Dermatology Video Gallery

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.

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.

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.

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.

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!

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.

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.

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!

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Stop you’ve got an air bubble.

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.

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.

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

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

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

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.

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.

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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

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

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.

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

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.

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!

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.

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!

Beautiful. So, she has very strong muscles in the front. We’re going to use 25 units of Botox. 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, Inserts into this skin. Perfect and so it’s really important when you’re doing that to have a very superficial injection. Perfect.