Nancy Samolitis, MD

When I evaluate a patient for using fillers, I think the most important thing to do is to take into account the entire face.  A lot of injectors will put some filler (Juvederm, in your case) under the eyes or in the cheeks, but will completely ignore many other signs of aging.  When this happens, a person can look unnatural or "partially overfilled" because other areas were ignored.  Because of your age and weight, you have lost a lot of overall facial volume including in the temple area, the lateral face in front of the ear, the browbone, and the lower jaw.  Since the filler was only placed in your mid-face area, it appears overfilled in comparison to the neglected areas.  Continuing to fill those areas is not the answer!  In order to make a person appear more youthful, all of these areas need to be addressed equally.  Many injectors do this with Sculptra because the results are gradual and it can be used over large areas at a relatively lower cost.  It is also longer lasting.  Similar results can be achieved with other fillers if the procedure is done by a skilled injector. 

Melasma is a very complicated and chronic type of skin pigmentation.  It is more common in women and particularly in people with skin that is dark or tans easily.  It can be exacerbated by pregnancy, birth control pills, heat, and especially sun exposure.  Laser can be useful, but I don't consider it the treatment of choice for melasma.  Due to the mechanism of action of each of the lasers, I feel that Fraxel is a better treatment option compared to IPL; however, there is a risk of worsening of melasma with any type of laser therapy.  My approach to treating melasma is to use daily sun protection with a chemical-free sunscreen such as zinc, a bleaching cream or combination of bleaching creams with retinoids and/or other exfoliators as tolerated, and chemical peels.  As I mentioned, melasma is a chronic condition and can not be cured by a simple procedure.  It requires maintenance to keep it under control.  All of these treatments should be supervised by a dermatologist. 

When Sculptra is injected properly, it needs to be mixed with a large amount of water and lidocaine.  The actual Sculptra molecule is a very small particle that requires hydration with sterile water.  If more water is used (usually at least 6-10 cc per vial), there is a lower risk of developing lumps.  Immediately after the injection, you can see the effect of filling with the water which usually is a more "bloated" appearance than the ultimate result you will get with new collagen production that gradually occurs with Sculptra.  You may have also had some reactive swelling as can occur after any type of injection.  If you have any concerns about being overfilled, I would recommend waiting 2 or 3 months between treatments so you can be sure you are seeing the full effect of each treatment before having another injection. 

Retin-A and Atralin both contain the same ingredient (tretinoin).  If you are using both of them, that may be too irritating to the delicate skin around the eyes.  Many people can tolerate a lower strength tretinoin, such as 0.02%, around the eyes.  If not, an over the counter retinol is the next best thing.  It can take up to 6 months to see improvement of wrinkles with topical retinoids.  Studies have shown an increase in collagen thickness with long term use of these products.  Some people do look worse before they look better because you can get an initial dryness and peeling as your skin gets used to the increased cell turnover for up to 6 weeks.  If this is tolerable, you can add a hydrating eye cream applied twice a day.  If you skin is red or itchy, you should stop using the product and consult your dermatologist to prescribe the correct strength for you. 

We now have a number of hyaluronic acid (HA) fillers to choose from in the U.S. and there are likely many more to come.  Each of them has their own unique qualities that affect the injection technique, results, and longevity.  The longevity of a particular filler can be variable depending on the area that was treated, the amount that was injected, and the person that it was injected into.  Essentially, there are not necessarily any rules about how long the filler will last.  Most of the HA fillers last at least 6 months, but many of them can last for a year or longer.  For example, if you inject a very small amount of a small-particle HA (such as Restylane) into a dynamic area such as the lips or around the mouth, it will wear off faster than if you injected a larger amount of the same filler in a less dynamic area such as the tear troughs or cheeks.  The bottom line is that you should allow the physician (a board-certified dermatologist or plastic surgeon) to choose which filler is the best option for your skin type and your needs.  Luckily, if you don't love the results, the HA fillers can be dissolved with hyaluronidase and corrected very quickly.