At the Toronto meeting, we heard about two new hyaluronic gel fillers that are edging ever closer to FDA approval. These are called “Belotero” and “Prevelle Lift”.

Like Juvederm and Restylane, they are made from the same basic molecule, the ever-popular hyaluronic acid gel. These new formulations, however, are manufactured differently, with the result being that the properties of the final injectable gel are significantly different.

If you were to look at filler gels under a microscope, most HA’s to date have a fluid portion and a separate, more granular component. They are called “bi-phasic” because of this. Belotero, on the other hand, has a smoother, more even consistency, and is called “monophasic”. Clinically speaking, which is what matters, people who have used Belotero feel that it also looks and feels smoother when injected, and is allegedly less prone to lumpiness. Belotero has been available in the UK since 2007, and has a good track record there. Reportedly, it lasts between 6 to 9 months, but, as always, take these claims with a grain of salt.

Prevelle Lift, also known as Prevelle DGE, is designed to fill out and physically lift the skin more than its thinner cousins. It’s targeted at the treatment of deep lines and wrinkles, and at applications that require more 3-D shaping. The Prevelle product also contains lidocaine, making injections less painful.

Hopefully, these two products will receive their FDA clearance within the year, and be available for use in the United States. Both look quite promising and useful for our patients…but time will tell.

And of course, we’ll really need to see some head-to-head comparisons with the established fillers to know where the newcomers will end up. To paraphrase the Iron Chef TV show, “Which filler will reign supreme?” – too early to say.

Here’s a neat little trick, courtesy of Dr. Laurie Casas, which was presented at the “hot topics” part of the ASPS meeting in Toronto: Sculptra users can get a better result if they combine the injectable treatment with the use of Retin-A cream. Dr. Casas explained that, since both products work by stimulating collagen, it made sense to try them together to see if a synergistic (additive) effect would happen. Her study found that the combination worked especially well for patients younger than age 55, and particularly well for those patients getting Sculptra in the cheeks and mid-facial areas.Often the patients found that they required less Sculptra product to achieve the desired result, when they used the Retin-A cream. Another money saving tip for you from PSB- the Plastic Surgery Blog!

With the availability of two great wrinkle-fighting products in Botox and Dysport, the inevitable question of “which one is better?” comes up.

Here’s one study, from the recent Facial Plastic Surgery meeting in Boston, that suggests Dysport works better on “crow’s feet” than Botox (link here). I think, though, there may be a problem with the study….read on.

Here’s what was done: 10 units of Botox Cosmetic were used to treat crow’s feet on one side of the face, while 30 units of Dysport were used on the other side. Investigator and subject gradings of the appearance of the crow’s feet wrinkles were obtained using a standardized grading scale before the injections and then two, four, six, and 30 days post injection. Sounds good so far, right?

Unless you have insider knowledge of this topic, most people would accept the findings at face value. (pardon the pun) However, there’s a catch. The doses of Botox and Dysport are not necessarily equal in this study. Most people use a 2.5:1 conversion ratio, when converting from Botox units to Dysport units, since the two medicines are not interchangable. And even that number is a bit of a guess- it might easily be 2.6:1 to 2.7:1.

In this study, using the 2.5:1 conversion ratio would mean that the Dysport dose should have been only 25 units, rather than the 30 units that were actually given. So, it seems like the Dysport side of the face got a slightly stronger dose – and a higher dose is naturally going to be more effective.

In my experience, I think that the Dysport product certainly has a slightly quicker onset of wrinkle reduction. But I can’t say that I’ve seen it work that much better, and get rid of more wrinkles than Botox does at the same dosage. It’s a bit like Coke vs. Pepsi, if you ask me.

Bottom line: too early to tell which wrinkle-fighting agent will win the battle here. I would suggest that they repeat this study with more equivalent dosings.

I saw a press release earlier this week (link) which claimed that a proprietary dietary supplement made Botox injections more effective. Naturally, I was curious, and began to investigate.

According to a study done by ophthalmologist Dr. Charles Sopakar at Methodist Hospital in Houston, giving a tablet of either zinc or zinc together with an enzyme called phytase made Botox more effective in 41 of 44 blepharospasm patients, when used for 4 days prior to the injection.

So, like a careful scientist, he’s expanding his research to a large scale study? No – actually, he’s run off and patented the phytase and zinc combination, which will soon be marketed under the name “Zytaze”. My opinion of his blatantly commercial intentions aside, could zinc help Botox or Dysport or Myobloc work better? Maybe.

Here’s what we do know about zinc and Botox:

1) Botox is a member of an enzyme family called zinc metalloproteinases. These enzymes actually require some zinc, which acts as a catalyst, to work properly.

2) Experimentally, if you treat Botox with an agent that removes the zinc (a chelator), Botox doesn’t work at all.

3) In laboratory studies, either too much or too little zinc prevents optimal functioning of the Botox protein.

4) Phytase helps the absorption of dietary zinc, and by itself, can help zinc deficiency.

So, should we start giving zinc supplements before cosmetic Botox treatments? In my opinion, this preliminary study, while very interesting, is not conclusive. The patients were blepharospasm and facial spasm patients, who have abnormal neuromuscular stuff going on. They are quite different than normal cosmetic wrinkle patients. The study really needs to be repeated in a double-blinded, placebo controlled way, with cosmetic wrinkle patients. I’m sure there will be no problem getting volunteers for this study!!

So, it’s too early to tell for sure…but I’ll be following the developments. If you want to go down to the vitamin store, and buy a zinc supplement – I don’t mind, as long as you only use it short-term. In this study, the zinc was used for just 4 days prior to Botox treatment, and not afterward. Let me know if you think your Botox treatment works better or lasts longer!

Selphyl is a new facial filler that’s getting a lot of buzz. It’s made on site at the doctor’s office, using a few vials of your own blood. Twenty minutes later, after processing, an amber-colored liquid is ready to inject into facial wrinkles. While it’s not a filler itself, the liquid contains platelets and platelet-derived growth factors, which stimulate your tissues to produce more collagen. At least, that’s the theory.This technology has been around for a while, but previously was limited to reconstructive applications. The Selphyl people have come up with an easy system to make it a convenient, standardized, in-office technique, and have taken it through the FDA approval process. The product is designed to be used in the correction of facial lines and wrinkles.

This stuff, however, isn’t for someone looking for a bargain. A typical Selphyl treatment costs about $2000, about 3-4 times the cost of our typical fillers. The company claims the duration of the treatment effect is 2 years – and so that makes it cheaper in the long run, compared to Restylane or Juvederm.

It also works differently than many other fillers. Restylane or Juvederm directly fill the area with their gel. Instant gratification. Selphyl, on the other hand, fools the body into making extra collagen by means of growth factors. It’s the new collagen which then gradually fills the area. Because of the lag time in collagen production, it takes 2 -3 weeks to see the desired results. If your body doesn’t make much collagen, you won’t see much effect. Selphyl is not recommended for patients over age 65 for this very reason.

So far, I’ve only seen 3 papers on Selphyl, all by the same author. So much of the data is still preliminary. We don’t yet know how long the effect lasts; the longest duration data I’ve seen on Selphyl is only out to 12 weeks.

Many practices are promoting it as a facelift-replacement, which as you can see is a patently silly claim. Selphyl will help to volumize an area, and the platelet-derived growth factors may have some other, as yet unknown, rejuvenative effects on the quality of the skin – but that’s it. There’s absolutely no reason to expect tightening of loose necks, lifting of jowls, or the other typical effects that we get with a surgical facelift.

Bottom line: interesting product, but need to see more data before I start using it.
Pros: autologous filler;
Cons: Pricey. About 10% of people get no significant benefit from it, even if they are under age 65.

While our surgical operations for the upper and lower eyelid can yield some pretty impressive improvements, not everybody wants to jump directly to surgery right away. Many patients want to know, “Doctor, what can you do for me without getting invasive?”

the answer: quite a lot, actually. The secret is to combine several non-invasive techniques in an artistic way.

For example, when we look at the eye area, we commonly see the combination of:
a) crow’s feet,
b) texture changes in the lower eyelid skin,
c) lowering of the brow position, and
d) the “tear-trough” groove, running diagonally downward from the inside corner of the eye, around onto the top of the cheek.

We can use non-surgical methods to address each of these concerns. The combination is synergistic – working together nicely better than any one treatment by itself.

Crow’s feet can be significantly reduced with the use of Botox or Dysport. A small dose of Botox (or Dysport) just beneath a low lateral eyebrow can elevate it in a subtle way. Filler injections, such as Prevelle Silk, can be used to fill in the valley of the tear trough area, making it much less prominent. Finally, a light chemical peel or laser can be used to resurface the lower eyelid skin, improving the texture.

Naturally, these options may not be as powerful as their surgical counterparts, but for many thirty and forty-somethings, it’s really all they need at the moment.

And none of these options requires a trip to the operating room under anesthesia!


Xeomin – another botulinum A toxin product – was approved earlier this month by the FDA. In an interesting twist, the FDA approved the drug for certain muscle spasm syndromes – cervical dystonia and blepharospasm – but not for cosmetic purposes yet. That all-important cosmetic approval will probably come at a later date.

Dystonias are neurological movement disorders featuring involuntary twisting and repetitive movements or abnormal postures. About 3 people per 10,000 have this problem, according to epidemiology studies.

What’s interesting about Xeomin is that it doesn’t have the associated complexing proteins previously needed for Botox and Dysport. The lowered protein load may theoretically reduce the incidence of allergic reactions and the potential for antibody formation.

According to Merz Pharmaceuticals, the manufacturers of Xeomin, more than 84,000 patients have been treated with Xeomin worldwide since 2005. The U.S. is the 20th country to approve the drug for the treatment of cervical dystonia and blepharospasm.

Here’s an incredible deal for our loyal readers and friends: 25% off of your next Injectable service for you and your friends. But act fast – this fantastic special is good from now only until August 20, 2010!

This special may not be combined with any other specials or discounts. The minimum purchase is for 25 units of BOTOX Cosmetic, an equivalent amount of Dysport, or one full syringe of the filler of your choice.

Please call to set up your appointment (407) 339-3222, or email us at:

It’s like a Back-to-School sale on beauty!

The Orange County (California) Register is reporting the death of a 22 year old California woman following illegal silicone injections to her buttocks (link here).

It’s a tragic story. Combine the ingredients of a young, uneducated patient with an unlicensed practitioner working in a non-medical setting, and add injections with some adulterated, non-medical-grade liquid silicone material, possibly mixed with other unknown substances. Bad news.

Just like the recent death of the former Miss Argentina under similar circumstances, pulmonary complications, due to the embolization of the injected material to the lungs, are believed to be the cause of death.

Other than retinal detachments and certain other specific ophthalmologic issues, I’m not aware of any legitimate (FDA-approved) cosmetic use for silicone injections. Long term problems caused by liquid silicone injections can be extremely difficult to repair. Just don’t do it. Even if it “seems like a good deal”.

Proven ways to improve the shape of the buttock area include:
1) liposuction of the waist, hips and thighs to shape the area;
2) fat grafting to the buttocks;
3) FDA-approved solid silicone buttock implants;
4) lower body lifting surgery.

Currently, there is no FDA-approved injectable material for large volume soft tissue augmentation.

Good news for patients who like Botox and Dysport: Medicis, the makers of Dysport, is extending their “Love it or leave it” challenge, which we detailed here, (link) until the end of September 2010. You can save up to $150 with the promotion, if you qualify for it.According to the company, of the 49,000 people that have tried it, 90% reportedly voted “love it” for Dysport. Of course, that’s a corporate press release…maybe they voted that way because of the cash rebate, we’ll never know!

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