Plastic Surgery Unplugged with Dr. Raghu: Episode 9

plastic surgery unplugged photo of dr. athre

A brand new episode of Dr. Athré’s podcast, “Plastic Surgery Unplugged” is here! In this podcast series Dr. Athré shares tips, tricks, and behind-the-scenes information on the plastic surgery industry. Listen in for interviews with professionals and patients, and Dr. Athré’s own personal anecdotes from his work in the industry. 

In episode 9, Dr. Athré gets real about the wide variety of facial injectables and fillers. He breaks down each one, from Botox to Radiesse, and gives us the scoop on where they should go, how long they last, and how effective they really are.

Listen on YouTube, Apple Podcasts, Spotify, Podbean, or Google Podcasts—and don’t forget to check out our archive of episodes 1 through 8.

Don’t forget to subscribe and share with friends and family. Here’s episode 9: “Ultimate Guide to Facial Fillers & Injectables ” Thanks for listening!

[Audio transcription via]

Dr. Raghu Athré:

Thanks for joining us for another episode of Plastic Surgery Unplugged. I’m Dr. Raghu Athré,  offering plastic surgery in Houston, Texas. So on today’s topic, we’re going to discuss the difference between fillers, injectable agents and all this Mabosh Mabo. 

So in a nutshell, injectable agents are the large umbrella category of a bunch of things that can be injected into the tissues of the face. I like to take this and put every into this category, like we got Botox, Dysport Restylane, Juvederm, Radiesse, Sculptra. So all these are different types of injectable agents and they all do different things.

Dr. Raghu Athré:

So from that large umbrella category, we’re going to take injectable agents and divide them out into different categories. The first category we’re going to talk about are Botox and Dysport. There’s a few other agents that kind of fall into this category. There’s Xeomin, there’s Jeuveau and all of these agents work by these same mechanisms. So I’m going to use the words, Botox and Dysport interchangeably. However, there are some other agents that fall into this category.

Dr. Raghu Athré:

So the first question is, how do these things work? These agents are neural paralytic agents. So how it works is as follows. 

So let’s take a look at these lines right in here. So we actually all have a little muscle that goes from here to here and here to here, like a V. It’s called a corrugator, and it allows us to do this, the squinch. So when that muscle contracts, we get a vertical line in the skin. So people call it the elevens, they call it the squint lines, whatever you want to call it. 

There is a nerve that goes from the brain all the way to that muscle. And that nerve has basically, there’s a little gap where the nerve is where the muscle is. And when the brain gives it the signal, the nerve releases a little chemical called a neurotransmitter, which goes across that little gap and causes that muscle to squinch.

Dr. Raghu Athré:

When that muscle contracts, you get the line. So what these chemicals or medicines do is basically stop that process of nerve talking to muscle. So when that happens, despite the signals from the brain, the nerve can’t send the appropriate messaging to the muscle to contract. And that muscle is effectively paralyzed. When that muscle is paralyzed, then you don’t get the line. That’s how these agents work. 

Now it takes the muscle nerve complex roughly about three to four months to regenerate, rejuvenate, and then it can talk again. So therefore you got to go do the procedure again. So Botox is made by Allergan. Dysport is made by Galderma. Kind of like Coke by Coca-Cola, Pepsi, Pepsi Company. Similarly they both make Cola. 

So very similar to that, these are the two major players in that field, the smaller players, you got Xeomin and Jeuveau now, where are these agents useful?

Dr. Raghu Athré:

Right in here for the squinch lines. You can use them across the forehead. For the forehead lines when you lift up and in these areas. For the crow’s feet lines. I like to call them happiness lines because you also get them when you smile. 

Now, there’s some other useful stuff that you can do with them, the lip flip. So you can inject them around some of the muscles in the mouth to cause the lip flip. They’re also very good for hyperhidrosis or excessive sweating. So they’re useful for that. 

So there are a lot of useful things for Botox and Dysport. So this is just a quick outline of some of the main areas that are injected. Now there’s advantages between Botox and Dysport. Botox is like the Coca-Cola industry standard, it’s been around for a long time. Botox takes about seven to 10 days to take effect.

Dr. Raghu Athré:

So therefore if I inject it today, you’ll start seeing the results in about a week and the effects last for about three months. On the other hand, Dysport, slight different chemical composition. And the advantage with Dysport is that it takes a little bit quicker onset, probably about four to seven days to start taking effects two to three days sooner and seems to last about three and a half to four months. So roughly about the same. 

You can expect, if you’re keeping on top of these treatments, you can expect to see your plastic surgeon about three to four times a year for a touch up to continue that rejuvenated appearance. These are not Cinderella treatments. 

So I told you, it takes about a week for the effect to take effect. So ideally if you got a big event coming up, try to see your plastic surgeon about two weeks to three weeks in advance.

Dr. Raghu Athré:

That way you’ve got the total effect and you get to enjoy it for your big event. So that was one category under the umbrella of injectables. Now the other stuff are filler agents. 

And I like to think about fillers kind of like you think about Bondo. So if you had a little crease in your car, like someone doored into you, you don’t really need to go and get a new door. You don’t need to go do really crazy body work, a little bit of body filler and some paint will make it look really good. Similarly, filler agents are very useful to deal with some of the lines like in here, the nasolabial folds some of the volume loss around the eyes. 

These are good areas for filler agents. filler agents, however, are not a substitute for a face lift. We’re doing something different.

Dr. Raghu Athré:

So if you got into a major accident with your car, you can’t fix that well with Bondo. Similarly, if there’s a lot of toastness of the tissues, you really can’t fix that with filler agents. They’re different types of filler agents. The biggest category of filler agents is hyaluronic acids. 

Hyaluronic acid is a naturally occurring chemical that’s in your body. You have it in your joint fluid, you have it in other places in your body for lubrication and for volume. So they synthesize this in a lab and voila. You have filler agents. 

Now the Hyaluronic acid is kind of like hair gel. You’ve got control and hold. So you can make small chemical link modifications in the Hyaluronic acid to either give you a lot more control where you want to use in some of the thin thin skin or more of the hold, where you want more structure.

Dr. Raghu Athré:

If you’re going to be doing filling to lift cheeks and kind of hold the tissues up, there are two big companies that are players in this market. You’ve got Galderma, which makes the Restylane family of products. You’ve got Allergan that makes the Juvederm family of products. In my opinion, I think they’re roughly about the same. I don’t see any huge glaring differences. Both families have a good diversification of the products, meaning enough products with the control area, enough products with the hold. And there’s some special situations.

Dr. Raghu Athré:

So let’s talk Restylane and family. So Restylane and family, I feel in my experience, the filler that has the biggest oomph of support is Restylane Lyft. You’ve got plain Restylane L, which is a good middle rung, which is useful for a lot of different things. And if you’ve got really fine lines that you really want to kind of fill right underneath the surface of the skin, you have Restylane Silk, they have some other products as well within their family, like Restylane Defyne.

Dr. Raghu Athré:

And they have Restylane Kysse, which really works well for lips. But this is kind of that family of products. And this episode is not long enough to go into all the intricacies of exactly which one. I have a few favorites, for example, under eyes. I really like using plain Restylane, in my hands I feel that it has the least amount of bruising and swelling, and that’s the reason why. 

The Allergan family makes Juvederm products. So if you’re looking for a lot of that hold where you’re looking for structure, that would be Voluma. Then the middle rung, that’s kind of an all purpose, I like Juvederm Ultra Plus and then for some of the really kind of fine stuff, I like Volbella. 

Now this is one thing I think each of the family Restylane and the Juvederm have their pros and cons.

Dr. Raghu Athré:

So as I told you, my favorite for the under eyes is Restylane. My favorite for overall structure, if I’m really needing to get structure to the gits, is Voluma. I think it’s got the greatest amount of hold. So this is why I think a consultation is really important so that we can really discuss what it is you’re trying to achieve and what the correct product is for you. 

Now, all of these companies make promises about how long the products last. I’m going to tell you as a clinician, this is what I roughly see. Lip products normally last about four to six months. Under eye products usually last somewhere around the nine month to 11 month range. And in some of the other areas you’re looking at a lot more. You can get 10, 12 months out of it, but most of those patients really do benefit from a touch up right around that 10 month. Maybe not to the same volume that they needed before, but maybe just a little touch up just to kind of give them that oomph. 

Dr. Raghu Athré:

Now, under the filler agents, you’ve got a couple of specialty products. One specialty product is Radiesse. Radiesse is not a Hyaluronic acid. Radiesse is actually made up of calcium hydroxyapatite, which is the foundation particle in bones. Imagine taking bone, pulverizing it into a really fine powder, putting it in a carrier and being able to inject it. 

I love Radiesse. It does take more effort to inject in that, you have to be very careful how you inject it. It’s not an easy injection, like the Hyaluronic acids, and hence takes a lot more technical expertise. It’s really good for thick tissues, smile lines, creating more angularity along the jawline, maybe deep injections along the cheek line to really define the cheek, works great.

Dr. Raghu Athré:

The other advantage to the Radiesse, is that most of the other fillers come in one CC syringe. Radiesse comes in at 1.5 CC. So you’re getting about 50% more. And the product itself lasts about 14 months. So if you have had fillers before comfortable with the look of fillers and want a longer acting filler in some of these thicker tissues may want to consider Radiesse. 

However, again, Radiesse really I feel is an injection that should only be injected by a plastic surgeon who has experience injecting Radiesse. 

Last but not least is Sculptra. This is another kind of special case type of product. Sculptra is a large area volume filler. Which means it’s really good for picking this entire area right in here where you can sometimes get hollowing. It’s good to create volume in there, replenish that volume. Sculptra works really well for that. Sculptra is made of the same stuff that dissolvable suture is made out of.

Dr. Raghu Athré:

So the sutures that we use in the operating room are dissolvable. It’s formulated into a fine powder, reconstituted and injected. Now, Sculptra works a little bit differently than some of the other products in that when you inject Sculptra, you will initially see the volume, that volume goes away within about a day or two. And then the body creates collagen based on that irritation of the dissolvable suture replenishing the volume. Again, it needs multiple treatments. It’s a great product. 

The only thing I would say that’s somewhat of a negative with Sculptra is that it’s a little expensive, and does require maintenance, just like any of these products. 

Now last but not least. One of the recurring themes that you see with all the products discussed are they all have a lifespan and need to come back and re-inject or, and do this. And some of my patients are going to go, “Doc, don’t you have something permanent”. And the answer to that is, “You don’t always want something permanent, your face is not permanent.”

Dr. Raghu Athré:

So sometimes there are things that can be done with Botox, Dysport and fillers that really cannot be done with surgery. So I think surgery is an important aspect to the rejuvenation puzzle, but I think this whole category of injectable agents is also an important puzzle. And sometimes there are things that cannot be done, that only one of those things can achieve the result. So I think that it is a great rejuvenation tool and it’s part of the armamentarium of facial rejuvenation. I really hope you’ve enjoyed this episode of Plastic Surgery Unplugged.

Dr. Raghu Athré:

I hope you’ve learned a lot. I hope that you’ve gotten a lot of information and maybe those wheels are turning and you come up with more questions, more concerns, more thoughts, anything to that effect. 

First of all, if you like this episode, please subscribe to us. It really helps us out. Leave us a review, give us some feedback. Finally, if you have questions and want more information, give our office a call, send us an email at info@Athré.com. Schedule a consultation. 

I look forward to meeting you and chatting with you and helping you along your plastic surgery journey. Thank you.