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If you’re curious about dermal fillers and neuromodulators, hear from Dr. Elizabeth Roche, of Elizabeth Roche MedSpa, to learn about when to get started on treatment and what to expect. Listen or read more to learn all about dermal fillers and neuromodulators.

John Maher: Hi, I’m John Maher. I’m here today with Dr. Elizabeth Roche, founder of the Elizabeth Roche MD MedSpa in Bergen County, New Jersey, a medical aesthetics center committed to providing people with the most advanced procedures available, to restore youth while preserving the beauty and functional health of your skin. Today our topic is dermal fillers and neuromodulators. Welcome, Elizabeth.

Elizabeth Roche: Thanks, John. Thanks for having me.

John: Sure. So, Elizabeth, what is a neuromodulator? What does that mean?

Elizabeth: Neuromodulators are medications such as Botox, Dysport, Xeomin and Jeuveau. More commonly people refer as Botox because that name has been around the longest, and what this medication does, it stops muscle movement, which may be causing wrinkles. So, you stop the muscle movement that’s folding the skin, and you diminish or reduce or make the wrinkles disappear completely.

Difference Between Dermal Fillers and Neuromodulators

John: Okay, and what’s the difference between a neuromodulator and a dermal filler?

Elizabeth: Yeah, so the neuromodulators; it’s an injection that stops muscle movements, so it’s a great beginning way to stop those wrinkles. As we age, sometimes the skin has been folded over and over and over, almost like a piece of paper. You stopped the folding movement, but you still have the wrinkle there. So, the dermal fillers come into play to fill in that wrinkle that’s present at rest, something that’s called a static wrinkle, whereas the Botox fixes a dynamic wrinkle.

Dermal fillers also help in replacing volume depletion. So, if there’s an area . . . aging causes volume depletion especially in the middle of the face, and you’re losing that support in the middle of the face. We use dermal fillers to regain and re-inflate basically, the area to help with deeper folds and wrinkles.

John: Those types of wrinkles, what we call those frown lines and things like that?

Elizabeth: Yes. Yeah. Frown lines or the common one is the fold that happens between the nose and the corner of the mouth, that’s called the nasal labial fold. That’s one that a lot of people come in for, or the hollows under their eyes, and this is all part of the natural aging process, and we can reverse that and make patients look refreshed and renewed by putting dermal filler in strategic points that just helps lift the face back up.

Types of Dermal Fillers

John: Okay. You mentioned some of the types of neuromodulators. What are the different types of dermal fillers?

Elizabeth:     Dermal fillers fall into basically three main categories. They’re the hyaluronic acids, the calcium hydroxylapatite and the bio-stimulators. The hyaluronic acid fillers are the most common, and they include fillers such as JUVEDERM, VOLUMA or Restylane products, BELOTERO, Versa. There’s many on the market and there’s even more so in Europe. The calcium hydroxylapatite filler is a RADIESSE and biostimulators include products such as Sculptra and Artefill.

Deciding Between a Neuromodulator and Dermal Filler

John: Okay. When is a neuromodulator needed and when is a dermal filler needed?

Elizabeth: So, the neuromodulator will basically calm the muscles down, relax the muscles. So, if you’re starting to see the lines being formed from muscle movement like frowning or smiling or raising your eyebrows up and getting horizontal lines across the forehead, that’s when the neuromodulators or the Botox medication comes in. When you need volume replacement, that’s when we inject the dermal fillers and that’s such as like a deflated cheek or hollows under the eyes, deflated lips. They’re very common and popular in using for lip fillers, so those two medications work great together.

John: And when you see a patient initially, you can help to determine based on their type of lines that they have on their face or the issues that they’re having, which one of these they would need.

Elizabeth: Absolutely, and that’s what’s so important about the consultation because I’m educating the patient, first of all, of like what happened, how did they get to that point, and what we can do with these medications, and sometimes other procedures, that can help reverse the aging process, help tighten the skin, help replace the fat loss in the face, or stop that repetitive muscle movement that’s caused the wrinkles.

A combination is always better than doing just one medication alone, and many people get confused. They don’t realize that Botox is, they think Botox can take care of all of these issues. But it’s a combination, some of this, some of that to make the best balance of a treatment.

Dermal Fillers Used on the Whole Body

John: Are these all used on the face, and are certain dermal fillers better in some areas of the face than others?

Elizabeth: Dermal fillers are mostly used on the face, but we use them off face too. Some of them actually have FDA approval off-label. We as physicians, we tend to use fillers or any medication off-label once the consensus is out there that it’s safe. So, some of the fillers are indicated to inject in the hands to rejuvenate the hands such as RADIESSE or a Restylane Lyft.

I use fillers in the neck to help with the horizontal necklines. In the ear lobes to re-inflate the depleted volume loss in ear lobes because patients earrings won’t look the same, and actually, what’s very, very popular now is using Sculptra. It’s a one of those bio-stimulating fillers in the buttocks area, to create a more perky, fuller buttocks, which is very popular among the millennials these days.

John: Can you do both dermal fillers and neuromodulator injections and if so, do you do them at the same time?

Elizabeth: Yes. We do both of the treatments at the same time very often, and it’s a great treatment to do both, because most patients have problems that are from possibly excessive muscle movement and also some volume depletion. So, if a patient is new to all of this, sometimes I’ll take it a little slower and just do the neuromodulators first, let them get comfortable with that, and then have them come back, and then we can do the dermal fillers but I can do both treatments at the same appointment time.

Side Effects to Watch Out For

John: Okay. Do dermal fillers and neuromodulators have side effects and if so, what are they?

Elizabeth: Yes. Everything we do has side effects. With every injection, whether it’s what I’m doing or injection that you get, a flu shot, there’s always a possibility of bruising because that’s the action of the needle penetrating the skin surface and possibly hitting vessels. So, you always have to be prepared for a bruise. It can last up to two weeks. So, I advise my patients, ‘Give yourself two weeks before an event at least. So, try to do it sooner.’

Many times, I have people coming in and they’re trying to get ready for a big event and if it’s not two weeks out, I won’t even inject them in case there’s a chance for a bruise. A bruise isn’t serious but it’s bothersome, and you don’t want to show up at a big event with a bruise on your face. So that’s what are the minor, more frequent sometimes things that happen.

There are other possibilities such as infection that can happen. There are some rare cases that granulomas or nodules can happen later on. Those are very, very rare occurrences but it’s in the literature and it’s treatable as well, but it’s a rare side effect.

Preparing for a Treatment

John: What does somebody need to do to prepare for the treatment before they come in?

Elizabeth: Well, one thing to decrease chance of infection, come in with a clean face and do not have your dermal fillers a couple of weeks prior to or after dental appointments. Because dental work stirs up bacteria in the mouth and it can flow right over the dermal fillers and it can because a bad infection. So we would go by the simple four week rule, no dermal fillers four weeks, after dental work and no dermal fillers four weeks before dental work. So that’s key. You don’t want to get an infection in these dermal fillers.

We also tell patients to avoid taking medications that may make them bruised such as aspirin or the nonsteroidal anti-inflammatory medications, which are Ibuprofen, ALEVE, MOTRIN. As well as omega fish oils, vitamin E, those can make you bruise and alcohol plays a big part, especially wine. That’s why it’s so good for your circulation. So, these things are things that we tell our patients to avoid and prepare themselves to get the best outcomes and decrease the chance of side effects.

Dermal Fillers and Neuromodulators for Men and All Ages

John: Okay. We think of these types of treatments like Botox, as being something that a lot of women do, but are the treatments popular with men as well?

Elizabeth: Well, I’m glad you asked that. I and many other women are happy to say that men are finally getting on board with caring about their appearance. I’ve been practicing aesthetic medicine for about 17 years and the majority of my patients are women, but this past year we’ve seen more new male patients than ever before, and the number one reason they are presenting is because they don’t like the deflated midface and the hollows under their eyes. They feel that that makes them look tired and older than what they actually feel that they are or they actually are.

Many people too, who exercise a lot and take care of their bodies, they burn fat and the fat’s going to be lost from their face as well. So, their physique looks good but then they look older in their face because they look a little drawn out and deflated there. So, I’d say the number one treatment that men come in for, are the dermal fillers but they get the Botox and they get skin treatments too.

John: Okay, interesting, and at what age are people getting treatments?

Elizabeth: The majority of my patients are in the let’s say 40- to- 60-year-old range. However, another trend that we’re seeing is younger patients seeking treatments to prevent the aging process, and this is really wise of the millennials to do this, because they realize if they do a small amount, a tiny little bit of let’s say, Botox to prevent those wrinkles from starting, they’ll preserve their youthful appearance for years ahead.

So instead of having to wait and say, “Okay, am I ready to get something because I look old?” They’re preventing so it’s a good philosophy to go by preventing instead of correcting, and I always tell patients, “Remember, it’s not what age should I start this, it’s how a patient sees themselves in the aging process.”

Dr. Roche’s Decades of Experience

John: Right. Can you give me a little bit of background on you, Elizabeth, and how long you’ve been doing these types of injections?

Elizabeth: Sure. I’ve been injecting Botox for 21 years now. I’ve actually began injecting it in 1998 when I was training at the University of Pennsylvania for pain management, and we did a lot of injections, and we would use Botox for the release of muscle spasms, and we would use it in pretty large quantities too, in the hundreds of units at a time and the neck and for migraine headaches; and I can remember treating some patients for facial spasms.

Then around 2002, Botox cosmetic was approved. So, they started having indications for cosmetic reasons, and that’s when I started beginning to inject for cosmetic reasons. I was interested in all this and so I got trained and started injecting dermal fillers since 2003. So overall about 20 years I’ve been doing aesthetic medicine, and I’d say the past 13 years, purely only aesthetic medicine. Before I was doing a little bit of both but the past 13 years, just dedicated my practice to injecting and doing other skincare treatment and procedures that hopefully I’ll get to talk to you about some day.

John: So, what should somebody look for if they’re looking to have dermal filler injections or neuromodulator injections? There seem to be a lot of places around that do this now. What should people be looking for in terms of deciding where to go?

Elizabeth: You’re absolutely right, of more and more people are doing this, and what I strongly advise patients to do some investigation work before you go somewhere, and I advise them to see physicians who have years of experience injecting, and they’re injecting out of a clean medical office, not a hair salon or someone’s basement. You hear horror stories about what can happen and go on the internet and you start looking at things. You don’t know who is injecting what, where the products are from.

You want to make sure that the physician is highly trained and obtaining their products from the companies directly, not buying them off of some discount internet. They may be overseeing experienced physician assistants or nurse practitioners and that’s totally fine too. Each state differs and who’s allowed to inject. In my office I have a highly trained physician assistant who actually trains physicians for one of the dermal filler companies.

So just do your homework, make sure you’re going to somebody who’s experienced. There’s a lot of people doing it on the side out of their . . .  mainly let’s say a dentist or a gynecologist and they’re doing things a little bit on the side. The other thing I would warn patients about is the bargains that are too good to be true from the, let’s say, group coupon people. Remember, you get what you pay for, and you should look your best and be really careful when you’re getting injections in your face.

Getting Started

John: Right. Right. if I’m interested in getting one of these procedures done but I’m new to it all, maybe I’m a little bit scared about getting injections and things like that, how do you recommend that people go about this process?

Elizabeth: Well, I always advise patients to come in, just talk. We’ll do a consultation. We’ll talk about what’s your concerns, what we could do to help it, and I tell patients, “There’s always different pathways to get to the end results.” So, someone may say, “The thought of Botox, I don’t want to do that.” So, I’ll say, “Okay, we can do these treatments and maybe some fillers or even a treatment called platelet-rich plasma where we’re taking the patient’s blood and using the plasma and injecting that.

So, number one, come in for a consult, talk about what your concerns are. Start off slowly until you’re comfortable and understand how the process is and what the results can be. I tend to offer my new patients who’ve never had any of these procedures done, to have what I call like an appetizer dose. Just a little bit to see what the expectation can be and what it feels like, and then when they get comfortable we can do a little bit larger dosing.

I always have my new patients follow up in two weeks so we can talk about what they see, what they like, what they don’t like; and I do have many patients who were extremely nervous about injections or even had needle phobias. But I find when they see and they come in and get a little bit, talk to the staff, we make them very comfortable with numbing cream, ice, they find that they get the idea and they see the results and they come back and they’re usually right on board with the treatment protocol and plans.

John: All right. That’s really great information and thanks again for speaking with me today, Elizabeth.

Elizabeth: Thanks for having me John.

John: For more information about dermal fillers and neuromodulators or other treatments, visit the website at ElizabethRocheMedSpa.com or call 201-505-1020. That’s 201-505-1020.

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