Seeking a quick, minimally invasive approach to reducing some of the signs of age?   Learn about soft tissue fillers.  Between the advancements in the safety of these products as well as our improved understanding of their use, fillers may be a good option for maintaining a more youthful appearance.

Soft tissue fillers comprise a large group of products of differing chemical composition.  This discussion is limited to hyaluronic acid (HA) fillers, which are based on a normal component of our extracellular matrix.  HA fillers have the advantage of being reversible, if needed, with the use of the enzyme hyaluronidase.  HA fillers are not permanent which, in my opinion, is an advantage in the event of an undesirable result.

Hyaluronic Acid (HA) Fillers

Currently, the following families of HA fillers are available in the United States:

  1.  Allergan’s products:  Juvéderm Voluma®, Juvéderm Ultra® and Ultra Plus®, Juvéderm Volbella® and Juvéderm Vollure™.
  2. Galderma’s products:  Restylane® Lyft, Restylane®, Restylane® Silk, Restylane® Refyne, Restylane® Defyne
  3. Merz Aesthetics’ Belotero Balance®.

While these products all contain hyaluronic acid, they differ in some alterations to the molecules and concentrations which affect their viscosity, “stickiness,” “thickness” and longevity.  Essentially, the thicker, more viscous products are used in the deeper areas of the upper cheeks to restore volume and provide lift.  The thinner, less viscous products are used to deal with subtle lines and deficiencies in the areas in and around the lips.  Middle-of-the-road products are typically used for prominent creases between the nose and mouth (nasolabial folds) and between the south and chin (“marionette” lines).

Juvéderm Vollure™, Restylane® Refyne, and Restylane® Define have only recently been released in the United States.  Consequently, specific information regarding the concentration, viscosity, thickness, etc. for these products is not immediately available.  Based on the information currently available, I rank these product families as follows (starting with the thinnest and less viscous products and ending with the thickest most viscous products):


  1. Restylane® Silk
  2. Restylane®
  3. Restylane® Refyne
  4. Restylane® Defyne
  5. Restylane® Lyft


  1.  Juvéderm Volbella®
  2. Juvéderm Vollure™
  3. Juvéderm Ultra®
  4. Juvéderm Ultra Plus®
  5. Juvéderm Voluma®

I have not listed the Merz products as they currently have a limited line of FDA approved products available in the Untied States.

In terms of cost, the Galderma products are generally somewhat less expensive than the Allergan products.  In terms of duration of effect, the Allergan products have generally been approved by the FDA for longer lasting periods of time.

Potential Risks

While there are many aesthetic benefits to the use of HA fillers, there are also some potential risks.  These risks range from minor issues such as temporary bruising to uncommon, but potentially catastrophic problems, such as scarring or blindness.  Other potential problems include skin discoloration, small blebs or bumps in the skin, aesthetically displeasing results and, uncommonly, nodule and abscess formation.  Your physician should be familiar with the underlying anatomy of the face, proper product selection, and how to inject to achieve aesthetically pleasing results.

Toenail fungus, otherwise known as onychomycosis, is an extremely common and persistent problem.  Certain people seem to have a unique pre-disposition to this toenail infection which makes it difficult to achieve a permanent cure.  Permanently curing this condition requires determination, persistence and know-how.  Often, a more realistic approach is palliative treatment instead of permanent cure.

Treatment of Toenail Fungus

The gold standard for the treatment of onychomycosis is systemic terbinafine.  This treatment usually requires at least 3 to 4 months of ongoing daily medication.  Care must be taken for individuals who have certain pre-existing conditions or who are taking other medications that may interact with this drug.  After approximately 6 to 12 months, the majority of individuals will improve.  However, without some type of ongoing maintenance, relapse is almost certain.

There are numerous recommendations floating around for the topical treatment of onychomycosis.  These range from various formulations of vinegar to the use of Vicks VapoRub.  Topical antifungal creams, sprays and powders fail because of lack of penetration into the nail tissue.  Even complete removal of the affected nail usually results in relapse.

Prescription Options

There are three topical prescription products available in the United States specifically for the treatment of nail fungus.  Listed below are their names, approximate effectiveness and approximate cost.

  1. Ciclopirox 8% nail lacquer, in one large study was shown to clear about 40% of cases.  In my clinical experience, the number is significantly less.  The price of this medication is approximately $60 for 6.6 ml of the generic.  As a point of reference, a teaspoon holds 5 ml.
  2. Jublia, in studies provided by the drug manufacturer, gave 20 to 30% clearance rates after 48 weeks of treatment.  This medication costs approximately $645 for 4 ml.
  3. Kerydin, in company provided information, gave response rates of a little below 20% at one year.  This drug is also priced at approximately $645 for 4 ml.

Over the Counter Treatment Options and Plan

Due to the lack of cost effectiveness of current prescription topical treatments, my preferred topical treatment for onychomycosis is the following:

  1. Apply over the counter terbinafine cream ($15.99/30 gm) to both feet, toes, web spaces and nails once daily.  Most people will have coexisting athlete’s foot and this strategy will help contain infection.
  2. Apply 47% urea gel (KERA Nail Gel $30/30 ml) thoroughly over and under the affected nails nightly.  If possible, work some of the terbinafine cream under the nail while applying the urea gel.  This concentration of urea will help dissolve away the infected nail, thus allowing the terbinafine to penetrate more effectively.

This treatment should be continued for 3 to 6 months and then reassessed.  While I do not have any research data on the effectiveness of this treatment, it is my clinical experience that many patients show improvement comparable to the much higher priced prescription topical medications.

Prescription Treatment Plan

For those highly motivated individuals in good health and not taking any other medications, I recommend the following approach for a complete and permanent cure:

  1. Systemic prescription terbinafine daily for 3 to 4 months.
  2. 47% urea gel nightly for 3 to 4 months.

Upon completion of this treatment program, it is essential to continue preventative maintenance indefinitely.  This is best accomplished with terbinafine cream applied to the feet, toes and nails daily after bathing.