Dr. Sam Lam Plastic Surgery Forum

Hello, Dr. Lam. How are you?

I would be most grateful if you could answer my questions for me. I have quite a few, so here goes....

Topic 1 -- Accutane and Restylane:

How long must a person be off of Accutane before they can have Restylane injections and/or laser resurfacing done? I've heard contradictory answers from varying sources. On the one hand, some dermatologists and plastic surgeons I've asked said 6 months, while others said no less than a year to a year and half.

Topic 2 -- Restylane correction of premature ageing:

How much does Restylane *typically* cost for "smile lines"? I believe I would only need one vial as mine are not what you would consider very deep creases. At the tender young age of merely 24, I am already beginning to experience visible, permanent creases from my nose to my mouth, fat loss and crepey skin from beneath my eyes, accompanied by dark circles. Needless to say, these are issues I had otherwise never suffered from until recently, seemingly out of the blue. I wonder if this accelerated ageing was brought about by recently being on two courses of high-dose Accutane, although I can't be certain.

Would you advise someone like me to have Restylane injections to fill out the under eye area alittle? Isn't that risky to inject so closely by the eye? Won't that create a secondary problem in addition to the first, in that the Restylane filler will stretch out the thin, overlying skin even more and exacerbate the hollow appearance beneath the eye once the filler dissipated within 6 months time? Sort of like when a person loses a good amount of weight they are left with saggy, stretched out skin?

Topic 3 -- Restylane correction of ice pick scars:

I suffered with a pretty significant case of acne for many, many years. Thankfully, my scarring it not what one would call "severe," however, it is definitely noticeable. I have a lot of small ice-pick scars all over my face; more so on the right side than anywhere else, strangely enough. My question is: Is it possible to use a small quantity of Restylane to somehow fill up or plump out the ice-pick scars? Do you have any experience with performing procedures like that? If so, have you and your patients been pleased with the results? Can I go to just any derm or surgeon to have Restylane done, or does the doctor have to specialize in it and have very specific credentials?

Thank you very much for your time and help.

Christi

hi christi,
1. Okay, that question is controversial and the three answers you got are all correct. We simply do not know when the sebaceous glands are fully back in play so that you don't risk scarring. However, Restylane injections are fine even on Accutane (in my opinion) so long as you don't make a physical incision or do any kind of skin resurfacing with lasers, peels, etc. If you are talking about skin resurfacing or physical cutting, I would wait 1.5 years because I am conservative. I think it is almost always wise to be more conservative when working on the face. However, as stated, in MY opinion, Restylane is probably safe. Why do I say that? Well, I have done a full face fat transfer on someone just off of Accutane a few weeks. In fact, I just did my second case two weeks ago on a lady a few weeks off of Accutane, and I did my first case over a year ago without any scarring. (Btw, fat grafting is entirely incisionless.)

2. I think oftentimes the "nasolabial folds", i.e., smile lines, are implicated in aging when they really are not that important in my opinion for aging. Now, in about 1 in 10 people I do treat them when I think aesthetically they matter. That is hard to explain because most people cannot see what I can see. That is why a consultation with me is so important. I don't have a knee jerk reaction to fill smile lines in everyone like most places.

I think most oftentimes someone 24 that looks older and gaunter is either due to genetics, severe thinness, or most likely to excessive sun exposure in youth prior to the age of 20. What is amazing is that the sun exposure you get leads to 20 to 30 years of ONGOING DESTRUCTION of your collagen. That is why I preach against sun tanning in a big way. Besides long-term cancer risks it will make you look terrible by 30 and frightening by 40. Okay, I hope I scared you a bit.

I don't believe that Restylane will stretch out the skin since you are young but, more importantly, we are talking about very little Restylane to make a big difference. I do not see the problems with Restylane around the eyes since I do not use needles. I use blunt cannulas a technique I invented which only 1 in 100 physicians know how to do.

3.Restylane for ice pick scars is not hard to perform but you should go to someone who is skilled in this technique. The reason for that is that if you inject into a tethered scar, you can actually fill around the scar itself making the scar even deeper (so-called "donut effect"). The good thing is that Restylane is 100% reversible in 24 hours with Vitrase injection so you won't have to live with it.

Best wishes,
SML

Hello, Dr. Lam.

Thank you for your thorough response.

My premature ageing might very well be due to genetics. I've never been a "sun person." I have always avoided the sun like the plague because I have a fair-skinned complexion which tends to make sunlight painful for me and tanning impossible. I wear a hat and sunglasses whenever I go outdoors (the majority of the time). On top of that, my dermatologist is convinced I have a mild form of Rosacea, because I flush easily due to heat and sunlight and the redness takes awhile to subside; hours, days, weeks, or sometimes even months. I, personally, have my doubts that I suffer from Rosacea. I believe my photosensitivity has more than likely been precipitated by the vast array of acne medications I've been prescribed since late in my childhood, but particularly within the time frame of the last 5 years. Most acne medications have a tendency to make your skin hyper-sensitive to sunlight, especially Minocycline, Benzoyl Peroxide and Accutane; three medicines I have used (at different times) religiously since early 2003 to November 2007. I always drink plenty of water, I'm fit, I eat healthy, I exercise, I have never smoked, used drugs, nor drank alcohol in my entire life -- so, it's still a mystery to me why my skin has begun appearing older than its biological age. I feel as though I have done everything correctly throughout my life to ward off the onset of creases and wrinkles and dark circles beneath my eyes, etc., and yet here they all are having a party on my face. I have, however, experienced A LOT of stress and emotional upset due to some very difficult challenges that have transpired in my life over the last 7 years. I heard once that extreme, prolonged stress can prematurely age you. That's the only other possible conclusion I can come to.

While I respect your opinion regarding the nasolabial folds, and their debated effects on exaggerating the appearance of a patient's age, I still would like mine fixed. They seem to age me by at least 5 years. Prior to these permanent creases creeping up on me, people would often mistake me to be somewhere between 15-18 years of age. Now, suddenly, since they've appeared, people either think I'm my actual age, or they think I'm in my late 20s. None of my peers have creases or "smile lines" -- which makes little sense to me because many of them worship the sun and/or smoke like a chimney, yet they have skin as flawless and beautiful as a movie star. I believe a smooth, crease-less face is a sign of youthful, healthy, resilient skin.

I agree with you that I would only need a small amount of Restylane for the eye correction I desire. Could you please explain the "blunt cannula" technique to me and what all that entails? About how much money would you charge for such a procedure? I will need to know the cost ahead of time so that I can reprioritize my finances a little if need be. I am hoping one vial would do the trick, because, again, I would only need a small amount around the eyes, and I could use the rest to fill in my smile lines. Would that be possible?

Thanks, again.

Christi

All of you what you said may be correct, i.e., stress and fair skin could be the culprits. If you have very mild smile lines and very little hollowness, then 1 syringe may be sufficient. My guess is that you will need to have 2 (worst case scenario). The cost would $1000. I take $100 off your second syringe.

The blunt cannula technique is something that I invented in which I use a cannula (see my glossary for a detailed definition) to inject the Restylane rather than a needle. I find that there is less bruising, a smoother result and less risk of other problems around the eyes. A cannula, in short, is a blunt instrument about 1 mm in diameter with a hollow core through the Restylane is injected and with a small side port hole through which the Restylane comes out. In short, it is a needle without the sharp end and with a small hole on the side instead of at the end.
best,
sml

Good morning, Dr. Lam:

I have a few additional questions, I hope you don't mind.

1. You said you believe that Restylane injections (performed with a needle) for someone on (or just off of) Accutane would not pose a problem with scarring. How is that so since it has to pierce the skin and make a "physical incision"? Also, what about using a blunt cannula? Can the same be said of that particular utensil, too, or does a blunt cannula pose a risk for scarring? (I've never heard of a "cannula" before, so please pardon my ignorance if that's a silly question.)

2. I saw on your website where you discussed the TCA CROSS treatment to repair acne scars. I saw your before and after photos and am quite impressed with many of them. Unfortunately, though, as we discussed earlier, it looks like I'll need to wait no less than a year, to a year and a half, since I've only been off of Accutane a little over a month now.

My questions concerning the TCA CROSS technique are:

(A) Can the TCA CROSS treatment be performed on all skin-types; ex: combination, oily, dry and/or sensitive?

(B) Are there any risks involved; ex: permanent hyper-pigmentation, worsened scarring, etc.? If so, how common are they?

(C) Can you please explain the pros and cons of TCA CROSS treatments?

(D) I have ice-pick scars all over my face; is it possible to do an entire facial treatment using the TCA CROSS method?

(E) If so, I assume it'll cost the same $500 amount per treatment, regardless of how much area on the face is treated per session, correct?

Thank you,

Christi

My answers are in all caps below:

1. You said you believe that Restylane injections (performed with a needle) for someone on (or just off of) Accutane would not pose a problem with scarring. How is that so since it has to pierce the skin and make a "physical incision"? Also, what about using a blunt cannula? Can the same be said of that particular utensil, too, or does a blunt cannula pose a risk for scarring? (I've never heard of a "cannula" before, so please pardon my ignorance if that's a silly question.)

NO, THE NEEDLE IS NOT A PROBLEM NOR IS USING A BLUNT CANNULA. THAT IS MY OPINION. YOU MAY FIND A PHYSICIAN WHO DISAGREES.

2. I saw on your website where you discussed the TCA CROSS treatment to repair acne scars. I saw your before and after photos and am quite impressed with many of them. Unfortunately, though, as we discussed earlier, it looks like I'll need to wait no less than a year, to a year and a half, since I've only been off of Accutane a little over a month now.

YES, I WOULD WAIT 1.5 YEARS. I AM CONSERVATIVE. SOME OF THE BEFORE AND AFTERS ARE SILICONE TREATMENTS. IN FACT, MOST ARE. YOU MAY NEED SILICONE. YOU MAY NEED TCA. YOU MAY NEED BOTH. IF IT IS SILICONE, I COULD START EARLIER. BECAUSE THERE ARE MULTIPLE, MULTIPLE NEEDLE STICKS WITH SILICONE, I WOULD PROBABLY WAIT 6 MONTHS POST ACCUTANE BUT THAT MAY BE EXCESSIVE.

My questions concerning the TCA CROSS technique are:

(A) Can the TCA CROSS treatment be performed on all skin-types; ex: combination, oily, dry and/or sensitive?

YES, EXCEPT IN INDIAN AND AFRICAN SKIN. BUT SKIN TYPES UP TO A HISPANIC, ASIAN ARE FINE.

(B) Are there any risks involved; ex: permanent hyper-pigmentation, worsened scarring, etc.? If so, how common are they?

I HAVE NOT SEEN PERMANENT HYPERPIGMENTATION AS A PROBLEM. GENERALLY, HYPERPIGMENTATION IS A TEMPORARY PHENOMENON. WORSENING OF SCARRING IS POSSIBLE WHICH I RARELY SEE BUT HAVE SEEN IN ONLY ONE OR TWO SPOTS IN ONE OR TWO OCCASIONS, WHICH I HAVE FIXED WITH SILICONE.

(C) Can you please explain the pros and cons of TCA CROSS treatments?

TCA CROSS TREATMENT IS ONLY INTENDED FOR VERY SHALLOW AND TINY HOLES, MORE LIKE LITTLE DOTS ON THE SKIN. IT IS NOT FOR DEEPER OR WIDER SCARS. THAT IS WHAT I USE SILICONE MICRO DROPLETS FOR. THAT IS $700 PER TREATMENT BY THE WAY AND WILL USUALLY REQUIRE 2 TO 4 INJECTIONS IN GENERAL ALSO SPACED A MONTH APART. I HAVE COMBINED BOTH TECHNIQUES TO HIT THE TWO TYPES OF SCARRING. SEE MY VIDEO ON ACNE SCARRING CONSULTATION. IT IS UNDER MY VIRTUAL CONSULTATIONS. YOU CAN LOOK AT MY MEDIA CENTER.

(D) I have ice-pick scars all over my face; is it possible to do an entire facial treatment using the TCA CROSS method?

YES, BUT I HAVE TO LEAVE A FEW MILLIMETERS BETWEEN EACH TREATED AREA SINCE THE TREATMENT IS DEEP AND THE SURROUNDING SKIN IS WHAT HELPS THE REGENERATION OF EACH SKIN PIT.

(E) If so, I assume it'll cost the same $500 amount per treatment, regardless of how much area on the face is treated per session, correct?

THAT IS CORRECT.

Thank you,

Christi

I am interested in making an in-office consultation with you sometime in the future so you can see the condition of my skin for yourself. I am impressed with your knowledge, your willingness to give free advice to help others make informed decisions, and, most of all, I am impressed with your *honesty*. You would be surprised how many cosmetic surgeons and dermatologists flat-out lie and tell their patients ANYTHING they want to hear to sell them on a certain procedure (or product) just to make a buck off of them, even when they know the procedure (or product) normally does not yield satisfactory results. Too many of them seem to view their prospective patient as a dollar sign before seeing them as a person. That might sound harsh, but I speak from experience, sad to say. Your *honesty* and desire to give people accurate information speaks volumes about your character and really sets your apart from the others in an admirable way. I respect that.

I think I might need to wait a little while before I come to see you, though. My dermatologist gave me a sample of "Tri-Luma" to help fade the lingering red spots my acne left behind (that have taken an unusual amount of time to noticeably fade; even after a year and a half they still have not completely faded). Anyway, after using the "Tri-Luma," I experienced a significant adverse reaction to it. My face developed a painful, red rash everywhere I put the cream. I want it to be gone by the time I see you. I don't want this rash to interfere with your ability to properly evaluate my skin. Hopefully it fades away very soon.

Have a happy new year.

Thank you for the kind words. I know what you mean. You can always rest assured that I will treat you like my family, and I mean that. I have dedicated my life to take care of people. That is all that matters in this lifetime.

I don't want to give you the wrong advice (because I have not seen you), but you may want to use a 1% hydrocortisone cream over the counter to knock down any irritative dermatitis (if that is what you have). Only use it for a few days until symptoms improve because it can thin the skin over the long run. looking forward to meet you.
best,
sml

Just to add my input. I've been on low doses accutane 10mg/day for 5 months. Right after I stopped it, I had fillers injected, Juvederm below the eyes, Radiesse in cheeks, silicone in lower cheeks. I did not have any 'scarring' nor I noticed 'slow healing'.

thanks for the input.
sml

Thank you, Summertan. I appreciate your feedback.

Hi, Dr. Lam:

You're very welcome. You deserve all the praise you receive. Also, I just sent you a private message regarding my upcoming consultation.

I have replied to your PM.
best,
sml

Hello, Dr Lam. How are you?

I met with you the other day and what a pleasure it was. Both you and your staff were warm and friendly and made my consultation a very pleasant experience.

I have a few more questions, if you don't mind my asking:

We discussed having my under eye hollowness and nasolabial folds corrected with Restylane. You stated it would require 2 vials to create the overall enhancement for both problem areas; $550 for the 1st vial, $450 for the 2nd vial; $1,000 total. (With every vial subsequent to the first costing $450.)

Recently, upon further researching Restylane, I have come to discover that numerous people complain of rapid absorption anywhere from within 1 to 2 to 3 months time. That tends to concern me.

(1) What percentage of your patients experience a speedy absorption rate with fillers (particularly ones like Restylane that are Hyaluronic Acid based since that's what we discussed you would use in my case)?

(2) What is the average rate of longevity for alternative fillers you use? Are there any other fillers that have proven to be just as effective but have a greater endurance rate and, relatively speaking, are as equally economical?

(3) If both of my Restylane injections only lasted a disappointingly brief period of time (like, say, 8 weeks or so), routine maintenance would be just about impossible. However, if each injection lasted at least a period of approximately 6 months, THAT would not create a problem. I'm certain I could handle twice a year. That said, I'm curious.... if your patient pays for Restylane injections and the correction disappears within a mere 2 (or 3) months time, do you extend any type of a backup offer where the patient is able to receive the next 1 or 2 vial(s) free of charge (or at least discounted) so that their initial payment spans a minimum length of 4 months total preventing them from essentially "throwing away their money" due to such short term results? What is your general policy with relation to that potential outcome?

I appreciate your time. Thank you.

Christi

Nice meeting you too. As far as Restylane around the mouth like the smile lines it can last a shorter time. In most of my patients about 3 to 4 months but less likely 6 months. Around the eyes, longer lasting like 6 to 8 months but could be shorter or longer. I would suggest if you are worried about the longevity around the mouth that we go with Perlane that should (but no guarantee to) last longer. As I said, Radiesse is even longer lasting but your smile line is different than most people's in that yours really shows up when you smile and less so when you don't. Even though Radiesse provides (I should say can provide) greater longevity I wouldn't do it for you, since it is irreversible, whereas Restylane and Perlane can be easily reversed or dissolved. The only negative of Perlane is that it is a slightly harder product that you might "feel" in that area during smiling. All of this requires some work to get right. If you really only last a short time then I would be open to giving you another syringe without charge but I generally do not given the time frames I have presented to you. There are no other options around the eyes other than Restylane except for fat grafting but you are in your early 20s and I would not recommend the cost with fat grafting plus you are going to have some changes to your face over the next decade and I typically wait until someone is at least early 30s before contemplating a permanent procedure. In addition, fat grafting fails in smile lines.
hope that helps,
sml

Good morning, Dr Lam:

Thank you for all of the helpful information you continue to provide.

I have also experienced fat loss in the areas of my cheeks located directly beneath my inner eyes. (I'm not familiar with the medical vernacular so I'm at a loss to cite the technical name for that area of my face.) Wow, at this rate of premature ageing at the tender young age of 24, I'm bound to look 40 by the time I hit 30. I confess, I am not particularly looking forward to that.

In my opinion, the creases alongside my mouth remain prominent even when my muscles are entirely relaxed. My smile lines bother me either way, although, mostly when I'm not animated. Judging by your suggestion, I agree, Perlane sounds to be a more viable alternative. Do you charge the same volume of Perlane per vial as you charge for Restylane? Since Perlane is a thicker consistency and has 10,000 gel particles per mil, does it pose a greater risk towards developing any bumps and irregularities visible through the skin? (It seems there are a few women who complain of fillers occasionally having that effect, which is the only reason I'm asking.)

Christi