Tag Archives: marionette lines

What Goes Where?

4 Aug

Prior to 2002, there was one type of facial filler: collagen. Many products have been developed over the past ten years which have caused collagen to become obsolete. There are now multiple categories of fillers, all made of different materials. The products in these subcategories have properties which make them better in treating some signs of aging than other areas or other products. Remember, fillers are different than Botox (it’s not all just Botox!). So what goes where?

Hyaluronic Acid (HA’s)

Synthetic forms of hyaluronic acid (a sugar that your body naturally produces) include products like Juvéderm, Perlene and Restylane. HA’s increase fullness and enhance the viscosity of the naturally occurring hyaluronic acid in your body. Although it may cost a little more, Juvéderm is currently the longest lasting product (in some cases lasts twice as long, and therefore is worth the extra $100 or so per syringe). I have performed over 200 Juvéderm procedures, and have personally been injected with this product many times!

*note: My face is just a model, I haven’ had all this work done I swear! I just love “Paint.”

  • Best for superficial lines (not very deep, not folds).
  • They are used in areas where “plumpness” is desired (like your lips!)
  • They can be used in cheek augmentation, vertical lip lines, and nasolabial folds, but might not be the best product. Cheeks and Nasolabial folds typically require a lot of filler, and cost-effectiveness wise, this isn’t the product. But if you just need to fix a little sagging, it can be used in the cheeks. If you want to overpay for deep nasolabial folds, then this product also can be placed in this area.
  • Vertical Lip Lines are usually superficial, which would make Juvéderm a good product, HOWEVER, if it is not placed right, the result is a monkey face.

Tips on Hyaluronic Acid

  • When I’m filling lines in the glabella, I always administer a dose of Botox to the area 2 weeks before injecting Juvéderm. This allows me to inject directly into the line; it is easier to aim at a stationary target! How do you know if you will need Botox and Fillers? If you have a line in between your brows at rest (a “1”, “11”, or “111”) and you pull that line apart with your fingers, do you still see a crease in the skin? If yes, you need both, if no, Botox is enough.
  • I always apply numbing cream 20 minutes before injections.
  • I never inject too close to the outer rim of the eye (distal orbital rim), it usually irregularities in the contour of the face.
  • Injecting into the tear trough is a very advanced procedure. I can’t tell you how many times I’ve seen this area over filled (which looks TERRIBLE). My recommendation: it is better to under-fill and book a follow-up. This area requires a minimal amount of product, and my personal policy is to allow a client to come back at no charge if they require a small amount more (within reason).

Particulated Fillers

These products, like Radiesse and ArteFill, contain synthetic beads or particles in different liquid carriers. They last longer than HA’s, because the body doesn’t break them down as fast. They are also thicker than HA’s, which means they satisfy a larger area of volume loss. These products are injected deeper in the layers of skin (never superficially like HA’s are). Why? Because they’re made out of beads in liquid… and in superficial skin that would make bumps! This means they NEVER get injected into the tear troughs or into the lips. EVER. For very, very deep glabellar crease, Radiesse can be used (but usually an HA is a better choice).

  • These products are for moderate to severe volume loss. As you age, facial skeletal changes, general tissue volume loss, and the effects of gravity flatten out your cheeks. If you look at the contour of my face on right side of my face (your left), you will see how round my cheek is. I think you can see in this picture that the apples of my cheeks are round as well. A lot of women will look in the mirror at their nasolabial folds and want to go straight for filling only those, but that doesn’t give the youthful round shape back to the face. On some people I like to do cheek augmentation with Radiesse as well as nasolabial folds. I always do cheeks before folds, because the cheek bone is the scaffolding for the lower face skin. When you change that, the depth of the NL fold will also change. Always top to bottom, never bottom to top, when it comes to your face fillers! **When you have extra weight on your face, you keep the roundness. Skinny people have really flat cheeks when they age. HA. Take that skinny people.
  • The marionette lines, prejowel, and oral commissure are usually treated as one area that needs to be fixed. They’re kind of like vector components of each other (for all you Geometry dorks out there, *brushes shoulder off*).
  • Again, skeletal changes that occur as you age cause your chin to recess and along with volume loss, change the angles of your jaw and chin. This is another area a lot of people overlook when spending that quality time in the mirror pulling at their face in the “this is what I would look like if I had a face-lift” pose. Even if you do have a traditional facelift, you aren’t doing anything about the volume loss. This contributes to the unnatural look of a face-lift.
  • Radiesse and Juvéderm can be used in conjunction to fix contour irregularities in the nose.

I hope that cleared up the two main classes of fillers. It’s a lot of information!!! The next post will be about Sculptra, which gets grouped in with fillers… but this is already too long! Lol.

xoxo SPRAY TAN – O – REXIC LK

Softening the Lines

10 Apr

P. is a 50 year old woman who has seen me twice over the past two years. To start, she had deep naso-labial folds that she hated. We first filled them with Juvéderm (which was my product of choice two years ago, but now I like Radiesse better for this area). We then did a little bit of cheek augmentation with a large syringe of Radiesse.

P.’s son is getting married and she wanted a little touch-up before the wedding. This is totally common with treatments (and weddings). Remember, any procedure should be done with plenty of time for healing to occur in regards to bruising or swelling.

Before


After


Again, remember, I’m not a photographer! The goal with P. was to soften the downturn on her mouth, the depth of her chin, and the depth of the NL fold.

Gravity…

As you age gravity causes several changes to occur in your face. The fat pads on which your eyes rest slides out from the socket and begins to bulge. At the same time, fat pockets in the cheeks break down in a known consequential manor. The combination of these two things and the pull of gravity on lax skin deepen the look of the nasolabial folds and add years to the face.

So What did I do?

As I said, P. and I have done a few treatments together before. We did the folds first, to fill the depth caused by lax skin and gravity, and then I did cheek augmentation. As I have become more advanced however, I have changed my practices to moving from the top of the face down (because of gravity) and from the most advanced sign of aging backward. I have found this to be the most effective way to treat aging. In retrospect I would have done the following:

  1. Cheek Augmentation

    By reconstructing the fat in the cheek area by filling it with product, this will decrease the laxity of the skin which forms the NL fold. I know women start pulling up the sides of their cheeks at around 30, wondering what a facelift would look like. Well this isn’t a facelift. It’s a laxity lift. (I made that up). It’s an improvement which will help me use less product in the laso-labial fold area. This means a better result AND less money. J


    **Do you do this in the mirror? As you can see, I don’t have much lax skin… from multiple procedures (cheek aug and ulthera mostly). But uh…. I do have roots. No one’s perfect! 😉

  2. Marionette Lines

    This is one of the most advanced signs of aging (because it’s the precursor to jowls). The marionette line starts from gravity pulling down the corners of your mouth and gravity pulling the fat down from the cheek. It’s just a big ol’ gravity mess! Pulling the needle around the corner of the mouth pulls up the downturn of the mouth.

  3. Naso-labial folds

    While this is the LEAST bad sign of aging, this is usually what women are drawn to fixing first. Depending on your age, and your current amount of fat in your face, and the money your willing to spend to have the best result, are all deciding factors on where to start first. Aging didn’t start overnight, and… to be realistic… one treatment isn’t going to restore the youthfulness to your face. Many women’s biggest fear is looking like a Desperate Housewife (fake and expressionless) but this is not the goal of aesthetic medicine. The goal is to restore and maintain your features.

“Softening P.”: A Maintenance Session

P. still had nice volume in her cheeks, and her N.L. folds still had some nice fill (1 year later). P. just needed a little softening to look her best.

X = needle insertion point

Line = needle direction of needle





  1. Mouth Corners
  2. Marionette Lines
  3. Lip line
  4. Chin Sharpening
  5. Jaw Softening
  6. Nasolabial fold softening

Again the Afters


This round of treatment was to soften and touch up. One large Radiesse syringe was used to treat 6 areas. The result is a softer looking face. There is not a HUGE difference in what P. looks like, but there shouldn’t be. Treating six areas with one syringe will not show a HUGE difference. Six syringes in 6 areas… now that’s a different story. Personally, I will only do ONE syringe at a time. Once you fill one area, you change the skin volume, and laxity changes. If someone tries to sell you six syringes at once, RUN. They are not looking out for your best interest, and you are going to leave the office looking like a different person (or something non-human!).

Master of Puppets

28 Feb

Ha. I made a Metallica reference! Not sure how many of my readers are Metallica fans… but still… go me for creativity points. ANYWAYS. This post is about puppet lines, also known as marionette lines. A client of mine inspired the title of the post.

“My granddaughter looked at me and said Nana you look like a puppet!”

Children are so painfully honest sometimes.  A patient of mine told me her granddaughter’s statement was her reason for being in my office.  (Maybe I should be employing two year olds?… Is that legal?  Can I pay in candy?)

Her granddaughter was referring to the folds that develop from the corner of the mouth to the jaw line, also known as the “marionette line,” one of the more advanced signs of aging.

Can you fix it?

Yes.  By injecting filler medial to the folds.  The product I typically use is Radiesse, because these folds are usually deep and require a thick volumizing fill. How I do things might not necessarily be how other providers do them… but it should be pretty similar. I also stand behind this product choice. If someone tries to use a Hyaluronic Acid in this area, get out of their office, because you will be spending a FORTUNE.

Before



What Needed To Be Done?

In Physical Facial Changes That Occur As We Age I spoke about what happens to the face as we age.  In this case, I’d like to point out prejowels beginning and marionette lines starting.

Marionette Lines

Prejowel lines

Topical numbing cream is applied to the areas that will be treated for about 20 minutes. The skin is then cleaned with alcohol. The full length of the Radiesse needle is inserted and product is deposited in a technique called fanning and product is deposited as the needle is withdrawn. The outside hub of the needle is a gauge larger than the inside to create a tract for the product to be placed. So the only discomfort is the actual needle, I add lidocaine to my Radiesse (which most people do). Really, not so bad as far as pain goes.


 The needle is inserted at the “X” and it goes straight up to the corner of the mouth. Like I said, product is inserted as the needle is withdrawn. This is called retrograde technique. Before the needle is taken out it is repositioned at a 30 degree angle, the full length of the needle is again inserted, and product is deposited as it is withdrawn. It is done again at a 45 degree angle.


Basically, it’s one insertion point (i.e. one poke) on each side, and the needle is pivoted while within the skin layers. It gets less painful as you go along because there is lidocaine mixed into the product.

Last the jaw line is sharpened. “X” is the insertion point. The full length of the needle is then inserted, and product deposited as it’s withdrawn.

After

This picture is immediately after. There is some swelling that has begun, but you can see some of the immediate results. This patient used a 1.5cc Radiesse syringe (the large). She could use a little more product in the jaw line and around the corners of the mouth. I personally like to do things one syringe at a time. Because swelling begins immediately, I find results are best this way. Also, some people don’t want to look perfect, they want to look IMPROVED. The most important thing to note on this client is that she no longer looks like she is frowning when her mouth is at rest. Fillers are AWESOME!

Side Note

Sorry friends, this is a super busy week for me! I have a 20 person Botox Party on Friday, on top of my regular clients! I will actually be seeing this patient again this week, and will have a non-swollen after picture for you. She looks amazing and is super happy! Yay!

*If YOU Are Considering Filler*

Fillers can bruise. Do NOT. I repeat. Do NOT do these things if you have an event within two weeks. This is a worse case scenario for bruising. Highly unlikely you will have a bruise for two weeks… but… I wouldn’t wanna chance it if I was planning on running into my ex-husband at my high school reunion and the whole reason I wanted to get filler was to look too good for words. Just saying.

The reality of the situation is you will bruise. Probably for a few days. You can cover it with make-up. And tell everyone you went to the dentist. (I know my friend Colleen-a dental hygienist- is going to yell at me for making the dentist sound bad. Sorry Col. I love the dentist. I really do. He makes for a great excuse for my clients.)

Expect to pay $300-$800 in the Boston Area for this treatment with Radiesse. The amount of money you spend is a direct correlation to the result you will receive. The amount of product you will require for the result you desire (poetry!) depends on a lot of different factors, so ask your provider!

ICE YOUR FACE AS MUCH AS POSSIBLE AFTER THIS TREATMENT. The more you ice, the less you will swell. Twenty minutes on, 20 minutes off. If you can do it the rest of the day, do it. If not, just ice as much as possible.

%d bloggers like this: