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Upper Eyelid Volume

The importance of Upper Eyelid and Orbit Volume on Eyelid Appearance

An often overlooked aspect of upper eyelid aesthetics is the role of volume on the development of extra eyelid skin. As we age, the following changes lead to excess skin of the upper eyelid.

  1. Skin laxity increases
  2. The eye socket becomes wider and bone volume decreases
  3. Fat and muscles around the eyes become thinner

The combination of the volume loss and skin elasticity creates extra folds in the upper eyelids (as shown below).

A commonly performed surgery for this issue is a blepharoplasty to remove excess skin. However, the less discussed role of volume is also important in the development of upper eyelid skin laxity. By replacing this volume, we are able to recreate the bone and fat volume that has been lost which is able to provide a “lift” to the eyelid and brow.

In the following patient, no eyelid skin was excised. Notice the appearance of the extra fold of skin of the upper eyelid on the before image. By adding volume, the extra fold of skin has been corrected by adding the missing volume for a more youthful upper eyelid appearance.

If you are considering a blepharoplasty, it is an excellent surgery for the permanent correction of the upper eyelid dermatochalasis, or excess skin. But keep in mind that some techniques of blepharoplasty can actually create more hollowing of the upper eyelid. That is why at the Facial Plastic Surgery Institute we use volume sparing techniques for upper blepharoplasty which focus on muscle and volume preservation with fat repositioning rather than fat removal.

I perform Blepharoplasty surgery in my Southlake and Fort Worth offices and is a great procedure with minimal downtime. I also perform injectable fillers for upper eyelid volumization in my Southlake and Fort Worth offices. Check out the blepharoplasty page for more information or email me with any questions you may have.

JR

Internet Consultations

Not from the Dallas/Fort Worth area and interested in a consultation with Dr. Rihani? Setting up an internet consultation is easy.

Step 1: Fill out the New Patient Paperwork

Download New Patient Paperwork Here

Step 2: Send 3 photographs (or 4 if a rhinoplasty) shown below and a description of the procedure you are wanting. Be sure to include details about any past facial surgeries!

Picture tips:

No Smiling

Have someone help you take them so they are not taken too close to your face.  

Picture 4 (if rhinoplasty consultation)

Send the paperwork, photos, procedure requesting to jordan@rihanimd.com. We will call you within 1-2 business days to set up a phone consultation.

 

Basic Plastic Surgery Photo Setup

I get asked about my photography setup regularly so I decided to share our current set up. It has been a reliable setup for me if you do not have a photo studio room and are just looking to take some quality and consistent photos from your exam rooms. I think my team does a great job with the photo lighting and keeping our before and afters standardized. Hopefully this information will get you on the right track and save you some headache.

Before and After Example

The Backdrop:

I use retractable, wall mount blue screens in my room. They can be placed behind the doors and do not tend to be too much of an eyesore. I recommend blue for plastic surgery simply because it is easy to discern facial borders for surgeries like rhinoplasty or necklifts – for patients of any color skin. If you are raising and lowering it regularly, they can take some getting used to and you may need to tighten or loosen the winding mechanism, so hang on to the instructions that come with it.

Link to purchase: http://www.belgerphotography.com/25X5-Rollup-Background-System_p_45.html

The Camera:

I am currently using a Nikon D3400. Camera quality is so good these days that this is probably the least important piece of the puzzle. That being said, I like using a DSLR because I like to shoot at a certain focal length – which is easier to do when you have a DSLR. The memory card pops out easily which allows easy and fast downloads as well.

Link to purchase: https://www.nikonusa.com/en/nikon-products/product/dslr-cameras/d3400.html

The Lens:

The lens currently on my D3400 has a pretty large focal length range, 70-300, which is not necessary. I really just use the 100-125mm range. I simply mark the focal length on the lens and the photographer lines it up before shooting. You can also purchase a dedicated 105mm Nikon lens but they tend to be a bit more expense. For an explanation of focal length, see the bottom of this post.

Marked focal length of 100-125mm

Link to purchase: https://www.nikonusa.com/en/nikon-products/product/camera-lenses/20068/af-p-nikkor-70-300mm-f%252f4.5-5.6e-ed-vr.html

Other options: https://www.nikonusa.com/en/nikon-products/product/camera-lenses/2213/af-s-dx-nikkor-18-140mm-f%252f3.5-5.6g-ed-vr.html

Full collection of Nikon Lenses here: https://www.nikonusa.com/en/nikon-products/camera-lenses/people-and-events-lenses.page

 

The Flash:

If you have a dedicated photography room, I would recommend a dual flash set up with mounted flashes – one in each corner. If you do not have that luxury, I am getting nice results with my Nikon Speedlight SB-500.

I am angling the flash upwards at a 30-45 degree angle instead of directly at the subject, see below. This prevents flooding of the subject with light.

Flash angled upwards
Avoid flash pointed directly at subject

Link to purchase: https://www.bhphotovideo.com/c/product/1082606-REG/nikon_sb_500_af_speelight.html

Positioning of the patient:

Frankfort Horizontal Plane

Frankfort Horizontal Plane: Patients are kept in the Frankfort Horizontal plane. Notice the alignment of the top of the ear canal/tragus and the inferior orbital rim. This is also maintained on the frontal view to prevent over rotation of the head up or down. Patients always tend to put their heads up in photographs and need a constant reminder to put their chin down a bit.

Demonstration of Frankfort Horizontal Plane. Photo Credit: Royal Photographic Society

 

Importance of focal length

Again, focal lengths are kept in the 100-125 range. This is marked on my cameras so that all photographs are taken at a standard focal length. Using a lens with a dedicated focal length is also easy (i.e. 105mm).

I often see injectors show me photographs of patients taken with their iPhones up close to the patient’s face. This is equivalent to a very small focal length and creates a large amount of distortion – creating warping of the sides of the head and enlarging the nose. This makes it nearly impossible to objectively assess photographs and, in my opinion, makes it useless to even take such photographs.

If you are confused about the effect of focal length, see the images below. Another work-around if you have to use an iphone/ipad is to back up and zoom in. This increases the distance from the patient and creates less warping at the edges of the photo.

Facial Distortion at Lower Focal Lengths. Photo Credit: Digital Photo Magazine

 

Hope that helps you all take some consistent photographs of your patients! Feel free to contact me if you have any questions or thoughts – jordan@rihanimd.com

JR

The Art of Injecting – Part 3

This three part series is meant as a guide for beginner or intermediate injectors looking for new concepts or interested in advancing their techniques. These concepts apply for injectable fillers as well as with Botox/Dysport. I also invite my patients to review these topics in order that they can be knowledgeable about their treatments. These are concepts that I frequently reference when performing trainings. I perform my own injections of filler and botox in my Southlake and Fort Worth, Texas offices.

The Art of Injecting – Part 3: Draw Attention Upwards (Towards the Eyes)

Avoid the Nasolabial Trap

I blame “FDA approved marketing” for the seemingly incessant obsession over the nasolabial folds and here’s why. When filler companies first began getting FDA approval for fillers, the facial folds – most commonly nasolabial folds – were the first indications to gain approval. As a result, a flood of fillers were now considered safe for this indication, and subsequent FDA approvals allowed rapid influx of products for this same indication. Avoiding legal ramifications of promoting off-label uses of fillers, this FDA approved use of fillers were mass marketed directly to patients.

To this day, we continue to have patients that come in for correction of nasolabial folds as their primary concern. As I tell my patients, it is normal for a baby to have nasolabial folds. What isn’t present on a baby are the hollows above the nasolabial folds from volume loss in the cheeks and mid-face. Therefore, for natural correction, I strive to achieve correction of this volume loss to elevate the nasolabial folds with a tent-pole effect.

 Volumize to Lift, not to Drop

Volume in the lower face should be used sparingly in areas that are gravity dependent and not adherent to bone. This includes areas like the lips and lower cheeks – which can hang lower with weighed down with filler. Areas along the bone can be filled in ways that provide support and use a cantilever-effect to lift areas that need lift.

Over-volumization of the lower face can lead to a monkey appearance if around the mouth or a masculine appearance if it causes squaring of the jaw line. Do not make this mistake! Lift, Don’t Drop!

How can I bring attention to the eyes?

This is my not-so-secret way of keeping things looking natural. I always ask myself this question while injecting, “What is distracting me from the eyes?” I then ask, “Will injecting the distraction make it less distracting or more distracting?”. If the answer is that it will make it more distracting, then you’re probably focusing your attention on the wrong area and may want to consider moving upward to the next closest region and ask that question again.

Inject Safely

This could be its own 3 part series, but the point is always use safe injection techniques or a nice result is useless. Complications can ruin an otherwise nice result. Act fast if there is any evidence of vascular compromise and flush with large amounts of hyaluronidase. If there are issues or questions, feel free to reach out regarding this topic. That’s all I will say on that topic for now.

Well that wraps it up! I hope that this series was helpful for injectors out there. Feel free to let me know what you think or if there is anything you would like to know about the topic!

Happy Injecting!

Jordan Rihani, MD

All original content, copyright 2018 Facial Plastic Surgery Institute, PLLC

The Art of Injecting – Part 2

This three part series is meant as a guide for beginner or intermediate injectors looking for new concepts or interested in advancing their techniques. These concepts apply for injectable fillers as well as with Botox/Dysport. I also invite my patients to review these topics in order that they can be knowledgeable about their treatments. These are concepts that I frequently reference when performing trainings. I perform my own injections of filler and botox in my Southlake and Fort Worth, Texas offices.

The Art of Injecting – Part 2: Know Your Products

Hyaluronic fillers have been FDA approved for treating wrinkles since around 2005. Since that time, the hyaluronic acid filler market has exploded in popularity with companies like Allergan, Galderma, and Merz leading the charge. The demand for new, longer lasting, more natural results has sparked a barrage of newer products with new technologies. The field of filler types has also expanded with different filler types like Poly-L-Lactic Acid and Calcium Hydroxylapatite. Similarly, Botox used to be the only player in the neurotoxin market, but now we are seeing the emergence of Dysport and Xeomin as well.

So what do we make of this rapidly expanding product market as injectors? How do we decipher the good from the bad?

Not All Fillers Are Created Equal

It is important to remember that as an injector, fillers have strengths and weaknesses. Therefore understanding the chemical strength and elasticity of each product on the market is crucial to being a top injector. Concepts of G’, viscosity, and cohesivity are important to understand. Basic knowledge of rheology may be helpful for intermediate and advanced injectors to help further their understanding. Simply put, Voluma and Restylane Lyft, for example, are created for structure and strength – which is great for cheek support, but would not be great for someone desiring a soft lip filler.

These same concepts apply for our neurotoxins – Botox, Dysport, and Xeomin. They may break down to the similar botulinum toxin, but due to purification methods, some patients experience differences in time of onset, total effect, and sensation. I see this often in my patients and is why my office offers all neurotoxins.

An Artist Must Know Which Paintbrush to Use

This metaphor is used by one of my close friends and mentors and I agree that you cannot effectively paint your best picture with a single paintbrush. Understanding which brush you would need for clouds or leaves of a tree or blades of grass allows you to create that perfect picture. If you are trying to use a product for something other than what it was designed for just because you may be more comfortable with it, you probably aren’t getting your best results!

Know the Feel and Pressure of Each Syringe

Since products have different viscoelastic properties, it is natural to understand that the feel of the injection is going to be different. A filler with a higher G’ may be harder to inject through a similar size needle, for example, but the syringe may come with a larger needle to accommodate for that difference. For this reason, I usually take syringes when injecting them for the first time and simply watch the product and the speed and pressure needed to extrude it.

When the needle is under the skin, you cannot really tell the exact amount of filler being used and therefore you need to rely on proprioceptive feedback and experience. So take the time to inject a spare syringe ex-vivo to help yourself. The last thing you would want to do is accidentally inject a large bolus into someones lip and need to deal with the irregularities that would cause.

Explore New Products

This seems obvious, but injectors that have been injecting for some time may not feel the need to step outside of their comfort zone. As a result, you may be missing out on new technologies and products that are more optimally suited for the needs of your patients. With the release of Restylane Refyne and Defyne last year, we were able to experience new flexibility in fillers that had not previously been available. As a result, my patients are experiencing more natural correction of smile lines.

Inject! Inject! Inject!

If you are performing injections, the more you can inject the better! Experience helps to develop feel for products and makes you more comfortable achieving you and your patient’s goals. If you are a beginner, don’t get discouraged, just work up through your comfort zone and rely on those with more experience to help guide you. Working in a busy cosmetic surgery metropolis like DFW, I have the fortune of having plenty of colleagues to bounce off ideas and techniques and even challenging cases.

Thank you for your attention. Be sure to check out Part 1 of the Art of Injecting if you haven’t already. Part 3 will be coming soon.

Any feedback or questions? Feel free to email me at jordan@rihanimd.com

Original content copyright 2018 by Facial Plastic Surgery Institute, PLLC

The Art of Injecting – Part 1

This three part series is meant as a guide for beginner or intermediate injectors looking for new concepts or interested in advancing their techniques. These concepts apply for injectable fillers as well as with Botox/Dysport. I also invite my patients to review these topics in order that they can be knowledgeable about their treatments. These are concepts that I frequently reference when performing trainings. I perform my own injections of filler and botox in my Southlake and Fort Worth, Texas offices.

The Art of Injecting – Part 1: Symmetry over Size

Symmetry over size has been something I recognized early in my injection career and is something I feel is not always emphasized. Always inject for symmetry over volume. Patients come to my office wanting to look “better” not “bigger”. To make them look better we must understand that our eyes are attracted to symmetry – whether we realize it or not. As a trained injector, it is important to be able to recognize lack of symmetry in order that we can correct it.

Step 1: Perform Facial Analysis to recognize symmetry.

This is the most important step. If you do not recognize that one cheek has a volume deficit compared to the other or that it sits slightly lower on the face, then it is impossible to correct it! Take the time to take pictures prior to touching a patient and study/review them.

Step 2: Review treatment goals with your patient, including pointing out asymmetries you are planning on correcting.

Although many patients may not recognize a lack of symmetry between the two sides of their faces, they should be noted prior to starting in order that you can show them where you are planning on using the products. For example “I will be using more product on your right side, in order to even the appearance of the two sides”. This allows them to feel comfortable if you are working more on one side or using more product. This also helps them understand why they may have more swelling on one side after the injections if you had to use more product

Step 3: Fill the deficient side first

In some patients, they may come to me desiring cheek volume. If they have significant flattening of one side compared to the other, it would be a mistake to put equal volume in both cheeks. Clearly this would have done nothing to address the fact that one side is more flat. Instead, you should start injecting filler on the side that needs more volume and correct to the level that the cheek volumes are equal. From that point, you can then add the volume that patient is desiring.

If I am using one syringe for a patient’s cheeks, it is not uncommon for me to inject 2/3 of the syringe in one side and the other 1/3 on the other side. As long as you can achieve that symmetry, the patients will notice the improvement right away.

Step 4: After asymmetry has been corrected, add desired volume

Only after both sides have been “evened” out to the extent possible, do I start adding desired equal volume. This prevents further distortion or more assymetry as a result of starting on the larger side, for example, and using too much product on that side, and then not having enough to catch up on the already deficient side.

Summary:

Patients notice improvements in symmetry, and although not always a drastic change, patients will be happy with their results. As injectors we have the responsibility to make our patients look better – not just add volume because they tell us to! And always remember – Keep It Natural!

Thank you for reading.

Jordan Rihani, MD

copyright 2018, Facial Plastic Surgery Institute, PLLC

Injectable Fillers in Southlake and Fort Worth – What I am using now

Dr. Jordan Rihani provides a recap of some of the current fillers that are out there and what he is currently using in his Ft Worth and Southlake offices. We use a variety of fillers including Juvederm, Restylane, Voluma, Vollure, Restylane Refyne, Restylane Defyne, Belotero, Radiesse, and more. Each patient has an individualized treatment plan and algorithm based on their needs and goals.

Is there a way to make Botox last longer?

 

Injecting Botox or Dysport every three months can be a bit of an inconvenience for some of my patients. So what kind of options do we have and what impacts the length of duration of Botox and Dysport? I inject my own patients in my Fort Worth and Southlake, Texas offices and get asked a number of these questions daily.

  1. Increase the dose – There is evidence that higher dosages of Botox and Dysport can result in longer duration of action. There are trials using twice the dosage which can show duration of action closer to 4-5 months in about 60 percent of patients. This may or may not be worth the added cost.
  2. Metabolism plays a role in duration of Botox/Dysport. For patients that exercise daily and participate in high intensity exercises, neurotoxins may last a shorter period of time. Extreme examples may be 2-3 weeks, but on average in my practice these patients can have a length of duration of around 6 weeks. Decreasing frequency or intensity may not be worth the trade-off, but is considered an option.
  3. Product resistence. This is a real phenomenon that we see in our practice. Patients may become resistant to one product or the other, but the alternative therapy may last longer or be more effective. The reasoning behind this may have to do with the proteins that allow delivery of the botulinum toxin. Trying Dysport if you are showing decreased response to Botox, or vice versa is an option.
  4. Next Generation Botox? There are new products on the horizon, although a year or two out. One promising agent is Daxibotulinumtoxin which may last up to 6 months from preliminary data. Check out our Daxibotulinumtoxin page for more details/updates.
  5. Nerve Destruction. There are methods of permanently cutting or damaging the nerves that travel to the forehead or glabella (corrugators or frown lines). These methods are performed using a radiofrequency probe which can locate and weaken the nerve.

If you have any questions please let me know by emailing me at jordan@rihanimd.com 

-JR

The Botox Browlift

How do you lift the brow with Botox?

This is a common request I receive from patients and is something not all injectors know how to assess properly. I want to outline proper assessment of brow position and how to avoid the much feared brow drop.

Step 1 – Assessment

Whoever is performing your injections should be assessing your brow position with your eyes closed! This is the most important part of the initial Botox/Dysport consultation. If they are not doing this, your chances of having a dropped brow are significantly higher. People naturally lift their brows when their eyes are open. Only when we close our eyes and really relax our forehead can the true brow position be assessed.

If your brow position sits below the rim of the eye socket with your eyes closed, Botox/Dysport should be used very conservatively in the frontalis muscle to prevent brow drop.

 

Brow Position with Eyes Open

 

Eyes Closed, Forehead Relaxed

 

Actual Brow Position (Where brows will fall if frontalis movement is eliminated)

Step 2 – Anatomy

Botox works by weakening muscles. If you weaken the upper forehead (frontalis) muscles, you will not get a brow lift, your brow will drop. The injector actually must weaken the muscles that pull down the brow. These muscles are the muscles BETWEEN the eyebrows (the 11’s, corrugator and procerus muscles) and along the OUTSIDE OF THE EYES (crows feet, orbicularis oculi). This allows decreased pulling of the eyebrows downwards and allows the frontalis muscle to lift the brow.

Step 3 – The Final Result

When the frontalis muscle is able to lift the brow, there is still upper forehead movement and wrinkles present, but the brow is now in a higher position. Again, this is the common misconception and something I educate my patients about. If you eliminate all horizontal forehead wrinkles then you will be dropping your brow down to the natural position of your brow (where it is with your eyes closed and your forehead relaxed).

Step 4 – Less is sometimes more

If you can understand these concepts, then you are steps ahead of many people that receive Botox/Dysport as well as many injectors! As my patients get older, I actually use less Botox in order to preserve a higher brow position.

Step 5 – Find someone you trust

If all this sounds rather confusing, then don’t worry! Find someone experienced that you trust to perform your injections. Preferably someone with a strong background and understanding of the facial anatomy and how it functions.

Lastly, are there surgical options to correct a low brow?

For patients with a low brow, the best correction that can both raise the brow and eliminate forehead wrinkles is a Browlift. This can be done through an endoscopic approach in most cases. Endoscopic browlifts are done through small incisions in the hairline and have minimal downtime. Most swelling and bruising is gone within 1-2 weeks.

Any questions? Don’t hesitate to email me: jordan@rihanimd.com

 

Post Rhinoplasty Expectations

Answering commonly asked questions about rhinoplasty surgery. Do I use nasal packing during surgery? What is the post operative visit like and is it painful?

How to Apply Retinol and Retin A

One of the most common issues patients have after starting retinol is peeling and skin sensitivity. Most often, the issue is actually improper application of the product. Start slow, apply as tolerated at night, and start in the oily parts of your face to prevent unwanted side effects. Check out our newest video with House of Preservation which sums everything up. And don’t forget to check out their blog at houseofpreservation.com!

 

What is the recovery for a facelift?

This is one of the most common questions I get, so wanted to answer this here.

What is the recovery for a facelift?

In general I say 2-3 weeks, although this varies for everyone. This is the amount of time that I generally recommend avoiding social gatherings or special events.

I do not use any drains after the surgery, so my patients are actually able to wash their hair the next day.

Is there a lot of bruising after a facelift?

Bruising and swelling vary from person to person. Some people have very little to no bruising, believe it or not. The majority of people fall somewhere in the middle with some light red bruising around the lower cheeks and neck. If eyelid surgery is performed at the same time, there is usually bruising around the eyes as well. Covering bruises with makeup is possible when the incisions have began to heal.

Some patients take Arnica Montana or Bromelain after surgery to expedite resolution of bruises.

Is a facelift painful?

Facial surgery tends to be well tolerated and patients rate pain levels as significantly lower than body surgery. I have some patients that take only tylenol after facelifts! I prescribe pain medications to all my patients and recommend they take them for the first few days.

What are the activity restrictions after a facelift?

Driving – If a necklift is performed at the time of your facelift, I require 2 weeks of no driving. If you look at the strength of a wound that is healing, 80% of the strength returns at 8 weeks. Any limiting of stretching and pulling (especially head turning during driving) will help prevent scar widening and compromise of your best result.

Exercise – return to light workout (walking) early after surgery is encouraged. I tell patients to avoid heavy lifting or neck straining for 8 weeks. If it feels tight, listen to your body!

 

Hope that answers a few of your questions. Feel free to email me with any others. Don’t forget to check out my facelift page.

 

JR

Lunch and Learn August 1st

Join us on Tuesday August 1st for our lunch and learn featuring Galderma.

Galderma is one of the global leaders in injectable aesthetic products and their US Headquarters is actual here, locally, in Fort Worth TX (which we love!). Their product line includes Dysport, Restylane, Restylane Silk, Restylane Lyft, Restylane Refyne, Restylane Defyne, and Sculptra.

The lunch and learn will be in our Southlake Office – 521 W Southlake Blvd, Ste 175 Southlake TX 76092 – from 11am to 1pm. Lunch and light refreshments will be provided. Product demonstrations will include a cheek augmentation featuring Restylane Lyft on a real patient. Raffles and give-aways at the door and discounts on all Galderma products, including injectables if appointments are made during the event!

RSVP is required so please email us at hello@facialplasticsurgeryinstitute.com

See you soon!

What is a Paramedian Forehead Flap?

What is a Paramedian Forehead Flap?

One of the most common ways to reconstruct the nasal tip is a flap known as the paramedian forehead flap. This uses skin and its blood supply borrowed from the forehead to replace lost skin of the nasal tip.

What does a Paramedian Forehead Flap look like?

The above example demonstrates the appearance of a paramedian forehead flap. This was used to recreate a nasal tip defect from skin cancer. There are two stages to this flap reconstruction. First step – rotate the forehead flap into place. This contains a flap of skin and its blood supply from the forehead. This is sewn into place over the nasal defect. The middle image demonstrates a finger-like connection between the patient’s eyebrow and the tip of the nose. This stays in place for approximately 4 weeks while new blood vessels grow from the nose into the forehead skin. The second step is to divide the flap blood supply and return excess skin back to the forehead while leaving the new skin on the tip of the nose.

What happens to the forehead when using a Paramedian Forehead Flap?

The forehead in most cases has enough elasticity that it can be closed easily. This heals up with a thin vertical scar that is about 4 inches long.

What are other options besides Paramedian Forehead Flaps for nasal tip defects?

There are other options for reconstructing the nasal tip including skin grafts, flaps taken from the cheek, and local flaps from the nose. The options are determined by the size of the defect and if the underlying cartilages are involved or if the inside lining of the nose is involved (which would require closure at the same time). I discuss all possible options with my patients prior to surgery. Closure using a paramedian forehead flap does allow similar thickness and color-match skin for an excellent cosmetic and functional result.

Should I have a facial plastic surgeon close my skin cancer defect?

I work closely with many Mohs surgeons in the DFW area for closure of nasal and facial skin cancer defects. I recommend patients with skin cancer of the face or neck see me prior to removal of skin cancer. This allows us adequate planning for the most streamlined process possible – often performing the closures on the same day as the removal!

Please do not hesitate to contact me with any questions and check our Facial Reconstruction page for more examples!

Total Facial Volume Replacement – Sculptra and Fat vs Gel Fillers

Total Facial Volume Replacement – Sculptra and Autologous Fat vs Gel Fillers

Misconceptions, Questions, and Expections

Is my face going to look too full or round? 

Short answer: No. I am replacing lost volume that has occurred.

Long answer: The face has lost about 25% of bone volume by age 60. That causes increased size of the orbits, decreased projection of the midface, and shortening of the mandible. Fat volume decreases (especially in temples, cheeks, and perioral areas) and the fat pads separate and descend down the cheek. Providing replacement of this loss in the proper locations, allows restoration of youthful shape and contour.

What is total volume loss? 

I use this term to refer to the changes described above. This differs from localized areas of volume loss that we routinely enhance such as the lips and cheeks. Total volume restoration allows more general replacement of the loss of subcutaneous fat.

What is the best filler to use for total volume replacement? 

There are currently two fillers that I feel address the total soft tissue loss that occurs in the face. Autologous fat (harvested from the patient) and Sculptra. Both allow soft improvement in the areas of volume loss without creating heaviness in highly mobile areas such as the lower cheeks.

I use these fillers to complement the typical gel fillers (Juvederm Voluma, Juvederm Ultra, Restylane, Belotero).  I continue to use gel fillers for bone-volume replacement (deep injections to provide structure) and for superficial, small-diameter wrinkles.

How long does Sculptra last?

Sculptra results last up to two years. It works by promoting the patient’s own collagen production. This collagen formation is appealing to many patients with its soft and natural feel. These results do take some time which is different than the immediate gratification of many of the other fillers I use.

Here is an example of a Sculptra injection schedule: 

Day 1: Injection of 2 vials of sculptra

Day 3: Back to normal without evidence of swelling.

Day 3-60: increasing collagen formation and volume replacement

Day 45-60: Injection of 2 vials of sculptra:

Day 60-120: further collagen formation

This can repeated for another cycle if needed.

Every year: Touch up with 1-2 vials of sculptra.

 

If you are interested in a consultation to see what the best options are for you, please get in touch with us! jordan@rihanimd.com

Have a great week!

JR

Facelift Post-Operative Instructions

Jordan Rihani, MD provides information to his patients following facelift, necklift, and browlift in this podcast. Jordan Rihani, MD performs facelift, necklift, and browlift surgery in Southlake and Fort Worth, TX.

Rhinoplasty Post-Operative Instructions

Jordan Rihani, MD of the Facial Plastic Surgery Institute provides post operative information for his patients undergoing rhinoplasty. Jordan Rihani, MD performs rhinoplasty in Southlake and Fort Worth, TX.

Improve Healing with Proper Nutrition

If you have a surgery in the near future or have chronic conditions that require healing, diet is an important part of that process. Proper nutrition provides your body with the building blocks it needs to heal itself. Let’s review a few of my recommendations for proper nutrition in the peri-operative period.

  • The power food groups:
    • Protein (Meats, Beans, Nuts, Milk and Yogurt) 
    • Vitamin C (Oranges, Grapefruit, Brussel Sprouts, Kale)
    • Magnesium (Pumpkin, Spinach, Soy)
    • Zinc (Beef, Lamb, Seafood)

 

 

 

  • Not a big eater? Eat more meals throughout the day. Try eating your typical meals, but increase to five or six times
    a day to increase your caloric consumption.
  • Consider supplementation of essential nutrients with a multi-vitamin if you are not meeting the nutritional daily requirements.
  • Control blood sugars if you have a history of diabetes. This is critical, as elevated blood sugars can have detrimental effects on wound healing.
  • Eliminate any nicotine-containing products from your daily routine. Patients who are quitting smoking are advised to avoid patches and gums which cause vascular constriction and impair wound healing.

 

Thanks and happy eating!

 

JR

 

See below for more information:

http://my.clevelandclinic.org/health/articles/nutrition-guidelines-to-improve-wound-healing

http://www.whfoods.com/index.php

Radiofrequency Skin Tightening

House of Preservation + FPSI collaboration now up! House of Preservation reviews Radiofrequency Skin Tightening at my office in Southlake, TX with information on how it works and what to expect. Rylie (from House of Preservation) was interested in collagen tightening of the face and jowls. The treatment feels almost like a hot stone massage as it heats the tissues beneath the skin. The endpoint of heating is monitored throughout the treatment to ensure precise temperatures are reached. This allows changes to the collagen under the skin, while preventing any damage to the surface of the skin.

Radiofrequency skin tightening is one of the many modalities available for skin tightening and can be combined with other rejuvenation options (including Botox/Dysport or Fillers) for optimum results. We employee this as well as other options such as laser therapies and radiofrequency microneedling in our Fort Worth and Southlake Plastic Surgery Offices. For more information on the various technologies that are out there and how they work, please see my technology summary page: http://facialplasticsurgeryinstitute.com/technology/

Non-surgical options for facial rejuvenation is obviously a huge market internationally. As someone who performs both surgical and non-surgical options, I am able to objectively provide opinions based on what the desired results may be. Feel free to contact me to schedule your complimentary consultation regarding both surgical and non-surgical skin tightening options.

Microcannulas vs. Needle Injection for Injectable Fillers

Isn’t it enough that there are so many different fillers out there? Now we have to keep up with HOW they’re injected? Bear with me, as I think this is an important topic for anyone that is undergoing filler injections – more important that the type of filler.

What is a microcannula?

microcannulaA microcannula is similar in size to a needle, but instead of a sharp point at the end, there is a rounded end with an opening on the side. Also, microcannulas are flexible and bend with pressure, as opposed to needles that are rigid and designed to pierce skin (and blood vessels).

What are the benefits of microcannula injections?

Because microcannulas are flexible and blunt-tipped, they are able to be push blood vessels out of the way. As a result, they cause less trauma to blood vessels which means less bleeding under the skin, and therefore less bruising. Patient also experience less pain and discomfort with microcannula injections. Lastly (and most importantly), microcannulas are SAFER. The most feared complication of fillers is due to intravascular injection of filler which causes occlusion of blood vessels. As a result, there can be loss of skin of the face due to compromised blood supply. Because cannulas are blunt and have a side injection port, the incidence of intravascular injection is substantially decreased.

Why aren’t all injectors using microcannulas?

Good question! I think this will change as the popularity of microcannulas increases. Unfortunately not all injectors have trained with microcannulas so there is a bit of a learning curve.

What areas are you using microcannula injections?

I perform most of my injections with microcannulas, including lips, cheeks, marionette lines, tear trough. I use needles very occasionally for fine tuning and deep injections in conjunction with microcannulas.

See the demonstration below for microcannula injection of sculptra:

Please let me know if you have any other questions! Have a great weekend.

 

JR

 

Technology in Plastic Surgery

versusI know how confusing it can be to keep up with all the brand names and technologies in this field. As a result, I have combined many of the name brand technologies (like Coolsculpting, ThermiRF, Clear & Brilliant, etc) into easy-to-understand categories. I will be updating this list based on your feedback or as new technologies emerge, so please keep me posted! You can find the list at facialplasticsurgeryinstitute.com/technology – ENJOY!

JR

Thinking about your first Botox consultation?

So you’ve heard about Botox and your friends may be getting it BUT you still have a lot of unanswered questions before you schedule a consultation like “What happens during the consultation?”. So here is my rundown of some common Q&A’s to get everyone caught up.

greeting

Some common questions:

Where should I start learning about Botox?  

Schedule the consultation! It’s complimentary and the best way to assess whether you would benefit from Botox in the first place! I see a large number of patients bothered by something and think that they need Botox, but in fact need something else quite different.  I invite you to explore my Concern Based Menu to research more information on the various options available to you. You may also explore the Botox page.

How long does a Botox consultation last? 

Consultations last 15-20 minutes and you meet with me, personally, to discuss the various options available and come up with a customized plan for you.  I see new Botox patients in both my Southlake and Fort Worth offices.

consult

If I want to have Botox performed, can it be done the same day? 

Yes. Botox can be done at my Southlake and Fort Worth offices on the same day and simply adds around 10 minutes to the length of the consultation.

Is getting Botox painful?

I have performed many, many Botox injections, but would say probably 95% of patients report that the injections were much easier than expected. I use a combination of ice as well as vibration nerve distraction (and good music, of course), to ensure patients are comfortable. Pain during or afterwards is rare.

How will I look after a Botox appointment?

Since effects take 3-5 days to start working, you will be moving your forehead normally when you leave. The effects are gradual. You may notice some small injection site swelling (less than a small pea) that resolves in a couple hours. Most people can go right back to work after their lunchtime touchup.

If I start using Botox, will I need to keep using it? 

The short answer is NO. People that ascribe to Botox prevention, typically maintain use of Botox because they like to avoid deepening of wrinkles on the forehead. However, when the effects of Botox wear off, movement returns to normal.

How long does Botox last? 

Typical results are 2-4 months.

How much does Botox cost? 

Typical Botox prices may range from $320 to $550.

What is the difference between Botox and Dysport?

Please see my earlier blog post on this topic. In short, I tend to use both interchangeably depending on the effect I am trying to achieve. They are both derived from the same original botulinum toxin, but simply purified differently. They are equal in price.

Any other questions? Simply send me an email at jordan@rihanimd.com.

 

Thanks!

JR

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