Webinar 8: Injectables

Board-Certified Plastic Surgeon, Dr. Kevin Tehrani is here to answer everything you need to know about plastic surgery and more in his latest segment called #TehraniTalks – During Quarantine. Injectables are one of the many non-surgical treatments we do here at APS. Think: Botox, fillers and more! Dr. Tehrani break down each injectable, discusses what makes them different, and who would be the best fit for which.



Transcript:



(00:00): Hello everyone. We’re starting this afternoon. This is a good sunny afternoon talking about some injectables. As the quarantine is getting closer to being over one and a half offices open we’re having a lot of requests for pent up demand for patients that are looking for having injectables. And I want to take a few minutes to discuss different injectables that we have and some of the nuances and differences between them and also talking about how some people are better candidates for one versus the other. And also really discussing some of the smaller differences between some of the injectables. We in the U S have a almost clean less than 20 injectables that are FDA approved for different uses. Whereas different countries like in Europe and South America have to things along the lines of about 40 to 45 different injectables available.

(01:07): So in a way, the stringent requirements of the FDA has for us to push, push injectables through the FDA process is good for consumers and actually good for practitioners as well because there’s a lot of needs. Who type injectables out there that are not necessarily better than the next one. And it’s a, and as you will see and I’ll discuss is more about power of the injector than the actual process and the product itself. So a, we’ll talk about some of those smaller things as well. So a lot of them are what we do and a lot of what we patients who requests has to do with what other celebrities and what social media personnel I’ve had done and you know, everybody equates Kylie Jenner lips, nose nasal labial folds and obviously those are, are all things that we get as a practitioner asks about all the time.

(02:12): Angelina Jolie’s lives into, for Kylie Jenner where the most commonly asked injectable profile in our offices here you have Haley who again, these are younger patients, they already haven’t got a canal tummy. And the small subtle differences without anybody really noticing, unless you’re on the spotlight is what injectables all of about. And you’re not going to have big facelift type volumes, even though there are some things that we can do with that. For most part, there are subtle small differences, which is what’s ideal that in daffodils. So first I want to talk about neuromodulators otherwise known as the toxins. Toxins sound a little scary, but right now the FDA approved are for injectables, Botox cosmetic here, which is the main contender in the neuromodulators market. They still have the largest market share. And in our practice that’s the majority of the injections we do is Botox.

(03:17): It’s all more than 15 years now, FDA approved and do remember FDA approval for on label use for some of these products could just be the 11 lines or they’re not, even if we do CrossFit injections with them, that’s considered an off label if appropriate. But off label use of a neurotoxin like Botox after rule talks, we actually have Xeomin which came on at this point approximately six or seven years ago. And then this board was was actually before Xeomin and the newest one Chabot, which is otherwise hashtag new talks cause they knew what’s the one now in the market. And then if you look at all these names, they’ll start with owner botulinum toxin pro budget on and toxin in co marshland and toxin. Those are all botulinum toxins. All of the active ingredient.

(04:14): And what works is botulinum toxin, some of the fourteens or a little bit that difference. As a matter of fact, Xeomin is the only one that’s considered in nature and botulinum toxin. So for some patients it works better on the other, for example, there’s small, small nuances. This for is it does spread a bit more. So I prefer that for male foreheads that we have a larger area for, for headaches that could be relaxed better with a product like this for. But we’ll talk to so we can go to in some patients ideal world would be trying to have the injectables last and that was six months. So he ended up needing to have it done twice a year as opposed to three or four times a year. And some, sometimes it means changing from Botox or Dysport or you will during the process to see if we get that kind of a longevity.

(05:06): So education is different and we’re trying to do that. So what areas can we inject with the neurotoxins? I’m going to start with the bottom. We can start to enjoy, I think that flex has more bands and the next we can inject the lips, very oral lines. Chin, we can inject, we can inject that around the nose a little bit. Funny lines. The Globo lines, which is the area that is actually the most commonly injected around the crow’s feet. And of course there four had to be injected in other areas that we can use it for is a boudin draw a line or the TMJ muscles. Some, some people have flights full of jawline and we’ll show you some examples of that. And those areas can really be improved with both tasks. I’m going to just use bullets astronomically cause that’s the one that we use the most often and everybody relates to the them.

(05:53): So this is a patient that we’re going to talk about Botox. She add full angry look or ripples. She has these deep lines. Obviously aging has something to do with that, but it’s also rad, a kind of conveying gate, his smile, prettier, less angry face. And there’s actually a study that showed it actually makes you feel better to have the Botox injections. Not necessarily because you look better, but because the whole idea when you smile they actually feel better internally. Botox is the exact opposite or that just the muscle frowning is not there anymore, which is critical. And it also can be used for headaches. And that’s another Botox. Cosmetic use actually is a Botox cause medication is what I use. But neurologists use it. Botox with different reasons for actual headaches. And as a side effect, management look better and depending on where it’s subjective.

(06:52): So this is the masseter muscle. This is a patient similar off label use that we talk to them about. As you can see, she’s very young. She’s pretty, but she has more of a boxy look in front of it. And by injecting Botox in that area, we can soften that up and make her look a lot better. And it’d be a more of a, a feminizing look there you will, very similar otherwise known as a new tax. It’s the newest one that’s available in the market right now. This is innovation on relaxed lines and looks better. And the other thing that all reasons and injectables is it’s not a bad freezing. The fourth most common thing that I hear from patients is I don’t want to be frozen. There are a few patients that do want to be frozen.

(07:38): I always we can do it, but it’s not my recommendation in general that frozen look is not a nice one. One, a nice natural reduction. You’ll still have animation. You’ll be able to work and, and, and discuss and have you need some anatomy to be able to convey messages facially, especially now that we have all bases covered. So we don’t want to completely eliminate all lines and it’s about how it’s injected to be able to show you that. Mmm. Difference. Xeomin similar to a Botox injections as I see with her forehead raised, she has quite a few wrinkles and then she doesn’t have to having it done. Now the other thing that is interesting with the different neurotoxin is how quickly they take effect. For example, Dysport and Xeomin data probably abandon day earlier than Botox does.

(08:38): Now, one of the newest ones, a Xeomin as you will that’s been started actually is the fastest passing one. It doesn’t mean necessarily that lasts longer for patients that have had it done and each patient is an individual, some of them are last longer rather. But, and those are the things that we try to do in the office and basically tailor each in each individual patient. This court is the one that has to be most interesting dosing unit and dosing in it for dysphoria is a little bit different than Botox than Xeomin the initial vote in that it’s not one, two, one, three, two, one. And for that your injector needs to be very advanced to be able to do that injection differently. And that’s, that’s one of the things that I really like to do in men.

(09:26): So in men likely to spread more and get into the last little bit longer from an in. And that’s what the main reason is that I use this word. They always talk about that injectable fillers. Injectable fillers are in the category of bio active or ones that actually make your own body building collagen and also kind of passive. And that passive variety is the most commonly ones used. And those are the Juvederm is the restaurants, the verses. And those are the ones that you hear about the most and they’re quite passive. They do not make your body significantly a build collagen around where it’s injected. They just have somebody sitting in there and they slowly get absorbed with what’s called hyaluronidase, which is a normal enzyme that’s found in your, in everyone’s body. And depending on where it’s injected and that’s the last longer or less time.

(10:22): So I’m going to go through those different injection injections with cereals and kind of key studies or patients that are hiding. So where do we inject disease? Some have long label use off label use of different areas. But in general forehead lines, brow lines, funny lines around the nose and nose itself for nonsurgical rhinoplasty cheese folds. Initially when these are oil falls, we’re the only places that we got FDA approved for, for like wrestle and for example, which one of the first ones that came out this is where we injected the most, but now we’re injecting chiefs a lot, draw a line, chin and obviously elsewhere in the body as indicator doesn’t off label use. We could have these fillers objective. So Jupiter on juvenile from the Allagash family comes in different kind of thicknesses and in different areas that we inject different things as a product.

(11:22): Voluma, which is the one thing that’s the thickest one. We inject in the cheeks and locally I inject it and install line in the mandibles. And that’s the one that has a two year longterm resolve, which isn’t the sickest one. From that we go down to ultra plus, which is a for an advanced injections or somebody who’s had multiple little injections, one, one to have the longest lasting resolve in injections for after those in the limps. That’s the old surplus. Ultra is kind of in between valorem will. Bella the sinister, what’s the long lasting? Bobby misers in the juvenile family and those are typically used in the nasal labial falls. Laura eyelids, one of my favorites is Volbella in the lower eyelids, a half syringe and tiny little difference. We’ll show you some of those examples for on Jupiter. So I’m going to play a quick video of a, where we having a Valore and a Bella injected lips.

(12:45): So you will see her before and after. And I’m going a little bit coming up. Obviously if we don’t do all of that as fast as it was shown. But bottom line that this patient, it was the fact that we injected quite a few areas. She is younger already, so this is not the bad making you look younger. It’s about rejuvinating the areas that you have or enhancing those areas. So basically she had a very, she’s injected with well for Luma. We also did some a nasal labial falls and that’s for lore and Marion airlines as QC. It’s much softer. Of course we injected her lips and I mean I gave him some volume and more voluptuous and she was great and a lot of these will last six, eight months quite a bit of of a long time.

(13:29): Now this is all hyaluronic acid so far. So want to talk about one of the advantages of hyaluronic acid, which is it is completely reversible if you want to reverse. Most very rare that we have to use that, but as a medication called hyaluronic acid, that can be injected to love the product away, similar to how your own body a muscle product away. So we can advance that. And it’s reversible for kind of a something to have in the back that you mind just in case you need it. One of the most common places that we inject fillers okays Malore or a lower eyelids. So one of the things that can happen to somebody really young liker is genetically speaking, she can have lower eyelids that make her look kind of like having bags in the lower eyelids. And that’s not an aesthetic look.

(14:19): And having small amounts of allure or Volbella in this area is how we get to this kind of an after results. We have minimal, a couple of days of swelling or a very minimal tooth boozing if that does happen. Of course. Non-Surgical, rhinoplasties and other important aspects of of injectables. And that’s typically done with thicker injectables like Juvederm ultra or short class. And by shaping the nose and giving support to the tip, you can have about a year improvement in nasal console without surgery. And that’s a, that’s a really nice option for patients that don’t want to undergo a rhinoplasty surgically. Certainly the most common place that we use hyaluronic acid after nasal legal forwards is limps. This is a patient that wanted a full injection ultra plus like seeing her lips nice pout and a fuller lips that will last close to eight months to a year.

(15:23): And that’s a nice thing about Jewish cultural plus restaurant family. Wasn’t a market leader in hyaluronic acids and on wrestling initially came out as a regular wrestling and then followed by wrestling and self wrestling lifts, which we used to be called curling is the almost like, you know, equivalent of a Voluma and that we could use it. Then there is the restaurant define and refine the different cohesiveness and the newest one was just called restaurant kiss that was just FDA approved. And for lips it has an in nicest double balance of having longevity at the same time, no lumps. And it’s a nice smooth product which is a really nice addition to the rest of the family. Also hyaluronic acids also completely reversible.

(16:16): So this is a wrestling silk patient having injected in around the lips. The rest of the sub wasn’t a go to for lips before the kiss came out. And now I even prefer to kiss over some because swelling and and bruising is significantly less with wrestling kiss than was with wrestling stock. This is a restaurant to land nasal labial folds and sheets for this patient. As you can see, she is young already, but those deeper lines make her look a little bit I’m older than she probably is, so it’s better to soften those up gently and early on. Certainly can a new jet flips with kiss, which is the nicest product for this area appropriately named. And last results are six to eight months, which is a really nice longevity for a product that is not fake at all.

(17:18): Yeah. We’re going to define and refine our ones that I prefer for nasal labial folds, for peri oral lines, similar to Valora and and Volbella for in the Allegan family or have a hyaluronic acid. So occasionally and very rarely having patients that are sensitive to some of these medications. So it’s really nice for us to be able to have options. And your office basically, we have all the options that we talk about. I mean, Jason, we invest in the market right now. We have in our office and it’s something that I like to provide to patients. So you have options for, you’re not kind of a honed into one or two products.

(17:59): It doesn’t define as you can see, there’s some well we call it secondary smile lines around the the mouth and the sheets and softening those off in small little injections will definitely help. Versa is, I’m not from the Allegan family and not from the restaurant. Family is its own thing and it’s the hyaluronic acid that is available for the pocket conscious. So it’s the newest one that’s out there besides the restaurant case. And the best thing about it is the fact that you don’t have some big company that’s behind it and we’re able to offer it to patients that are a price conscious. And this is a really nice option for lives. For nasal labial folds. It doesn’t last as long as some of the other ones, but again, it’s very individual. I’ve had patients that this lasted eight, nine months and so it’s we can always I have this as an alternative for patients that want to try that.

(19:04): And that’s a really nice product for wimps for me as a labor falls for even cheese. I particularly don’t like it for low eyelids though cause it’s a little too thick for that area. So, and that’s, that’s the option of having different injectables available for different areas. Radius is the first product that you are talking about in terms of injections is not the hyaluronic acid. This is a Calvin calcium hydroxy product the Titans product, which is bioactive. So this is the first product that actually builds your own column. And so all of these products that we kind of talk about that builds your own collagen mean that they’re going to last longer. So for longevity, these are really nice products. I know we have a picture of a hand, which looks great in this area of on label use for a rainy as to inject it and hands.

(19:54): But the most common place that I inject radius is actually your cheeks. So the mailer area, and one of my favorite things about radius is the fact that the one syringe is 1.5 CCS, which kind of is like the perfect amount for most people’s folds and a nasal labial area. And that’s one of my go to injectables for cheeks. So it’s a really nice product. It builds collagen, it’s injected deeper so that you don’t see it at all. It’s a kind of a white substance or engine needs to be injected deeper and in both college. And so last, last a long time. So it was a very common that I start injecting this maybe once every other year or sometimes every two years. So it’s a really good guy. Injectable four G’s hands, nasal labial folds, not grateful lips, not grateful or eyelids.

(20:46): Oh, great. For nose. Non-Surgical rhinoplasty is a really good option for people that have tried the hydronic acid and not want something that’s a little bit longer lasting sculpture. Here we have a picture of a of a button. Scott is a really good volumizer. The best thing, the best culture is the fact that we can inject it in the chiefs nasal labial folds. For somebody who needs a lot of volume. One vial of sculpture could be six to nine CCS, which is quite a bit. So it was part of the reason why we actually injected moot in a patient’s BOM or head of dibs because in volume you need quite a bit of volume in that area. So would the typical injection for Sculptra, which is again another bioactive which makes somebody go college, is an injection two months and partner for three sessions.

(21:43): So you need about a six vial commitment to be able to get back to number resolve that lasts approximately two to two and a half years. So it’s long lasting because of the builds collagen, you can inject it everywhere. I’ve injected in breasts, I’ve injected in, in products, certainly the most common areas injected is chief’s temple area. And of course elsewhere in the body, the longest lasting injection that’s out there and be improved is one called Bellefonte. So Phil has a five year FDA shelf indication as indication for nasal labial full soft tissues of the face and acne scars. It is made of [inaudible], which is microscopic, tiny little classic visas, what it is and needs to be injected by a master injector and eat chemicals. Nodules if you don’t inject it right. So it’s not for somebody who’s just having injections done the first time is for somebody who’s had multiple injections and before we need to actually test you for it, wait a month, make sure your knowledge into it and it gives you very lost long lasting results. Five years plus. And as far as I’m concerned, some of that actually is a pretty permanent, I’ve have it in my own face, so it’s a nice product injection deep and you will not feel it. But it gives you a really nice longevity.

(23:05): Bella is another injectable category and that’s a category of fat. Resolvers Kybella is one. Before Kybella we had lipos stable, which is actually the active ingredient in Kybella injections. A few sessions of injections four to six weeks for product FDA approved now for necklines fullness. So we injected like this patient has seen her jawline and line has improved quite a bit in having these injections sessions done. Are there areas that we injected? Is the broader role in this area to be injected in the arms? Can immunization and the size in our advice for small areas of reduction is a really nice injection. It’s not a surgical result, but it’s a nice injection. After about three sessions of having the procedure doc, another new area that I really like in Jackson, Kybella is for people that don’t have a whole lot of loose skin but have a lower eyelid and bulge.

(24:05): So the ones that have bulges, you don’t necessarily want to camouflage by adding volume in that area. Now you’re trying to remove some of that fat. So this is her after having three sessions of Kybella in her lower eyelids is kind of a little a compartment. The nicest thing about cradle is what’s been removed is permanently gone. So you don’t have to keep doing it. Once you get to the resolve that you like you’re done that what’s that’s been permanently reduced. Soul’s fossils are gone forever. And that’s a really nice thing about highball ACL is an off label use of a product, which is a cellular matrix that derives from pixels that allow your own body to bring products like STEM cells to the area. Have one, we have it for PRP injections in the scalp. I occasionally injection injected in the hip tips like for the bum like sculpture that I showed you a picture of earlier. Also in small irregularities after liposuction or around the breasts where patient’s own fat either is not available or if it is available, it requires them to be operating on a cell that does not. So was a really nice long lasting alternative for patients that don’t have the own fat or a once a magical results like this gentleman’s hair.

(25:34): Thank you for joining us. Hopefully we I answered some of the questions that you have. I know there’s some answers here and on our Instagram live as well. So I’m on Jackie shoot with your questions so we can answer some of those questions that already is.

(25:51): Sure. Okay. Thank you so much dr Charney. So yeah, like he said, if you guys want to write some questions in the chat, I can read them out loud and dr Ronnie can answer them. And then we also had some questions written in prior to the start of the webinar, so we can also run through those. So let’s get into it. One person wrote, they’re interested in Botox for the TMJ. Can you speak to

(26:17): Great. So the Botox for the TMJ is different than the masseter muscle, which is injected for the outside. The Botox for TMJ is an injection on the inside of the mouth, which relaxes what’s holding terrible white muscle, which is on the inside of the mouth and it works really well. And the patients are having done, some dentists even do it benefit from it and may not even need it more than twice a year. There are other non-cosmetic injections for Botox and it’s been talked about. Team is one hyperhidrosis for, for excessive sweating is another one. I’ve done it for hyperhidrosis and the excessive sweating in the scalp hands. There, there are many other non-cosmetic injection indications for it. But TMJ is a really good one. And as a matter of fact, we occasionally have patients in the office that are just here for Botox in the forehead. Then they’re like, my jaw line really hurts. Or I clench my teeth a lot and we give them one shot and they’re just really easy, amazing improvement in that area.

(27:19): Oh, okay. That’s cool. So a couple of questions about like the under eye injections, the tear troughs is that safe to inject for in that area or

(27:31): It’s a very safe area if you know the anatomy and how you do injections. And we talked about this a little bit beforehand. It’s not about the product necessarily, it’s about the injector for the most part and how the area is being injected and the products do help and the, you don’t want to, as I mentioned, you don’t want to, for example, for the bevel, for wellness, your trough and that’s gonna be a bad thing. We’ve got us a week. Having said that I prefer, yeah, to your trough injections being done very subtly, which means you have to do less, but a few more sessions are continually get to where you want and that typically means a half a syringe. And my favorite one in that area is little Bella, which is 0.5 CCS. And I inject that in this year. And for some people that’s just enough after one session, occasionally you need a second session, which I do in about two to three weeks. And then that lasts in good eight months to a year. And then we do some small trials after that.

(28:36): Okay, cool. So someone’s asking what’s the best for a subtle eyebrow lifts that kind of gives you that ponytail lift.

(28:45): Okay. Yeah. So that’s done with the neurotoxin and that’s done with any of the neurotoxins that you mentioned. Botox with Xeomin with [inaudible] or just for, and that has to do with how it’s injected. The way you inject Botox in the forehead is you telling the muscle, Hey, you need to relax in this area. So if you can differentially relax the midline and not relax the outside, he gives you a nice little tail and that’s the artistry of where you inject in the neuromodulator and is, it can be done with it. Any of those neuromodulators.

(29:18): Okay. And that’s the same for like a ponytail lift where you kind of just look like your whole forehead’s lifted? Correct. Okay. That’s great. Let’s see what else we have here. So if you were to inject Kybella into the inner thighs if you have very fat thighs, someone said, is that possible? How many maybe syringes would you need?

(29:42): Yes, it’s an area if you have like the rubbing area in between your side that can be injected with Kybella, depending on how much there is, you may need multiple sessions or multiple vials. I wouldn’t, I wouldn’t assume if your size or rubbing is an area that you would have to have probably two vials injected three sessions. So I would say starting point and probably about six vials of Juvederm of Kybella rather. But it’s it’s something that we really have to take a look at you virtually and I will be able to give you exact recommendations.

(30:15): Okay, great. And then actually someone on Instagram live, they said about Kybella, do you recommend a surgical procedure over Kybella for the chin and the jaw line or the injection?

(30:26): It’s, it’s a very common question. As a matter of fact, it’s almost always that would give you the patient a proposal for both options. One that will be a surgical option, which certainly has a downtime associated with it, but it’s a one time, one and done thing. Whereas with Kybella you have to do a few sessions. So it’s really nice to be able to give the patient the option of doing either or and understanding the pros and cons of with a surgical procedure, which is typically done on the local anesthesia. So I’m even ask to go to sleep for it. You may get some bruising, swelling and maybe about three to five days of downtime. But then, but then it’s done as opposed to when get some swelling lasts a few days and you have to do a few sessions of that.

(31:08): Okay. Okay, great. Let’s see what else we have here. Are there any new fillers and toxins coming out that you know,

(31:16): The newest one is kissed that we talked about that’s FDA approved. There is one that I’m really looking forward to seeing in the pipeline and that’s a newer modulator that is not a fee approved yet, but it’s supposed to last longer than all the ones that I just mentioned. The biggest problem with neuromodulators that we have now is some of them are kind of like a, me too, a me too drug, which they do basically the same thing and the only difference in them then their price point maybe a little bit different, but they’re not giving us that really long term outcome, which is what’s really been lacking in the neuromodulator market. And there was one that’s promising that’s hopefully be FDA approved.

(31:59): Hmm. Okay. That’s exciting to ignore too. Let’s see. Someone wrote in what is the best for a droopy jawline?

(32:08): Yeah, that’s very, very individual. I assume that you’re talking about the [inaudible], which is something that patients is one of the earliest signs of aging of the lower face. And that typically the very first time that I inject that area is typically within either radius or hydronic acid depending on the age of the patient. If they’re younger, actually start with a bioactive like radius. But for most patients we start off with hyaluronic acid, like Juvederm or cultural class.

(32:38): Okay.

(32:41): So someone said, where can we find more information about injectables? I’m from or like from good and reliable sources. For someone starting in the field, the best thing to do is to go for either virtual or in person consultation within core physician that’s for certified plastic surgeon. Expert injector is another place to look at because the only people that become an expert injections are ones that are either core physicians, board certified or work for a board certified plastic surgeon, dermatologist. It’s really important to look at them. Somebody had practice that offers all of the products that we just talked about and that’s quite a few of them. So it’s important to look for that.

(33:24): Right. And our website also aristocrat, ps.com. If you just want to read up on some of the injectables, we have different pages for that, such as check out our website. If you want more information, you’re welcome. And then someone actually asked you offer any courses for medical professionals for injectables or if not, do you recommend any specific courses?

(33:47): I would love to have the time to do that, but unfortunately we’re very busy clinically and cannot do that. I also have my own fellowship, so the only way to get that kind of a training by me is to be part of my fellowship. There are actually quite a few courses that are available by different providers nurses plastic surgeons, dermatologists, and are very good. And I encouraged taking many courses. I’m kind of picking up little nuances on everyone and because everybody does ingestions differently and the expertise comes only by experience and that as you start doing it and finding out how some of the subtleties make a nice differences when you become an expert in Jasper. So that’s how it would get recommend doing that.

(34:41): Okay. so next question. Are there laser facial treatments that would help promote facial collagen production or would that harm injections

(34:53): Depending on the depth of where something was injected? And the depth of the treatment, those actually can overlap. So for example, the lower eyelids is an area that’s very thin. So if you want to have a resurfacing and you have that filler superficially injected, those will coincide. Same thing. Very commonly patients want to come out in our office to have a laser procedure like the laser facial done. I had one Botox the same day, so we have to sag or that for them to have the Botox and that’s their, their laser and treatment. Because if you have the laser on top of Botox, they heat from the laser and actually inactivate the Botox that we just inject it for you. So those are all very important questions that needs to be individualized to the procedure that you haven’t done.

(35:37): Okay.

(35:39): And next question. Does Bellefield absorb or will it stay on your skin for specifically acne scarring? So Bella is that long lasting polymath FEMA FAQ related that lasts a really long time. So the initial part you get a bit of resorption of what’s there, even though it’s FDA approved for five years, it’s permanent. It’s, that’s what’s amazing about it. And they cannot, the company can say permanent because for a fee pool will be, you cannot show permanence, but they’ve shown five year results, which is pretty amazing. So for acne scars is, is, is wonderful. It’s actually, I’ll go to ingestion frankly.

(36:17): Okay, cool. And I think this is maybe our last question. Can you address the Canto plasty option for the almond eye shape for younger people?

(36:27): So that has to do with where you inject some fillers in that area. So there’s some patients want to increase that angle and by injecting a hyaluronic acid, typically in that area of, well Bella or you can slightly reshape that, there’s a certain extent that you can go past, but for the most fucking reshape to add to the shape that you want.

(36:50): Okay. Oh, we actually have some, a couple more on Instagram live. So someone wrote what is the downtime for a surgical Joel align or like a chin lift or if you use injectables for that area

(37:05): For injectables. The doubt that there was a procedure called a wireless where we actually send the jawline really nicely and that lasts about two years downtime, about five days to a week. For the most part, the surgical ones have more downtime for which is about a week to two weeks. But again, best to talk about that with with our virtual consultations. Thank you.

(37:31): Okay. And then I guess this is something that we didn’t really talk about. We have another question. Can you talk about maybe desolving injections if they were bad injections or poorly done? Specifically Voluma. Someone acts on Instagram live.

(37:46): The biggest problem with dissolving injectable is knowing what was injected. If that injectable was a hyaluronic acid injectable, like for example, Juvederm Voluma whether or not it was wrestle and wrestle lifts, if any of those were done, yes, you can inject it with hyaluronic acid or highlights. Another nice name for it is VIN trace. Again, something that we have in our office just in case it’s necessary and it’s also necessary to occasionally to do that in an injectable emergency. I’m glad that it happens very infrequently. I’ve had him one time in our office where you get a vessel that gets occluded with a solar and you have to inject it to remove that and you need to do that immediately. So all offices that do a lot of injections need to have that available are force we happen in the office.

(38:34): Oh wow. Okay. Okay,

(38:36): That’s great to know. And also speaking of the eyes, instead of performing a blepharoplasty, what injection well injectable could you use for a similar result? So lower blepharoplasty if you don’t have a lot of loose skin can be done with [inaudible] Bella for upper eyelid blepharoplasty with bralettes or chemical or newer from browsers, you can rejuvenate in that area. And sometimes we actually combine that with a resurfacing type laser like laser resurfacing and solar at the same time for a nonsurgical list in that area. That’s more for younger patients. If you have a lot of loose skin in that area, having filler in the area is not a good idea and actually makes, makes area who looked more bulgy or or fall.

(39:23): Okay, great. I mean I think it looks like those are the only questions unless someone else has a couple more questions to write in, in the chat. It looks like that’s about it. So for anyone who’s interested in getting injectables, if you mentioned that you were on this webinar, we’ll give you $50 off for your consult fee and our offices, at least our great neck office is open for elective procedures. Still waiting to know about our Manhattan office. But injectables we’re doing, we’re up and running. So we hope to see you guys soon.

(40:00): All right. Thank you everyone. And thank you Jackie, for putting it all together. I’m looking forward to seeing you virtually and in person.

(40:08): Thank you.