Frequently Asked Questions
What are fillers used for?
Oftentimes at the first appointment we can help patients better understand what signs of aging fillers can improve. Frequently, patients will indicate they want Botox when in fact what they would be best served by is a filler.
Fillers, as the name implies, fills up areas of volume loss. Part of the natural process of aging is a falling down of the cheeks which then pushes on the folds around the mouth (melolabial fold above and the Marionette line below). The lips can become thinner and you see less of the red lip. Fillers can help to correct some of the volume loss in the cheek as well as fill in the deep creases around the mouth to restore a more youthful appearance.
The most common location requested to inject fillers are the deep folds around the mouth. The next most common is to help augment thin lips or improve the finer wrinkles around the lips (helps with lip stick bleeding into the lip). The next most common location are fine and deeper wrinkles around the mouth and face followed by the cheeks over the cheek bones. The best areas for you can be discussed at the time of your consultation. As these are injections under the skin, to minimize your risk of bruising it is advised to hold off from taking any blood thinners (Aspirin, ibuprofen, Warfarin, Coumadin, Plavix, vitamin E, gingko biloba) for one week ahead of time. However, if you are taking any of these currently this is not a reason we cannot perform the injection, we may just take more time to minimize your risk of bruising.
How long does it last?
This depends on the filler used. The original fillers (bovine) would last for about 3 months. Fortunately, the longevity has greatly increased. Most would say that the results will last up to one year (Juvederm XC) depending on the filler that is being used with some of the newer ones (Juvederm Voluma) reporting results lasting as long as two years. However, not all fillers can be used in all locations and specific fillers may be needed to correct your specific condition.
Does this replace the need for a facelift?
Fillers are a temporary solution. They are non invasive but they do not replace the results achieved with a facelift. The volume required for injection varies depending on the patient with more severe signs of aging oftentimes requiring more than one syringe.
There are many fillers on the market. The original fillers were made from bovine collagen (cows) but these are rarely used now days and not used at our Spa. There are permanent fillers but these are not used at our Spa. The more popular filler types now are made of HA (hyaluronic acid) which is a compound that naturally occurs in the human body. Each different HA product varies their formula in a way that affects how long it lasts, its firmness, and how easily it can be injected. The benefit of using HA based products is that they are both temporary (lasting about 1 year) and they can be removed immediately with a simple injection. Other options include Radiesse (calcium hydroxylapatite) which can be used for deep rhytids and is also available. It is not as versatile as the HA based fillers but can be a first line option for cheeks.
I carry Juvederm Ultra XC, Juvederm Voluma XC, Volbella, Vollure, Restylane Silk, Restylane Lyft, Restylane, Restylane Refyne, and Restylane Defyne. Juvederm Ultra XC is great to add volume to the lips. It is made by the same company that makes Botox and it includes lidocaine in the syringe. It is also great for the melolabial folds and marionette lines (the folds between the mouth and cheek). It does a great job pulling in water to add even more volume to the area, so when you like the result the day of treatment you will love it in two weeks.
Juvederm Voluma XC is a thicker product than Juvederm Ultra XC. This makes it ideal for deeper injections. It is most suited for the cheek area to add more volume. It also can last up to two years in this location. Because of its thickness, though, it cannot be used in more superficial locations.
Volbella is a thinner product that has more cross linking than Juvederm. Unlike many fillers, it is sold in 0.5 cc vials. This makes it a nice filler for the lips when you don't want as much volume.
Vollure is thicker than Volbella but has the same cross linking properties. It won't pull it as much water as Juvederm but it can be another excellent option for the melolabial folds.
Restylane is a great filler. It is an excellent choice for the tear troughs which makes it one of my more commonly requested fillers. It does not draw in as much water as Juvederm Ultra XC which is what makes it better for the thin skin around the eye. This makes it less likely to have contour irregularities or prolonged swelling.
Restylane Silk is a great option for fine lines on the face, including those around the lips. It is also great for helping hydrate the lips to improve definition and fine lines on the lips. It does not add as much volume as Juvederm Ultra XC does to the lips, so for greater volume I would go with Juvederm Ultra XC. The benefit of Restylane Silk is that it is a much more conservative filler for those who are just trying out fillers or for those with minimal signs of aging around the lips. It is also perfect for the fine lines around the lips and face that other fillers would not treat well.
Restylane Lyft is similar to Juvederm Ultra XC. It is a thicker filler designed for deeper injections. It also tends to last longer like Voluma. It is great for cheek augmentation and can be used in the folds around the mouth. Because it is thicker, it is not meant for superficial injections such as fine lines or the tear trough area.
Restylane Refyne and Defyne have the greatest ability to stretch. This makes them helpful in more dynamic areas around the mouth. Refyne stretches more but doesn't add as much support as Defyne. Depending on how the creases around the mouth and folds appear, this can be excellent options.
What are some possible risks?
The most common risk associated with the use of fillers is bruising at the site of the injection. Other risks include redness at the injection site, lumpiness at the injection site which can be improved with massaging, and contour irregularities. A very rare risk is injection of the material into a blood vessel. This risk is minimized based on the techniques utilized by Dr. Guy. These risks are minimal but no one can ever guaranty a risk free procedure. These materials have been in use for many years with a long track record of safety.
Is there such thing as a liquid face lift?
There are many advertisements and claims out there about “liquid facelifts.” This is somewhat of a misnomer but the idea is accomplished with various fillers. These are appealing for their lack of incisions and minimal downtime. It is not a true lift in that the face is not being resuspended like you get with a surgery. It is more of a plumping technique. It is known that with age some of the bones in the face become a little thinner, skin begins to sink (forming jowls and prominent lines around the mouth), and normal fat deposits in the cheek area begin to fall, worsening the prominent lines around the mouth. By using a combination of fillers placed in the areas of the cheeks, lips, and folds around the mouth, the face can be plumped up and many of the signs of aging camouflaged. The benefits will last up to the length of the fillers with various fillers lasting for different amounts of time (the longest lasting one is not good to be used everywhere). The most common side effect with this type of treatment is bruising at the sites of injection. In most people this is minimal but those on any blood thinners are more prone to have greater bruising. The drawback to this method is that unlike traditional surgery, where the skin that is removed and the tissues that are resuspended will always have a more youthful appearance (i.e. you will continue to show signs of age but you will always look more youthful than if you had not had surgery), there are no long lasting results from filler injection. This type of a treatment is most beneficial for someone in his or her 20s to 30s who are just beginning to show the signs of aging but would not receive as much benefit from a traditional surgical procedure.
How long do the results of a face lift last?
This is a common question we receive. In a sense, the results of a face lift are permanent in that the excess skin removed and the structures that are lifted will always have a more youthful appearance than if nothing had been done. However, gravity, the sun, and other external influences will continue to act and the face will continue to age after surgery. The best example of this is considering the aging process like a conveyor belt. With surgery you are picked up and moved back on the belt about 10 years, for an example. Time will continue to go on and the conveyor belt will continue to move but you will always be 10 years younger appearing than if you had not had any surgery.
I don't want a "full facelift." What do you recommend for me?
To answer this question it is first important to define what a facelift is. In my opinion, it involves the surgical repositioning and elevation of tissue in the face and neck back to its more youthful position. This excludes all of the non invasive procedure...s such as Ulthera, Peleve, creams, and other incisionless procedures and techniques. These do have a place in aesthetics but the true "lifting" is minimal at best, and they do nothing to address the extra skin.
As facelifts have become more mainstream, marketing of facelifts became important. Techniques such as the lifestyle lift, short scar facelift, mini lift, etc. developed. Many of these are simply modifications of previously established techniques. In any of these procedures the incision is limited to just in front of the ear and a small area behind the ear. This is ideal for someone who only has a little excess tissue around the cheek and jowls and possibly early signs of neck aging. likely in their 40s. The benefit is there is less downtime and less bruising. But with less movement of tissue, the long lasting results may not be what you are hoping for. By extending the incisions to other areas, still remaining camouflaged as you can see here you can get a more dramatic and longer lasting result.
What can I do to improve my neck?
Signs of aging in the neck are one of the things that brings many people to the office. With time, the neck skin slackens and hangs, the muscle sheath in the neck weakens producing bands, and a little collection of fatty tissue develops between the muscle bands in the midline. Depending on what you have in particular, options include liposuction through a very small incision just below the chin in a natural crease, cutting or sewing together the edges of that muscle, and resuspending the neck tissue to the sides and removing the excess through hidden incisions behind the ears at the hairline. This is what is considered the "neck" part of a facelift. It may be combined with other parts of a facelift or done alone based on what you would need. This can all be discussed with Dr. Guy in a consultation.
What can I do to improve the quality of my skin?
This is a very broad topic. Most people don’t realize that the skin is the largest organ in the body but it is often neglected. A good skin care regimen is the key to keeping a healthy, youthful skin. This begins with avoiding the damaging UV rays from the sun or tanning booths. It is important to use a sunscreen that is protective against both UVA and UVB rays. Protective clothing can also act as a physical blocker as well.
Since this advice probably comes too late for most people who have enjoyed the sun throughout their lives, improving the current quality of skin becomes the next priority. To understand how you can improve your skin it is important to know a little bit about the skin. It is made up of the epidermis (top layer), dermis (just below), and the subcutaneous tissue (fat and other tissue). The epidermis has 5 layers. The top layer is where most over-the-counter skin care products work. They help to shed off the top layers of dead cells. This can also be accomplished mechanically with scrubs, brushes, or a Buf-Puf.
As you move into the deeper layers retinoic acid (tretinoin or Retin-A) helps to improve the quality of the skin. It works by stimulating the deeper cells to replicate faster. This makes more youthful skin appear on the surface. It is important to realize that his may make your skin flake a little bit. If this happens then cut back on your frequency or go to a lower concentration.
What can I do to improve the color of my skin?
There are several products out there that act as skin “bleachers.” They do not really bleach the skin but they each work by acting on the skin cells that create pigment known as melanocytes. Each of the various medications takes time to be effective because what they are preventing is new pigment form being laid down, not erasing pigment that is there. This is why it takes about 6 weeks to see a result. The most commonly used product for this is hydroquinone or HQ. It is frequently found in prescription and over the counter beauty supplies. It can be effective for splotchy skin colors and can be used around the time of resurfacing procedures such as lasers, dermabrasion, or chemical peels. Another option is azeleic acid which is derived from wheat. It also helps to prevent the pigment cells from producing the pigment color.
What can I do to help shrink my pores?
I probably get this question every day. Unfortunately, there is no great way other than resurfacing. You can thank your parents for your pore size. Using some of the products listed above you can help to clear your pores which can help them appear smaller. Resurfacing procedures such as chemical peels, dermabrasion, and lasers can improve them but there is associated downtime. Avoid oil based products as this can lead to obstruction of the pores and make them appear larger.
What are common characteristics of skin cancer?
There are many types of skin cancer, each with its own patterns. The most common type of skin cancer is a basal cell cancer. If you have to get a skin cancer, this is the best one. The reason it is grows very slowly and almost never spreads. They are frequently seen in sun exposed areas of the head and neck, especially around the nose. Look for small bumps that are new and appear to be growing slowly. They often have the appearance of having small blood vessels (telangiectasia is the doctor word) and almost a pearly or waxy appearance. If you pick at them they tend to bleed and come back. Because they grow slowly, you may have had it for over a year or more. It is important to remove these sooner rather than later because as they continue to grow the removal becomes more difficult and the reconstruction more difficult.
Squamous cell cancer is the second most common. It is also found in sun exposed areas. It tends to grow faster than basal cell cancer. It will often bleed. The sides of it may be elevated compared to the middle which almost looks like an ulcer or crater. It may first appear as a scratchy area on the face. It also has a low chance of spread early but the chance of metastasis goes up the longer it is present. This is another reason to get checked early.
Melanoma is the next most common and is the most worrisome. The ABCDs of melanoma include: Asymmetry or it looks different between the two sides, Border or the edges are irregular, Color or it has multiple colors present like brown and black and red, and Diameter greater than a pencil eraser. When caught early, the survival rate is above 97%. Unfortunately, when caught late melanoma can be very deadly.
Common to all of these skin cancers is change. They are growing, adding color, raising up, etc. Another characteristic that is concerning is itching. They may or may not be painful. Any spot on the skin that bleeds and fails to heal should be considered a skin cancer until proven otherwise. A history of skin cancer is another risk factor for developing new skin cancers.
What can I do to prevent skin cancer?
This is a great question because there are so many things that can be done. Unless someone has a genetic predisposition making them prone for skin cancer (runs in families so you would know if you had it), prevention is the key. The damage from UV radiation is cumulative. A severe sunburn in childhood increases your risk. Use sunscreen with a high SPF factor. Apply sunscreen 20 minutes before going out to give it a chance to absorb before you sweat it off. Make sure to reapply frequently and any time after you have been in water or sweating. Physical blockers such as hats, clothing, and umbrella help, especially ones that advertise they block UVA/UVB radiation. Avoid the sun during when it is at its peak as the radiation is the highest then. This does not mean you cannot be outside as the sun and summertime are very enjoyable. It simply means take a few extra steps to be able to enjoy the outdoors without increasing your chances of developing skin cancer.
Finally, the most important advice I can give is to avoid tanning beds. There is no such thing as safe UV light. Spray on tans do not carry this. Unfortunately, tanning beds are frequently used by younger people and as the damage is cumulative, it can significantly increase the risk of skin cancer later in life.
How long does BOTOX last?
The benefits of BOTOX last for about 3 months in most people. Some lucky people have noticed benefits up to 6 months and others for only 2, but on average you can expect the results to last for about 3 months.
If I keep using BOTOX can the effects become permanent?
This is a very common question I receive. Unfortunately, the answer is no. To fully answer this question it is important to know the history of BOTOX. It was originally used for a spasm of the eyelid (eye twitching). It was noted that the patients began to have improved wrinkles around their eyes and cosmetic BOTOX was born. However, BOTOX is used in many other conditions, including voice and swallowing disorders, excess sweating, and even sweating when you eat in doses that can be much higher than those used for cosmetics. Unfortunately, these patients still have to come back every 3 months for retreatment throughout their lives.
How does BOTOX work?
The full answer is very scientific and difficult to understand (deals with synapses, vesicles, neuromuscular junctions, etc.). Therefore, I would like to simplify this. Consider that your brain sends a signal to a muscle for that muscle to contract. BOTOX acts like a crossing guard. When it is present, it blocks that signal and the muscle will not contract so you see an improvement in the wrinkles caused by the muscle. The body works around this by "building a new road" which bypasses that crossing guard. This process takes about 3 months which is why that is how long BOTOX works.
Do men get BOTOX?
Once of the fastest growing markets for non invasive cosmetic treatments are men. You may have heard of the term "Bro-Tox" which is when a group of guys go together and get Botox injections. The market is advancing so quickly that the company behind Botox has just launched a webpage exclusively for men: www.BotoxCosmetic.com/Men/
This does not mean that every male is a candidate but it does help show that men should consider the benefits of Botox and realize that these types of treatments are commonplace among other men.
I have an event coming up, when should I get my treatment?
During the holidays there is often an increase in people seeking Botox and other neuromodulators. It is important to realize that it takes up to 2 weeks to reach the maximum effect (and about 3-5 days before you start noticing any difference). It is important to keep this in mind if there is an event coming up. What you don't want to do is get treated the same day as your event since you won't get any benefit.
Will my insurance cover this surgery?
First off, I can never make any statements regarding what an individual insurance company will cover. However, I wanted to answer this question because I hear it about once a week from patient's looking to rejuvenate their eyes. For insurance to cover the surgery, several criteria must be met, at a minimum. The eyelid skin from the UPPER eye must be hanging over the eye so much that it actually blocks vision. This is the person whose eyelid skin hangs over the eyelashes. A test is performed by the eye doctor to assess your visual fields (what your eyes see). The test is then performed a second time with your eyelids taped up to see if there is an improvement in how much you can see. Depending on how much you improve between tests will determine whether your insurance would cover the surgery.
Can this surgery improve the puffiness around my eyes?
The short answer is yes. There are three fat bags in the lower eyes and two fat bags in the upper eyes. When young these fat bags remain behind a nice tight membrane so they aren't noticeable. With time, this membrane weakens, almost like an old trampoline. This lets the fat bags become more prominent. It is almost like a hernia. Surgery is perfect for these patients. For the day to day changes in puffiness that develop, as seen with allergies, surgery does not improve these. This is usually seen in the lower eyelid and can also change with eating a heavy salt meal or drinking alcohol.
How much does an eye surgery cost?
This is an excellent question that is also hard to answer. It depends on whether this is performed in the operating room (required if you want your lower eyelids operated on) or in the clinic. Obviously, the operating room will be more expensive. It also depends on whether you have bulging fat or only excess skin to be removed and whether you would want the upper eyelids or the lower eyelids or both. On the low end my costs begin around $1,700 but can increase depending on what all is needed to be done. This can all be discussed at the time of consultation.
What can I do as the patient to improve my scar?
After the original incision or trauma, what you do afterwards can greatly affect how your final scar will look. Even carefully planned surgical scars can look better with proper care.
Keep the wound clean. I prefer to use hydrogen peroxide multiple times a day to clean the wound gently.
Avoid tension on the wound. Tension is a scar's worst enemy. If you feel the wound pulling or it hurts, don't do that. A scar will respond to more tension by creating more scar. So if you keep fighting the tension you can widen the scar, elevate the scar, or change the color of the scar. In any case, listen to your body and avoid tension.
In the early phase of healing, right after the wound is created, keep it moist. I prefer to use bacitracin ointment. Studies have shown that moist wounds (not wet) heal more quickly and with a better scar. I don't recommend triple antibiotic or Neosporin because they have an ingredient that many people can develop a reaction to (neomycin). Once the wound is healed and no longer producing any crusting or fluid, stop putting on the ointments as you can begin to develop a reaction to even bland ointments.
Avoid the sun on your scar. If a scar gets a tan that color will always remain there. It is best to use a physical blocker such as a hat or SPF rated clothing. If this is not an option then make sure to keep sunscreen with an SPF of at least 30 on the wound until it turns from pink (the healing phase) to white (the final scar). In the early stages of healing while the wound is still crusting or weeping it is best to avoid the sun altogether.
Do you recommend any topical products to improve my scar?
A topic frequently heard in medicine is called Evidence Based Medicine, or EBM. What this means is as doctors, we look at the research that has been performed, the results of that research, and then make recommendations for the best treatment based on the available evidence. Several studies have shown an improvement using topical products.
Anti-tension tape helps to relieve tension at the level of the skin. This has been shown to help the final scar and is something I frequently apply. However, it cannot be used for every scar so it is not always an option.
Topical silicone gel has been shown to improve scars. I don't recommend one product over another but if you see the active ingredient as silicone gel, this can improve your scar when applied daily for an extended period of time.
Do you recommend topical vitamin E?
This is similar to the topic above and relates to evidence based medicine. It is also one of the first questions I get after a suture a laceration with the brand name Mederma most commonly asked about. A study comparing the use of topical Vitamin E to a bland cream showed no difference between the portion of the scar treated with the vitamin E compared to the bland cream. This does not mean it does not help. It only means in this study there was no difference. However, since this is the only study I've seen I cannot recommend the use of topical vitamin E without any evidence to support it. If you feel it helps then I certainly support that decision.
What can you do as a facial plastic surgeon to improve my scars?
There are many things that can be done to improve a scar. It is first important to recognize what makes a scar more noticeable. If the scar is longer than 2 centimeters (about 1 inch), elevated, depressed, different color, or crosses natural lines of the face it will be more noticeable. In the early stages, time alone may be the recommendation. Scars go through a cycle of healing and the maturation or development of your final scar can take up to one year. Surgical intervention, if needed, is usually performed between 6 months and 1 year. This can be performed earlier in a few situations, such as the scar crosses many lines of the face or there is a gross alteration in a natural structure. The latter can be seen with a cut to the lip where the red part of the lip is not lined up appropriately. Time won't help this and a revision would be recommended sooner rather than later.
From a surgical stand point, the scar may be excised to allow a new one to develop, its lines may be changed to minimize the number of facial lines that it crosses, or it can be attempted to be placed closer to natural lines of the face.
Early in the process when the scar is still developing, the injection of steroids can be very helpful. This can also help with the itching and pain associated with some scars.
Resurfacing using either dermabrasion or lasers can help to blend the scar better with the surrounding healthy skin.
And the least invasive option is using makeup as camouflage. Although this doesn't address the underlying problem, it doesn't require any treatment and that may be appealing to some. But all scars are different and what is recommended for one patient may not be recommended for another. All of this can be discussed with Dr. Guy at the time of consultation.
How long does it take to heal from surgery?
This is a great question and depends on what surgery is being performed. In general, your swelling will increased for the first 2-3 days, stay there for 2-3 days, and it isn't until the 4th or 5th day that your swelling begins to subside. By 2 weeks 80% of your swelling will be gone and by 2 months 90% of your swelling will be gone.
How soon after a facelift could I go out?
It takes about 10-14 days for the swelling to go down enough to go out in public. With the help of a little make up the average person would not have any idea you had anything done.
How soon after a rhinoplasty could I go out?
This depends on what all is done. On average, when the splints come off in a week you would be fine to be out. If bone work had to be performed there may be some bruising as well but this is usually minimal. To get the final result from a rhinoplasty it can take up to a year. The reason is that the tip tends to hang on to swelling the longest. If you have thick skin then frequently you will also require some injections during the healing phase to get the final result.
How soon after a blepharoplasty could I go out?
Depending on how prone you are to bruising, it takes about 7-10 days to be close to your baseline. When just the upper eyelids are operated on you tend to heal faster and this time can be as little as 5 days.
What is Kybella?
Kybella is the first and only FDA approved injectable product designed to remove fat from the area below the chin. It is deoxycholic acid which is a product that is found naturally in the human body.
How does Kybella work?
It works through a series of at least two but usually around four series of treatments lasting about 20 minutes each performed in the clinic. Kybella acts by causing the fat cells to break apart and be absorbed by the body.
How long does Kybella last?
In essence, the result is permanent in that the fat cells that are destroyed by Kybella will not return. However, it does not remove all fat cells, so the ones that do remain can grow larger if you were to gain weight. The benefit is that the area will always look better than if the treatment had never been performed, even if you do gain weight in the future.
Does Kybella replace surgery?
When it comes to getting the maximum improvement in the neck area, surgery will remain the gold standard. This is especially true in the aging neck with bands or lax skin as Kybella will not improve either of these. Kybella should be thought of as an option for those who do not desire surgery, who have extra fatty tissue in the neck, and minimal other signs of aging.
What are the options for lip augmentation?
The most frequently used options for lip augmentation are temporary fillers. I prefer to use either Restylane Silk, Juvederm Ultra XC, or Volbella. These all provide for a natural feel and enhancement to the lips. I tend to be a conservative injector with the lips, as I am not a fan of the overdone or "duck lip." For those with more advanced signs of aging, there are surgical procedures which can be performed.
How much volume to you need for lip augmentation?
People frequently ask how much volume they need for their lips. I say that the important factor to consider is our goal look and shape to the lips. We are not going for an absolute volume of injection (such as 1 ml). For some patients I use less than 0.5 ml. For others needing greater volume I go with more. I'm not actually looking at how much volume is going in. Rather, I constantly evaluate how the lip is looking as the injection proceeds. For almost all patients, less than a complete syringe would be used for lip augmentation to avoid the overdone look.
If I get lip fillers injected, what should I expect?
When it comes to the lips, I recommend to be conservative. You can always add more with a touch up if needed. For the injection itself it is important to realize that the lips are a sensitive area. I use a topical anesthetic that makes it essentially pain free for most patients. This is a huge plus if you have ever been treated there without a topical anesthetic.
Following the injection, the lips tend to swell. The more volume needed for augmentation the greater the swelling will be. The topical anesthetic includes a medication that shrinks blood vessels to help minimize the swelling and the risk for bruising. If you do have swelling, it can last for up to a week or two. Using ibuprofen AFTER the injection as well as cold compresses (the one provided by Dr. Guy) can also reduce any swelling. Because of all of this, if you want lip augmentation it is best to come in at least a few weeks before any major event, but most people who have it performed the same week or even the day before have no problems.