Dr Michele Koo, MD, FACS is a Board Certified Plastic Surgeon in St Louis, Missouri who has extensive experience with Juvederm and other fillers to minimize and plump those deep creases on your face. In 30-40 minutes in the office, Dr Koo will be able to fill those deep nasolabial folds, corners of your downturned mouth, and soften your lips to keep you from looking so sad and gaunt.

As we age and try to eat right and maintain our weight, our faces become volume depleted and the lines seem to deepen as the skin begins to lose its elasticity. With BOTOX AND JUVEDERM (FILLER), Dr Koo is able to soften your face and fill those deep crevices of your nasolabial folds and marionette lines of your chin. She can just ever so slightly plump your lips so your face is not so drawn and shrunken. Dr Koo is very subtle and gentle with her application of BOTOX AND JUVEDERM and you will not appear “done” or obvious with your BOTOX AND JUVEDERM. You will look rested and rejuvenated in 30 minutes!!

Dr Koo wants you to understand the safety of JUVEDERM and the following is the continuation of the article by Dr Mary Lupo as it appeared in the Plastic & Reconstructive Journal, January 2008.

Safety
The occurrence of treatment site reactions was similar for Juvéderm Ultra Plus and Zyplast. The majority of individual treatment-site reactions (e.g., erythema, induration, pain, edema, nodule, bruising, pruritus, and discoloration) lasted for no more than 7 days and were mild or moderate in severity, with no intervention required. No hypersensitivity reactions were reported for Juvéderm Ultra Plus, and there were no serious treatment-related adverse events.

Effectiveness
Initial Treatment Period
Although the mean correction after treatment was similar for both products, nasolabial fold severity scores from the treating investigators for the Juvéderm Ultra Plus filler were significantly better (lower) than for Zyplast at each follow-up time point from 4 to 24 weeks (Fig. 1). Over the 24-week period, the scores for Zyplast nearly returned to baseline (mean, 2.5), whereas the Juvéderm Ultra Plus scores remained low (mean, 1.3-equivalent to a mild wrinkle). Not surprisingly, the level of improvement in nasolabial fold severity score for both fillers was greatest at 2 weeks after the last treatment. At 24 weeks, the mean improvement was still 1.7 with the Juvéderm Ultra Plus product but only 0.5 with bovine collagen (Fig. 2). Clinically significant improvement (defined as mean greater than or equal to a one-point improvement relative to baseline) was maintained with Juvéderm Ultra Plus but not with bovine collagen at 24 weeks after optimal correction was achieved. The proportion of nasolabial folds showing significant improvement was consistently high for Juvéderm Ultra Plus (≥96 percent) but not so with collagen (41 percent at 24 weeks). Furthermore, 67 percent of the Juvéderm nasolabial folds had at least a two-point improvement at this 6-month visit (Fig. 3). Subject assessments of effectiveness were similar to those of the investigators. An overwhelming majority of subjects preferred Juvéderm Ultra Plus (85 percent) versus collagen (10 percent) or no preference (5 percent).

Among the subjects who returned at 1 year or beyond, assessments just before repeated treatment showed that 81 percent of subjects with severe nasolabial folds at baseline who were treated with Juvéderm Ultra Plus had maintained at least a one-point improvement in nasolabial fold severity and that 38 percent had at least a two-point improvement (Fig. 3), with a mean improvement of 1.3.

Repeated Treatment Period
The volume of Juvéderm Ultra Plus required to achieve optimal correction was significantly less at repeated treatment than at initial treatment. The median volume of Juvéderm Ultra Plus injected at initial treatment was two syringes (1.6 ml), and at repeated treatment 6 to 9 months later it was less than one syringe (0.7 ml).

Trends in Wrinkle Assessment Scale scores for the subset of subjects who were followed up to 48 weeks after their repeated treatments mirrored those observed in the initial study period. Although the sample size was small at 48 weeks, clinically significant mean improvement was still observed for Juvéderm Ultra Plus (Fig. 4), and 88 percent of the severe nasolabial folds treated with Juvéderm Ultra Plus in the original study and at repeated treatment still had a clinically significant correction at 1 year after repeated treatment despite the significantly lower injection volume at repeated treatment.

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DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI wants you to know that JUVEDERM and BOTOX are an extremely safe, economical way with no down time to soften your face in a significant way by smoothing and filling in the facial wrinkles that make you look tired and older than you are. Why always be asked if you are mad or tired? Take charge of your life and in 30 minutes in Dr Koo’s office rejuvenate your face with JUVEDERM AND BOTOX to lift up the frowns around your mouth, ever so subtlely plump your lips, and fill in those deep nasolabial folds.

Dr Koo wants you to know that JUVEDERM AND BOTOX are extremely safe and has been FDA approved for facial use to fill creases and smooth the dynamic lines of your face around the eyes and forehead.

The following is a continuation of an article by Dr Mary Lupo, published in the Plastic & Reconstructive Journal, January 2008. Dr Koo hopes that this is helpful information to let you understand the fillers that are available and to realize that the fillers are very safe.

One small open-label study in France treated 49 subjects with Juvéderm 30 in either one or two of four possible injection sites, the nasolabial folds (59 percent), upper lip (37 percent), glabella (16 percent), and bitterness folds (10 percent).4 Most subjects had a touch-up at 1 to 2 months after treatment, with a mean of 0.6 ml administered at each session. Wrinkle severity improvement of approximately 50 percent on a five-point scale remained stable up to 11 months after initial treatment.
Interestingly, in our study, the nasolabial folds initially treated with Zyplast returned almost to baseline after the initial 24-week period, but subsequent treatment with Juvéderm Ultra Plus resulted in the same duration of clinically significant improvement as seen in the nasolabial folds originally treated with Juvéderm Ultra Plus.

The most significant finding from our studies is the extended duration of correction for Juvéderm Ultra Plus, in particular, for severe folds. Other resorbable fillers (collagens and hyaluronic acids) have not been proven to last beyond 6 months. The most comparable product, Perlane, was developed to treat deeper folds in that it is indicated for injection into the deep dermis and has larger hyaluronic acid gel particles than its sister product Restylane, both from Medicis Aesthetics (Scottsdale, Ariz.).5 Juvéderm has a different manufacturing process that creates a homogenous gel without a granular consistency.

In a split-face study comparing Perlane to Zyplast in 68 subjects with a range of different wrinkle severities from mild to extreme, 26 percent were classified as having severe nasolabial folds before treatment, although results were not stratified by baseline nasolabial fold severity.6 At 6 months after optimal correction, 59 percent of all Perlane-treated folds maintained correction, as opposed to the 96 percent noted in the Juvéderm Ultra Plus severe folds study. Moreover, at 9 months, only 49 percent of the Perlane folds were rated as superior to Zyplast, with 37 percent showing equivalency between Perlane and Zyplast and 14 percent showing Zyplast to be superior to Perlane.

Given that Juvéderm Ultra Plus outlasts the temporary dermal fillers, perhaps it should be compared with the semipermanent fillers Radiesse (BioForm Medical, San Mateo, Calif.) and Sculptra (Dermik Aesthetics, Berwyn, Pa.). Radiesse consists of synthetic calcium hydroxylapatite microspheres suspended in a gel of glycerin, water, and sodium carboxymethylcellulose.7 Following injection, the gel dissipates, collagen production is stimulated for volumizing, and phagocytosis gradually breaks down and eliminates the microspheres.

In December of 2006, the U.S. Food and Drug Administration approved Radiesse for correction of moderate to severe facial wrinkles and folds such as nasolabial folds and for facial lipoatrophy in people with human immunodeficiency virus,8 although the product had earlier been approved for other uses such as vocal cord augmentation and was used off-label, particularly for deep creases such as severe nasolabial folds.9 The pivotal trial involved 117 subjects treated with Radiesse in one nasolabial fold and human collagen in the other nasolabial fold with up to two touch-ups allowed at 2-week intervals to attain optimal correction (mean Radiesse injection volume, 1.2 ml).8 Rated on a six-point scale using blinded photographic assessments, the mean improvement in wrinkle severity at 6 months was 1.3 (compared with 1.7 on a five-point scale for Juvéderm Ultra Plus at the same time point), and no long-term data were provided.

In a small open-label study, patient self-reports showed duration of nasolabial fold correction of 10 to 12 months for four of 18 subjects and greater than 12 months for 14 of 18 subjects.10 Another open-label study was based on surveys sent to 609 subjects who had received Radiesse injections to the nasolabial folds or other facial areas.11 Responses to the 6-month survey were received from 155 subjects, and responses to an additional survey sent between 12 and 24 months after initial treatment were received from 112 subjects. Average subject satisfaction at 6 months was 3.9 on a five-point scale (with 5 being most satisfied). In the 12- to 24-month survey, 69 percent reported satisfaction, although the most common comment was thought it would last longer. Importantly, 84 percent of subjects (n = 512) required repeated treatments to achieve or maintain optimal correction. Of those, 63 percent had touch-ups at 4 to 6 weeks and 53 percent at 5 to 9 months.

Sculptra is an injectable poly-L-lactic acid indicated for correction of lipoatrophy though, like Radiesse, it is used off-label for cosmetic wrinkle correction and volumizing. The product must be reconstituted with water at least 2 hours before injection, and the correction fades within 1 week as the fluid is absorbed. The mechanism of action is the stimulation of collagen production, which requires several injections at intervals of at least 2 weeks to generate cosmetic improvement.12 Clinical studies on Sculptra have focused on human immunodeficiency virus-positive subjects with facial lipoatrophy13; thus, the longevity of correction in facial wrinkles is unknown.

One salient point about the semipermanent fillers is that they are generally injected through larger needles than used with collagen or hyaluronic acid-based fillers to prevent the particles in the product from clogging the needle. A 25-gauge needle is preferred for Sculptra,14 and a 25- to 27-gauge needle is recommended for Radiesse,15 with a larger needle having greater propensity to generate tissue trauma and pain on injection. In contrast, Juvéderm Ultra Plus is injected through a smaller 27-gauge needle.2 Moreover, Radiesse and Sculptra are intended for placement only in the deep dermis or dermal-subcutaneous junction and do not have the flexibility to treat finer wrinkles and folds, as can Juvéderm Ultra Plus.

CONCLUSIONS
Juvéderm Ultra Plus represents an excellent combination of attributes for a dermal filler. Permanent products bear some long-term risk if the initial correction is excessive or misapplied and can result in an unnatural appearance as aging tissues shrink and make the filler visible.16 Semipermanent fillers, in contrast, are prone to the problems endemic to the particulate nature of these products, may require larger needle sizes, and have limited utility in superficial defects or wrinkles. Juvéderm Ultra Plus may have found the sweet spot of an ideal duration for wrinkle correction with a good safety profile.

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI wants you to have to latest information of the research on BOTOX AND JUVEDERM. This is the continuation of the article by Dr Mary Lupo published in Plastic and Reconstructive Surgery Journal, January 2008.

Dr Koo stays ahead of the learning curve and constantly re-evaluates the products available to you as well as her own results to give you the best and newest most optimal treatments. Furthermore, she performs all of the treatments herself and follows you very closely so as to tailor all future treatments for you so they will be as perfect as possible for your skin and face. Dr Koo believes in custom tailoring your treatment. She is respecful of your budget and time and will discuss all the options available to you for smoothing the wrinkles on your face and softening the years away with filler.

This continues the article on Juvederm by Dr Mary Lupo as published in Plastic & Reconstructive Surgery January 2008.

Subjects in the subset with severe nasolabial folds (Wrinkle Assessment Scale grade 3) were included if they had fully visible bilateral nasolabial folds that were severe at the deepest part (as assessed by the evaluating investigator) and were approximately symmetrical and of equal severity on each facial side. Exclusion criteria included hypersensitivity to bovine collagen or hyaluronic acid; history of atopy, anaphylaxis, multiple severe allergies, or allergy to meat or lidocaine; current immune therapy or history of autoimmune disease; tendency to develop hypertrophic scarring; use of oral retinoids or, in the nasolabial fold area, over-the-counter or prescription antiwrinkle treatments, microdermabrasion, or chemical peels in the 4 weeks before randomization; and any cosmetic procedure or tissue augmentation at the nasolabial folds in the 6 months before study entry.

Subjects were eligible to enroll in the repeated treatment study if they completed the initial 24-week period, indicated at the final visit that the Juvéderm-treated side was preferred, and the repeated treatment was performed between 24 and 36 weeks (±14 days) after initial optimal correction was achieved in the pivotal study. The main exclusion criteria included facial hair that would interfere with the visual assessments of nasolabial fold severity and having undergone or having plans to undergo any tissue augmentation with temporary, permanent, or semipermanent dermal fillers; botulinum toxin injection; laser resurfacing; dermabrasion; chemical peel; or face lift in the lower two-thirds of the face less than 30 days before the repeated treatment or at any time thereafter through the end of the extended follow-up period. Eligible subjects underwent their repeated treatment to both nasolabial folds on the same day with the same Juvéderm formulation that was used during the pivotal study treatment.

Statistical analysis was performed on the intent-to-treat population for effectiveness data and on the as-treated population for safety data. A value of p < 0.05 was used to determine statistical significance. The improvements in nasolabial fold severity score were compared with baseline using a signed rank test, and the proportion of nasolabial folds with a clinically significant improvement (one or more point decrease on the five-point scale compared with baseline) was evaluated using a McNemar test. Mean nasolabial fold severity scores were compared against the control by means of generalized estimating equations analyses.

RESULTS
Subjects
The initial study enrolled 439 subjects through 11 investigational sites across the United States. A total of 87 subjects with severe nasolabial folds (both nasolabial folds rated as a 3 on the five-point scale) were randomized to treatment with Juvéderm Ultra Plus in one nasolabial fold and Zyplast in the opposite nasolabial fold. Nearly all [n = 82 (94 percent)] of the subjects completed the 24-week follow-up period and most [n = 70 (81 percent)] of the subjects returned for the complimentary repeated treatment. Because of varying circumstances (e.g., scheduling issues, Hurricane Katrina), a small number of subjects (n = 16) had effectiveness evaluations 1 year or more after their last study treatment (before any repeated treatment). These subjects were statistically similar to the other study subjects in terms of injection volume and nasolabial fold severity at 6 months. Thus, these subjects’ long-term results (i.e., effectiveness at 1 year or more) can be extrapolated to the overall population.

Demographic data revealed that most subjects were female Caucasians with a mean age of 49 years (range, 26 to 74 years). The full range of Fitzpatrick skin types was represented, and 36 percent of subjects had darker skin types (Fitzpatrick types IV through VI).

Five of the original 11 sites participated in the repeated treatment study, enrolling 17 subjects from the Juvéderm Ultra Plus severe fold baseline cohort, all of whom completed the originally planned 24-week follow-up period after repeated treatment. Although the 48-week time point had already passed for a number of these subjects before the protocol amendment extending the study, eight subjects enrolled and received an effectiveness assessment at 48 weeks. Demographic details for those subjects participating in the repeated treatment study were similar to the original study.

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Before Juvederm Ultra Plus Injection

After Juvederm Ultra Plus Injection

If you have one hour to spare, Dr Michele Koo, MD, Board Certified Plastic Surgeon, St Louis, MO, 314-984-8331 can fill your deep creases around your mouth, marionette lines and nasolabial folds to soften your face and remove 20 years. This will refresh your face and rejuvenate your look without surgery and down time in one hour and last up to 12-18 months.

Dr Koo uses Juvederm, Restylane, and various other fillers depending on how deep your creases are and the type of skin you have. The injectible fillers are hyaluronic acid which as a normal component in human skin.  Dr Michele Koo performs the injections herself and carefully evaluates the results and designs the perfect fill for you on all your subsequent follow-ups. She makes sure that you have individualized attention and care so as to perform the right filler injection just for you. She never allows an aesthetician or nurse to do the injection and feels extremely passionate that the results of the first injection will guide her to tailoring your treatment so that it is refined and subtle so you look refreshed and rested.

The following is an article by Dr Mary Lupo in the Plastic and Reconstructive Journal, January 2008. This should be helpful to let you know that BOTOX and JUVEDERM are extremely effective and safe and there are studies that actually look at the results and longevity of BOTOX and JUVEDERM.

With the baby boomer generation firmly ensconced in middle age and the ubiquity of botulinum toxin type A, nonsurgical facial rejuvenation is becoming increasingly prevalent. As this generation continues to age, products with greater therapeutic power to correct aging changes will be in growing demand.

A multicenter, double-blind, randomized, within-subject, controlled study was conducted comparing Juvéderm Ultra Plus hyaluronic acid filler with bovine collagen. A subset of subjects classified as having treatment for severe nasolabial folds is presented in this article. Subjects received Juvéderm Ultra Plus in one severe nasolabial fold and Zyplast collagen in the other nasolabial fold; up to two touch-up treatments were allowed at 2-week intervals. Nasolabial fold severity was evaluated every 4 weeks for 24 weeks using a five-point scale. Treatment site reactions and adverse events were also recorded. A complimentary treatment was offered at the end of the trial, with effectiveness evaluations just before retreatment and up to 48 weeks after repeated treatment for a subset of subjects.

Of the 87 subjects, most were female Caucasians, but all Fitzpatrick skin types were represented (36 percent types IV through VI). At 24 weeks, 96 percent of nasolabial folds treated with Juvéderm had maintained clinically significant correction, and 81 percent maintained the correction for 1 year or more. Results were similar for those subjects with follow-up through 48 weeks after repeated treatment. The median volume required for repeated treatment with Juvéderm was significantly less than that for initial treatment (0.7 ml versus 1.6 ml).

Juvéderm Ultra Plus provides correction of severe nasolabial folds through 1 year or more.

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Let Dr Michele Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis, Missouri rejuvenate your face by removing wrinkles and frowns in the office in a matter of minutes. 

Let’s start with some background on dermal fillers. This market has been growing rapidly, and we expect the growth to accelerate with the introduction of a new entry into the hyaluronic acid segment. Baby Boomers are fueling growth as they more actively fight the aging process. What they’re seeing in the mirror is a loss of volume under their facial skin; that’s a visible sign of aging. The role of dermal fillers is to reduce lines, restore volume, and contour facial folds to restore a more youthful appearance.

The generally accepted signs of aging in the face are the thinning of the dermis layer and the atrophy of fat pads underneath. As a result, there is greater visibility of some unattractive features such as bony areas, blood vessels, wrinkles, and furrows. Because of their placement on either side of the mouth, the nasolabial folds become more prominent and deeply grooved. Some people think of the NLFs as parentheses that call extra attention to the area around the nose and mouth. Others think of them as smile lines. They’re not always welcome, and they can be corrected.

 Let’s stop a moment and note that wrinkles can have one of 2 origins. Either they are “dynamic,” meaning they are visibly highlighted when the underlying muscles are in motion. Think of the lines that appear when you smile or frown. Or the wrinkles are classified as “static,” meaning they appear when the face is at rest or not moving. Dermal fillers are used in the treatment of static wrinkles of the face.

 In contemporary practice, the physician and patient have a choice of many different types of filler. One of the primary distinguishing features is whether a filler is temporary or semipermanent. Among both varieties of fillers, there is considerable variability in duration. There is a broad spectrum of choice among fillers, with animal, nonanimal, human, and synthetic all available. The physician and patient must weigh a range of risk-benefit scenarios in making a choice, and value must also play a role. Finally, fillers are quite versatile, with products developed that are suitable for many areas of the face: fine lines, deep rhytides, folds, lips, and contouring of the face.