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Minimally Invasive Facial Rejuvenation- by Dr. Mark Bishara, MD

Aside from being the largest organ of the human body, skin is also the only organ continually exposed to the surrounding world, interacting with the environment and reflecting the general health condition and age changes.
How Skin Ages
Understanding the mechanisms by which the skin ages has been increasing significantly, along with considerable progress on the way to prevent and reverse the visible signs of aging. However, there are still several mysterious factors concerning aging process and why we all appear to age differently. Aging of the skin is likely caused by both intrinsic (biologic) ‘intrinsic aging’, and extrinsic aging (environmental) factors ‘extrinsic or photoaging‘; these factors are interconnected and may share a final common pathway. The quality of skin features is greatly affected by aging, as skin ages, it tends to become roughened, lax and wrinkled with some pigmentary changes.
The main feature of photodamaged skin is solar elastosis; with accumulation of elastotic material in the dermis. Meanwhile, photoaged skin shows gradual decrease in collagen content. Additionally, collagen becomes disordered with decreased synthesis and enhanced breakdown. These changes contribute to the skin laxity and wrinkling formation.
Skin Rejuvenation
Besides being an art, facial rejuvenation is a developing science. Patients now routinely present to their physician requesting information on improving the signs of facial aging; it is the physician’s responsibility to select the most appropriate intervention(s) based on the patient’s age, physical needs and concerns, extent and location of volume loss and cosmetic goals. Different therapeutic approaches were used throughout the years to give the face a youthful appearance. However, because each person is unique, there is no one modality that is best for everyone. Therefore, to choose the most appropriate therapy, distinctions must be done between rhytides caused by loss of collagen within the dermis, wrinkles due to volumetric loss of fat, redundant folds created by gravitational pull and those caused by hyperfunctional facial muscles.
For ease of patient education, the treatment options for addressing these changes may be simplified into five categories, often referred to as the ‘5 Rs (Redraping, Resurfacing, Retaining, Relaxing and Refilling) of skin rejuvenation: surgically Redraping and lifting redundant tissue; Resurfacing photoaged skin with ablative or non-ablative technologies whether physical, chemical or mechanical; Retaining with skin care; Relaxing dynamic rhytides that are due to hyperfunctional muscles with neurotoxins and Refilling of diminished subcutaneous tissue by restoring 3D volume.
Ablative and Non-Ablative Procedures
Although ablative modalities remain the gold principle for photodamaged skin rejuvenation, its use is associated with risk of side effects as well as a prolonged and an unpleasant post-treatment ‘downtime’ and recovery period. Thus, interest in ablative treatment has waned considerably while non-ablative modalities as well as fractional skin rejuvenation have become appealing alternative treatments.
New perspectives in non-ablative skin rejuvenation treatments have been established with the development of new technologies and techniques, which are used to rejuvenate skin with minimal downtime and complications. Many different terms have been used to describe these procedures including: subsurface resurfacing, laser toning and minimally invasive skin rejuvenation. These modalities are designed to produce many cosmetic benefits, including improvement of wrinkles, skin laxity and texture.
Beside lasers and various in-office procedures, many topical skin care agents were used for prophylaxis as sun screens and for rejuvenation such as retinoic acid and different anti-oxidants including vitamins C and E, co-enzyme Q10 and green tea.
Choosing the appropriate treatment modality which will be the key to success in skin rejuvenation depends on careful evaluation and determining the patient’s needs, skin type and condition, to frame a treatment plan. Good candidates for minimally invasivetechniques tend to have minimal facial sagging. Patients should understand that skin texture will improve and fine lines will be softened but not eradicated. Cumulative aesthetic benefits will occur gradually and will be less dramatic than those seen with ablative resurfacing. Patients with Fitzpatrick skin type III or less are generally best candidates for different procedures with minimal risk of complications.
Goals of Minimally Invasive Treatments
The goal of most minimally invasive treatments is to induce selective dermal injury which results in wound repair response; while keeping the overlying epidermis intact. In response to the induced dermal injury, the healing process begins to stimulate the fibroblast with deposition and reorientation of collagen bundles. Such modalities for skin rejuvenation could be classified into two types, the first relates to treatment of ectatic vessels, pigmentation and pilosebaceous changes, while the second refers to dermal remodeling with wrinkle reduction and/or skin tightening.
Dr. Mark Bishara, whith office in Mansfield and Southlake, TX- provides a wide range of cosmetic procedures to help patients look and feel their best. These procedures are designed to improve the appearance of the face and body through minimally invasive techniques that provide highly effective results. Many of these procedures can be combined in order to achieve your desired appearance. All of our procedures are performed using the most advanced, state-of-the-art equipment.
At our office we offer many treatments that are ablative as well as non-ablative.  Our Pragon Med Spa offers many laser services- skin tightening, skin resurfacing, as well as peels and microdermarbrasion.  Our office also offers Botox, Juvederm and Radiesse.  The new Juvederm Voluma XC will be coming soon.  Please call our office for more information at (817) 473-2120.
 

 

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What Age is Too Old for Cosmetic Surgery- by Dr. Mark Bishara, MD

According to an opinion piece published in JAMA Dermatology, when considering the appropriate ages for aesthetic procedures, the question isn’t so much “What age is too young” as it is “What age is too old?”

In that edition’s Viewpoint feature, the authors write that deeply-etched facial lines that develop as patients age “are caused by repeated folding of the skin and include lines of facial expression and sleep lines,” and that in young adulthood these lines predict “the unique pattern of facial wrinkling that will be seen without expression years later.”
Regular treatment with a neuromodulator when patients are in their 20s or 30s will minimize etched facial lines by the time they’re in their 40s and 60s. They cite the case of identical 38-year-old twin sisters. One began regular botulinum toxin (Botox) injections in the forehead and glabella when she was 25, while the other got injections in the same areas just twice over seven years. They write that while lines glabella and forehead lines were visible at rest, they were not visible in the regularly treated twin four months after her last treatment.
“This observation suggests that regular treatment with a neurotoxin, beginning in young adulthood, can prevent the development of etched-in lines. So there really is rarely a time that is too early. Perhaps the better question is, ‘When is it too late?’”
CST Trends asked two doctors to give their opinions on the issue concerning when is “too early” to begin aesthetic treatments.
“I basically agree with the opinions of the authors but also understand the biopsychosocial implications that may be argued by those who disagree,” says Joe Niamtu III, D.M.D., a Richmond, Va., specialist in facial cosmetic surgery. “I can guarantee that you will see some negative feedback on this viewpoint article, with the opposition saying that we are creating a society of ‘plastic’ people who can’t deal with the normal process of aging … I can see both sides of the argument.”
Dr. Niamtu says he thinks the real “take-home point” of the article is that while preventive treatment can influence the future appearance of aging, “treating younger patients has positive and negative benefits that reach beyond the needle. There are clearly some patients that would benefit from treatment at a younger age and others who would suffer body-image issues if they did do it or wanted to do it and could not afford it.
“The other very important piece of this discussion is that we could not discuss this topic 20 years ago, as there were basically no fillers, neuromodulators or light- and energy-based therapies,” he adds. “I think that the current discussion will become lost in time because in another 20 years we may have easier and more effective treatments that are more effective and preventive and may be highly used by younger patients.”
Joel Schlessinger, M.D., a dermatologist and cosmetic surgeon in Omaha, Neb., concurs with the viewpoint authors.
“I agree wholeheartedly with the authors,” he says. “Sadly, most people take the opposite viewpoint, waiting until it is too late, as the authors comment, and either missing the opportunity to have a full correction or even any chance to have a significant change. On the other side of the equation, there clearly are individuals with body dysmorphic syndrome, who have no issues at all and undergo multiple surgeries in pursuit of a ‘better’ look. This is something that all dermatologists run into at one point or another.
“Overall, it is best to have a discussion with the individual and prepare a plan of action and an ongoing concept of how to diminish signs of aging over time,” Dr. Schlessinger says. “This approach is highly successful and leads to less intervention in later years and, surprisingly, less expenditure over the years.”

 

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Fillers Demand Is Steadily Increasing- by Dr. Mark Bishara, MD

Dermal fillers are versatile tools for perfecting facial contours.
INJECTABLES ACCOUNT FOR MORE THAN HALF of the minimally invasive procedures performed today. Before Restylane (Medicis, restylaneusa.com), the first non-animal-based hyaluronic acid (HA) dermal filler, was introduced in the United States in 2003, botulinum toxin (Botox) was the most popular injectable in aesthetic medicine. Today, Botox has taken a backseat in growth to HA injections, which have increased to more than 1.3 million procedures per year.
As the demand for fillers has increased, the materials have too. Finding the right dermal filler is like choosing the right brush if you’re a painter. A free-flowing hyaluronic acid gel may be the perfect tool for painting a plumper lip, while a thicker filler with a higher molecular weight may serve you best for adding definition to the chin or cheekbones.

Choosing Your Tools

While today’s HA fillers are all non-animal sourced and stabilized, they do have some important differences, including the manner in which the molecules are cross-linked, the particle size and their affinity to bind water (hydrophilic properties). These distinctions determine a filler’s hardness or resistance to deformation. Picture squirting out the contents of a tube of toothpaste. If the paste retains its shape without flattening, the material reflects a high G prime; a runny liquid that rapidly loses its peak formation has a low G prime.
Restylane (Medicis, restylaneusa.com) demonstrate stiffer qualities, which translates to a higher lift capacity. The stiffer quality of these fillers provides not only lift but also structural support. These would be more suited for creating a cheekbone, increasing chin projection or temple lifting.
Other fillers, like Juvederm (Allergen, juvederm.com), are softer materials that are ideal for filling lips, nasolaboial folds and finer lines.
Juvederm, one of the more hydrophilic fillers, is a popular tool for imparting a soft shape around the lips but is not as well suited for treatment around the eyes. Restylane, which is not quite as hydrophilic, might work better for treating the tear troughs and the nasojugal folds.
For defining the border around the lips or filling fine lines, both Restylane and Juvederm are good choices. Many physicians prefer the softness of Juvederm for filling the lip.

Typically, HA fillers can last anywhere from six to 12 months. Expect fillers to dissipate more quickly in areas subject to more motion, such as the lips, where they generally last five to eight months. In more stationary areas, such as cheekbones, effects can last up to 12 months. In the periorbital area, treatments with HA fillers have been reported to last as long as two to three years.

Collagen-Stimulating Volumizers

While HA fillers are a top choice for specific indications, such as fine lines and icepick acne scars, collagen-stimulating fillers, such as Radiesse (Merz Aesthetics, radiesse.com) and Sculptra (Valeant Aesthetics, sculptraaesthetic.com), can help create volume across a larger region with results extending to 24 months or longer.
The stiffer quality of these fillers provides not only lift but also structural support.

Managing Complications

With modern HA fillers, the potential for allergic reactions is very low, and no skin testing is necessary. That said, injecting fillers can yield potentially significant complications if not managed properly.
The most common complications are bruising and swelling at the injection site, which can last up to a week. To reduce bleeding and bruising, ask patients if they are taking any anticoagulant medications or supplements, including ibuprofen, aspirin, fish oil, omega-3, vitamin E and herbal supplements, including ginkgo biloba, as these may induce more bleeding.
Another common problem is injecting too much of a product or injecting into the wrong plane. HA fillers are somewhat forgiving in that you can use the enzyme hyaluronidase to dissolve the HA when patients are not pleased with the results. This not true with non-HA fillers, such as Radiesse, Artefill and Sculptra.

The Future Of Fillers- Juvederm Voluma XC

Though dermal fillers have been part of cosmetic medicine for almost 30 years now, there are still some truly innovative materials entering the market. Voluma XC (Allergan, allergan.com), an HA filler, will soon offer U.S. patients effects that last 18 months or more and a high G prime for more lift and fill with less product.
JUVÉDERM VOLUMA™ XC injectable gel is the first and only filler FDA-approved to instantly add volume to the cheek area. Juvederm Voluma is the Juvederm specialty product for volumizing. It is designed for injection in the deep dermis to treat age-related facial volume loss. Voluma has the optimal thickness of a volumizer while still retaining the smooth nature of the Juvederm family.
It gives you a subtle lift, helping to restore contour and for a more youthful profile, for up to 2 years, in patients over the age of 21. It’s different than JUVÉDERM® XC and works on a different area of the face. JUVÉDERM® XC smoothes out moderate to severe wrinkles and folds around the nose and mouth, like parentheses. JUVÉDERM VOLUMA™ XC, however, adds volume to the cheek area.
As new fillers continue to come to market, the trend toward specialized products that treat specific concerns and regions of the face continues to grow. In the future, physicians can look forward to a growing variety of materials that smooth, volumize and fill the skin with fewer complications and longer results than ever before.

Dr. Mark Bishara offers minimally invasive procedures, such as injectables- for patients. These treatments are designed to provide subtle enhancements that can improve your targeted problem areas, while allowing you to return to work and your regular activities the very same day. Dr. Bishara is proud to offer a wide range of enhancing, minimally invasive procedures such asBotox, Xeomin, Juvederm Ultra Plus XC and Radiesse.  Juvederm Voluma XC will be available soon. We will keep you updated or call our office for more information at (817) 473-2120.
 

 

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FDA Okays Cheek Volume Filler Juvederm Voluma XC- by Dr. Mark Bishara, MD

The US Food and Drug Administration (FDA) has approved Juvéderm Voluma XC(Allergan) to correct age-related volume deficits in the midface in adults aged 21 years and older, the company has announced.

Juvéderm Voluma XC is a gel composed of cross-linked hyaluronic acid suspended in phosphate-buffered saline with 0.3% lidocaine. It is the first dermal filler approved in the United States specifically for deep (subcutaneous and/or supraperiosteal) injection for cheek augmentation to correct age-related volume deficit in the midface.
As reported by Medscape Medical News, the FDA’s General and Plastic Surgery Devices Panel unanimously agreed that Juvéderm Voluma XC is effective and safe and that the benefits outweigh the risks, according to the clinical trial data presented to the panel.
“As people age, the cheek area can lose volume, causing the cheeks to flatten out and the skin to droop and sag,” Derek H. Jones, MD, said in a company news release announcing the approval. Dr. Jones is associate professor of dermatology at the University of California, Los Angeles; founder and medical director of Skin Care and Laser Physicians of Beverly Hills; and clinical investigator in the Juvéderm Voluma XC pivotal study.
In the study, “physicians and patients were able to see instant and visible results, including correction of age-related volume loss in the cheek area and a more youthful appearance to the face,” Dr. Jones said.
JUVEDERM VOLUMA(TM) XC is made with Allergan’s proprietary VYCROSS(TM) technology, an advanced manufacturing process that results in a smooth gel that flows easily and consistently. This unique formulation contributes to the lift capacity to correct volume loss in the cheek area and to the duration of the product.(2,3) Additionally, JUVEDERM VOLUMA(TM) XC contains a small amount of lidocaine which helps to numb the treatment area during the injection procedure. The JUVEDERM VOLUMA(TM) formulation without lidocaine was first introduced in Europe in 2005. JUVEDERM VOLUMA(TM) with lidocaine was first introduced outside the U.S. in 2009. As of August 31, 2013, JUVEDERM VOLUMA(TM) with lidocaine (branded as JUVEDERM VOLUMA(TM) XC in the U.S.) is distributed in 72 countries, including markets in Europe, Latin America, Middle East, Asia Pacific, and Canada. The JUVEDERM(R) family of products, including JUVEDERM(R) Ultra and Ultra Plus, are marketed and sold in 85 countries outside the United States.(4)
The most common adverse effects observed in the clinical trial included temporary injection-site tenderness, swelling, firmness, lumps/bumps, bruising, pain, redness, discoloration, and itching. The adverse effects were predominantly moderate (uncomfortable) in severity and lasted 2 to 4 weeks.
Juvéderm Voluma XC will soon be available at Dr. Mark Bishara’s office.  We will keep everyone updated when the product will be available in both of our Mansfield and Southlake offices.
This news is brought to you courtesy of Dr. Mark Bishara and The Paragon Plastic Surgery & Med Spa


 

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Juvederm Voluma XC…Coming Soon – from Dr. Mark Bishara

What is JUVÉDERM VOLUMA™ XC injectable gel?

JUVÉDERM VOLUMA™ XC injectable gel is the first and only filler FDA-approved to instantly add volume to the cheek area.Juvederm Voluma is the Juvederm specialty product for volumizing. It is designed for injection in the deep dermis to treat age-related facial volume loss. Voluma has the optimal thickness of a volumizer while still retaining the smooth nature of the Juvederm family.
It gives you a subtle lift, helping to restore contour and for a more youthful profile, for up to 2 years, in patients over the age of 21. It’s different than JUVÉDERM® XC and works on a different area of the face. JUVÉDERM® XC smoothes out moderate to severe wrinkles and folds around the nose and mouth, like parentheses. JUVÉDERM VOLUMA™ XC, however, adds volume to the cheek area.
What else should you know about JUVÉDERM VOLUMA™ XC?

  • First and only Hyaluronic Acid (HA) filler FDA-approved to instantly add volume to the cheek area, resulting in a subtle lift
  • Clinically proven to last up to 2 years with optimal treatment
  • JUVÉDERM VOLUMA™ XC is from the makers of the #1 family of fillers
  • After 24 hours, you should be able to resume your normal activities
  • Side effects are moderate and generally last 2 to 4 weeks. Common side effects include temporary reactions at the treatment site such as tenderness, swelling, firmness, lumps/bumps, bruising, pain, redness, discoloration, and itching.

Hyaluronic Acid (HA) is a naturally occurring, hydrating substance found in your skin. As you age, you start to lose HA, which causes the skin to lose structure and volume.
Dr. Mark Bishara offers minimally invasive procedures for patients. These treatments are designed to provide subtle enhancements that can improve your targeted problem areas, while allowing you to return to work and your regular activities the very same day. Dr. Bishara is proud to offer a wide range of enhancing, minimally invasive procedures such as Botox, Xeomin, Juvederm Ultra Plus XC and Radiesse.  Juvederm Voluma XC will be available soon. We will keep you updated or call our office for more information at (817) 473-2120.
Rewards Program:
Dr. Bishara and The Paragon Med Spa are proud to offer the Brilliant Distinctions Program for our patients. All you have to do is earn points for your purchase from our particiapting providers, including Botox and Juvederm.  Then start saving by redeeming points per treatment for instant savings off your next purchase.
For example:  For 1 Botox/Juvederm cosmetic treatment you earn 200 points (a $20 Value)
For more information on participating in this program visit https://www.brilliantdistinctionsprogram.com
 

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