Archive | July, 2013

Peanut Head: Volume Loss at the Temples

29 Jul

I’d argue the most over looked sign of aging is loss of volume in the temple. As we age, the temples lose fat and begin to narrow, shifting the balance of the face downward. Volume loss here contributes to the appearance of drooping and sagging of the cheeks and eyes (see Structural Changes in the Aging Face for other changes).  It begins as early as in your 20’s. It is most notable in athletes who have very little fat on their bodies, I’ve found especially runners.

As you can see, the area of total volume loss is pretty big when you actually look at it. In order to achieve the youthful contour of the temple, a patient will require a lot of product here. Adding filler to the temple is easy and almost painless, but deciding what filler to use can be difficult, they all have pro’s and con’s.


This is usually my first choice with patients. For some reason… people tend to be nervous about filling this area! The great thing about Juvéderm is that it’s disolvable. The bad thing about Juvéderm is… you need a lot of it to fill this area, and that can be expensive. I’ve found great results by diluting the product before injection. The patient can see the result immediately. It may not last as long this way, but it is a good starting point. Most people love the result and usually step up to Sculptra when they notice they need a “refill.”


I personally don’t use Radiesse in the temples. It always reminds me of the scene from the Real Housewives of Beverly Hills when Adrienne Malouff’s husband injects Taylor and she has this big bump in her temple and Adrienne goes “is it supposed to look like that?” Although you get more volume with Radiesse, you also have more of a chance for lumps in this area. It’s not as smooth as Juvéderm (which is literally defined as a smooth consistency gel). It’s just not my preference, but for extreme volume lost I can see it being more cost effective.


I personally have had Sculptra injected into my temples. Sculptra is not a filler, but a biostimulator. Over several weeks post injection it promotes collagen production. It may take more than one treatment (usually 1-3 vials 1-3 treatments) to achieve the desired result. This is the longest lasting, and most cost effective product if you consider the longevity, but up front can be expensive. If you are the type of patient who is doing multiple fillers at a time, you should probably step up to Sculptra.

Fat Transfer

Fat injections can also be used in the temples but are only cost effective if a large amount of volume is needed for the entire face. I recommend only allowing a plastic surgeon perform this procedure (although a nurse can do it in Massachusetts). The fat is harvested from another area of the body (usually the lower back) via liposuction and transferred to areas of volume loss in the face (usually not just the temple). There is a lot of swelling and bruising with this treatment and not all the fat will graft (stay alive after transfer). It is also an expensive and invasive procedure. This being said, it can yield great results for patients who really need it.

The Procedure

Numbing cream is applied to the temple. The product selected is mixed with lidocaine and deposited on the bone until achieving desired volume. There is very little pain associated with all injectable products. Bruising isn’t typical; however, there are many vessels in this area, so it can happen. Expected cost depends on the product selected, but expect to use at least 1-2 syringes during time of treatment.

Good luck!

Hyperhidrosis – Botox for Armpits

10 Jul

Botox isn’t just used to make you look pretty. It is approved in over 85 countries for over 25 different clinical indications. In the U.S. it is also approved for migraine headaches, cervical dystonia, blepharospasm, strabismus, increased muscle stiffness in elbow, wrist, and finger muscles in adults with upper limb spasticity and symptoms of severe primary axillary hyperhidrosis.


Hyperhidrosis is a condition characterized by excessive sweating, where patient’s sweat up to 5 times more than a normal person. It can be generalized to the whole body (usually secondary to another condition) or localized to a specific area, most commonly the hands, feet and armpits (where there are relatively high concentrations of sweat glands). Although the cause of localized hyperhidrosis is unknown, it is contributed to an over-activity of the sympathetic nervous system. If you have this condition and you get nervous or excited, you’re nervous system is going to cause you to sweat even more.

Severe Primary Axillary Hyperhidrosis

Severe underarm sweating may be exacerbated by stress, emotion or exercise, but often occurs spontaneously. Botox injections were approved as treatment in this area by the FDA in 2004. The effects of treatment are temporary, lasting approximately 6 months. The treatment is used as a last resort when topical medications are not effective. It takes a lot of Botox to treat this area, about 50 units in each armpit, which costs approximately $1,000 -$1,500 depending where you go.

Although Botox is not approved for hyperhidrosis of other areas, that doesn’t mean it won’t work in that area. It is just considered an off-label use. A lot of bartenders Botox the palms of their hands so they don’t sweat. Personally, I’m considering Botoxing my feet. My roommate has several times given me some sort of foot deodorizer as a gift… and she constantly complains about my gym sneakers. I’ve also been known to track foot powder through her living room… Yea… I guess my sweaty feet are a problem.

The Injection Process

The armpit, as most of us can attest to, is a VERY sensitive area. Numbing cream should be applied about 20-30 minutes prior to injections.

Sometimes you can see the sweat glands, it’s usually marked by the hair follicle, but this particular patient had previously had laser hair removal. So I used a powder to help me see where the sweat gland was. As you can see, several rows are injected. A very small amount of product is deposited into the sweat gland at each injection site. The whole process is very fast once it is started; it takes about 10 minutes to do each underarm.

Don’t sweat it.

Happy Summer Everyone! Remember you’re awesome hat and SPF!!!

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