MedEsthetics magazines offers business education and in-depth coverage of the latest noninvasive cosmetic procedures for physicians and practice managers working in the medical aesthetics industry.
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28 JULY/AUGUST 2015 | Med Esthetics LIP SERVICE outline; medium viscosity fi llers such as Restylane or Juvederm Ultra Plus for deep lip injection for volume; and heavy (high G prime) fi llers for oral commissures," says Dr. Niamtu. "I use the thicker fi llers to form a pyramid at the base of the commissure and work from the base of the pyramid (mandible) to the tip of the pyramid at the commissure. The base helps support the down-turned corners of the mouth and the surgeon and patient can actually see the lift." Dr. Alessi combines fi llers and energy devices to treat deep nasolabial folds and marionette lines. "Occasionally I will do fi ne lines with Belotero or Restylane Silk, but only when there are just a couple that are deep," he says. "If there are signifi cant nasolabial folds, then I prefer Voluma XC for injection, and we get good results with Thermage targeting that area. We also still do quite a few endoscopic mid-facelifts for signifi cant nasolabial folds. If prominent marionette lines are an issue, then Juvederm works well—deeper injections have a chance of migrating to the upper part of the marionette fold and making it more prominent. Thermage also works well in this area. For fi ne lines around the mouth, my preference is fraction- ated CO 2 laser with PRP." For aging and sun damage, ablative CO 2 laser resurfac- ing is still the preferred modality. "The difference between laser and fi ller is like the difference between a bullet and a rocket," says Dr. Niamtu. "There is no doubt that the laser can do things that fi llers cannot. Fillers can plump and may have extremely minor collagen stimulation. Lasers on the other hand, remove the aged skin, induce the growth of new skin, produce neocollagenesis and improve dyschromias. No fi ller can touch this." Additionally, he prefers ablative resurfacing to fractional. "The gold standard for the improvement of rhytides (including perioral) is fully ablative, full coverage, high fl uence, high density, multi-pass CO 2 laser," says Dr. Niamtu. "Yes, the recovery is a bear, but you get what you pay for. Not in terms of money, but in terms of recovery time. Ten days without makeup is not a bad deal to improve a half century of aging." Practice Points To guide patients who come to you for perioral rejuvena- tion or lip augmentation, consider the following advice: 1. Promote a comprehensive plan and do not promise more than you can deliver. "Older females, especially smokers, can have extremely challenging perioral aging," advises Dr. Niamtu. "It is also important to ask the patient what bothers her most. Some patients may only need a 'little air in the tire' with a single syringe split deep in each lip. Other patients only need a little outline to improve Cupid's bow and the vermilion cuta- neous junction. Some many need a single area treated while others will need all areas treated. Give the patient a clear understanding of the problems and possible solu- tions, and attempt to engage them in a progressive plan within their budget and recovery guidelines." 2. Relieve the pain. "Filler injection does not have to be a white knuckle procedure," says Dr. Niamtu. "I have gained many new patients from other doctors who hurt them. I use local anesthesia for 100% of my fi ller treatments—I do not rely on lidocaine in the fi ller syringe. That is like putting lidocaine on your scalpel blade; by the time it takes effect, it is too late." 3. Don't market, educate. "We don't promote any service per se, but we do have a website that lists and explains all of our services and a Facebook page. We do not show before and after photos and we do not offer discounts," says Dr. Day. "I have a master's degree in journalism and completed a special program in medical journalism. I do have a blog and take special pride in pro- viding unbiased, clear information on all kinds of aesthetic treatments. I see what we do as very powerful—we have an opportunity to help patients heal, and we can help them see how beautiful they are by emphasizing their best features. Changing their perception of themselves can make a huge difference in their lives." Linda W. Lewis is the contributing editor of MedEsthetics. cov ry r, but you g at yo or. No r n y, bu r cov ry t ." Younger patients often seek unnatural results. Before and after images and simulation software can help physicians communicate potential outcomes. © GETTY IMAGES