The Newest In Dermal Fillers

Dermal fillers remain one of the most known methods of non-surgical rejuvenation, due to its popularity and effects, many patients have preferred dermal fillers. However, not everything ends well because of the possible adverse effects of dermal fillers. Thus there have been studies to ensure the safety of administering inejctables.

A couple of studies.

Double Injection Technique

Novel techniques are developed and presented to ensure the delivery and safety of the filler. Injecting requires skill and precision, thus it is crucial to learn safer techniques in injecting dermal fillers especially in the danger zones. One dermatologist mentioned that during a demo, the subject had become blind also.

Intravascular injection is something that all providers avoid due to disastrous side effects it causes on patients, and due to this delivery of injection, there have been cases of blindness and providers must always practice care and precision in administering the injection. 

The technique was double injection, as presented by the researchers, Huang and Lin, which could help prevent intravascular injection. Their method aims to thwart the possibility of intravascular injection, basically there would be an inner and outer needle in performing the procedure. In the event of drawn blood, the inner needle would move the blood out.

The researchers do admit limitations to their method and there could be more research that may be done in order to use this method.

Regeneration is the new Rejuvenation?

Dermal fillers could also demonstrate its efficacy in regeneration. Only two studies have examined dermal filler use for regeneration, it seems likely that in the near future, physicians could use dermal fillers for soft tissue regeneration. There are two studies regarding tissue regeneration and filler or fat injection, which have regenerative properties.

Fallacara et al. (2017) suggest that Urea could be cross-linked with HA considering its properties. According to the researchers, this could be the future of dermal fillers, and that could treat cosmetic issues other than its usual common dermatological concerns (e.g. psoriasis, calluses)

Additionally, there is another alternative to filler for tissue regeneration, which was discussed in detail by Dr. Cohen through Medscape that fat was also helpful in rejuvenating and regenerating  the reason he used fat was it made for a more natural look and that it lasted longer as compared to using fillers. Additionally, it adds more volume.

CaHA with Ascorbic Acid?

The study examined the efficacy of CaHA with Ascorbic acid to treat stretch marks. The researchers tested it on 35 patients, and on areas where stretch marks commonly appear such as: thighs, knees, buttocks, abdomen, and breasts. 

Findings:

• 63% of patients in the study were satisfied with the treatment; while only 1 was unsatisfied.
• Most patients were more satisfied in areas like abdomen, buttocks, and breasts.

Dermal fillers would have more potential uses in the future, and that it could have other uses in the future. For now, dermal fillers remain as one of the most popular treatment for cosmetic concerns, leaning towards rejuvenation.

A list of cosmetic dermal fillers here.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426873/
https://www.researchgate.net/publication/315818101_Hyaluronic_Acid_Fillers_in_Soft_Tissue_Regeneration
https://journals.lww.com/prsgo/Fulltext/2017/09000/Calcium_Hydroxylapatite_Combined_with.17.aspx

Injection Techniques for the Hand and Neck

In our previous post, we discussed filler injections for hand and neck rejuvenation. These procedures are on the rise, and many physicians are considering this procedure in their practice.

Injection Techniques for the Hands

There is a significant amount of literature for hand rejuvenation. Most have focused on injections and laser for the hands, as a non-surgical alternative. For this article, we shall go in detail on the injection techniques included in two studies.

LeFebvre-Vilardebo, Trevidic, and et al. (2015) go in depth with injection techniques, as different authors included in the study present their own injection methods on hands. The researchers also introduced their own injection technique: Scrape Skin Threading Technique (SSTT). Below is the table detailing more on the injection techniques.

Data from Lefebvre-Vilardebo (2015)

LeFebrve-Vilardebo and Trevidic (2015) suggest using a blunt-tip cannula when injecting. The researchers use four injection techniques to administer the CaHA.

The first method only injected without massaging, and it is most effective on a less fat hand. On the 2nd method, massaged aided in distributing the filler evenly. However, the third method showed the filler only stayed under the tendons. In using their own technique, the SSTT, it was the only technique that showed where the product was targeted.

For Dr. Moradi (2015), he used Radiesse with lidocaine HCl. In performing the procedure, he tented the skin and utilized a bolus injected in the dorsum of the hand. Specifically, Moradi injects “…proximally by the wrist-hand junction, distally the metacarpal-phalangeal joint” (p. 265s).

In addition, the doctor added smaller units for added improvement on the hands. Its intended result is to lessen the appearance of veins and tendons and improve volume.

Alternatively, in Dr. Busso’s work (2015), he used HA that would minimize the appearance of tendons. The patient should be in supine position. In order to see the veins better, Dr. Busso suggests placing the hand below the level of the heart. In addition, mark all injection sites. Then, finally, raise the hand slightly above the level of the heart.

The injection on the dorsal superficial lamina would yield easier injection administration. Injected fillers can easily spread and lessen any abnormal skin formation. Skin tenting is recommended to separate the veins from the injection area. There is a risk of nerve injury, so refrain from doing any intracompartmental injections “below the deep dorsal fascia” (p. 270S).

As for Drs. Sutton and Bucay (2015), their choice of filler is Radiesse. Like the previous cases above, cannula was used to administer the filler. The insertion of the cannula is between the 2nd and 3rd metacarpal.

The common observed side effects were edema and erythema in all cases.

Dr. Rivkin (2016) also conducted a study on hand rejuvenation and injection techniques. The author makes use of needles, instead of a cannula as mentioned in previous studies mentioned above. The technique the author adopted was injecting between the phalanges. Rivkin carefully fills in the spaces. The author expects that the appearance of vein and tendon reduce. After administering the procedure, it is recommend that the hand is massaged.

After the procedure, the author advises the patient to have hands elevated for the next couple of days and any tedious activity.

Injection Techniques for the Neck

The literature for injection techniques on the neck is limited; most studies have only studied on the use of lasers on the neck. There have been research on the neck using botulinum toxin, and there are doctors who use botox on their patients to perform a non-surgical neck lift.

Physicians should take note of the danger zones in the neck. The researchers introduced a new injection technique on the neck, which is the “Three-Dimensional Circumferential Injection Technique” (p. 1). They applied this approach on the Posterior and Lateral Subcutaneous Areas of the Neck and Anterior Subcutaneous Area of the Neck and Horizontal Neck Rings.

Below is the table that further details the study.

Data from: Calisti and Elattar (2017)

Hand and neck rejuvenation are two procedures that result in patient satisfaction. The procedures are not nascent, and it is expected to rise in the coming years.

Why You Should Review Injecting Techniques

Injectables are one of the many popular non-cosmetic procedures. Around 45% of the aesthetic/cosmetic procedures done in 2015 in the US was injectable procedures. It ranks high as an alternative to cosmetic surgery, and it is expected to rise in the coming years. These procedures have received praise by many patients. However, there is a constant need for reminder on injecting dermal fillers and botulinum toxin on patients. It is all in the [method of] injection, declares all practitioners. Additionally, some studies and researchers have emphasized the importance of administering procedures.

Some patients have reported that they have issues with fillers, which have caused adverse side effects like disfiguration of the face and vision loss. These side effects should serve as reminders to practitioners.

In the latest study by Scheuer, Sieber, Pezeshk, Campbell, Gassman, and Rohrich (2017) the authors present how to minimize problems in administering soft tissue filler injections. The authors suggest to inject slowly with small doses. In addition, a serial puncture technique is best in high risk areas. They cover six regions, which are considered danger zones.

Even with experience, physicians and certified injectors could still make mistakes in administering these injections. Thus, physicians must remember these safety concerns and administering of injections.

 Brow and Glabellar Region

• Digital injection must be applied.
• The authors recommend that intradermal injections must be done for this area.
• Blindness and tissue loss are common serious side effects in this region.

Temporal

• The measures of the danger zones in this area are 2.5 mm lateral and 3.0 mm superior to the peak of the brow (Scheuer, Sieber, Pezeshk, et al., 2017).
• Deep and superficial injections can be done in this area,
• The adverse side effect when injecting in this area is blindness.

Infraorbital

• Practitioners should refrain from injecting deeply
• Authors suggest to inject laterally and pushed medially
• Tissue necrosis is an adverse side effect in this region

Lips/Commissure

• On the commissure, the linear crosshatching method in injecting is safe.
• Injections done in either lips must be done superficially with around 3mm deep.
• Tissue necrosis is a serious side effect in these regions.

Nasolabial Fold

• Intradermal injections can be administered as well injected in the preperiosteal plane.
• Injections on the deep and superficial subcutaneous and dermal areas in the nasolabial fold are safe
• On the alar base, only intradermal injections should be administered.

Nose

• Fillers should be injected deeply and greater than 3mm.
• As suggested by the authors, any injections done on the tip and dorsum should be in the preperichondrial and preperiosteal planes.
• Tissue necrosis and visual loss are some of the adverse side effects.

To learn more about the injection techniques, you can watch the video provided by the authors here: http://journals.lww.com/plasreconsurg/Pages/videogallery.aspx?videoId=972&autoPlay=true

The Beauty and the Buzz at ASLMS

Just like many of you, my day is scheduled from morning to night and I am lucky if I can grab a bite to eat in between patients. It’s a real challenge to carve out time for professional development (and lunch). That’s why I appreciate the annual conferences hosted by the professional organizations. I can block out that time months in advance knowing that I will come back with new ideas.  

The American Society for Laser Medicine & Surgery (ASLMS) is on my must attend list year after year. It’s probably the best in the world for exchanging ideas and real science in the world of aesthetics, and not just marketing hype.

This year was no different. The 2014 meeting held in Phoenix, AZ was full of ideas. So many ideas that I wish I had a longer flight home to research them all.

When I returned my staff asked “What was the highlight”? The truth is there were so many highlights. I came home with so many pearls of wisdom about so many different areas of practice. I’d like to share a few of them with you.

Privacy Laws    
This year brings changes in HIPAA privacy and security rules. There are new rules addressing the sale of protected health information for marketing and fund raising purposes. There are new rules surrounding business associates that you contract with. There are also new waves of audits to ensure compliance. The meeting was a call to action to get my staff prepared for the new guidelines.
Under Eye Bags
For those of you not familiar with Neotensil, I suggest you take a look. It is a new film-like substance, made by a hair care line Living Proof, which reduces the appearance of undereye bags. It’s sold through physicians’ offices, but applied by the patient at home.  
Injectable Filler Technique
Take that extra care, that extra wipe step, with Voluma and other facial fillers. When injecting fillers in the hollows of the lateral orbit, think microcannulas with a lateral point temple zygomatic point of entry.  And on those crow’s feet, think of almost individual dosing per severity of lines at those two to three lateral orbit injection points. I also learned about pre-injection disinfecting wipe pads that combine clorhexidine with isopropyl alcohol.
Acne Suppression
There was a lot of buzz about keeping acne at bay using combinations of both short pulsed and long pulsed YAG lasers. It seems a paradox, but patients did better long term when they did laser acne treatments after finishing a course of antibiotics.  For patients with unresponsive rosacea pustular acne, think SIBO or small intestinal bacterial overgrowth and order a lactulose breath test screen.  
Bruising
For that post treatment unintended or inconvenient bruise, think of speeding up its disappearing act with an IPL treatment about 2 days after.  
Tattoo Removal
Here is a tip for tattoo removal for those of you not yet into Picosecond lasers. Treat the area through a hydrocolloid dressing, such as Second Skin.  
Noninvasive Fat Removal
There was a ton of chatter, all of it exciting, about noninvasive fat removal. The players are CoolSculpting,  Liposonix and the newest kid on the block, Vanquish.

Some of the above ideas are reality for me. We added Vanquish to our list of noninvasive fat removal a few months back. It’s a great fit for our practice and patients. Other ideas may not be a fit. But that’s the beauty of the meeting. With so many new products and protocols shared in one space, you are bound to come back with ideas to push your practice forward.  

Question: Calcium Hydroxylapatite For Collagen Stimulation - Which technique is best?

What Calcium Hydroxylapatite injection technique is best for collagen stimulation?

It is well known, that CaHA stimulates collagen production. Which is the best-in-class injection technique to maximize the desired effect and ho much risk should you take?

Mesotherapy with CaHA? Linear threading with blunt tip Cannulas after having effected subcision?