Online Health Chat with Shilpi Khetarpal, MD
Chat Date: January 18, 2017
Cleveland Clinic dermatologic and plastic surgeons have been pioneers in the field of facial cosmetic surgery. Each of our board-certified surgeons performs the full range of cosmetic facial procedures, with extensive expertise in alternatives to face and neck lift surgery, short-scar facelifts and minimally invasive facelift techniques. Cosmetic facial procedures can range from nonsurgical facial rejuvenation (such as BOTOX®, injectable fillers and KYBELLA®) to surgical facial procedures (such as eyebrow and forehead lifts, eyelid surgery, cosmetic nose surgery, cosmetic ear surgery, face or lip lifts, facial implants and chin surgery). These procedures can help restore your youthful appearance and re-awaken your natural beauty.
From fillers to BOTOX to microdermabrasion, Cleveland Clinic’s cosmetic and plastic surgeons can help patients decide if and which type of facial cosmetic procedures may be right for them.
About the Speaker
Shilpi Khetarpal, MD, is an associate staff physician in the Department of Plastic and Cosmetic Surgery at Cleveland Clinic. She specializes in facial cosmetic procedures including injectables and fillers for facial rejuvenation, cutaneous laser surgery and general dermatology. Her interests include BOTOX and cosmetic injectable fillers, including human fat injections, liposuction, JUVEDÈRM® and KYBELLA. She is board-certified in dermatology and fellowship trained in cosmetic dermatology.
Let’s Chat About Injectables, Fillers & More
MarthaMee: What is KYBELLA and how does it work?
Shilpi_Khetarpal,_MD_: KYBELLA, or deoxycholic acid, is a substance naturally found in your body that works to breakdown fat. It was approved by the FDA in 2015 for “submental fullness,” or a double chin. It is injected into that area and dissolves fat cells permanently, leading to a more youthful appearing lower face and neck. It also helps with skin tightening and sharpens the jaw line. It is a minimally invasive procedure done in the office and takes less than 20 minutes. Most patients need a series of treatments (usually two to four) to see significant improvement.
Carie: Can you please explain what Ultherapy® is and whether you feel it works to tighten the skin? If yes, approximately how long after the treatment can I expect to see any results? Thank you.
Shilpi_Khetarpal,_MD_: Ultherapy uses microfocused ultrasound to tighten the deeper portions of the skin known as collagen. This helps with tightening loose skin and making the face and neck look more youthful. After a treatment is done, it takes six months to see the maximum result.
Wee: What is the newest, upcoming filler?
Shilpi_Khetarpal,_MD_: A brand new filler that was just released is JUVEDÈRM VOLBELLA®. It is FDA approved for one year to treat fine lines around the mouth, as well as to enhance the lips.
Ms. Lioness: Regarding the deoxycholic acid: Do you think it will be approved for other areas to permanently remove fat? Is that being considered?
Shilpi_Khetarpal,_MD_: KYBELLA, or deoxycholic acid, is currently only FDA approved to reduce fat in the submental (chin) region. It is currently being studied for use in other areas.
RichardP: I heard there is a new treatment for male- and female-pattern hair loss called platelet rich plasma (PRP). What exactly is it and how is it done?
Shilpi_Khetarpal,_MD_: PRP is a plasma concentrate from the patient's blood that comprises predominantly platelets. Numerous growth factors are present within the PRP and have been shown to improve patterned hair loss when injected into the scalp. A blood draw is done in the office then spun down in a special centrifuge to separate the PRP from the platelets. That is then injected into the thinning areas on the scalp. Patients typically require three to four sessions, done one month apart, for optimal results.
burton: What is microneedling and on which areas can it be done?
Shilpi_Khetarpal,_MD_: Microneedling is a minimally invasive procedure that uses tiny needles to create micro-channels (tiny holes) in the skin to stimulate the body’s natural ability to heal itself and grow new collagen and elastin. It is useful for scars of any kind and shallow lines, especially around the mouth. It is done after using a topical anesthetic cream and is tolerated well.
Greeneyes35: Will microneedling help pigmentation issues? What would be the best thing for pigment problems and rolling/ice pick acne scars?
Shilpi_Khetarpal,_MD_: Microneedling can help pigment problems, but is mostly used for textural changes such as acne scars or lines around the mouth. Depending on the type of pigment, lasers can be used to lighten hyperpigmentation. Lasers can be done in conjunction with microneedling to yield the best results.
Kate L: Can microneedling helps scar tissue that is UNDER the skin (in addition to surface scars)?
Shilpi_Khetarpal,_MD_: Microneedling helps surface scars and scars right under the skin. Depending on how deep the scar is, microneedling may or may not help. In general, if the scar is visible, then microneedling will likely help.
Wee: Is microneedling similar to silk peels?
Shilpi_Khetarpal,_MD_: Chemical peels are different than microneedling in that they are much more superficial. Microneedling can reach depths of 3mm into the skin, whereas most chemical peels don't even go 0.25mm.
Renice: After getting an injectable (Bellafill® to be exact), how detrimental is it to use a Clarisonic®?
Shilpi_Khetarpal,_MD_: Once the swelling has subsided, in about a week, it is fine to use a Clarisonic device to cleanse your face. It will not affect the Bellafill or other filler.
sweetc8: What is best to fill "clown lines" around the checks and mouth?
Shilpi_Khetarpal,_MD_: Hyaluronic acid fillers are best to fill lines around the mouth. The type of filler used would depend on the individual person and his or her anatomy. It is best to see your physician in consultation to determine the best filler for you.
Kate L: Can fillers be used to help with a facelift that is "too tight" or to fill in "depressions" from other face surgery?
Shilpi_Khetarpal,_MD_: There are different categories of fillers; the most commonly used fillers are in the family of hyaluronic acid. They are a natural substance found in the skin and joints; therefore, it is not possible to have an allergic reaction to them. There are other, less commonly use classes of fillers that can rarely cause allergic reactions.
cosmona: Can you comment on the cost of hyaluronic acid fillers (roughly)? Are employees eligible for any discounts? Thank you.
Shilpi_Khetarpal,_MD_: Fillers range in cost by product because they come in prefilled syringes. The larger the syringe and the longer each product lasts, the more expensive the product is. Cleveland Clinic employees receive a 20 percent discount off cosmetic treatments such as Ultherapy, fillers and BOTOX.
osmona: Is there a fee for consultation? Thank you.
Shilpi_Khetarpal,_MD_: There is an $85 fee for consultation.
Wee: Why do some hyaluronic fillers last longer than others? For example, VOLUMA® can last two years versus others that last six months to one year.
Shilpi_Khetarpal,_MD_: Fillers last different amount of time depending on how highly cross linked they are and also how large each molecule of filler is. Large-molecule fillers that are highly cross linked such as VOLUMA last two years while very small-molecule fillers such as BELOTERO® last for six to nine months.
Ms. Lioness: Is there any procedure or cream that can improve the appearance of my elbows? As an African American, my elbows are dark and scaly.
Shilpi_Khetarpal,_MD_: There are several reasons why skin can be dark and scaly. The best thing for you to do is schedule a visit with a dermatologist to have your skin evaluated. Most times, there are topical creams that can help improve the appearance of this condition.
Wee: What topical ointment would you recommend to heal fresh scars on the face?
Shilpi_Khetarpal,_MD_: The best way to heal scars is by using Vaseline®. All other topical therapies, such as Mederma® and Vitamin E oil, have not proven to be more effective than Vaseline or petroleum jelly. It is more the act of rubbing the scar with a moisturizer that helps break up scar tissue rather than what topical agent you are using.
Sukie: I was told by a Cleveland Clinic doctor who performed a blepharoplasty on me four years ago that the best thing I could do for a more youthful appearance was to have skin resurfacing. Can fillers and injectables help somewhat to avoid resurfacing. I am 71.
Shilpi_Khetarpal,_MD_: Resurfacing aims to give the skin a more youthful appearance by improving fine lines and pigmentation, and improving the overall texture. Injectables such as BOTOX are used to soften lines associated with muscle movement, while fillers are used to improve volume loss. Injectables will not improve skin texture. In general, none of these treatments are used in the place of another, but used in conjunction to give the face a more youthful appearance.
Walknstyle: What type of procedure will help remove or minimize hyperpigmentation on my face and back?
Shilpi_Khetarpal,_MD_: There are many causes of hyperpigmentation (melasma, post-inflammatory changes, sun spots). Depending on the cause, there are lasers and chemical peels that can help lighten hyperpigmentation. It is best to see a physician in consultation to discuss various treatment options.
Wee: Can you continue to naturally stimulate the body to produce new collagen, regardless of age?
Shilpi_Khetarpal,_MD_: The only way that has been shown to continuously stimulate natural collagen production is by using Vitamin A derivatives such as retinol, which is over-the-counter, or tretinoin, which is prescription.
Wrestling with Wrinkles
Linda-Lou: I am 71 and would like to know the best products, or minimal procedures, for facial wrinkles. Thank you.
Shilpi_Khetarpal,_MD_: The best procedure to address facial wrinkles with muscle movement is a neurotoxin such as BOTOX, which relaxes muscle movement and can improve the appearance of wrinkles. For wrinkles at rest, without movement, resurfacing lasers can help minimize the appearance of these. Aside from these therapies, using a daily sunscreen (SPF 30 or greater) and a Vitamin A product (retinol, which is over-the-counter or tretinoin, which is prescription) can help minimize the appearance of these as well.
SBruce: What is the best over-the-counter product that you have seen for wrinkle-reducing results?
Shilpi_Khetarpal,_MD_: The only over-the-counter products that have shown to improve the appearance of fine lines and wrinkles in clinical studies are those containing retinol, which is a Vitamin A derivative.
WN: I had a blepharoplasty done about nine months ago, and I'm very pleased with the results. Is this a procedure that might need repeating in the future?
Shilpi_Khetarpal,_MD_: There are many factors that influence whether or not you will need to have surgery in the future. BOTOX can be used to open the eyes and enhance the effects of the blepharoplasty. However, each person and his or her anatomy are different, so it would be something you and your doctor should decide together.
Kittens: I have some loose skin on my mid-neck. Aside from surgery, what procedures would tighten this area? Thank you.
Shilpi_Khetarpal,_MD_: A procedure named Ultherapy, which uses ultrasound to tighten collagen and skin, can provide significant tightening of the lower face and neck. It is non-invasive and is a great procedure for those who want to avoid surgery.
Wee: Will fillers and lasers soon make facelifts obsolete?
Shilpi_Khetarpal,_MD_: Very good question. Each of these procedures aim to do something different. Fillers help restore volume loss to make the face look more youthful; resurfacing helps reduce the appearance of fine lines and wrinkles; and surgery removes excess skin. All of these procedures together help someone look more youthful. However, each person is different so it is best to see your physician in consultation to determine what would best benefit you.
tk: Other than an endoscopic brow lift, is there a nonsurgical procedure that raises your eyebrows better than BOTOX? Also, is there a nonsurgical procedure that will lift a sagging face around your chin and lower face? I understand that BOTOX and Ultherapy or something similar are used. Thanks for your advice.
Shilpi_Khetarpal,_MD_: BOTOX can open the eyes and raise the brows to some extent. Ultherapy is used for skin tightening, and can be used on the forehead and eyebrows to tighten the skin, raise the brows and help lax skin look more youthful. Ultherapy can also be used on the lower face and neck to tighten skin.
Clearing the Air
Realtor: What is the difference between an injectable and filler, and how is each used? What determines which is used?
Shilpi_Khetarpal,_MD_: Fillers are gel-like substances that take up space. They are used in areas where volume loss has occurred (loss of fat or bone that occurs normally with age). There are various fillers on the market, and they vary by thickness. Some are very thin and are used for fine lines, while others are thicker and are used to lift up larger areas like the cheeks. The filler used depends on each patient and the area being treated.
la4: One of the participants earlier asked what the difference is between an injectable and a filler and how each is used. I saw your description of fillers, but what is the difference between these two types of products? How is each used? Thanks in advance.
Shilpi_Khetarpal,_MD_: An injectable simply refers to either a neurotoxin (such as BOTOX) or a filler. BOTOX aims to decrease muscle movement and reduce lines associated with expression, while fillers are gel-like substances that are used for volume loss.
cleclifan: I have a vascular malformation on the left side of my brain. Will getting BOTOX or any other injectable into my forehead, lines between the brows or anywhere else on my face be risky?
Shilpi_Khetarpal,_MD_: Neurotoxins such as BOTOX will not have an impact on the vascular malformation in your brain. It is safe to use BOTOX and fillers.
Carie: Which do you think is better for filling out hollow areas under the eyes: fat transfer or some type of filler?
Shilpi_Khetarpal,_MD_: Fat transfer is more unpredictable than a filler. Given that the under eye area is very delicate, I prefer using hyaluronic acid fillers to improve hollowness under the eyes, also known as the tear trough. These fillers are safe, natural and very effective at improving this area, and they last for several years.
coconut: Can you tell me the best injectable for drooping jowls? Also, is it feasible to inject fat cells into this area with success, and how long would that last. Thank you.
Shilpi_Khetarpal,_MD_: Hyaluronic acid fillers can help lift up the mid-face and improve the appearance of jowls. A skin-tightening therapy called Ultherapy can also help tighten skin and improve jowls. It is best to schedule a consultation to see what options are best for you.
JLH: Is there a recommended age when one should consider surgery for an eyelid lift?
Shilpi_Khetarpal,_MD_: There is not a general age; however, there are a combination of factors that determine when one would benefit from an blepharoplasty (eyelid lift). These include genetics, sun exposure and lifestyle habits. It is best to discuss with your physician if you are a candidate for a blepharoplasty.
Ultraviolet: Do you suggest having fillers before or after plastic surgery (facelift)?
Shilpi_Khetarpal,_MD_: Fillers can be done before or after plastic surgery. In general, it may be better to wait until after surgery since facial anatomy can change.
Greeneyes35: I’ve had Fraxel done one time and Dermapen® done four times. The Dermapen broke up a lot of thick scaring and helped rebuild. I think it’s a slower process, but it works. The Fraxel made me purple, but the results were quick. Dermapen helped me return to my normal skin tone. I'm not sure where to go from here. I have a lack of pigment in the areas where the worst scars were, and I'm at a 50 percent improvement with the rest.
Shilpi_Khetarpal,_MD_: Usually, it takes a series of Fraxel Restore treatments (on average four to six) to see improvement in acne scarring. It is best to be seen in consultation to determine which therapy would benefit you most moving forward.
Wee: What works best for filling pores and old acne scars? Would Bellafill be an option?
Shilpi_Khetarpal,_MD_: Bellafill is a permanent filler that can have many side effects. There are newer, safer therapies for acne scars including resurfacing lasers and microneedling. These stimulate the body to produce new collagen, thereby giving permanent improvement in the appearance of acne scars.
Risks and Benefits
riegl: Can you have allergic reactions to fillers? How severe can they be?
Shilpi_Khetarpal,_MD_: The most commonly used class of fillers are those called hyaluronic acid fillers. Hyaluronic acid is a natural substances normally found in the skin and joints. Because it is natural, it is not possible to have allergic reactions to it.Other, less commonly used classes of fillers can rarely cause allergic reactions.
LaurensMama: Is there bruising or noticeable swelling with injectable fillers for under eye bags? I was curious of downtime after the injections.
Shilpi_Khetarpal,_MD_: Each person is different; some people can have bruising associated with injections (either BOTOX or fillers) while others don't. Fillers are at a higher risk for bruising than neurotoxins (such as BOTOX and Dysport®). Those who take NSAIDs such as ibuprofen and aspirin are more likely to bruise. Usually, there is no “downtime” associated with injections, and bruising can be covered easily with makeup. We recommend that you don't have any injections done within two weeks of a major event just in case you do get some swelling or bruising.
Looking at Lasers
Wee: Is there anything you recommend to diminish pores?
Shilpi_Khetarpal,_MD_: A laser named Fraxel® Restore has been proven to decrease pore size. The only other things that have been proven to decrease pore size are prescription Vitamin A creams named tretinoin.
Wee: What specific type of resurfacing laser works best for old acne scars and pores? Is Fraxel still a good option?
Shilpi_Khetarpal,_MD_: Fraxel Restore (1550 nm) is considered the gold standard for improving acne scars and decreasing pore size. Cleveland Clinic offers this laser procedure at the Richard E. Jacobs Health Center in Avon and in Twinsburg.
Kittens: I have age spots on my face. Which is a gentler laser that can be used for these? Thank you.
Shilpi_Khetarpal,_MD_: We have a laser called the Alexandrite that can treat individual, larger brown spots. We have another laser called the Fraxel Dual (1927nm) that we use to treat the entire face to eliminate the appearance of age or sun spots.
That is all the time we have for questions today. Thank you, Dr. Khetarpal, for taking time to educate us about Injectables and Fillers.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.
Shilpi_Khetarpal,_MD_: Thank you for all the questions and for joining us in this webchat. I hope this information was beneficial, and I appreciate all the participation.
To make an appointment with Dr. Khetarpal or any of the other Cleveland Clinic cosmetic specialists, please call 216.444.5725 or call toll-free at 1.800.223.2273, ext. 45725. You can also visit us online at clevelandclinic.org/beautifulyou or for specific procedures visit my.clevelandclinic.org/cosmetic-plastic-surgery/procedures/injectables.
For More Information
About Cleveland Clinic
Cleveland Clinic’s Department of Dermatologic and Plastic Surgery provides expertise for both surgical and nonsurgical cosmetic procedures ranging from body contouring to breast procedures to BOTOX injections. The Center offers patients access to a range of cosmetic specialists including plastic surgeons, dermatologists, oculoplastic surgeons, head and neck surgeons and aestheticians. Additionally, our surgeons are dedicated to improving patient outcomes through innovative cosmetic surgery advances including minimally invasive facelift techniques, alternatives to face and neck lift surgery, short-scar facelifts and SmartLipo technology.
To see a full listing of our cosmetic services, specialists, locations and before/after patient images, visit clevelandclinic.org/beautifulyou.
Cleveland Clinic Health Information
Learn more about Injectables, Fillers and other skin health information:
- An Overview of Your Skin
- Basic Skin Care Tips
- Aging and Skin Care
- Treating Aging Skin
- Skin Care and Cosmetics
- Cosmetic Surgery: Today and in the Future
- For additional health information, visit clevelandclinic.org/health.
- Cosmetic Facial Surgery Treatment Guide: Please use this guide as a resource to learn about the treatment options available.
For additional information about clinical trials, visit ClinicalTrials.gov.
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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2017. The Cleveland Clinic Foundation. All rights reserved.