxer (and may worsen it) but must be filled. Depending on the skill of the injector, different layers of the tissues will fill out the depression of the fold. I have used and recommend deep tear trough filler using Voluma, Perlane or Juvederm Ultra Plus. More superficially, consider Restylane or Juvederm Ultra. Silk that may migrate onto the lower lid skin may create too much swelling and if used must be injected very sparingly.
​
​With so many choices, it is best to consult with a well experienced, Board Certified Plastic Surgeon, Facial ENT Surgeon, OculoPlastics Eye Surgeon or Dermatologist.
​
​I hope this has helped. All the best!

​

Facelift six-hour surgery with local and oral sedation?

Dr. Dean Kane Q & A.

Q. I am planning to have a facelift, cheek lift, fat transfer, and laser in one operation. The doctor favors local with oral sedation. I am concerned that a six-hour procedure may have me aware and exceed my tolerance level. I'd love to hear from others who have gone through six-hour facial procedures under local with only oral sedation.

A.  ​​​​​I prefer local anesthetic and intravenous sedation with monitoring by a anesthesia provider. Most surgeons request general anesthesia provided by an anesthesia provider too.

​Local anesthesia with oral sedation does not provide you the same level of monitoring or anesthetic risk / benefit ratio.
​Due to the length of the procedure, under local / oral sedation, the surgeon must perform the procedures during which he / she is also monitoring your vital signs ( heart rate, blood pressure, respiratory rate, oxygen saturation and level of consciousness). Longer procedures will expose you to greater levels of local anesthetic risk whereas a "cocktail" of mixed sedatives or inhalant anesthesia reduces this concern.

In the December 2014 article “Local Anesthesia and Plastic Surgery: Marketing or Reality?” (http://drdeankane.com/ok-conduct-open-rhinoplasty-local-anesthesia/) , Heather J. Furnas MD states:

“An increasing number of patients ask to have their surgery done with local anesthesia   “because it’s safer.” Guess what? That isn’t always the case.
​
​The Mayo Clinic has weighed in on the use of general anesthesia, explaining it should be considered if your operation:

1.  Takes a long time
2.  Exposes you to a cold environment
3. Affects your breathing, such as chest or upper abdominal surgery.
4. They also state that: “Most healthy people don’t have any problems with general anesthesia. Although many people may have mild, temporary symptoms, general anesthesia itself is exceptionally safe, even for the sickest patients. In general, the risk of complications is more closely related to the type of procedure you’re undergoing, and your general physical health, than to the anesthesia itself.”
5. ​She also notes the increasing concern amongst properly trained surgeons and patients alike that MD's offer this marketed advantage at the disadvantage of the patients health.”
6. It is also noted in another physician comment, that such an option should raise flags of concern that the facility in which the procedures are performed may not be fully accredited / certified by a state / or national regulatory agency and the physician may not have been properly credentialed. I desire to provide my full concentration on the performance of the procedure and not distracted from this which is the full time job of a anesthesiologist or certified nurse anesthetist.
7. Or more hours of potentially listening to others conversing or should there be a concerning occurrence during the procedure, become aware of and develop anxiety from correction of this event, restlessness or discomfort / pain; I believe is not in your best interest.

I hope this is helpful. All the best!

Are under eye filler/Botox/ Restylane permanent?

Dr. Dean Kane Q & A.

 

Q. Are under eye filler/Botox/Restylane permanent? If not, how long does it last? I'm thinking about getting my under eye bags/dark circles done. The dark circles under my eyes constantly make me look tired. I want to know if injections is something you do once or if I will have to keep getting injections.

A.  ​​​​Pigmentation or dark circles under the eyelid may come from any combination of the following.

1. Eyelid bags and laxity with shadowing
2. Cheek laxity and shadowing
3. Thin eyelid skin with a reflection of the underlying muscle
4. Eyelid veins.
5. A separation of the eyelid structures from the sagging cheek structures
​6. Pigmentation and fine lines

Many options are available depending on the problem above.
1. Eyelid lift
2. Injection of fillers, either into the skin or deep under the fat for volumizing using Restylane, Perlane, Juvederm, Voluma or fat
3. Vein ablation
4. Mid-face lift, a lift of all the structures of the cheek with a eyelid lift
5. Facelift
​6. Exfoliation, ZO Therapeutic Skin Health
​
​No option is permanent as the body continues to age. Each option has its advantages and disadvantages and must be weighed upon your findings at consultation with a well experienced, Board Certified Plastic Surgeon, Facial ENT and / or Ophthalmologist.
​
​Botox, Dysport and any other muscle relaxers will last on average 3-4 months and worsen bags and dark circles if you are not the right candidate.
​
​Hyaluronic acid gel fillers may also worsen eye bags and shadowing if not performed correctly. Depending on the "linking" of the molecule, HA's are rated to last 6-24 months.
​
​Surgery maybe the best option in the correctly selected patient but may have a longer recovery.
​
​I hope this has been helpful.

All the best!

​

This is my first time using Botox. Is this normal?

Dr. Dean Kane Q & A.

Q.  I just had Botox for the first time. I am 37 with minimal wrinkles. I wanted to try Botox in the "crows feet" area and asked if it would help with slight wrinkling under my eyes when I smile. Injector asked me to smile, made a couple of marks and injected me 3x below each eye (25 units) and said "you're done". She didn't inject anywhere near the "crows feet" area and I'm wondering if my injection site is normal?
A. Botox is a muscle relaxer which when injected properly will help many but not all active (directly created by a muscle) lines and creases.
​Crows feet are the radiating lines created by the thin, circular muscle (called the orbicularis oculi) under the skin surrounding the upper and lower eyelids, upper nose, brow, lateral orbit and onto the upper cheek. Since this muscle attaches to the inner corner of the eye next to the nose (called the inner canthus), it contracts and:

1. Closes the eye,
2. Pulls the brow inward and downward,
3. ​Creates lines radiating from the inner canthus onto the nose,
4. ​Creates lines radiating from the outer eye called crows feet
5. Will lift the upper cheek

When properly injected along the outer radiating lines, Botox will relax the downward pull of the outer brow allowing it to raise and soften the crows feet.
​
​If placed under the 4:00 position of the left eye, or 8:00 position of the right eye, side-effects due to relaxation of the orbicularis and other muscles in this area include:

1. Creation of swelling and fat bags
2. Rounding of the lower eyelid margin
3. ​Loss of ability to drain tears
4. Passive lowering of the upper cheek
5. ​Possible drop in the upper lip

Botox or like muscle relaxers are science and art.
​
​It is best to discuss your concerns with your injector. You may also consider a second opinion from a well experienced, Board Certified Plastic Surgeon, ENT Facial Surgeon, Dermatologist or Ophthalmologist.
​
​I hope this was helpful.
All the best!

​

Could something like CoolSculpting or cryosurgery treat Gynecomastia? Can the cold kill glandular tissue? I'm not worried about fat.

Dr. Dean Kane Q & A.

 

Q.  I know cold at a certain temperature for a certain time can cause cell death in fatty tissue. I imagine it could do the same with any living cell. At what temperature would cells in your mammary glands die?
A.  ​ ​​Great question! ​CoolSculpting's cooling endpoint is just above freezing where well perfused tissues retain the heat to remain alive and where superficial fat is stimulated to die via apoptosis.
​
​Male breast tissue includes non-active tubules (which transfer breast milk) and no lobules (which make breast milk). This tissue is not easily penetrated by the cooling and appears to retain enough heat not to undergo a programmed cell death.
​
​If the endpoint goes below freezing, frostbite occurs and all tissues die within this frozen zone. This concept is used in cryotherapy for debulking or killing tumors in many areas of the body.  It is for this reason that the feed-back relays on the CoolSculpting machine are so important.
​
​There are several ways to remove such tissue depending on the amount of residual breast mass and the skills of the surgeon. These include:

1. ​Lipocontouring with a unique cannula used for breast tissue
2. ​Areola incision with a "grasp and cut" or full excision
3. ​Breast mound excision with breast reduction techniques

Please consult with a well experienced Board Certified Plastic Surgeon to consider your options.
​
​All the best!

What can I do to take years off my face?

Dr. Dean Kane Q & A.

Q.  After ten years of a very stressful life, I have decided to invest in me! I lost my only child at age nine to brain cancer medullablastoma then 13 months later lost my husband to a brain aneurysm then my brother passed with liver cancer and last March loss my dad. The toll on me is self evident, it is written on my face, please tell me what can be done to take away the imprint these losses have left me with. Not happy with what I see, I'm ready to write the rest of my story.

A.  ​​​I am sooooo sorry for your losses! Congratulations on pulling yourself up and moving on! Thanks for sharing your photos with us.
​
​Your best initial option will be a face and neck (with platysmaplasty) lift. Depending on the skills of the surgeon, a modified face and neck lift without platysmaplasy will be less expensive and give you a great new start.
​
​Thereafter, consider extending the outcome of your surgery with minimally and non-invasive options. I have added a long winded discussion....
​
​Various options for facelifting, minimally and non-invasive facial enhancements and skin texture improvements are available according to the skin laxity and areas of lift or tightening you wish or need. Both surgical and minimally invasive / non-surgical options are listed below.

Surgical lifts would be likened to pulling the bedspread and or top-sheet of your bed up to the head-board and removing the excess material.

Minimally invasive procedures such as fillers provide volume such as adjusting a pillow under the bedspread. Botox and Dysport act by pulling the top-sheet which drags the bedspread upwardly. If the bedspread (or skin) continues to fall to the foot of the bed despite fillers, Botox or Dysport you will need to consider a facelift.

Non-invasive options such as laser and light therapies, skin tightening products and technologies perform their tightening and smoothening of the skin similar to sending your bedspread to the dry cleaners. A more refreshed, even colored, glowing smoother and tighter spread covers the surface of the bed.

The most popular of the fillers, Restylane and Perlane, a jelly-like clear skin filler is used to fill lines, wrinkles and folds. Juvederm and its longer lasting "cousin" Juvederm Ultra Plus are similar skin fillers, used to soften and fill the nasolabial ("parentheses") and marionette folds, the brow ("number 11") lines and fill and lift the cheeks and lateral brow or chin. Voluma is the longest lasting, up to 2 year duration HA filler. Each one is used to expand or volumize the loss of tissue associated with expression, weathering or aging. All the fillers come with numbing anesthetic!

Non-surgical facial contouring is possible with fillers such as Radiesse, a bone mineral for the nose or cheeks, jaw and chin as well.

Scuptra is the latest of the injectibles stimulation collagen at different levels of the skin adding volume but primarily firming and adding resistance to the formation of wrinkles, folds and descent.

Botox and Dysport too have been found to rebalance excessive facial expression, provide a non-surgical brow lift and lip lift and reshape the nose, as well as reducing wrinkles!

Dr. Obagi's new, second generation ZO Skin Health programs may be added to personalized chemical peels, light and laser resurfacing and tightening and will, smoothen and even the color of your skin.

IPL and fractionated lasers such as CO2 and erbium and now RF (radiofrequency) are additions to smooth the texture of the skin, tighten and reduce red and brown uneven pigmentation.

If you can pinch more than an inch of skin along the jawline in front of your earlobe, you should consider a surgical option to redrape and remove extra skin.

You may consider: a traditional face and neck lift, short scar face and / or neck lift.

The recent resurgence of the S-Lift (created in the early 1900's), also called by other names as the Quick-Lift, Lifestyle-Lift, Swift-Lift, Soft-Lift, MACS-Lift and others; are a single modification of the S-lift targeted to elevate sagging lower cheeks jowls and lateral upper neck. The shorter scar, limited undermining and second layer lift achieve the "quicker" procedure but not necessarily the quicker recovery or the improvement you desire.

Face lift and / or neck lift or any of the other procedures and their combinations should be discussed following a proper examination by a Board Certified Plastic Surgeon who performs all of these options so you will not receive a biased approach because he or she is limited in their skills.

​
I wish you the very best!​