Restylane For Under Eye Volume Restoration & Facial Augmentation

I first sought treatment for under eye hollows with Sculptra® in November of 2004 and again for my second treatment and also to nasolabials in February of 2005. It lasted for about 18 months and since I had developed a nodule from the Sculptra®, I decided to try a product which I felt had less possible complications, Restylane. So August 30, 2006 I had my first Restylane® under eye injections with Jonathan Hoenig, M.D. in Beverly Hills, California. Incidentally the video to the right was from a treatment in September of 2009.

Watch Video

I also would be treated with 5FU injections (8/2006) to correct the scar tissue between my left cheek and under eye from the fat grafting procedure I had in 2004. Granted, I had the demarcation prior to any facial procedures, but the fat grafting seemed to accentuate it.

What Is Restylane®?
Restylane is made from non-animal hyaluronic acid gel and is my product of choice for the lips and under eye hollows . Restylane contains 20 mg/ml stabilized hyaluronic acid which contains approximately 100,000 gel particles per ml.

Indications For Restylane®

"Restylane is indicated for mid-to-deep dermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds."

[Restylane Product Sheet - http://www.medicis.com/products/pi/pi_restylane.pdf ]

However, doctors may legally use the product off-label for soft tissue augmentation in other areas of the face which are not depressed, such as for cheek and lip augmentation.

Am I A Candidate For Restylane®?
Patients must be in good health, not have an auto-immune or wound healing disorders, and also have realistic expectations. Although Restylane is an injectable filler, and considered less invasive, anesthetics may be used and there are inherent risks of any procedure including allergic reactions to the anesthetics or infection. Please read the risks section.

Preparing For Your Restylane® Treatment
You should refrain from any irritating topical medications or products (such as tretinoin [Retin A], TCA, glycolics, lactic acid peels, etc. before your treatment. If you really don't want to bruise, you should also cease consuming aspirin and vitamin E for 2 weeks before your treatment. This will assist in lessening your chances of bleeding and bruising. If you take Coumadin you should more than likely continue taking your meds as ceasing to do so can be life threatening. Just be sure to let your physician know.

What To Expect At Your Restylane® Consultation
After having chosen a doctor to possibly inject your Restylane, you will schedule a consultation appointment. This meeting is designed for you and your surgeon to discuss the procedure, its risks, and see before and after photos. Experience with injecting Restylane under the eyes or elsewhere is very important so please determine the amount of patients and injections the doctor has performed before choosing to undergo the procedure.

The doctor will examine your skin and ask you which areas of your face you feel need correction as well as offer where he or she feels you would benefit from Restylane injections. After discussing your medical history, your doctor will then determine if you are a good candidate for the treatment.

If you have decided that the doctor is the one for your treatment, you will more than likely have your procedure that very same day. If so, you will be asked to sign more paperwork, which may include an informed consent sheet explaining the risks of the procedure.

How Restylane® Treatments Are Performed
Having Restylane injected can cause discomfort so an anesthetic, although not necessary, can be used to alleviate this. A topical anesthetic such as EMLA is commonly used in sensitive areas, although your doctor may instead choose a regional anesthetic (shots of local anesthetic into a nerve cluster that supplies the treatment area). The injection of local anesthetics to the treatment area prior to Restylane injections is not recommended due to the distortion it can cause which will interfere with judgment in product placement. I had a topical anesthetic because I was also getting Radiesse injections to my cheeks. Needless to say the topical anesthetic was very welcomed! The undereye area is very sensitive so I would be surprised if a patient chose no anesthetic at all.

If you chose to have an topical anesthetic or regional anesthetic, your doctor will wait until you are sufficiently anesthetized. Your surgeon will gently tap on the treatment area and feel the skin between his or her fingers and then carefully inject Restylane in the undereye area, or under the folds or whatever area you are having treated. The surgeon will release pressure on the plunger as he removes the needle so that no product is accidentally injected near the skin's surface. Your doctor will gently tap and feel the area to determine where more is needed and lightly press or massage if necessary.


Right under eye injections	Left under eye injections


Checking for under eye hollows during facial animation	Upright, with shades open to determine shadowing


looking in mirror at nasolabial	Slight nasolabial correction

I had just had Radiesse® injected into my cheeks before having Restylane® injected into my undereye area and nasolabials.

The Road To Recovery
You may have swelling at first but it should subside in under a week. Although you may like the swelling as it smoothes out wrinkles. You may also have bruising. Be sure to keep the treatment area out of the sun and to wear a good sunblock.

You may need a touch up treatment in about 2 weeks once the swelling has completely dissipated. To maintain your results, treatments are repeated approximately every 4 to 6 months. Read My First Restylane Under Eyes Journal.

When I first started getting Restylane, it only lasted about 3 to 4 months, but with repeat injections I have found that I only need it once a year, no more than twice a year. Although I do notice that the augmentation diminishes gradually over about 9 months, the dissipation is far less pronounced than before. Ideally I would get injections twice a year to maintain a constant level of augmentation, obviously requiring less on this schedule than if I were to wait the full year. Also, I had one injection in the upper eyelid years ago and now I am finally due for a touch up (3 years!).

Injection site lumping has been reported to occur in the lips (which I have experienced) but it diminishes within a few days. Although reports of the Tyndall effect (Tyndall light scattering, a bluish hue to the skin after injection) have been made, I have not experienced this since having Perlane in my lips.

Risks & Complications Of Restylane®
Common side effects are slight swelling and bruising. Rare complications include hematoma, seroma, infection, possible skin necrosis if injected into a blood vessel, hyperpigmentation from bruising, and prolonged abnormal inflammation.

The below info is from the Restylane® Product Sheet on the Medicis website.

Contraindications

Restylane is contraindicated for patients with severe allergies manifested by a history of anaphylaxis or history or presence of multiple severe allergies.
Restylane contains trace amounts of gram positive bacterial proteins, and is contraindicated for patients with a history of allergies to such material.
Restylane is contraindicated for patients with bleeding disorders.
Restylane is contraindicated for implantation in anatomical spaces other than the dermis.

Warnings

Defer use of Restylane at specific sites in which an active inflammatory process (skin eruptions such as cysts, pimples, rashes, or hives) or infection is present until the process has been controlled.
Injection site reactions (e.g., swelling, redness, tenderness, or pain) to Restylane have been observed as consisting mainly of short-term minor or moderate inflammatory symptoms starting early after treatment and with less than 7 days duration. Refer to the adverse experiences section for details.
Restylane must not be implanted into blood vessels. Localized superficial necrosis may occur after injection in or near dermal vessels, such as the glabellar area. It is thought to result from the injury, obstruction, or compromise of blood vessels.
Delayed onset inflammatory papules have been reported following the use of dermal fillers. Inflammatory papules that may occur rarely should be considered and treated as a soft tissue infection.

[Restylane® Product Sheet http://www.medicis.com/products/pi/pi_restylane.pdf]

The Average Prices Of Restylane®
The average cost of Restylane is approximately $300 to $500 per syringe.

My Personal Opinion: Comparing Sculptra®, Fat Grafting and Restylane®
I have had Sculptra, Fat Grafting (Twice) along the sub-orbital bone, and Restylane® to my under eye area and I must say that overall, I prefer the convenience, the smoothness and immediate satisfaction that I goe from Restylane.

Sculptra®: In retrospect, I DO like how it thickened the dermis, filled out lines and decreased the visibility of the under eye vascularity. It actually made the skin thicker so that the veins did not show through as well. Unfortunately, Sculptra may not be the best for the under eye area. I feel that the benefits versus the risk of palpable nodules in the under eye area is not worth it considering the other products and procedures which are out there now. I feel that it is nice for cheeks and the buccal area (lower, sunken in area of the face) however, but I am very impatient and 6 weeks per treatment with gradual augmentation just isn't what I want out of a product. This is just my personal experience.
Fat Grafting: I feel that fat grafting, although nice, smooth and natural (and I LOVED the slight, post-operative swelling I had even after 6 weeks, it just doesn't last as long. Plus fat transfer requires a donor site and also I felt that I did have scar tissue from the placement of the fat. I do realize that today, with the use of your own stem cells, the fat graft can have a better chance of survival so this is promising for future endeavors.

Restylane®: I do prefer Restylane® for the undereye area (and also for my lips and anywhere else on my face my doctor is willing to inject it!). It gets an A in my book. Incidentally, I also like Juvederm® in my nasolabials.

Product and Procedure Comparison Based Upon My Own Experience

Product	Mechanism	FDA approved	Discomfort	Longevity	Cost	Would get again?
Sculptra®	Catalyst	Y	suggest regional anesthetic and/or topical	18 months	$900	Maybe
Fat Grafting x 2	Filler	N/A	suggest sedation	6 months	$2,500	Maybe
Restylane®	Filler	Y	suggest topical anesthetic	5+ months	$400	Y

The Least You Need To Know

What: Restylane is an injectable filler comprised of 20 mg/ml stabilized hyaluronic acid which contains approximately 100,000 gel particles per ml.
Made by: Q-med (licensed by Medicis Pharmaceutical Corp in the US), which is possibly being acquired by Galderma (2011)
Indications: FDA approved for moderate to severe facial wrinkles and soft tissue depressions.
Good for: Glabella, Nasolabials, Cheek Augmentation, Chin Augmentation, Lip Augmentation, Under Eyes, Buccal area augmentation.
Not recommended for: Fine lines, although Restylane Fine Line® is appropriate for this application
Does it hurt? I think so, However, relief can be given by using a topical anesthetic, which is what I do) or regional anesthetic injection (nerve block).
Risks: Infection, Hyperpigmentations from bruising, hematoma, palpable nodules, Tyndall effect (Tyndall light scattering) which is a bluish hue observed when injected in thin-skinned areas.
Recovery time: Swelling can last up to a week, however most visible swelling subsides within 3 days. Bruising can be apparent for a few weeks, depending upon how you tend to bruise as an individual and the area in which it is injected. Bruising tends to last for me under the eyes and I rarely bruise in the lip or cheek area.
Cost: $300 to $500 per
How Long Does it Last? 3 to 9 months, with natural tissue formation occurring from repeat injections.

How Patients Rate This Procedure

References
Interview with Dr. Jonathan Hoenig
Interview with Danya Hoenig, P.A.
Personal Treatment Experiences
Restylane® Product Sheet http://www.medicis.com/products/pi/pi_restylane.pdf