Why You Should Be Cautious of The New Trend in Vaginal Health

They’re coming for your vagina!

14866828_blogLike it or not, it’s the latest profiteering trend in healthcare, your vagina.  Today I received this email from Sciton one of the best manufacturers of laser technology and the manufacturer that we use at The Maercks Institute:

“The vaginal health market is a growing and profitable business driven by postmenopausal women seeking treatment for symptoms like dryness, itching, and urinary incontinence.  In the US the average age of menopause is 50.5 years, which suggests a target population of 53 million women according to the most recent U.S. census (2010).  This new trend creates a large and new client base for a growing practice such as yours.  While there have been a number of laser manufacturers that have entered this market recently, we believe our product will leapfrog the competition by providing a safer, more predictable, and more customizable procedure which will ultimately result in better efficacy.  Currently in its final phase of clinical trials, we are getting excellent feedback from physicians who say patients are very happy with their results after treatment.”

Cynosure, the manufacturer of the “MonaLisa touch” system a CO2 fractionated laser that shoots inside the vagina, send me endless emails about how I can make amazing amounts of money by being an early adopter.  Before you know it this will be a recommended add on to your annual appointment.

What the public has to understand is that the drives behind these products are not efficacy but rather capitalization on the dreams and desires of most people.  Just like there are hundreds of different machines that will “make you skinny and toned with a painless and noninvasive visit to a practitioners office.”  Of course none of them work but it is a billion dollar industry because people will be pay if you tell them what they want is easy and painless.

Laser treatments on a basic level are controlled wounding that incites a healing process to make your body generate healthier tissue.  I am very concerned with the widespread use of CO2 based laser technology in amateur hands to women’s vaginas.  CO2 technology has been largely abandoned by knowledgeable practitioners because it causes extensive “coagulative” or heat based damage to the tissues that can result in scarring, thinning and destruction of components of the skin.  I only use a more advanced erbium laser on the face for example.  The long term effects of repeated CO2 laser on the vagina could be devastating and to make things worse, the practitioner is protected from mistakes because they are hidden on the inside and not readily visible.

My advice is for women to stay far away from these interventions for now.  At The Maercks Institute in Miami, FL, I perform vaginal rejuvenation and tightening with a special technique of fat transfer that improves the vascularity compliance and health of the vaginal canal while making it smaller and drastically enhancing sexual pleasure for both partners without a potentially destructive laser.  This is usually performed at the same time as an aesthetic MACIE labiaplsty for the esternal rejuvenation and can be combined with G-spot enhancement.

Don’t fall prey to the latest marketing hype that could potentially cause severe long term effects!

Book Your Appointment With Dr. Maercks.

Rian A. Maercks M.D.

Aesthetic, Craniofacial and Reconstructive Surgery

The Maercks Institute




Obstacles to Natural Looking Scarless Transaxillary Results in Breast Augmentation Surgery

Why Do Augmented Breasts Look So “Augmented” or Fake?

In this weeks edition of “Why Does Everyone Look So Weird?” I will examine the obstacles to attaining what so many women want in a breast augmentation: A scarless full youthful look that doesn’t have “plastic surgery” written all over it.  The obvious “augmented look” is rampant and well tolerated by the public and celebrities alike and I am sure some readers will be thinking right now “but I like the augmented look better than the natural look.”  I am the first person to say that I am not the plastic surgeon for everyone but I will say that even when patients come to my office with that mindset they nearly always leave with a complete reorientation wanting a natural looking augmentation.  The problem lies in understanding what a beautiful natural look is.  Most think natural means low and flat and augmented means full.  When I show patients requesting an augmented look pictures of the widely separated overly round and low “augmented look” and pictures of my results which have gentle slopes without harsh edges and separation I almost always get a “no no no that’s what I want response.”


Call (305) 328-8256 to schedule a consultation with Dr. Rian Maercks to learn more about breast augmentation.

Breast Augmentation Info

Breast Revision To Subfascial Plane
The Augmented Look vs The Natural Look in Breast Augmentation

Augmented look vs Natural look

Before getting deep into this issue, I will flatly say that my thoughts about breast augmentation and breast aesthetics are VERY contraculture to the mainstream conceptions and standards of my field.  It is my opinion that many practices in medicine and plastic surgery are very dogmatic.  I find the well accepted aesthetics of the augmented breast very disappointing even though this is a very high patient satisfaction procedure.  Not everyone will understand, relate to or agree with what I write here.  I am unwilling to intentionally deliver unnatural appearing results to the face breast or body.  I perform 100% subfascial breast augmentation, I perform 100% transaxillary (through the armpit) in primary breast augmentations that do not require lifting and I use 100% low profile anatomically shaped implants.  These three components are aberrations from mainstream plastic surgery..

Here we go…  I find a great starting point for understanding mainstream breast augmentation is to use one of the tools developed by expert plastic surgeons and industry partners, a software platform called TouchMD.  It is  a convenient tool with patient education diagrams and videos that one can draw on in consultation.  I will use screen shots from this system to illustrate my points.  Forgive the preschool looking drawings and writing displayed as this is not a  high accuracy fine art system.   Below see the first illustration in the breast augmentation section, a picture titled “before breast augmentation”:


Before breast augmentation.”

Does the picture above look like a pair of natural breasts to you?  It certainly doesn’t look like any natural pair of breasts that I have ever seen.  Lets look at why.  First of all they are round like balls:


There is also a ridiculously large space between them.  They are very far from midline demonstrated by the orange hashed space:


In fact it is not hard to imagine fitting a third breast between them.  If you are old enough to remember the movie Total Recall this will look familiar:


So now we are left with the question: Why would a team of expert plastic surgeons and this company produce a very expensive practice enhancing software suite with such a ridiculous representation of normal untouched breast anatomy?!?!

My simple answer: This is the now accepted norm for “augmented breasts” and the aesthetics of submuscular high profile implants have become the standard aesthetic goal for most plastic surgeons.

Lets take a look at why and how this has happened.  The most commonly used type of breast augmentation procedure in the United States is what the public calls “under the muscle” and what surgeons call “dual-plane.”  The pectoralis major muscle natively exists in a position and shape roughly as sketched below:


In a conventional “dual-plane breast augmentation, the inferior attachments and much of the midline attachments of the pectoralis major muscle are destroyed as the black dotted lines depict below:


The muscle then “window-shades” upwards as depicted by the orange shape below:


We will cover implant selection and why surgeons select implants that will create a fake look in depth later but for now we will just leave it at the fact that 90%+ of augmentations in this country are performed with moderate to high profile round breast implants.  With the dual-plane submuscular approach, the remaining origination attachments of the muscle prevent the implant from approaching midline, and the implant ends up exactly where this illustration depicts a “natural” breast existing as demonstrated below.


This separation leads to the wide flat sternal space so commonly seen in breast augmentation, what we jokingly refer to as “The Miami Valley” as seen in the yellow hatched box below.


It is however important to realize that the pectoralis major muscle is not a floating pad that is likely to create a blended soft breast, it is a muscle!!!  It is an important muscle that participates in most movements of daily life and arm stabilization.  As such it ALWAYS has tone unless we are sleeping or dead, thus like a rope pulled taught will quickly return to the shortest distance between its origination and insertion.  In the case of the pectoralis major muscle, this means the chest wall.  What does this mean for the implant?  Further downward and outward displacement as illustrated below:

Forces in the sub muscular or dual-plane breast augmentation technique lead to widening and inferolateral implant malposition.

The return of the muscle towards chest wall leads over time to an implant falling towards the armpit and down with a completely flat central and upper chest unless the patient is wearing a supporting and lifting garment.  Thus the flat superior pole, shelf like appearance of the top of the implant and the widely separated look has become the halmark “augmented” look until further progression of these forces over time cause a “rock in a sock look.”

The resulting “augmented look” is a narrow projecting breast accentuated by surrounding contrast of flatness

Now lets realize that although these features describe most augmentation results out there, most women are pretty happy with them.  Mostly they look good in clothes and the breasts are bigger.  Most women accept the rest.  I believe this is true because they are unaware of other options.

Lets again look at this in real life.  The patient below did not come to me for breast concerns.  She was a model and a facial aesthetics patient of mine.  One day she was in the office and said “its been almost two years since my breast augmentation can you take a look so I dont have to go back to my other surgeon.”  I of course obliged her.  When I examined her I told her that she had a good result for whats out there but in my practice I found the result to be unacceptable.  We discussed what I do and the aesthetics I try to obtain with a technique I developed called the Cold-Subfascial Breast AugmentationR.  The patient related that she changes in front of other models routinely and pretty much all of them look like she did.  She was however interested in a revision after seeing the typical results with Cold-Subfascial Breast Augmentation.  Revision from dual-plane or sub muscular is possible because the complete fascia is usually intact and window shades up with the muscle.  In revision the muscle is returned to its natural anatomic position and the fascia is used to support the implant.  I revised her and delivered a softer, more centralized and supported result as depicted below:

Breast Revision to Subfascial plane3
Revision of a dual-plane breast augmentation to a Cold-Subfascial Breast Augmentation
Breast Revision To Subfascial Plane
Revision of a dual-plane breast augmentation to a Cold-Subfascial Breast Augmentation

To understand the difference lets look at some more illustrations.  Overlying all muscles is a layer called fascia.  Fascia is strong connective tissue that condenses into tendons which allow muscles to concentrate force and pull.  It is the white stripe identified in cross section below.

The pectoral fascia used in subfascial breast augmentation

In Cold-Subfascial Breast Augmentation, I dissect the fascia away from the muscle, as depicted by the blue line below, lifting this structure intact to be used as a shaping and supporting structure for the breast augmentation.  The muscle itself stays preserved in its natural anatomic position.


I dissect the fascia to create essentially a supporting and shaping support bra inside the breast.  The dissection allows control over the placement and dimensions of the implant.


I place the implant depicted in blue inside this “sculpted support bra” to achieve soft sloping shapes.  I select low profile anatomically shaped implants to support the cause of creating a natural shape.  This allows me to achieve true superior pole fullness that appears soft and natural and also to create a “soft start” of the breast just next to midline.  The width afforded by lower profile devices also allows me to create the subtle projection of the breast just lateral to chest wall to create an elegant female silhuoette.


The small amount of subcutaneous tissue depicted in yellow tends to come up with the fascia redraping and achieving a soft teardrop like effect of a natural breast.

Creation of a natural appearing tear-drop shape in Cold-Subfascial Breast Augmentation

Lets compare this with what we know of subpectoral dual-plane augmentation.  Below we see the flattening effect of the pectoralis major muscle on a round projecting implant.  It creates the recognizable “augmented look” that I really don’t believe many women would chose if given a choice.

The flattening forces of the pectorals major muscle in dual-plane sub muscular breast augmentation leading to the fake, unnatural “augmented” look

If we contrast the different approaches in profile, we will see that conventional techniques(dark brown profile) and practices lead to a small focused projection(extra brown area) that is surrounded by contrasting flatness- the augmented look.  What I consider to be a more natural look, that of the Cold-Subfascial Breast Augmentation is a less projected(light brown profile) form that occupies the true aesthetic “real-estate” of the breast both centrally laterally and very importantly creating true superior pole fullness (light blue hatched area).


The secondary advantages of the subfascial plane are that the implant not only is free from the displacing forces of the pectoralis major muscle, but the axillary fold is also not altered.  When the pectoralis major muscle is cut in dual-plane augmenation the axillary fold rises creating what I call axillary breast disjunction.  This creates the appearance of a fatty collection near the armpit that bothers most women.  Having the muscle in its native position also prevents the distracting “muscle jumping” or muscular animation seen in dual plane breast augmentations when women move their arms.

COLD-SUBFASCIAL BREAST AUGMENTATION natural appearing results. The picture to the left exhibits naturally occurring pectoral-breast disjunction causing the appearance of loose fatty tissue near the armpit. Dula-plane techniques tend to exaggerate this by raising the axillary fold when the muscle is cut and lowering the appearance of the breast. The Cold-Subfascial result to the right demonstrates that by leaving the muscle in its native position and achieving true superior pole fullness the disjunction disappears.

I hope that thus far I have demonstrated that there is a dogmatically indoctrinated acceptance of sub muscular “augmented” looking breasts among surgeons and patients alike.  Now I would like to demonstrate how this conception and technique lends itself to selection of implants that can never deliver natural appearing results.

Consider the two implants below, which one is larger?


Contrasting appearance of a projection round 500mL implant that is most commonly used in breast augmentation and a low profile anatomically shaped 500mL implant used in Cold-Subfascial Breast Augmentation

You probably like most viewers out there picked the one on the left to be the larger one.  The fact is they are both the same exact size.  They are both 500mL implants.  The one on the left is the style most commonly used, the type of implant all plastic surgeons are trained to use in residency myself included.  They are round and projecting, pushing out on their own (see my blog entitled “the aesthetic evil of push”).  They look big because all the volume is concentrated on a small narrow base.  The implant on the right is an Allergan 410FM style implant, the line that I most commonly use which is the lowest profile anatomically shaped implant on the market.  It doesn’t appear to be huge because it has a much wider and taller footprint.  I select these because they allow me to fill out the true aesthetic dimensions of the breast.  You are probably thinking why the heck don’t more surgeons use these in light of what was discussed above and the answer is that they can’t.

Recall the illustration above demonstrating how the dissected muscle of the dual-plane technique limits how close the implant can get to midline.  This limits the width of the implant that can be used.  Similarly height is limited because the muscle will use additional height to push down further cramping the implant even lower in the inferior pole.  The restricted footprint of the dual-plane breast augmentation requires use of narrower shorter implants thus projection is turned to for increases in size.  Unfortunately the result is a breast that is aesthetically too narrow for the chest wall and overprotection that leads to more muscular force down and out.

One of the many beautiful aspects of subfascial breast augmentation is that the ideal aesthetic breast footprint can be created in most patients creating a harmonious shape that appears made by nature.

Alright so why doesn’t everyone perform subfascial breast augmentation?

There are many reasons perhaps most importantly is that it is not taught in training.  As a matter of fact in my training I was told that transaxillary breast augmentation was impossible with silicone implants, transaxillary revision was impossible and the subfascial plane does not exist.  All of these procedures are core elements of my current practice.  A true subfascial augmentation particularly transaxillary (through the armpit) takes a more advanced skill set.

Learn More About Cold Sub-fascial Breast Augmentation

Placing an implant under the muscle is very easy.  The plane between the pestoralis major muscle and the chest wall is what we call a “loose areolar plane.”  What this means is that it is a potential space, if you were to place a straw in this plane and blow it would instantly open up as it has no structures binding  it.  When a surgeon performs a sub muscular breast augmentation, a small hole is made in the muscle, a finger is inserted into this potential space and with a quick sweeping of the finger most of the dissection is completed.

There is no potential space between the pectoral fascia and the pectorals major muscle.  It is tightly bound.  Thus when a true subfascial fascia preserving technique is performed such as the Cold-Subfascial technique, there is meticulous dissection required.  I perform the entire procedure under direct visualization using lighted retractors and all sharp instruments like scalpel and facelift scissors.  It is a different beast.  It is very unlikey for a surgeon who has had years of success with a much easier procedure to adopt a more difficult one.

Another key feature to realize is that although strong, the pectoral fascia is very thin and laminar.  This means that if high power electrocautery is used in dissection much of the fascia is vaporized and if blunt dissection is used the fascia is delaminated and weakened.  I think this explains why so many with heavy general surgery mastectomy backgrounds will say that the fascia doesn’t exist, they are used to vaporizing it with high powered cautery in mastectomies.  This is one of many reasons why I developed the Cold-Subfascial technique.  The fascia itself is well studied with many anatomic dissections and structural characterizations in the published literature.

More on this to come in future blogs.  I hope that I have demonstrated why the augmented look exists and why it is so well tolerated.  More natural and beautiful results are attainable safely and efficaciously but is very unlikely to ever be mainstream.  Thanks for reading!  If you have questions or suggestions for future blogs I am all ears.  Drop a note through this website or the Facebook page.  Until next week…

Rian A. Maercks M.D.

The Maercks Institute

Aesthetic, Craniofacial and Reconstructive Plastic Surgery


Dr. Rian A. Maercks, aesthetics expert and Aesthetic Craniofacial and Reconstructive Plastic Surgeon





FDA Warnings on Soft Tissue Fillers and Devastating Complications

Why Does Everyone Look So Weird?

How the current FDA warnings will further encourage the creation of strange, dehumanized and puffy faces.

On May 28th the FDA issued an important warning regarding soft tissue fillers of all kinds and devastating adverse effects that have been reported (www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm448255.htm ).  These adverse outcomes all revolve around embolization which means the substance being injected enters a small artery  and blocks the downstream flow of blood resulting in death of the tissue that was fed by that blood supply.  In the most unfortunate cases the product embolizes the ophthalmic artery and leads to blockage of flow to the retina and blindness.  These events are extremely rare and usually are in a situation where dangerous technique is performed by a practitioner with inadequate training knowledge or experience.

Call (305) 328-8256 to schedule a consultation with Dr. Rian Maercks to learn more about safe injectable fillers.

This report is important as hopefully it will raise the public’s vigilance in selecting an appropriate plastic surgeon to perform their aesthetic procedures.  Unfortunately since economics lead industry to push these products into the hands of any practitioner that can legally administer them and marketing forces lead patients to believe it is acceptable to get aesthetic procedures completed by the practitioner that cares for your toes or teeth, this probably will not happen.  I drive by the below sign every morning on the way to work:



“Podiatry and Cosmetic Surgery” proudly signed on this building front.

In residency we used to say “if it was easy everyone would do it.”   Well the problem is that the public and practitioners now believe that it is easy so everyone is doing it.  Industry of course pushes this belief to maximize consumption of product in the spa at the dentist even the psychiatrists office or a visit to a physician assistant or nurse.  There is nothing easy about safely and effectively performing an aesthetically sound injectable procedure.

For the past five years this has been a daily part of my practice and it takes me 20 minutes to an hour to perform each procedure and I am concentrating fully the entire time.

The reality is that while importantly raising awareness to these outcomes, the ramifications will be even more unaesthetic results.  The reason is that the FDA is not suggesting that injectable procedures be performed by those well versed in the surgical anatomy of the face at all, instead it is warning:

“While unintentional injections into blood vessels may occur with injection sites anywhere on the face, the FDA’s review of literature disclaimer icon and adverse event reports submitted to the FDA identifies certain injection locations where blood vessel blockage have been reported more often. These sites include the skin between the eyebrows and nose (glabella), in and around the nose, forehead, and around the eyes (periorbital region).”

Why is this important?  Because all the areas that are indeed “danger zones” are the areas that need to be treated for aesthetically sound volumization and rejuvenation of the human face!  The area that is most commonly injected, the mid cheek, is very safe with low chances of any complication but creates “volume of age” and a “masked facies.”  The FDA is warning practitioners back into the mid cheek instead of trying to convey the truth that this stuff is not easy and takes knowledge judgement and skill.  Below are photos from Juvederm Volumas marketing and training campaigns:


This patient’s face looks fuller for sure, but definitely not prettier.  It looks like she might have gained thirty pounds but I would not say she is prettier.  This is the result of mid cheek injection.  The beauty of the mid cheek it that anyone can stick a needle here and inject away almost with impunity as far as safety and complications.  There is a relatively low density of blood vessels and they are all small.  This site never really bruises and can be a zero downtime injection site even with moderate volume.  This site is great for practitioners and industry alike, it is essentially fool proof and consistent.  It makes the product look really good as obvious complications are avoided.  It can be delivered by anyone after a one hour training by a pharmaceutical representative with a bachelors degree in communications.  Most patients see tighter appearing skin and fullness and  walk away satisfied and start their evolution to what I call “monkey face” or the golfball in the cheek look.  We will examine this progression further in the next blog.


The above illustrated guide to injection produced by Dr. Julius Few and used for Allergan’s training shows the low mid cheek injection sites that are prescribed.  All of which create a fat, “overfilled” looking face that becomes more monkey or lion-like

Most practitioners even some plastic surgeons are very hesitant to inject around the eyes and nose and for good reason!  Continued attention to these danger zones will push more and more injectors into the safety spot of the unaesthetic mid-cheek.  I will cover in the next blog how this reinforces what I call “volume of age.”

What should you, the patient-consumer take away from this warning?

Injectable procedures can be performed safely and effectively with wonderful aesthetic results, however most of the time they are not.  Success requires knowledge, skill, judgement and vision of the practitioner.  Even in the best hands an adverse outcome can happen.  Don’t trust your face, vision and health to a practitioner that cannot understand all the facets of anatomy, technique and art of aesthetics.

Rian A. Maercks M.D.

Aesthetic, Craniofacial and Reconstructive Surgery

The Maercks Institute



Why Botox and Dysport Are Not The Best Solutions for Wrinkles

In this edition of “Why does Everyone Look So Weird” I will explain why I do not think neuromodulators such as Botox and Dysport should have a significant place in aesthetic interventions and why you think they should.

You Paid for What?!?!


(By the way this is an image from Botox marketing campaign)

I personally have not been to a high society event or exclusive fashion show in years without seeing a wealthy socialite that I consider a victim of Botox or similar neuromodulator.  Shiny flat forehead skin with a disconcertingly unnatural v shape to the brows that have moved far away from each other and just a few strange lateral wrinkles.  Certainly not all administrations of neuromodulators result in this clown-like appearance but overzealous dosing and injection help demonstrate the extreme.  I must admit, I too have a loyal following for Botox and Dysport and I consistently deliver rests that are subtle aesthetic improvements.  Importantly, however, I always try to talk my patients out of it every time.  Lets’s take a look at why.

If I am going to inject neuromodulators into a patient’s face I am thinking of true aesthetic improvement and not just treating wrinkles.  Thus the goals of neuromodulators in the periorbita (the area around the eyes) is to cause the impression of laterally lifted brow while delivering the appearance of softness to the forehead.  In my practice I will use 50 units of Botox or 150u of Dysport for this intervention and charge the patient $850.  The delicate nuances of this intervention include artfully bridging the treated and untreated areas of the forehead and balancing the orbicularis oculi(the muscle around the eye) to allow lateral brow elevation.  Everyone understands this concept but very few are good at delivering a natural appearing result thus the splaying, dropping brow and sometimes startling “V-face.”  I will note here that I do not think it is possible to efficaciously deliver a balanced result with less than the dosage above and thus I think the ever so common 10-20u Botox treatment for a couple hundred bucks is a total waste of money that cannot yield aesthetic improvement.  I mention dosing and pricing above because I want to make an argument that everyone can relate to- financial feasibility.  If you are to keep a stable neuromodulated experience, you are going to pay about $850 every two to three months every year.  This can add up to five thousand dollars very quickly and two months later you have nothing to show for it.  Yes I think neuromodulators are a rip off but we will get back to this, lets talk aesthetics to understand why neuromodulators are just not a good answer for wrinkles anyway.

Take a second and think back to when you were thirteen years old.  Did you have crows feet?  Did you have the “elevens” that Botox marketing has focused our attention on, forehead creases?  The answer is clearly no.  Now lets consider the muscles that are routinely being paralyzed in the name of aesthetics.  Were your muscles of facial animation stronger or weaker when you were thirteen?  Well I hate to break it to you, they were stronger.  Now on a very basic level does it seen intuitive that the cause of wrinkles is excessive muscle activity or strength?  No of course not.  Why did you have stronger more active muscles but no wrinkles when you were thirteen?  Eureka! You had thicker more robust soft tissue and skin.  With age comes thinning of the skin and the subcutaneous soft tissues and our skin starts to exhibit wrinkles.  Ok so now the tough one, which sounds like a better treatment for wrinkles: #1 paralyzing weak muscles or #2 restoring the soft tissue of youth?

Before I get deeper into why option #2 makes so much sense given the amazing products and techniques that are available to us today, let me finish explaining why neuromodulators don’t really make sense.  In the best of hands there will always be some brow splay or separation which is almost always an aesthetic negative.  This can make people look quizzical or confused when extreme.  Secondly the relationship of the brow to the dorsal nasal lines of the nose is often disrupted.  Although no one really notices this consciously, these features make a big impact on the aesthetic judgement an observers brain creates before we have time to think.  Think about what I just wrote and look at the illustration above that is part of the Botox marketing kit.  Do you think that looks good?  I once again admit to getting very nice subtle results with neuromodulators, however this is not common with the masses of injectors out there.

Lets talk about long term effects and bang for the buck.  We have already established that neuromodulators are an expensive recurring cost with zero residual value.  To make things worse many people get less sensitive to them with time and they loose efficacy or require higher doses.  I commonly explain to patients that if they spend about what one year of neuromodulator maintanance costs( approximately $5000) once on the proper treatment they will have a tremendous aesthetic improvement for years to come without the necessary upkeep.

So what is the proper treatment?  In my opinion it is expert application of hyaluronic acid(HA) based fillers, i.e. Juvederm, Perlane, Restylane.  I will also note that the technique and applications that I employ and describe are NOT FDA indications.  I will also note that in my opinion ALL FDA indicated uses for fillers are not aesthetically sound.  We should also note that the FDA just released a statement warning about the use of fillers in exactly the areas I place them daily with warnings of tissue loss and blindness.  This is something patients need to be aware of and another reason to pick your injector very carefully.  I perform this type of injection daily in my practice and have been doing so for about five years with no such outcomes but it requires care thoughtfulness and meticulous technique.

Now back to why HA fillers are a godsend.  It just turns out that much of our body is made up of HA and there is no allergy to it.  Now it gets even better.  Stem cells, although marketed to be all kind of things they are not , are actually present all over your body.  They are all over the microvasculature of your face waiting to be called on in injury to heal and other functions that we honestly do not understand.  These stem cells actually have a special cell surface receptor that binds… you guessed it, HA.  The receptor signals activation causing the stem cell to make vascular tissue, a process called angiogenisis.  The HA fillers listed above are actually long chains of repeating HA and as they degrade, are constantly releasing HA monomers.  These individual pieces of HA can bind and activate local stem cells telling your body to make new healthy vascular tissue( very different from the destructive inflammatory scarring caused by other products such as sculptra radiesse and others but that’s for another blog).  When these fillers are applied with special techniques such as what I call “Aesthetic Facial Balancing” in my practice, the aesthetic benefits last years and years not the 6-9 months we are told.  When they are gone they can leave behind healthier more robust tissue than was present before.

“But wait what about my wrinkles?”

Yes.  The wrinkles.  It is no secret that I don’t think wrinkles are very significant aesthetic problems, but yes they go away.  I usually try to reorient patients that come to me seeking neuromodulators towards aesthetic facial balancing primarily of the periorbita (area around the eyes).  The reason is severalfold.  Most patients benefit most from having this region rebalanced as we start loosing significant high malar soft tissue as early as the late teens and early twenties.  We start noticing bags or tired eyes.  Aesthetic Facial Balancing of the periorbita creates a lifted appearance of the cheek and brow and hides the bags.  As what I consider a side effect it also treats the wrinkles and crows feet that originally leads the neuromodulator seeking patient into my office.  Thus when I am successful in reorienting a patient, they walk away not just with their wrinkles treated(the right way), but they also walk away with a face that glows and appears healthier, happier and usually more than a decade younger.  There is no need to rush back for a repeat but I will note that most patients love the results so much they are eager for further refinements.  When you treat the actual problem a natural appearing and lasting result can be produced.

I will add one more note on the prolonged use of neurotoxins that no one wants to talk about, particularly relevant to patients with the dramatic V-deformity I referred to at the beginning of this blog.  Neuromodulators work by poisoning the neuromuscular junction(NMJ), where a nerve signal is turned into a muscle action.  Basic muscle physiology and maintenance requires intact NMJs and some stimulation.  A muscle with a cut nerve for example will quickly atrophy and pretty much disappear into a layer of fibrous tissue.  Chemodenervation, blocking the NMJ with neuromodulators, does the same thing.  Thus with long term use the subtle negative effects of brow splay and malposition can worsen and worsen leaving permanent deformity.

I encourage people to try to undo the brainwashing we have all gone through that glabellar wrinkles coined the “elevens” and crows feet are the most important features that affect our aesthetics.  They are not.  Its the big picture, the shapes of the facial features and how they relate.  There is no time to analyze wrinkles in the less than 300 milliseconds that a human brain uses to generate and aesthetic opinion.

In summary neuromodulators are very powerful drugs with some great uses, however, they are not the right choice for most people with aesthetic concerns and wrinkles.  I personally treat my neck and back pain routinely with neuromodulators, they work phenomenally well for trigger points and pain.  Restoring healthy soft tissue in an anatomically relevant and aesthetically sound fashion not only saves you money in the long run but it improves the health of your facial soft tissues can render a very significant aesthetic improvement….and it may just keep you from looking weird if you pick the right practitioner!

Rian A. Maercks M.D.

Aesthetic, Craniofacial and Reconstructive Surgery

The Maercks Institute