3 mistakes to avoid when getting lip filler

Lip filler injections can be great or gruesome

Lips that look done usually don’t look very good.  Over-plumped, distorted lips were somewhat popular several years ago but now most consumers seeking lip enhancement want a more natural look.  Here in NYC, my patients don’t want to be stared at just because their filler treatment went overboard.

This is where Restylane Silk comes in.   It was FDA-approved for lip plumping and to soften the wrinkles that form around the lips. It’s different from regular Restylane because it’s softer, which is perfect for the lips.

Like many of the popular wrinkle fillers it’s made from hyaluronic acid which is safe because it’s a substance that is naturally in the body.  Restylane Silk will last for about 9 months and it is reversible with an enzyme injection.

How to avoid fake-looking lips

I made the video above to convey the 3 most important ways to avoid the overdone lip look.  It’s crucial that you and your injector are on the same page when it comes to aesthetics.  You have to tell them what you like and what you don’t like.

In general, you want to:

1. Avoid too much filler and use legitimate fillers (not industrial caulking!)

2. Respect the shape of the lips and don’t try to completely change their shape

3. Keep it subtle and make small changes at a time and pick a provider that is experienced and well-trained

The mini-lip fill

The modern lip enhancement is a subtle, beautiful thing.  A mini lip fill uses just enough filler so the lips look plump but they still look like your lips and they definitely don’t turn heads in a bad way.

The best fillers for lips are Juvederm, Belotero, Prevelle Silk, and now Restylane Silk. Each of these fillers is reversible, meaning you can take them away with a simple injection (hyaluronidase) whenever you like.

How the lip filler treatment works

When I perform lip filler on my patients, I recommend a local anesthetic to help numb the area.  The lips are extremely sensitive.  I place very thin layers of the filler (a soft gel) under the mucous membrane of the lips.  Occasionally I will outline the edges of the lips and fill the philtrum to enhance the cupid’s bow, that curve at the middle of the upper lip.

The treatment takes about 10 minutes.  While bruising is uncommon, it can occur and it may last for a few days.  Some swelling is also normal for the first week after the treatment, but this is usually not very noticeable.

juvederm lips

Before and After lip enhancement with filler injection








Brett Kotlus, M.D.

135 E. 71 street

Phone: 212-882-1011

Under eye fat injections – do they work?

What are facial fat injections?

Fat is used as a natural filler to put back the fullness and suppleness in your face that is lost as you get older.  Small amounts of fat cells are suctioned from one part of your body- your belly, hips, thighs for example, and then this fat is placed where it is needed to make you look the way you did years earlier.

transfer fat

Where do fat injections go?

The earliest parts of the face that lose fat are the grooves under the eyes, the cheeks, and sometimes the temples and eyebrows.


This is one of my patients that didn’t like the look of bags and sunken-under eyes.

bags under eyes







I suggested a lower eyelid lift, with fat injections.  You can see she has sunken areas under her eyes where she is missing a roundness to her upper cheeks.

This is where I placed fat, by injecting tiny amounts with a thin tube (cannula) deep under the skin and muscles of the face:

under eye fat grafting







And this is what she looked like after recovering from the procedure:

before and after under-eye fat












In addition to fat injections, a minor amount of bulging fat was removed from behind the eyelid, also termed a scarless lower eyelid lift.  With these two procedures I eliminated her eye bags and the hollowing in her cheeks.

Another example of under-eye fat injections with scarless lower eyelid lift to reduce bags and hollowing:

fat grafting eyes

Fat injections vs. fillers

Much of what can be accomplished with fat under the eyes can also be done with filler injections. Fillers (like Restylane and Juvederm) are in-office procedures, performed in minutes, and often with little downtime.


The benefits of fat are:

1. Fat lasts longer (possibly permanent) when compared to the most popular fillers

2. Fat is a natural part of your own body

3. Fat is softer than fillers

4. Fat reserves tend to be plentiful


The drawbacks of fat injections:

1. Your body may absorb some of the fat requiring a second treatment

2. Fat injections have more downtime than fillers (about 1-2 weeks)

3. Fat injections tend to cost more than fillers


How to ensure fat injections will last

There are many ways to handle and process fat to be used for injections, or fat grafting.  Gentle handling with sterile techniques and meticulous injection practices help to ensure the best chance of long-term fat cell survival.  Many surgeons will quote a 50% – 70% rate of fat acceptance.  For this reason, slight over-correction is desirable immediately after the procedure.

I centrifuge the fat at low speeds after collecting it with low-force suction. This purifies and condenses the fat cells.

purified adipocyte






The final product is a golden slurry of your own fat. I inject fat in small amounts using a one milliliter tube (1/5 of a teaspoon) as depicted below.  Each injection layer consists of one tenth or one twentieth of this tube.  Very small fat deposits create a smooth and accurate fat placement.

injection fat grafting







So yes, fat injections under the eyes can effectively fill in hollow and sunken cheeks and under-eyes.  The combination of fat grafting with lower eyelid surgery, facelift surgery, or even brow lifting is a great way to look younger without looking “done”.



Brett Kotlus, M.D.

135 E. 71 street

Phone: 212-882-1011

Cannula tear trough filler under eyes for dark circles and eye bags

Cannula tear trough filler

Eye bags and dark circles may be present from birth or can develop with age.  They make us look older and more tired.

In my NYC practice I fill the so-called tear trough to minimize hollowing under the eyes and to soften the under-eye contour.  Filling this area makes the eyes look less tired.

Here is what a tear trough is: it’s a valley under the eyelid that contributes to shadows, dark circles, and the appearance of under-eye bags.  I describe it at more length here.  It is caused by the tight attachment between the eye closure sphincter muscle (orbicularis oculi) and the rim of bone under the eye.

The cannula tear trough filler treatment is a way to minimize or eliminate eye bags without surgery.

See this example:

filler under eye

Another example:

How is cannula tear trough filler done ?

An injection delicately and precisely places a biocompatible material under the skin to lift the sunken area.

There are a few filler types available (Restylane, Juvederm, Restylane Lyft, Belotero, Volbella, Vollure,  etc.), and these consist of gels that are packaged in a syringe or a tube.  At the tip of this tube is a needle or a cannula that delivers the gel in the right place.

Restylane is arguably the best filler for the under-eyes.

Read this article to hear more about why Restylane is the best for under eyes based on my experience with thousands of treatments over more than 12 years.

Needle vs. cannula

A needle is the traditional way of performing filler treatments.  It has a sharp tip and works with a high degree of accuracy.

A cannula is similar to a needle but the tip is not sharp, it is blunt and rounded.  The cannula eye lift has a few benefits:

1. Cannulas can be less likely to cause bruising after filler treatment

2. Cannulas may be less painful than needles

3. Cannulas may require less entry points because they tend to be longer than needles

4. Cannulas may be safer than needles because it is less likely to puncture a blood vessel and inject filler where it doesn’t belong

Which one do I use?

I use cannulas for the tear trough, mainly because of the improved safety and reduced risk of bruising.  Here in NYC, my patients want to be able to return to their busy lives with minimal recovery time.  The cannula makes that much more likely than needle treatments for eye bags.

However, I don’t use cannulas for every filler treatment I perform because certain situations are better suited for needle injections (e.g. shallow fine lines, acne scars, surgical scars).

Example of cannula eye lift with Restylane immediately after one side was completed:

eye bag cannula

How long does the cannula eye lift last?

After under-eye Restylane treatment, you should expect a year or more of improvement in the appearance of eye bags.  If the upper cheeks are filled at the same time, the results can last longer due to the improved volumetric support.

Surgery or filler for eye bags?

Aside from the cannula eye lift, there are both surgical and non-surgical ways to improve the under eyes- I created an infographic that helps you decide if fillers or surgery are a better option for you.  You can find it by clicking here.

Before and after cannula eye lift with Restylane

eye bags filler

eye cannula
 under eye filler

cannula eye lift

Getting the cannula eye lift in NY

When patients come in for the cannula eye lift, they often have their initial consultation and their treatment on the same day.  The entire procedure takes about 15 minutes.  I highly recommend you see a cosmetic eyelid surgery specialist (oculoplastic surgeon) for the procedure.  A good portion of my practice is devoted to correction of eye procedures performed elsewhere by non-eyelid specialists (revision procedures) and this includes correction of under-eye fillers that were incorrectly administered.  It’s best to get it right the first time but if you do encounter an issue a fix is usually possible.

Phone: 212-882-1011

dr. brett kotlus botox or fillers

What is the difference between Botox and Fillers ?

Botox or fillers ?

“Do I need Botox and fillers?”

I’m asked this question almost every day in any of my New York offices (not to imply that wrinkles only happen to New Yorkers, it’s just where I practice).

The answer depends on where you have wrinkles or loss of fullness.

Sometimes the answer is both Botox and filler

Botox works best around the eyes- the frown lines between the eyebrows, the crow’s feet, and the forehead.  Botox (and Dysport) relax the muscles that cause these expression lines.

In the hands of a Botox expert, Botox can gently lift the eyebrows, improve lines around the mouth, and lift the corners of the mouth.

Fillers are best for deeper creases, nasolabial creases (from the side of the nose to the mouth), lines that are not from expressions,  and sunken areas (under eyes, cheeks, lips, temples).

“Will I have to do it again?”

Yes, if you want to keep looking younger .  This infographic I made describes some of the differences and applications of Botox and fillers including the very popular Juvederm Voluma, Sculptra, and Restylane.  Most of my patients who enjoy the benefits of injectable treatments undergo Botox approximately 3 times per year and fillers once or twice a year.


infographic botox


How to get rid of crow’s feet

Crow’s feet arise from repeated expression

“Crow’s feet” are the creases that radiate outward from the outer corners of your eyes when you smile or squint.  They begin to show up for most people in the mid 30’s to early 40’s.  They are thought to convey sincerity when you smile (see this video about the SQUINCH by photographer Peter Hurley).  The crow’s lines can make you look more photogenic, but if you have too many or they are too deep, they make you look older.


smile wrinkles

“Crow’s Feet”


How do I get rid of them?


Use a broad-spectrum sunscreen of at least SPF 30 and preferably a mechanical blocking agent like zinc oxide.  Even while you are driving, your face is exposed to damaging UV radiation that causes aging signs and wrinkles. Other ways to prevent these lines from forming or worsening, use scientifically-proven topical creams like a prescription-strength retinol and a vitamin C  (L-ascorbic acid).   I don’t recommend that you stop smiling in order to prevent smile lines.  You may look younger, but you will lead a less happy life!


Botulinum toxin type A (Botox, Dysport, Xeomin) are liquid protein injections that selectively relax the muscles that create the crow’s lines.  An expert injector can do wonders by placing small amounts of Botox in just the right places.  Botox done well looks natural and gives your eyes a younger glow.


Lasers (fractional CO2 and erbium) and chemical peels (glycolic, TCA, phenol) will remove the outer skin layers leaving space for newer, smoother skin to take over.  In the case of crow’s feet, if you continue to crease with repeated expressions, the lines will eventually return.  A combination of resurfacing with Botox as maintenance will provide the longest-lasting results.

What about fillers like Juvederm or Restylane?

Fillers have a limited role in treating crow’s lines but can be helpful in smoothing very deep, fixed creases.  Dermal fillers can also stiffen and plump the skin to limit the amount of folding and creasing that occurs when you squint.

What about eye lift surgery?

A lower or upper eyelid lift may somewhat reduce crow’s feet but is not a good choice if your primary target is expression lines. Surgery is better for heavy upper eyelid skin or lower eyelid bags.

How long does Botox last?

Botox starts to work after a few days and lasts for months.

How many months is the big question.  I’ve been treating patients with cosmetic botulinum type A since my residency days in New York City and I’ve administered thousands of Botox injections.  On average, Botox lasts about 4 months.  But, this isn’t the case for everyone.  Why?

Botox works better with successive treatments.

The smoothing effect on wrinkles is a result of targeted muscle relaxation.  When a muscle isn’t moving as much as it used to, it begins to shrink.  Just like when you remove a cast from your arm that has been there for 2 months, the arm looks smaller. With the next Botox treatment, your muscle may take longer to recover because it’s smaller.  I have some patients that see Botox results for 6 – 9 months, mostly if they have been getting treatments for a few years.

What if Botox lasts less than 4 months?

The most likely reason for a shortened duration of action is under-treatment.  My first consideration would be to look at how many units were used and perhaps a stronger treatment is required.  There is a rare possibility of developing antibodies to the Botox molecule,  but this is unusual.  Some doctors advocate the use of supplements that improve the absorption of zinc in your diet.  These supplements may help but they’re not completely reliable.

Botox remains the most popular cosmetic treatment in the world so the length of effectiveness is acceptable to most people.


botox duration

timeline for botox cosmetic


How Botox became #1 in popularity

Botox, also known as botulinum toxin type A, is a purified protein that stops the transmission of nerve signals to muscles.  In other words, it relaxes muscles.  It was discovered based on the muscle weakening effects of the proteins produced by a bacteria named clostridium botulinum, named after the sausages that used to harbor the microorganisms.  Current commercial forms of botulinum toxin are highly purified and delivered in small, safe amounts.  As a medical therapy, it has come a long way from its original use in alleviating crossed eyes caused by overactive extraocular muscles.  Now it is used for a wide array of conditions including migraines, neck spasm, overactive bladder, and excessive underarm sweating.

But its claim to fame will always be its amazing anti-wrinkle properties.  It is the #1 treatment to date for glabellar wrinkles (the “11” lines between your eyebrows) and for crow’s lines (the smile wrinkles that radiate from the outer corners of your eyelids).  After a treatment, the results typically last for about 3-6 months.  It is expected that the global market for Botox will reach $2.9 billion by 2018!

Why is Botox so popular?

1. It works.  It reduces or eliminates frown lines and crow’s feet and lifts the eyebrows. It can work almost as well as surgery for some people.  And it prevents future deep wrinkles.

2. It is a no-downtime procedure. Botox can be done during your lunch break and when you return to work no one will know you had something done.

3. It is safe. Its safety has been proven over many years. Over 5 million Botox treatments were performed in 2013 alone, and its safety record is better than that of aspirin.

As a cosmetic eyelid and facial surgery specialist I have performed many hundreds of Botox treatments and it remains one of the most requested procedures in my office.  As this infographic details, it is the most popular cosmetic procedure in the world!