Dermatology Video Gallery

Hi this is Dr. Kenneth Beer in West Palm Beach Florida. Hope you guys are all riding out the quarantine safely and enjoying the time with your friends and family. We are going to talk today about some injectable fillers and things that we can do when the quarantine lifts. As part of this we are going to have questions and answers and if we don’t get to you question upfront, please don’t worry we will get to it this afternoon and make sure that we answer it. In addition to that we are having a virtual week of beauty, so it is an opportunity for you guys to call the office, you can purchase fillers and injectable and lasers and a variety of other things so that when the quarantine is lifted we can get you in here and start making sure that everybody looks as good as they feel once everything is back to normal. So that is at 561 655 905 5. So let’s just jump right in, today we are going to talk about fillers and things like Kybella and all kinds of products that we use in the skin to make you look and feel better. And the nice part is there are so many opportunities and so many products now that are available, whereas 10 or 15 years ago we only had a few things today we have probably about 20 somewhat products available that are approved in the US and there are a lot more approved outside so Canada and Europe have probably 40 or 50 and there is going to be more in the US so it is going to be an ever changing landscape. It is going to be a lots of fun for those of us in the industry because for instance with this newer round of products we were part of the clinical trials so we have been using them for months and months and months and we will have the opportunity to train other physicians which is always fun. So today we can start by answering some questions you guys have and feel free to go ahead and ask them.

So when we started with everything years ago we used to inject collagen and collagen was a product that was okay it was not great, it really didn’t last as long as it should have and it was lumpy and bumpy and there were 2 or 3 different types, and this is probably 25 years ago we were injecting that and then along came Restylane which was being used in Europe and Canada. Restylane was a nice product because unlike collagen it was clear and it was a gel so it was smoother and it was more long lasting. In addition it was made out of bio compatible hyaluronic acid, and hyaluronic acid is a sugar that is found in all of your joints, all of your skin. It is pretty much in equitas throughout nature and it is one of the products that really has done well over time. So we have more than 20 years’ experience with that product. Restylane has been evolving over the years so we started with just Restylane and then it evolved into a thicker product called Perlane. Perlane then got rebranded as Restylane lift but it is the same as Perlane, used to be and those are products that are gels that get pushed through a screen, so instead of being a solid block like Jell-O would be, if you take a block of Jell-O and put it through a screen you can get fine little particles, so if we have a big screen you get Perlane or Restylane lift. If you get a smaller screen you get Restylane and you can do just about anything with these products provided that you know what they are and where to place them, they are really nice, nice products and those are from Gel Derma there is a whole other family of Restylane products, including Refine and Define. They use a slightly different technology and there the sugars are cross linked and a little bit smoother so they are better for areas like the nasal labial crease that is subject to a lot of motion, so we use those all the time in areas that are moving a lot. There is also some newer products called Restylane kiss, which as the name suggests is designed for the lips and those products are all highly, highly bio compatible. Patients do really well with them as with any product you can get some lumps or bumps but typically these are minor and in addition as with any injection you can get a little bit of bruising. Then there is a whole other family of products called Juvéderm and started with Juvéderm Ultra and Ultra plus, and these products are all from Allergen. So there is a whole range of them we now have Juvéderm Volbella which is a really nice product for the lips, we have Juvéderm Vollure XC which is an intermediate product that we like a lot. We use this, a lot in the nasal labial crease, we use it in the marionette line, and then something that has become very, very popular is the Juvéderm Voluma which is designed for cheeks. We also use it in other parts of the body such as the temples and variety of other places and it has done remarkably well. So jumping back what we use a lot of in the office, in addition are things like Restylane lift that I mentioned before and there you can see the product has Lidocaine in it. What the Lidocaine does is makes for a much more comfortable injection. This thing Restylane lift it is a little bit thicker and we use it a lot for sculpting the face. It is the cheek bones, the temples, the marionette the jaw sometimes we place them deep to build, and again as we mentioned before this is regular Restylane which is still pretty very popular all throughout the world, it is a really nice product we use it for a variety of things. It is just what works in a lot of practices. Alright so next – we have some other products that are a little bit different.
So from the Merz family we have something called Belotero which is a really, really nice product. It is soft as we use it a lot and the area around the eyes we use it in the lips. There is also something called Radiesse and Radiesse is really nice, Radiesse is a calcium based product so it is a little bit white and it is a little bit more durable, but at the same time it is very thick so it is great for structure we dilute it out and we constitute it and inject it in the back of the hands and it does well. I like Radiesse for people with thick skin or men who have really deep folds. It is a wonderful product we typically inject it with a cannula and it does really, really well. So that is another option. Sometimes people just lose volume we like to use something called Sculptra and Sculptra is a series of injections that we like. Usually we do them 4 to 8 weeks a part and what this does is it stimulates your skin to gradually make some collagen. Each time we inject it we inject either one or 2 bottles depending on how much we need, recovering and it is sort of like planting grass, you just put it under the skin and watch it grow. So this is a really nice product, sometimes we use it in the mid face, sometimes we use it in the other parts and the nice part is you can reconstitute it based on where you are going to put it so you can make it more or less diluted, if you are using it on the legs, the butt, the face you can blend it as you want. So this is a great product but it is depending on your body’s ability to make collagen so that varies in different people.

So one other thing that we inject a lot of is Kybella, and sometimes we use this with our cool sculpt device or other machines this is a great product for getting rid of some excess fat. We use it primarily in the area under the chin, but there is all kinds of other places we put it to and it works really nicely like other injections though. It is not one and down we typically inject this 2 to 3 times deepening on the area and how many bottles we are injecting so there is a whole range of products that we use. Let’s take a look for some questions. So one of the questions is which product would you use in different areas and really it depends on the thickness of the person’s skin. For thin skinned patients that are looking for fine lines sometimes we will reconstitute or blend with some lidocaine to thin it out and sometimes we will use a very soft or smooth product, so the nice part about having all these products is that we can blend or customize or we can just use different products based on what we are trying to accomplish. So it is a very different scenario now than it was 5 years ago. Let me see – Kristen, hi Kristen thanks for joining us and Coleen thanks for being on and Carla. So really a nice group of people and we are happy to answer any question you guys have.
So the other thing is which product lasts the longest and it really varies. I think if you inject one product 2 or 3 times in the same region you will start to get duration and that is always nice. If you do it once a year you will tend to get hills and valleys where you face looks really good and the product dissolves and goes away so we try and have people come in more consistently and try and develop a programme that fits their goals and their budget and their risk tolerance, because sometimes you get some bruising from these injections and does not really matter who does it or how it is done, some people just tend to bruise and I find that in my practice if we have them on aspirin they bruise more. I try and get people to stop taking aspirin a week before but we have people on blood thinners that do perfectly well and we have people who don’t take anything that bruise so it is a whole range of people.
When we are filling the cheeks we like to use a thicker product something like Radiesse or Voluma or Restylane Lift, and when we are doing fine lines around the mouth, we like to use something like Restylane Kiss when it is available or Restylane Silk which does really, really nicely. We also use a lot of Volbella in that area and sometimes we will reconstitute some of the regular Juvéderm, or Juvéderm Ultra Plus and that works really nicely we use very small micro needles for that we get a lot of very pretty results. So in terms of that the durations are all different. Some of the newer products are more durable and will last longer so there is a benefit to using them if you want to go long distance. A lot of people like to get injected twice a year which is what we recommend, mostly because the body is always changing so we can always keep up with it if we have more opportunity to inject and sort of customize your face. Sometimes people come in and they want to do every 8 to 12 months and for those people we have to end up using a lot more material to try and cover all the ground, so that is when we use different things.
There is a question about Kybella and what we see is Kybella has been very popular and we are seeing a lot of people using it off the face where its approved for so we see it used sometimes in different parts of the body and it works pretty nicely again, it is just an experience type of thing if you used a lot of it, you will be fine getting it done.
So then there is a question about Radiesse. Radiesse tends to be good for very thick skinned people with deep folds and wrinkles. I would not use it around the mouth and I would not use it in the lips at all so you just have to be careful about that. It is also white so you want to be careful about that, that you don’t put it in places where you will see lumps or bumps it is designed to be placed deeply, let’s see what else do we have. Sculptra – like Sculptra a lot particularly in patients that are over 60 because what it does is it restores collagen and elastic fibers and that is really a nice way to help people and it is a durable correction that is if you do enough of it in the beginning what you can do is have the person come back every 8 months and do a bottle or 2 as a refresher just because we can reverse the clock, we can’t stop it so a lot of times it is really nice when we can see you a few times a year sort of do maintenance on that. So that works out really, really nicely.
Let’s see – we have Gabrielle there. Nice to see you Gabrielle, we know that you have always been a big fan and we appreciate that and any other questions or any other comments that I can mention. One question that we always see is, what is the difference between fillers and Botox or fillers and Dysport or fillers and Xeomin or fillers and Jeuveau and the difference is that the botulinum toxins that we use tend to relax muscles whereas the fillers and the other products tend to add volume or subtract volume depending on where we are putting and which product we are using. So there is a big difference and I want to make sure that you are being injected by someone that knows the difference and somebody that does a lot of this, you would not want someone that does not know the difference or interchanges the two. Because if you put them in the wrong places you can have a really bad outcome and we try and make people look like they are rested but still they recognize themselves. We don’t want dramatic transformations just people that look like themselves ten years ago. So we welcome you to attend our virtual week of beauty, we are having some promotional products and some interesting combinations of things for those of you that have not been able to come in for the past few weeks. We understand your frustration and when things use up or so we are going to try and get everybody in. So just be patient with us and we will be happy to work with you. Let’s see there is Lauren popping up, hey Lauren how are you? Thanks for being here. If there are any other questions we are happy to see you or chat, and again if you have questions later, feel free to call us at the office at 561 566 9055 then we will be happy to speak again. Visit us online and take a look at what we have, the virtual week of beauty will be phenomenal and we welcome you to attend it. Thanks again for your time we will do these every day and look forward to speaking to you. Thanks!

Now what we are going to do is inject her frown lines here, and what we are going to do is use a little bit of a botulinum toxin just to relax this. Basically in the face there is one muscle here that pulls everything up, and everything else pulls it down. So by relaxing this set of muscles here and here – we will be able to relax the muscles that pull down as she should get a little bit of an eyebrow lift and that will look really nice. Sometimes we go ahead and combine that with a little bit of injection out here, and again that allows us to relax the muscle that pulls it down here giving you a lift, so botulinum toxins are all opposite when you relax the muscle that goes down you get an elevation and when you relax the muscles here that hold the eyebrow and eye lid up you get a droop. So a lot of times I will see people that come from other places, and what they have done is had injections through here to try and get rid of these lines, and unfortunately what that will do is drop you so what we will do is go ahead and start. Go ahead and frown, give it a little pinch. What we like to use here are these very, very small microscopic needles to place the protein perfectly where it belongs. Pinch – it also decrease the discomfort and we have a few other things that we do here that make it much more comfortable for the patient. In general, no matter which product we are using we try and do about 5 or 6 injection sites and that gives us a very nice pattern. How are you doing? Good! So you can see it is a fairly simply injection and what we are doing is using these imported needles from Japan and they are so small you can barely see them. We go through a lot of these, the other thing is that sometimes we will use our insulin syringes again because they are very small very comfortable. Minimal, minimal bruising. You will see a little bit of fluid there and you will see just 5 little fluid bumps and what that is, is this saline or salt water that we use to reconstitute or mix up the toxins, and most of the ones that are available today are similar in that respect. Some of the newer ones will come pre- mixed. Raise your eye brows for me? So again this is one muscle here called the frontalis that is pulling everything up. In her it is giving these lines, but they are not that deep and we don’t really want to every go below the bottom third. If we go below here and she will get an eyelid heaviness. So go ahead reach up, lift up for me, little pinch sorry – and so in contrast with some of the other injections we do. What I am doing here is spreading the protein out evenly with tiny, tiny, tiny injections. So we are not going to get every single line but we are going to clean up the neighborhood, and make her look a little bit more relaxed and less stressed. How are we doing? Good. So I am taking my time here and going along and trying to make sure that the body of the muscles relaxed and that she still has something that works to hold her eyebrow up. Trying to make it as symmetric as possible, and again that is a pretty easy injection. Are you okay? Mhmm. So that is how we treat the frontalis or forehead muscles and that is how we do the frown lines or glabella but very, very easy to do the only thing is you have to know where you are going and use the right amount of product. There are many different products available today from Botox to Dysport to Jeuveau to Xeomin and they are pretty interchangeable to some degree. You just have to understand the difference between them and correct for some dosage. There are some subtle differences that we will also talk about in the next part. So you should be perfect for that!

Okay, so let’s see. So what we will do now is we will talk about the different types of Botulinum toxins, of course there is one called Botox that has been around for more than 20 years and been approved for cosmetic use, and it has been one of the ones that everybody starts with and now there is all kinds of other products available and it is really a lot like Coke and Pepsi so there is all kinds of things that we can do with each of the different ones and sometimes we add them together to get different effects sometimes we us different products in different regions in the same person, but there is a lot going on and as you can see behind me, I have written a book about the use of Botulinum toxins and that book has been used for several years and has now been translated into a few different languages so the first one that we saw approval for in the US is called Botox and it is a type A Botulinum Toxin, it has been around for a while we use it to treat all kinds of things, I like to use it for what is called the masseter muscles or the chew muscles in here, in people that have grinding teeth or have a little bit of thickness in the lower half of their face, we use it here in the front lines or glabella, here and here. I like to put a little bit in the chin and in some people that have deep wrinkles around their mouth, we will put a little bit of Botulinum toxin in there too. The next product that was approved is called Dysport and that is also a really outstanding product, it is a type A toxin that we use. A lot of people think that it is a little bit more of a diffused or gentle spread so we use it in muscles that are a little bit larger and more diffused, and again it is really Coke and Pepsi. Some people just absolutely love one product and don’t want to go back, some people rotate, some people just want to try the next thing, but we have everything in this office, the next product that was available is called Xeomin. Xeomin is an interesting product. It is also a type A toxin but unlike the other toxins that are available, it has no carrier protein so it is referred to as a clean product. We use that in a variety of patients and again it is a Type A toxin that works pretty well and again feel free to ask questions we are here to answer whatever you guys have and talk about all the different toxins in addition we are right now running our beauty week and this is the last day of beauty week, and to participate in beauty week all you have to do is, call the office at 561 655 9055 and speak to one of the receptionists and they will walk you through what beauty week has, offering some promotions on different injections and lasers and skin care products so that everyone who is in quarantine can feel and look better! Let’s see the last product that we will talk about is Jeuveau and Jeuveau is the most recently released product it is really a wonderful product like the others, and it is used in frown lines we think that in the near future they will get approval for some other areas and then will be using it all over the face again your doctor or injector has discretion. Once the product gets approved we can use it in any part of the body that we and the patient think is appropriate so a lot of times when we see patients with different needs we use the same product even though sometimes it may not be approved for that area, that is considered an off label use. I see a lot of my patients and friends are watching, Kristen thanks for tuning in, if anybody has any question please let us know – be happy to help you answer them! So lots of the questions that we see are about how long proteins last and again it depends on the person. If somebody is a marathon runner they are going to metabolize the protein and build muscle – so they probably won’t get more than 3 months and if they are doing triathlons they probably won’t even get that. If it is a male that is very muscular we tend to dose them a little bit higher but in general if people are getting injected on a sort of routine basis and getting the correct amount of protein we think that they tend to last about 3 and a half months. I have patients that have been doing it for 20 years and they you know, there are few of them that can come twice a year and be perfect! So the more frequently you will do it the better you will do, and a lot of times what we see is people that stick with a regiment and come in, start to get duration that is really much longer. The other thing we see sometimes is after a while patients will sort of form a bond with one product or another, and I will find that one product lasts for 4 months and another for 3. Very, very patient specific.

So we see a lot of that. The next question new get a lot of is, injections are 200 dollars in this place, and 400 dollars in your place – what is the difference? And the difference typically is 2 fold. Number 1- the integrity of the product, and also the experience of the injector, so some places dilute out their products to try and get them to last longer and we don’t, we try to make sure that the products are used as directed. Let’s see there is a question – do you have to be in a certain age group to get these injections? The answer is no you can be in any age group and get injections with Botulinum toxins. In general they don’t really need to be done before 25 years old, and I do a have a few patients that require them earlier. Thanks. So we see that pretty much anytime is a good time to start if you are genetically programmed to have wrinkles then you might as well start treating them before they are etched in. Once they are etched in we use a little bit of filler to try and get them unetched and more flat, and then we will use the botulinum toxin type A to keep them from etching in further. Let’s see next question can you exercise afterwards? We like to have people not exercise for the rest of the afternoon. Certainly the next day is fine. Let’s see – the last question is what are other places we inject? I like to inject in a variety of places. A lot of times we do the chin and the neck, and sometimes we will do the under arms to treat sweat and we have people who do that frequently and what it does is it allows them to not have as much sweat and look great in their dresses. So I think that was a really nice session and I want to thank you guys for watching! Again any questions feel free to call us. Thank you.

K.B – Beer Dermatology
Cosmetic, General & Surgical Dermatology

A lot of times when the lines are etched in, and you can’t get rid of them with toxins what I like to do is use a bent needle and a soft filler and try to etch them out. I leave the needle at 45 degrees. Stays superficial and just erase the lines

K.B – Beer Dermatology
Cosmetic, General & Surgical Dermatology

And now what I am doing is beginning to elevate this side of her nose a little bit, she had a little bit of a depression here by injecting a soft gel - hyaluronic acid I was able to easily and efficiently. Raise that up so it looks perfect.

K.B – Beer Dermatology
Cosmetic, General & Surgical Dermatology

When I am injecting the tear trough I like to keep my non dominant hand on the inferior aspect of the orbital rim, I then use a small needle to get very deep and try and feel very gentle with very little pressure as I re-inflate the tear trough to make it look anatomically correct

K.B – Beer Dermatology
Cosmetic, General & Surgical Dermatology

So what I am doing here is using a long cannula to get all the way under her skin, and go up to the proximal knuckle and you can see it just gently flows through what we are using is Radiesse, it is just a perfect product because it is a little bit opaque, it is white because of the calcium and what I like to do is, spread it around using the cannula and then I will use a little bit of pressure with my finger and what that does is it spreads it homogenously and provides really wonderful coverage. Very, very minimal trauma even though the skin here is incredibly thin, and you can see off her vessels and everything else, but what happens is you lay the Radiesse down on top of it, just like that, you can spread it out and it camouflages the vessels, the tendons and everything else.
You can see it is a pretty easy procedure to do, the way I do it is I make 4 small incision points at 12 3 6 and 9 with 12 being her right third knuckle, and what we will do is just gently fill into her digital space with a little bit of Radiesse and you can see it just really gently flows, we are using a soft fill cannula at this point which has several exit ports and what I am doing is just filling a little bit at a time, and you can see as we fill that spot there – we are gently going to coax it over, and so we are just going to use a little bit of pressure and spread out the material so it is evenly distributed and then a lot of times what I like to do is take a semi ablative laser and just tighten the skin up and it looks beautiful when you are done so that is it.

Skin and her face up a little bit, we are going to pull it this way. Then where she is a little bit hollow in here, we are going to put a little bit of filler too. We are going to start here, a little pinch sorry – and in this instance we are using Restylane Lyft. There are many products that will fit in here and give her an exquisite result, this just happens to be the one we are using today, and I think she is going to love this. This is half a syringe and we will do one side, then look at it and then look at the other side. Pinch and you will hear a little bit of a cracking as we fill, you might feel a little funny because it has an anesthetic in there, but what this does is it will lift the brow a little bit and enough to make a really pretty difference. It is also going to fill out those hollowness, she does not have the hill valley hill phenomenon that we see so frequently in women. Good! How are we doing? It is good it didn’t hurt at all

Frown for me Elizabeth. We are going to treat this area here and a little bit out here on the sides to give her a nice brow lift. Ready? Frown push hard, push, push, push, push, push! What I like to do is start early. Elizabeth is in her 20s and it is a great time to start before those lines get etched in, it takes much less product to do it, and much less frequency. She will have a gorgeous result by starting this early; she will get the muscles into the habit of relaxing instead of contracting. We are using small amounts so this is 20 units of Jeuveau which is the FDA recommended amount. She will have a perfect result. Smile! Now we are taking out a little bit of her orbicularis and that muscle pulls the outside of the brow down, turn this way – smile. Without this, she will have nothing to pull the outside of the brow down so her whole brow should rise up like that. Beautiful. You okay? Yep

Frown for me – so Samantha here has a pretty active procerus muscle which is the muscle that holds her forehead down. Frown push down and now we are going into the corrugator muscles, which is giving her, her elevens we are using tiny, tiny needles here, so the degree of discomfort here should be minimal. Now going after the middle part of her corrugator muscle, and the talmud raise up, so this is a frontalis muscles, the frontalis ends here we are just going to go across with these tiny little injections. Just to soften it, we don’t want to obliterate her wrinkles in her forehead she is going to use some of them to keep her eyelids up and her eyebrows in the right position, but we do want to soften these lines a little bit so they don’t get etched in and deep. Sometimes when that happens we are going to have to use some fillers, and again in the middle third of her forehead we are going to put in a little bit of extra if we don’t do that she will have a flat forehead in the upper and then a lot of wrinkles in the middle.

Frown. Push down – so what that does is it activates the procerus muscle which is the muscle in the middle of the nose ridge and that is the muscle that pulls everything down. Frown, and now we are hitting her corrugators on both sides, really important to be symmetric and not splash this stuff around. We are going right into the belly of the muscle by placing the protein right there, you won’t have a lot of drooping; you will have a lot of precision. One other thing when we inject in this area – if you notice we are staying really close to the surface. That is where the muscle inserts into the skin and that is really where you want your protein to go. Raise your eyebrows – so today we are using the newest Botulinum type A toxic called Jeuveau. The units are very similar to Botox, little bit different than some of the other products, but it is a great product we are seeing a lot of interest in this, and a lot of patients are trying it in my opinion it is like Coke and Pepsi. Very subjective, Botox itself has been incredibly popular for more than 20 years and remains popular to this day. Right now we are injecting her forehead or frontalis and we are – what I am trying to do is a bunch of small injections so that not any given area has a huge amount, and we spread it out, and that is sort of correlative of her anatomy. Raise your eyebrows – her frontalis muscle goes all the way out to about here, and you can feel where it stops, so we want to keep our Jeuveau in a line that goes across the middle of her forehead but stops here. If we go past here it’s just wasted. She has a pretty low forehead so we are not going to waste product up into her hairline, however putting it across here will help her. So that is an easy, easy injection. It takes about 3 to 7 days to work, and it is an injection that we do three or 4 times a year depending on how much we put in and how much she metabolizes it. So it is a very simple injection, after the injection – we don’t want a lot of pressure, we like a little bit of gentle dabbing, that helps. How uncomfortable was that? Not at all. Ok, thank you!

K.B – Beer Dermatology
Cosmetic, General & Surgical Dermatology

So what I am doing here is using a long cannula to get all the way under her skin, and go up to the proximal knuckle and you can see it just gently flows through what we are using is Radiesse, it is just a perfect product because it is a little bit opaque, it is white because of the calcium and what I like to do is, spread it around using the cannula and then I will use a little bit of pressure with my finger and what that does is it spreads it homogenously and provides really wonderful coverage. Very, very minimal trauma even though the skin here is incredibly thin, and you can see off her vessels and everything else, but what happens is you lay the Radiesse down on top of it, just like that, you can spread it out and it camouflages the vessels, the tendons and everything else.
You can see it is a pretty easy procedure to do, the way I do it is I make 4 small incision points at 12 3 6 and 9 with 12 being her right third knuckle, and what we will do is just gently fill into her digital space with a little bit of Radiesse and you can see it just really gently flows, we are using a soft fill cannula at this point which has several exit ports and what I am doing is just filling a little bit at a time, and you can see as we fill that spot there – we are gently going to coax it over, and so we are just going to use a little bit of pressure and spread out the material so it is evenly distributed and then a lot of times what I like to do is take a semi ablative laser and just tighten the skin up and it looks beautiful when you are done so that is it.

Gently – so what I am doing is I have made a little bit of a nick in her right hand, I have mixed up some Radiesse in this case, but you can use Hyaluronic acids, we are just injecting it all under her skin to reduce some of the veins and the stringy-ness of this. Getting it, alright

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I gradually do this and again we have used a little bit of injected anesthetic to make this more pleasant for her. She has a pretty shape so we are not going to change the shape too much just gradually going to fiddle and give her a little bit more volume in her mouth. What we are doing is we are putting it in, in what is called a wet dry junction and that is where the pink part of the lip meets the beige part of the lip. Again really a gentle gradual injection, even though it looks a little bit lumpy. Once we are done with her, it is going to look phenomenal and now I am going to the peak and threading it into that corner and you’ll see it fill gradually.
How are we doing with that? Great. How uncomfortable is this? Not at all. Good, so by doing what I just did and filling out her little rolled border she will get a really nice definition and separation, so her lower lip looks really nice. She just needs a little bit of volume. So that is what we are going to do here, we are going to fill it gently and you can see the product flowing pretty evenly so, even though we are out off to the side you can see it filing all the way to here. That is one thing to just watch.

K.B – Beer Dermatology
Cosmetic, General & Surgical Dermatology

Injecting the lip with Voluma

As you can see she has a really pretty jaw line, her cheeks are already treated so they are in the proper place. What I am doing now is putting a little bit in her chin to give her a little bit more definition and balance the bottom third of her face with the middle third as well as the upper third. So I am using is a little bit of the Voluma. I am in the sub periosteal plane and there is really very little resistance in that plane. We are staying in the middle to avoid the nerves and arteries that are there, and as you can see she is tolerating this very nicely. So when we are done she will have a lot more of the chin, and it will give her a really pretty lower third of the face. So when I am doing this, I do it very gently. I asked Pray to make sure we are in a good place and then just put the product in very gently. So with this technique you can see, shell do very nicely. When you look at this from the side you can see already just from that little bit she is much better now and the bottom third is no longer appearing. So I think that this is a great treatment for patients that have thin or small chins. It is very easy from a technical perspective, and I think patients really love it. So what we are doing is just giving her a little bit more balance in the bottom third of her face, and then with additional procedures, we can give her more sculpting of the neck area the sub mental.

Again fairly simple injection but it will give her better definition in the lower third of her face. Beautiful.

Are you alright? Mhmm. We are putting a little bit of Voluma in her cheeks to lift her face up, I tend to like to draw a line down from the lateral aspect to the eye, and just go into that line to raise the cheek up. Good. Are you okay? Yes thank you

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Hurts a little – to think I volunteered for this! (laughs) Mike is going to kill me after my heels need to be numbed! Yeah it was like I’ll say 30 percent and the rest I barely felt. Yeah. Hopefully it will swell up and it will go up like that, and you’ll show it. Yeah if you are not swollen like a bullfrog tomorrow you have got to call it in – you have got to deal with that, because that is an FDA – that’s a financial thing.

Did anything change? I am going to look to see. Are you alright? Yeah I am fine! Right now it just feels burning, that’s it.

We’ll see one more round, and one thing – you know there are 2 things, you don’t want to get the margin on the mandibular – it crosses somewhere around here – you can feel the notch, and second is I can’t believe that nobody has ever been intravascular with this product.

It’s a nice little sting, I noticed the middle areas is more sensitive than the outer areas. It’s weird.

Stop you’ve got an air bubble.

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Doing alright? Mhmm. A really, really easy injection – you should have no problem. What we are doing is customizing it, we are using small amounts in some areas and larger amounts in others. Should give you a perfect result. Kybella starts to swell a little bit but is a really, really quick procedure that works really nicely. Done!

Okay, again? Mhmm. Are you okay? Mhmm. Again – you don’t have to tell me every time you stick. And then at the edges gently use 0.1 – like here? Yea like right about there. okay, and you have got to try to remember to do that on the other side, alright so you have done this row – Mhmm, let’s do this row. Maybe put 0.1 up there where you are. Good, alright next route here. Okay next syringe.

Beautiful – so she has very strong muscles in the frown, we are going to use 25 units of Botox. Pinch – it’s a pretty standard easy dose. So 10 units there, 5 units here, and then 2.5 units here and this injection is where the muscle called the corrugator insets into the skin. Perfect! And so it is really important when you are doing that to have a very superficial injection. Perfect!

So next we will do her DAO. The Dao is a muscle that runs as a triangle from the base here to the corner of the mouth and it is responsible for pointing the mouth down. Bite down for me – we are going to go ahead and put a little bit of Botox, in her DAO.

Botox in her chin will relax the mentalist muscle which as you can see is putting in about 5 units with two injection sites and that will cause her muscle to relax a little bit. Beautiful – very easy injection, very well tolerated. Good!

And the DAO is relatively easy to find, but that little tiny injection will help lift the corners of her mouth and when we go back and do fillers here, it is going to make it look that much better.

You can see she has 2 big blood vessels – one here and one here, so we are going to go between them and try and treat her crow’s feet and again we are using Botox. The recommended dose for this area is 24 units. We are going to use 25 for her, and you can see that this is causing her outside eyebrow to be pulled down. So in addition to cleaning up some of the fine lines that we see here, this is going to help give her an eyebrow arch.

Go ahead – what we are going to do is soften up her frontalis muscle, not get rid of all the expression but just make it a little bit softer but really what we are going to do is confine ourselves to the upper half of her face. The bottom half where she has the lines above her eyebrows, we are going to leave those because those are supporting her eyelid and her eyebrow and she is using them to hold her face up. Perfect – that is about 20 or 25 units of Botox up top.

There is nobody there, so we’ll just wait for some people to log on. Okay so you have one person that is logged on. How cool! Amy is watching at the moment, Amy Greggor. Thank you for joining us I am Dr. Kenneth Beer I am a Palm Beach Dermatologist and today we are going to talk about various skin care products and what you should and should not do for your skin. Hi Amy! I see Amy in the background there – we will talk about prescription strength products, we will talk about over the counter products we will talk about things that are sort of hybrids of the two, a lot of what I think skin care is, is how many products you can use in a day. So if you know in your heart you can use one or two products don’t buy 6 or 7, and if you are really in to skin care, start with 3 or 4 and then add one or 2 every 2 to 6 weeks depending on what your goal is. So I guess the cornerstone of everything is some type of product kind of like this – which is retinae micro and retinae is what call a retinoid. This is a prescription strength product, and it has been around forever. It is a great product and retinae micro is the latest form of it, and what it is, is what is called micro sponges and these little tiny capsules filled with retinae so their slow release is more gentle.

So for people that get irritated by regular retinae – sometimes retinae micro is a nice solution and If you are getting irritated by retinae there is usually something going on. A lot of times what happens is you are putting the retinae on while your skin is still wet and retinae will separate into its base product and its molecule and cause irritation, so try and let your skin dry out a little bit before you put your retinae on in the morning and if your retinae is still irritating you, you can let your skin get used to it and by doing that I would like you to use it every other day for about 6 or 8 weeks and then try it again, every night. That would get your skin time to get used to it and acclimate it, but retinae is a really good products for everybody so whether you are sort of young and trying to get rid of damage and older and trying to treat your fine lines, and pigments – retinae is a god cornerstone.

The generic is obviously much cheaper than the micro but the micro is a better product. There are various forms of retinae and some of them are more conducive to your use than others. There are also other products called retinoid. What they do is they share the same background as retinae so they are like them but different, so they include Differin, which is now over the counter, primarily used for rosacea and acne and Taseract which is also a retinoid that can be used and it works really well. So retinae is not only for the face but also the neck, the arms the hands, and there is some great studies done with retinae that shows that if you use retinae every night for 9 weeks, the collagen and elastic fibers will start to come back in your face and neck, your chest and arms and everywhere, so again retinae is a great place to start. If you wanted to do more than that, which I think is worthwhile – I would add in something like vitamin c and the vitamin c typically looks like this, and it is usually in a darkish bottle and the reason why is because vitamin c is pretty unstable.

So if it heats up from the sun, it will start to decompose. That bottle of retinae the little tubes should last you maybe 2 weeks, 4 weeks – vitamin c should be used every 4 to 6 weeks, so if you have a bottle that is 6 or 12 months old probably worth investing in a new bottle. It comes as a serum so it is sort of a light liquid and my product has a dropper in it. I think that the dropper is really easy to control and lets you get a precise amount on, the other thing with vitamin c is because it is unstable there are different types of vitamin c that are put in there, so there is different chemical structures that allow vitamin c to be more stable so that is a great product. So if you are going to use 2 products I would say the vitamin c and a retinoid like retinae if you are going to add to that regimen, I would use a cleanser or an exfoliator.

The exfoliator that we have which I think is very good – is called the white bamboo exfoliator and again all these are available on our website, but the white bamboo exfoliator is a great way to polish the surface of your skin, it is great to use in the shower and what you can do is buff out some of the debris that accumulates on the skin, because it is an exfoliator you would not want to do it all the time, and you would not want to irritate your skin so what you do is you use that 2 or 3 times a week and that will help cycle your skin from the bottom of your skin to the top of the surface of your skin it takes about 28 days, so when you are starting a new skin care line it is worth remembering that, because you are not going to see changes immediately. The cells that are on the bottom of the skin have to cycle all the way through and that takes about a month and sometimes a little bit longer.

So again if you are going to use a few products the exfoliators are a great one, the vitamin c is a great one and then a retinoid. Next up on the list what we see is a lot of people with pigment abnormalities. Now we treat that a lot in the office with chemical peels, we also use lasers like Fraxel or C02 to resurface the skin, and chemical peels can be the subject of a whole other session and maybe we will do that. There is all kinds, there is glycolic there is Salicylic, and we use a lot of Salicylic because Sal acid is great for pigment and fine lines. It is also pretty comfortable because it neutralizes itself. If you wanted to use something to lighten your skin we like this product which is a brightening serum and the brightening serum has botanical extracts to lighten the skin.

There are other ways to lighten your skin, you can use prescription strengthen hydroquinone and usually that is 4 percent and that helps a lot with pigment. You have to use it with sunscreen of course otherwise you will make more pigment, but it is worthwhile trying that. If you are not going to use hydroquinone and a lot of countries have banned it because of a theoretical risk of sun damage and skin cancer, then you should use the botanical products like the brightening serum. So there is our brightening serum, there is other products that have different types of complexes, some of them are from mushrooms, some of them are derived from licorice like Licorizic acid, there is a whole range of products that are wonderful for brightening the skin. The key is to be consistent and use high number sunscreen or better yet sunblock and the difference is that sunblock is like an umbrella for your skin, whereas the sunscreen is sort of like a sponge and tries to gather up all the sun damage you can and filter all the sun. In my estimation it is better to reflect the sun than to absorb it.

Everybody has to clean their skin and some people use a bar of soap so it is okay if your skin is sort of oily and thick, might not be the best bet for you if your skin is sensitive and for sensitive skin we have a very nice calming cleanser, ours has green tea in it and it is really nice particularly if you have any irritation or rosacea or any type of inflammatory response on your skin we have all kinds of other products we have a PH balancing cleanser which is a really nice way to calm down your skin as well, so there is all kinds of stuff that we can use, finally there is some other products that we have here called a daily hydrating cream and what the hydrating cream does is it incorporates hyaluronic acid filling spheres and basically carries the moisture deep into the skin, so this will help hydrate your skin and thicken it, it will also help to get rid of some of the fine lines even if it is just temporary because of the swelling that occurs as your skin absorbs the moisture.

The lifting serum is another product that I like a real lot and what it has is a bunch of different ingredients but what they will do is help to form a film on the skin’s surface to make your skin less wrinkled in appearance and it also has a retinol in there, so not only will you get an immediate fix but you will get a really nice long term improvement of the appearance of the skin. So this product is really a nice way to go. When you are using any type of product, I don’t really like products that are a mixture of sunscreens and cleansers and sunscreens and moisturizers, I mean you live in very different parts of the world than in the United States, even in Florida, some people get a lot of sun some people don’t. I think if you are not going to be out in direct sunlight for more than 5 or 10 minutes, maybe using a 100 SPF is a little bit more than your skin needs. If you are just going to work or going to the gym and you are doing a 50 yard dash to the car, I really wouldn’t put sunscreen on my skin for 2 reasons, 1 a little bit of sun is not really going to be that bad, it is good for your brain to cycle the hormones, I also think it is great for some vitamin D and the other reason is by adding all these sunscreens you are going to irritate your skin.

So I love some protection and I am a big advocate of doing that, but I think that it is ridiculous to try and do it every day if you are not going to be outside. I also don’t like if it is mixed in as an afterthought to other products, so my product are very focused and you see that in a lot of other products now too which is wonderful. But what you want to do is get a sun protection product, one of the ones we like here is from Elastin and elastin makes a variety of really, really nice products. This is a mineral based tinted sun protection that is 36 SPF, and what that allows you to do is put it on have a little bit of colour on your skin and that works instantly. So in contrast with something like sunscreens, sun shield - sun block will act pretty much instantaneously. Sunscreens require 15 to 20 minutes to activate, so the first few minutes you are outside in the sun what is happening is, you are really giving your skin a little bit of a work out, and you don’t really want to do that because you will burn.

There are so many sunscreens out there, they range in price from 3 or 4 dollars up to 2 or 300. Not much of a difference in the structures chemically, if I had to go out and get stuff there is a million products that are great, again we like the elastin here, because it is just a really nice tinted easy to apply product. What else? We have so many products to talk about – if you are going to be travelling a lot you probably want to use a hydrating or barrier type of lotion we see products that are really good for the skin that will help hydrate and those are really nice to use when you are travelling in Florida probably during the summer months you probably won’t need that much hydration because the relevant humidity is so high, but up north in the various northern or western states you probably do still need some humidity and moisture, particularly in the night time when you are sleeping because if the humidity in the room you are sleeping in drops, it will really do a number and suck out all of the humidity in your skin, so you wake up dry and we can certainly talk about various different products.

There is all kinds of stuff we can use here, and some of the other things that are really popular both with us and with other manufacturers are these clearing pads which are glycolic acid and salicylic acid, and what they do is they help to minimize the appearance of fine lines and wrinkles and they have a really nice peeling system easy to use, disposable and you can use those a few time a day. So there is that, then there is all kinds of other things that we use on the daily basis – so that the mild cleansers is one of them, and then obviously you put all this stuff on under your make up and when you are applying stuff you want to put the active ingredients on first, and let them get through the skin – takes about 15 or 20 minutes to do that. So when we are talking about a daily skin care regiment you have to think through that you need a little bit of time to do it, you can’t just pile one on top of the other, the other thing that I have a lot of patients asking about is how come this stuff is not working and when you speak to them a little bit you find out what they have done is they have put on the sun protection as a layer or moisturizer as a layer and then they put the vitamin c or the retinae on and what they are basically doing is putting it on a barrier that the active ingredient can't get through, so always put your active ingredients on first and let it get through the skin for anywhere from 10 to 15 minutes.

So that is another really important tip that you want to do and when you are trying new products, yeah give them a change to work, don’t give them 2 or 3 days, give them 6 or 8 weeks and then if you don’t like them, try something else to figure out why you didn’t like it, whether it is dry or irritating – do they not do what they are supposed to so most products today are so well-made and are well engineered they tend to be really good after about a month. So there is a lot of stuff we can add to the next. Other things I like to add, are other botanicals there is all kinds of botanical extracts like Licorizic acid and other roots that calm the skin, Elizabeth just asked why is exfoliating important. That is a great question, exfoliating is important because the surface of the skin just accumulates damage and schmitz so you want to polish the skin’s surface as much as you can and try and clean the pallet. Once you have a nice canvas to work with, all of your active ingredients are going to work much, much better and I think you will find that your skin looks better and feels better after that, but that is a great question.

So other actives – Niacin and niacinamide have been around forever, people have used them as oral medications, and they are very, very strong and good anti-inflammatory so I like niacin and niacinamide, there are several products that incorporate them, niacin and niacinamide are different and you would not want to take one and switch it for the other, because you can have all kinds of problems. Stick with niacinamide by mouth and niacinamide topically, and those products have been shown to decrease the incidence of skin cancer as well as to brighten the skin and help to treat fine lines and ageing so niacin and niacinamide are wonderful products you should try and stick with them. If you really want to go and do more advanced stuff, there are several extract available and some of the extracts are things like extracts from seaweed and the botanicals and the molecules and the minerals found in seaweed can be very, very helpful. Most sea weed tends to be very rich in magnesium, sodium, potassium and things that the skin will use. There are also proteins that are being used now and they are helpful as well.

One thing that I don’t think is helpful to a skin care regime is some of the newer products like edible collagen. I don’t think that edible collagen is going to be absorbed in any meaningful amount so what I really recommend is staying away from edible collagen and using more of a topical based product like hyaluronic acid. So that is my recommendation for skin care regimes. There are some prescription that you may want to talk about – with your physician, and that is Trryluma and Hydroquinone. Sometimes we compound them and by compounding we make them or have them made for us, the benefit of doing that is you can make it any strength you want and sometimes the local compounding pharmaceutical make a really nice supply of it using a 6 percent hydroquinone and very strong cortisone in the base, and what that will do is it will bleach the skin really quickly in a number of weeks and decrease the inflammation so that is a good way to do it. The Trauma is one of the products of prescription and it includes a retinoid, it includes a brightening or belching product and it includes a topical steroid. That is an old, old formula that was formulated by Dr. Albert Kligman and he was the inventor of retinae which was the first cosmeceutical.

So again when we are talking about skin care regimens there is so many interesting things to do that once you find your regiment you should try and stick with it and probably add to it. So there is all kinds of things that we can always add, and in addition to topical there are some nutraceuticals that we can talk about on another day. So there is all kinds of fun stuff we have here, and there is all kinds of stuff that is available at your dermatologist or plastic surgeons office, there is all kinds of stuff available at department stores, I think you should work with someone that knows your skin like a dermatologist or a plastic surgeon, I think in the end you will get better results and much better outcomes and probably save you some money as well.

So with that, I would like to thank all of you guys for being here and participating. There is plenty of stuff we can talk about so I welcome you to attend these on an ongoing basis and what we will do is we will answer any questions and talk about anything that you guys want, there is a lot of stuff going on now, so it is an exciting time in dermatology, and there are really great products that are available now and more that are on the way. So I want to thank you for sitting in on this and again any questions we are available, and you can always visit the website – beerdermatology.com. Thank you!

How do you address skin tightening at your practice?

I address skin tightening in a variety of fashions. In some patients we actually inject products to help tighten the skin, in other patients we use radio frequency, and in some patients, we use radio frequency and ultrasound.

What types of products do you use for this treatment?

We have 13 different types of energy products, so we have a full suite of devices to help patients achieve their goals.

Are these treatments, personalized?

As with everything else we try to customize how we perform our skin tightening per each individual person.