drlouisayim

Dr Louisa Yim

Aesthetic Physician

Home

Case Studies

Soft tissue filler (Questions and Answers)

Recently, I received an email from a client regarding Tear trough treatment (under the lower eye lid region).

With her permission, she has agreed for the questions and answers to be posted on the web. I hope that you will find this useful too.

Q: Hi Dr. Louisa,

I saw you a while ago at xxx to discuss my options for dermal filler treatment under the eyes.

Initially you suggested that I use a gel cream and see how that helps (which I purchased directly from xxx).

I have been using until now, but would still like to have treatment in this area to help reduce dark circles and fill the area under the eye.

I have made another appointment to see you on xxx at xxx to get this treatment done. Just a couple of questions:
1. Will you be able to do the treatment on the day or will you need to determine if I needed it? Just need to know as I have planned to take annual leave.
2. How much does treatment in this area normally cost? So I can ensure I have the funds to pay you.
3. I read your Bee 4 and Afters, is there anything else I should do beforehand and also where do I purchase the cream suggested by you for swelling?

I look forward to hearing from you soon.

Kind regards.

A: Dear,

Thanks for your email and Happy New year!

The technique of Dermal fillers under the eyes, also known as the tear trough area, is quite specialised.

Dermal fillers around this area can only restore the natural volume that has been loss.

Remembering that it is restoring to it original position. Hence, it is important to choose the right filler and right amount.

Choice of filler will be the lighter filler (rather than the heavy duty one) because this area doesn't allow enough room for filler expansion, as compared to the lips area (where there is a larger area for filler expansion). Due this this very same reason, there is a limited volume amount that can be placed at each treatment session.

PLEASE remember that dermal filler WILL not reduce the dark circles.

UNLESS, the dark circles are due to light reflection from the tear trough.

Most people will find the dark circles are less obvious but unfortunately, this may not apply to everyone.

Please refer to the answers below:

I have made another appointment to see you on xxx at xxx to get this treatment done. Just a couple of questions:
1. Will you be able to do the treatment on the day or will you need to determine if I needed it? Just need to know as I have planned to take annual leave.

Most likely I can perform the treatment on the same day, unless I do not think that dermal fillers will help you in this case.

Some clients come in hoping that this can be done, but in fact, some clients might need other treatment such as surgery.

I am sorry but I can't quite recall the depth, width and length around your tear trough area.

It is unlikely that you will need to take annual leave (due to bruising).
This is because I use the "cannula" technique, where there is only one very small entry point on the skin.

The only time it will bruise is if there is a lot of spider veins or small blood vessels around the entry point of the skin.

As the cannula is BLUNT not sharp, it will move and push the underlying vessels away.

Most of my clients will go back to work on the same day or the next day.

Avoid anti-inflammatories, evening primose oil, fish oil, aspirin, nurofen, vitamin E, garlic oil about 5 days before the treatment will minimise bleeding and bruising.

2. How much does treatment in this area normally cost? So I can ensure I have the funds to pay you.

Treatment cost depending on the amount of fillers required, therefore it will be between xxx (please email Dr Louisa for updated price list).
This is the cost of per session.

REMEMBER that IT WILL ONLY TAKE EFFECT BY THE 2ND WEEK. Some of my clients got a bit nervous when they couldn't see the effect after the first week. That is because this particular filler takes 2 weeks to absorb all the water molecules from the skin before it expands. All dermal fillers come "partially hydrated" when it is packaged.

This means it will only FULLY hydrate once it keeps in contact with water / skin.

Please make another review appointment in 2 weeks time (after the treatment) to see if a follow up treatment is required. It is important not to overfill each time.

Start low and go slow. Otherwise, it will be lumpy.

3. I read your Bee 4 and Afters, is there anything else I should do beforehand and also where do I purchase the cream suggested by you for swelling?

Avoid make up, exercise and alcohol before the treatment. Anything that may cause facial blushing will increase the likelihood of dilatation of vessels around the face.

Arnica by Brauer from Chemist warehouse. It is found usually near the supplements area. Although it says for arthritis it is because it has anti- inflammatory effects.

Here is a link for you:

http://www.brauer.com.au/products/arthritis/arthritis-relief-cream-200ml/

Once again, thank you for your email and I hope you will find this information useful.

I look forward to seeing you next Friday.

Kind regards,

Dr Louisa

Q: Hi Dr Louisa,

Many thanks for your prompt reply and answers to my questions. Happy New Year to you too!

I didn't think you would remember me, but we chatted about the process and you didn't really say if you think the dermal filler will help me.

You suggested that I purchase the Envion eye cream to see if it would help.

You gave me a handout with some information on a home care plan and to make another appointment if needed.

I am pretty dark under the eyes but I do have a noticeable tear trough that can make me look tired and darker than normal.

I have fair skin which doesn't help.

I can usually cover the dark circles with concealer, but the depression in the tear trough can't be hidden!

I also get a spray tan at xxx as it seems to make things less noticeable.

As you can imagine I have been doing quite a bit of research on this treatment.

I have seen some before and after photos of clients that have had this treatment and the results have been amazing. Refer to the below link:

http://www.thevictoriancosmeticinstitute.com.au/tear-trough-eye-bag-treatment/

The tear troughs are completely smooth for all three clients. ( I'm guessing they would only post photos showing their best results!)

It also mentioned on this website that they normally inject one syringe of filler type JU to lift the area of the tear trough and the results are immediate and should last between 1 to 2 years...is this information correct?

The "cannula" technique seem to be the best way to go and I have seen a couple of YouTube videos on how this is performed.

When you say xxx per session, how many sessions do you normally need?

I have read that one session will normally be enough for at least minimum 9 months.

Thanks for the information about on Arnica by Brauer...I just want to be prepared!

Kind regards,

A: Hi,

Yes, it is true that most doctors will only put good photos on internet!
I looked up the website you provided (thank you), these were performed by Dr Gavin Chan.

Unfortunately, it only shows you what happens immediately after. It doesn't show you what happens 2 weeks after.

I would never use 1 syringe of JU for anything above the nose.

This is, in my opinion and from my experience, that Ju products produce too much swelling as they hinder lymphatic drainage.

A lot of ladies will come back once a month saying that it gets puffy for around 7 days (around their time of the month), this is common too.

One syringe JU is 0.8ml and having 0.4ml to each side is too much! Maximum amount for each side and each treatment session is 0.2ml!

Having said that, I would not use more than 0.15ml on each side due to potential complications (which I have seen in clients treated by other injectors). These complications are swelling and puffiness. Sometimes, you can even see the products!

Here is a website I found on why I don't use Restylane or Juvaderm in the tear trough region.

http://www.westsidemedicalspa.com/tear-trough-under-eye-treatment-with-juvederm/

I use Es from Mondeal. ALthough, you might not see the immediate effect but I can ensure that there will be no blue/yellow discolouration and less chances of lumpiness or overfilling leading to swelling.

Yes, it might not last as long up to 9 months, most clients will get 4-6 months out of it, but certainly I charge only based on the amount used.

1 syringe JU usually cost around xxx.

Most client only need 1 treatment.

I like to review clients in 2 weeks to ensure they are satisfied or whether they would like a bit more (once again, the cost for the second treatment is based on the amount of filler used only).

You have asked really good questions, I think, if you don't mind, I will add these questions on my web so it might help other clients in the future.

Your name and email will be omitted of course.

Thank you!

Regards,
Dr Louisa

Liquid Mini Face Lift (without the knife) - April 2011

(Before) (5 minutes after with make up)

This is a young lady in her early 20s and she wishes to freshen up her looks.

There are some signs of early aging:

1) Some hollow areas around upper eyebrows and temporal regions (please note her right eyebrow is lower than the left).

2) Mid cheek hollow, leading to formation of early nasolabial folds.

3) Mental crease (also known as the chin crease) - this is an important region to treat, because it frames and restricts her lower face.

One syringe of 1.0 ml Re (Q-Med) is used with cannula technique to these areas of concerns.

Note her right eyebrow after treatment - It was almost to the level of her left eyebrow.

This is also known as a a gentle eyebrow lift technique.

(Before) (5 minutes after with make up)

Her nasolabial folds are quite prominent due to the loss of volume in her mid cheeks.

These folds can be softened by replacing the volume that is already loss in her mid cheeks.

(Before) (5 minutes after with make up)

Mental Crease or Chin crease can also be softened.

Overall, this liquid mini face lift creates a fresher and NATURAL look without having to spend too much money or go under the knife!

MARIONETTE FOLDS - (March 2011)

(Before) (5 minutes after)

Marionette folds are due to the pulling down effect by the depressor angular oris muscles and the loss of volume in two areas:

in the mid cheek and between the corner of mouth and the chin.

This lady has already had her mid cheek treatment and now she wishes to have a more softer look around her mouth.

This lady had Ra product (from Merz) with Cannula technique - note the lack of swelling, bleeding and bruising achieved with

this technique.

The blanching (white area) around injection point on the BEFORE photo is the effect of the local anaesthetic with adrenaline.

The adrenaline causes vasoconstriction and hence, less bleeding occurs.

This technique is good for skin with minimal acne scarring.

Other views

(Before) (5 minutes after)

LIPS AND CHIN - (February 2011)

(Before) (Immediately After)

A lot of clients ask whether they can have a "small" treatment just to enhance their upper or lower lip, sometimes both.

The answer is YES with minimal trauma to adjacent skin area.

This client wishes to have her upper lip enhanced slightly but still maintaining its natural shape.

After local anaesthetic, she received a total of 0.2 ml (0.1ml to each side) JUP with CANNULA technique and 0.3 ml of JUP to

her chin crease.

Please note that apart from minimal swelling, there is very little evidence of the entry marks or bruising.

Cannula technique is fantastic in highlighting the vermillion borders (LIP LINES) with absolutely minimal bleeding.

This is because there is only one entry point to the skin on each side.

Cannula technique is NOT SUITABLE for clients with very fine dynamic lines or areas with pre-existing scar tissue.

Her nasolabial folds (very fine smile lines) have both static and dynamic components, these can be treated with ferning or

pin-point technique.

OTHER VIEWS

(Before) (After)

RIGHT MID CHEEK ENHANCEMENT - (June 2010)

(BEFORE) (AFTER)

The normal ageing process causes loss of bone and soft tissue just under the eyes and in the mid cheek region.

Most clients report that they have a very tired look and feeling down. In order to restore the more "refreshed" look,

a dermal filler can be placed along the tear trough (just under the eyes) and also in the mid cheek region.

This Client received half a syringe of product to each side, total of one syringe with JUP with lidocaine.

LEFT MID CHEEK ENHANCEMENT

(BEFORE) (AFTER)

LIPS ENHANCEMENT

Another aspect of a normal ageing process is the thinning of lips.

This client reported that she was not able to use lipstick as it highlighted her small lips.

She received half a syringe to each upper and lower lips, a total of one full R product.

A dental nerve block was in place prior to the treatment for analgesia.

(BEFORE) (Immediately AFTER)

Please note that swelling always occur after the treatment and may last up to 72 hours.

(BEFORE) (Immediately AFTER)

(Side view - BEFORE) (Side view - AFTER)

Successful treatments:

Before treatment of the outer hips	Before treatment Upper Lip with lost of definition	Before treatment "Turkey Neck"

After Treatment with Injectable mesotherapy (x 3 sessions)	Post Treatment Upper lip Dermal Filler more Definition of lip line	4 weeks After Treatment with injectable mesotherapy (1x session)

Before treatment Note the angle of the nasal bridge. This is a common presentation and usually there is a family history.	Before treatment Note the volume loss on right side of nose (5/2/2010) There was no prior history of surgery or injury to the nose.	Before treatment - tear trough (right eye) Note the hollow under the right eye. With the reflection of light, it creates an image of "dark circle" under the eye, a TIRED look.

Immediately Post Treatment 15 mins "nose job" with minimal swelling and bruising. Note the correction of the acute angle from the nasal bridge.	Immediately Post treatment - phase one only: Reconstruction of nasal bridge first (so as to minimize down time) Phase two remodelling of the nostril (next month)	Immediately post treatment - tear trough (right eye) Note the hollow has been treated with a dermal filler. The correction allows light to reflect off the skin and no longer creates the "dark circle" and tired look effect.