Juvederm & Voluma
JUVEDERM XC® is an injectable gel of hyaluronic acid indicated for correction of moderate to severe wrinkles and folds.
It is injected in the office after application of a topical numbing gel. Results are seen immediately and improve over seven to ten days. Longevity of the Juvederm® is expected to be 9 – 12 months. No pretesting for allergies is needed.
JUVEDERM VOLUMA XC® is another form of Juvederm that has thicker consistency and is used for deep injections only. It is indicated to restore lost volume, especially in the cheek area. Results are expected to last at least two years. This injection is also done in the office, and results are immediate.
Read Episode Transcript
“Welcome to Plain Talk About Plastic Surgery, a podcast narrated by myself, Dr. Elizabeth Kerner, giving you practical and down to earth information about plastic surgery operations, procedures, and other news of interest.
Today I’m going to talk about fillers, and mostly, I’m just going to talk about the fillers that I offer in my office. Obviously, if I don’t offer it, I don’t have much experience or any experience with it, so I shouldn’t speak to other fillers. And we’ll talk about the good, the bad and the ugly of fillers.
The War on Wrinkles: from The Early Days of Animal Collagen and Silicone, to Today’s Injectable Dermal Fillers
So what are fillers? Fillers are hyaluronic acid. Medical science has created a hyaluronic acid that mimics the hyaluronic acid that is naturally occurring in our collagen. Because hyaluronic acid is hard for me to say repetitively without stumbling, I’m just going to call it an ‘HA’.
HAs (hyaluronic acid) constitute a good part of our collagen. So, as you probably know, when we age, our collagen becomes deficient. That leads to flattening of the skin and more wrinkle lines. And it’s of course, way, way, way, way more complicated than this. Hyaluronic acid and changes in collagen are not the only things that create aging but, for our purposes, that’s what we’re going to talk about today.
So HAs can be injected into areas that need to be plumped up. I’m surprised there’s still so many people that are a little confused about Botox, which is a neurotoxin, meaning it makes things not work – in other words, muscles not to contract – which will make wrinkles less. And then HAs will actually fill the indention.
In the old days we had collagen, which had to be patched tested because there was pretty high allergic reaction to it. And it really only lasted about three to four months. So you had to be prepared for some pretty significant maintenance when you used collagen.
Women have also had silicone injected into the wrinkles. This was popular kind of late 60s, early 70s. And came with all the complications that you would imagine, which would be nodules, and infections, and extrusion.
Absorbable Fillers for the Lips, Cheeks and Face – Advantages over Permanent and Semi-Permanent Fillers
I only inject absorbable fillers. Silicone is a permanent filler. I don’t like the permanent fillers, or even the semi-permanent fillers that you know are going to last three to four years, because there’s no out for them.
So if there’s a problem, let’s say you get a little nodule or a bump, or it’s just in the wrong spot; if I put an HA in, I have an enzyme, hyaluronidase, meaning that enzyme that dissolves hyaluronic acid, that I can inject into that little bump and ‘presto change-o’, it’s gone. With some of the others, like Radiesse, there isn’t any out for that. So if you have a problem, you’re kind of stuck with the problem.
So the fillers I used are the Juvederm family which, unfortunately, all start with a ‘V’ now. They used to be different names, but there’s Volbella, Vollure, and Voluma. They’re thin, intermediate, and thick if you want to think about it that way.
Juvéderm Volbella® and Vollure®: Properties and Uses for Varying Depths of Wrinkles
Volbella is the newest addition to the family, and it’s a very thin preparation of hyaluronic acid, and it’s designed to be used in lip lines. So the lines above your lip; the vertical lines; the bleed lines right along the vermilion border, which is the pink part of your mucosa where it touches your skin, that little red line there; and then you can also put it into the lip proper.
If you don’t need much fill, Volbella will do quite well for lips. If your lips are quite deficient, then I would use Volbella on the lip lines because, quite frankly, nothing works as well as that; and then do Vollure, which is the intermediate one, to actually give some more volume.
Occasionally a patient will have such deep cracks around their lips that I’ll actually start with Vollure, the intermediate one, and put that in as a kind of deep layer on the wrinkle; and then come back a week or two later and put a little bit of Volbella on top, because Volbella we can put very close to the surface of the skin.
For the folds, which are the two parentheses lines by your nose, the corners of the mouth – the kind of marionette lines, the deep lines that go down along your chin; and the creases between your eyebrows, those are called the glabellar creases, I think Vollure works very well, that’s the intermediate one. Vollure is kind of the workhorse, and it goes kind of right at the top part of the dermis. You can put a moderate amount in without having to worry about lumpiness.
Juvéderm Voluma®: A Deep Facial Filler for the Cheeks to Build Volume
If you really need a deep filler, then we have Volluma. Obviously ‘Volluma’, based on ‘volume’, would signal that this is used when you really need to volumize an area. Volluma is approved for along the cheeks. So if you have someone who’s gotten a lot flatter along the mid to lateral aspect of their cheekbone, putting in Volluma works extremely well there.
It is supposed to be placed down adjacent to the bone. I don’t use Volluma hardly ever any other place. You can put it along the prejowl sulcus, which is that little dip right in front of your jowls, because that would be down along the bone. I don’t use it underneath of the eyelids. I think that it’s just way too thick to put there and very, very occasionally I’ll put it in the upper part of the nasolabial fold, which is by the nose, if someone is really really deep.
Undercorrection: The Problem with Facial Fillers and Lip Fillers
The biggest problem with all of the fillers, I think, is underuse. Most patients that come in, when I look at them, I can kind of tell in my head when I look at the areas that are bothering them how many syringes they’re going to need and, unfortunately, it might be a lot more than what you want to pay for.
If you undercorrect an area, so if I look and say, “I really think you’re going to have to have three syringes to get to a really reasonable correction, and something that you’ll be happy with”, and you say, “Well, I can only afford one syringe”; because it’s undercorrected, you’re just not going to see as much.
So as the injector, and as your advisor for fillers, it’s always a balancing act between: I want you to get the nicest result – I want to be able to use as much product as you need; but I also don’t want to break the bank, and unnecessarily have you pay for more product than you might need.
How Does the Process Work? What About Swelling?
We do injections in the office. We have you come in and take a photograph to document what you have, because it’s amazing how quickly we will all forget what the wrinkles look like. And then numbing cream will be put on for usually 20 to 30 minutes. It will really help to numb the surface of the skin.
The fillers all have lidocaine, which is a numbing agent, in them. So as we inject the area deep, it becomes more numb. If someone is really quite needle-phobic and quite concerned about their lips, I can do a dental block, that’s certainly a possibility.
So we take pictures, put the numbing cream on, and then the injection is just done. The needles are little bitty. Vobella is a 32-gauge, which is really tiny. Lower lip, I’d say, very little discomfort. Actually in the lip proper, a little discomfort from it. Upper lip lines, they’re kind of touchy even with the numbing cream.
After, we do put ice on, and we’ll give you a small package of Arnica that will help for any swelling and bruising.
Most people don’t get too much swelling and hopefully very little bruising. The bruises you get are because I’m injecting through the skin and I can’t see where the veins are, and occasionally we will get a small bruise. The Arnica will help with that. Of course, time and ice will help as well.
Upper lips – you will definitely have some swelling, usually two to three days. If it’s the lip and the lip lines, you may have kind of noticeable swelling for four to five days. By about 10 days the product is settled in. It will pull water into, it’s kind of cool. So it plumps up a little bit, which is why I always undercorrect just a bit. Then you can look and say, “Gosh, like this result” or, “I think I need more.”
Fine Tuning for the Best Results
If I’m uncertain whether you need a touch more on a wrinkle line or an area, I may leave a little bit out and just have you come in at about 10 days after the injection, and look at that particular wrinkle line or the area. And if we’ve left a little bit out, then we can just re-inject to get it up to correction without you having to purchase a new syringe.
We do hold on to leftover Juvederm. So if I only need a half a syringe, I will store it and then we’ll call you about a month ahead of time and say, “Get on in here so you can use it up.” We’ve had absolutely no problems with infections or any issues whatsoever. If you don’t use the Juvederm within a month or so after it’s ‘best by’ date, often times it begins to get too thick. And I can’t inject it through the syringe in which case we have to throw it away.
How Long Will My Results Last?
So those are the three Allergan products of Juvéderm®.
Voluma®, which is the thick one, which is usually put along the cheek for volume. Almost everybody is going to require two to three syringes of that. Longevity is supposed to be about two years, I’d say it’s probably more like one and a half years, if you get fully corrected. So let’s say you take three syringes: at one and a half to two years, you may do just fine with just doing kind of a top up of one syringe, splitting it between the two sides.
Vobella® and Vollure® are supposed to be about a year and a half each. I’d say, you know, most patients, they’re nine to 14 months – somewhere in that range. Again, if you are a little bit undertreated, you’re going to notice loss of correction a bit earlier than if you were fully treated.
What About Manufacturer Discounts?
All of these are part of the Allergan product line so you can get Brilliant Distinction points for that. You should go online and enroll in the Brilliant Distinctions loyalty program. When you have an injection, we put the numbers in to Allergan and then they will load points into your account. And those points can be redeemed for cash-off coupons. They usually put points in on your birthday, and Mother’s Day, and other things like that. Or, if they’re just having a promotion, sometimes they’ll do that for Brilliant Distinctions.
I was just looking the other day, and I think our patients have done over $35,000 in money-off coupons for Botox and fillers through Brilliant Distinctions. So it’s really quite a worthwhile program, I think.
What is Sculptra® and How is it Used?
The other filler that I use is called Sculptra, and Sculptra is a different filler; it’s been out for quite some time. It was first given approval for use in the HIV population. When patients with HIV AIDS are treated with retrovirals, oftentimes, they will develop significant loss of facial fat which leads to gauntness. And even though they might feel well and be healthy, they look unhealthy because their face is so gaunt. The Sculptra injections are injections of polylactic crystals. They’re little tiny balls that we hydrate – takes about three to four days to hydrate them – and then they’re injected.
Again, this tends to be a deeper filler. In along the cheekbones, it can be the the upper folds, mid cheek area as well, and also in the temporal area where a lot of patients have hollowing. And it is injected in with a volume of fluid so, right after we inject, you kind of see what you’re going to look like. And then that fluid, the body reabsorbs it, and then your body will make collagen in response to these little polylactic crystals.
The most important thing as an injector is not to cause little lumps, and bumps, and nodules of them. And to help prevent that, the patient is asked to massage the area five minutes, five times a day, for five days. So there’s a little bit of quasi-maintenance involved with this.
I love Sculptura. I think it gives me the most versatility across the face, with the exception of the lips. You can’t put Sculptura in the lips, it would be really quite a disaster. But for volumizing and getting to where you want slowly but steadily, it’s just a great filler. The negative to it is it doesn’t work right away.
When I inject, like I said, you will see a result when you’re in the office, but by the next morning, it’ll all be gone. And then at about six weeks, your body will begin to make collagen. And it takes about three to four months to get to your response. Most people need about a vial per decade, if you’re really going to correct them. Again, it depends on what your face looks like: if it’s very thin, and gaunt, you might need that amount; if you have a little bit more fat in your face, you could use less.
But I usually start with two, so I’ll do one vial on one side of the face, and one vial on the other. And then have you come back at about eight weeks and do the third vial. And then I like to wait a couple of months and see what you look like and if you’re happy with the correction, then just see you when you’re ready for more.
We have many patients who do a maintenance program with this, where they come in about every year and a half and just get one more vial – just sort of topping up, and keeps the correction for quite a long time.
Little more risk of bruising with this (Sculptra), the needle has to be slightly bigger to inject. And again, there are more injections to put the product in, and they do tend to go a bit deeper.
Surprisingly, most patients that have Sculptra say it is much less uncomfortable than having the Juvederm products.
Fat Tissue from One’s Own Body as a Filler
The last filler of course would be fat. Fat is a wonderful filler. You’re putting in your own tissue, but it does require harvesting – which means we have to liposuction an area, then the fat has to be cleaned, and processed, and injected.
I don’t do this in the office, but I do do it in the operating room. And almost all of my facelifts will have a fat injection of some sort, just to help with refilling the aging face because, again: Loss of facial fat is almost always the underlying culprit to why we look so aged.
What Are the Risks of Complications?
Complications of fillers are pretty low. I would say bruising; pain on injection; persistent swelling for more than, you know, four to five days – like in the lips: if you had swelling for seven days; those would be the big complications. Getting nodules or bumps are very uncommon. They are easily taken care of because we do have the enzyme, but it actually happens very infrequently.
I would say the biggest problem is under filling, in that I think you need four syringes, and you only want to have two – in which case expectations have to be lowered quite a bit if we’re not going to fill the amount that you really need.
Infections: I’m sure I’ve had an infection but they’re pretty uncommon. Persistent nodules with Sculptra: I’ve only had one, and that did respond to a steroid injection.
Recovery & Restrictions
There are no activity restrictions after fillers, except probably no facials for about a week or 10 days so that you don’t accidentally massage the filler out, or too deep – in which case it would go away. You can put makeup back on, and you can exercise, and basically do whatever you want.
You might time your filler injections for a couple of days before you have any major social event. That just seems to be Murphy’s law that, if you’ve got something big to do the next day, you’re probably going to get a bruise. That would just be a wise course of action.
That is all I have on fillers. If you would like more information on fillers, I direct you to the Juvederm website, or the Sculptra website. They are both extremely informative: lots of science on the different molecular weights, and density of the different hyaluronic acid fillers; and long-term studies on the Sculptra as well; lots of before and after pictures. I think they’re both really good websites.
To schedule just call the office and tell them this is what you’d like. We usually will inject the day that you come in. So I’ll give you a brief overview of fillers and talk to you about what your expectations are, and what I have in my armamentarium to use, and get you a cost because, of course that’s most important. And then we’ll do pictures, put numbing cream on, and do your injections.
For other episodes and upcoming episodes, you can go to my website www.DrKerner.com/podcasts, or you can subscribe to our newsletter to know when a new episode is available. Or you can find my podcasts almost anywhere you get your regular podcasts, and this is also on YouTube.
Thank you very much for listening. Have a great day and don’t forget to use your sunblock.
Learn more at www.juvedermusa.com.
There is no surgery or down time, and treatments usually take 10 – 15 minutes. As with all injectibles, if you are taking medications that can prolong bleeding such as aspirin, ibuprofen, Aleve®, or blood thinners, this may result in increased bruising at the injection site.
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