Facial Rejuvenation Therapy Neurotoxins and Dermal Fillers Advanced Course © 1.

Facial Rejuvenation Therapy Neurotoxins and Dermal Fillers Advanced Course ©
1

AAI Disclaimer This program is jointly sponsored by Global Education Group & Aesthetic Advancements Institute Participants can claim up to a maximum of 8.5 credit or contact hours for this activity. Certificates of credit will be distributed via within 6 to 8 weeks upon completion of course and submission of the activity evaluation form. Off-label cosmetic uses of neurotoxins and dermal filler products will be discussed and demonstrated during this program Remind them it may take up to 8 weeks to receive their certificates

Review of Manual Contents
Section1 - PowerPoint Section 2 - Charts Section 3 - Suggested Readings/References Glossary of Terms Folder: Supply lists Laminated quick reference guides PRIOR TO BEGINNING LECTURE Have them review the manual contents Have them review the folder contents

FDA Approved Dermal Filler Products by U.S. Manufacturer
ALLERGAN GALDERMA VALEANT MENTOR MERZ SUNEVA Hyaluronic Acid Juvederm Ultra (XC) Juvederm Ultra Plus(XC) Juvederm Voluma XC Restylane-L Perlane-L Prevelle Silk Belotero Balance Calcium Hydroxylapatite Radiesse Poly-L Lactic Acid Sculptra 80% Purified Bovine Collagen and 20% Polymethylmethac rylate (PMMA) Microspheres, with 0.3% lidocaine Artefill 4

FDA Approved Aesthetic Indications per Dermal Filler Product
Moderate to severe facial wrinkle and folds, such as nasolabial folds Lip augmentation Shallow to deep nasolabial fold contour deficiencies and other facial wrinkles Mid face volume Juvederm Ultra (XC) Juvederm Ultra Plus(XC) Restylane-L Sculptra Juvederm Voluma XC Perlane-L Belotero Balance Radiesse Artefill 5

Qualities of US Approved HA Fillers
HA content (mg/mL) Cross-linker Belotero 22.5 BDDE Restylane 20 Perlane Juvederm Ultra 24 Juvederm Ultra Plus Voluma Prevelle Silk 5.5 DVS 6 6

FDA Approved Neurotoxins by U.S. Manufacturer
ALLERGAN GALDERMA MERZ Botulinum Toxin Type A BOTOX Cosmetic OnabotulinumtoxinA Dysport AbobotulinumtoxinA Xeomin IncobotulinumtoxinA 7

Neurotoxins Botulinum Toxin Type A
Definition Purified protein; One of the 7 serotypes of neurotoxin (A-G) produced from the germ Clostridium Botulinum; BoNTA strongest and longest lasting of the 7 Mechanism of Action Causes a temporary paralysis of muscle activity by interrupting the release of acetylcholine at the neuromuscular junction. A muscle exposed to acetylcholine will contract. Botulinum toxins types B, D, F,& G cleave synaptobrevin; types A, C, and E cleave SNAP-25; and type C cleaves syntaxin FDA Approved Cosmetic Indications For the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity; lines associated with orbicularis occuli muscle activity in patients 18 to 65 years of age (onabotulinumtoxinA only) BOTOX-A is the only neurotoxin worldwide approved for 21 different indications across approximately 80 countries. BOTOX-A Cosmetic, first approved in the United States in 2002, has been the most popular physician-administered aesthetic injectable treatment for the past seven years and has since received approvals in more than 60 countries worldwide, marketed under different trade names. Approximately 22 million vials of BOTOX-A and BOTOX-A Cosmetic have been distributed worldwide since the product was first approved and nearly 17 million treatment sessions have been recorded with BOTOX-A and BOTOX-A Cosmetic in the United States alone over the past 14 years ( ).iii With approximately 2,000 articles on BOTOXÆ and BOTOXÆ Cosmetic in peer-reviewed publications,iv the product is one of the most widely researched medicines in the world.

Mechanism of Action: Botulinum Toxin
Arnon, 2001, Page 1061, Figure 1B B Arnon, 2001, Page 1061, Text below Figure 1, Bullet B D A C Botulinum toxin leaves the injected muscle & binds to the neuronal cell membrane at the nerve terminus and enters the neuron by endocytosis. (marked by letter A) Light chain of the botulinum toxin breaks away from heavy chain and cleaves specific sites on the SNARE proteins, preventing complete assembly of the synaptic fusion complex and thereby blocking ACh release.(marked by letter B) Botulinum toxins types B, D, F,& G cleave the SNARE protein synaptobrevin; types A, C, and E cleave SNARE protein SNAP-25; and type C also cleaves syntaxin. (marked by letter C) Since the SNARE complex cannot form, the neurotransmitter can’t be released. (marked by letter D) Blocks release of Ach; without ACh release, the muscle is not able to contract. Reprinted with permission from Arnon S et al. JAMA. 2001;285: 9 9

Safety Profile of BoNTA
Widely tested and used for over 20 years Derived from a natural occurring protein Medical-legal implications for use of counterfeits Estimated lethal dose is 3,000 units in a 100kg human (1200 units is the largest documented dose utilized therapeutically) “Black Box Labeling” required (4/09) for all BoNTA products, stating the potential complication of migration of the toxin far from injection site *(This move stems from reported complications in children with cerebral palsy treated with BoNTA; no reports with standard cosmetic dosages) Important for the practitioner to include this information in the consent form as well as be aware of the differences in dispersion between ABO and ONA . The move stems from reported hospitalizations and deaths attributed to botulism poisoning in children with cerebral palsy treated with botulinum toxin for muscle spasms. Hospitalizations requiring ventilation have also been reported in adults treated with botulinum toxin for involuntary muscle movement and frequent neck spasms. Deaths among adults are suspected but could not be confirmed. No serious side effects related to the distant spread of toxin have been confirmed among people who have used Botox and the related product for cosmetic purposes. (Dover, et. Al. Procedures in Cosmetic Dermatology: Botulinum Toxin: 2005)

Freeze-dried (lyophilized) Human serum albumin 125 ug/vial
Onabotulinum toxinA AbobotulinumtoxinA Incobotulinum Manufacturing preparation Powder Vacuum-dried Freeze-dried (lyophilized) Storage conditions -5oC or 2oC – 8oC 2oC – 8oC Room temperature Pre reconstitution Post reconstitution Shelf-life (unreconstituted) 24 months 15 months 36 months SNARE target SNAP 25 pH after reconstitution 7.4 Inactive gel carrier Human serum albumin 500 ug/vial NaCl ug/vial Hemagglutinin Human serum albumin 125 ug/vial Lactose 2500 ug/vial 1 mg/vial Sucrose 5 mg/vial Albanese, 2011, Page 90, Table: Marketed Brands of Botulinum Toxin Dressler, Page 1765, Table 1: Properties of different therapeutic botulinum toxin preparations Adapted from: 1Albanese A. JAMA. 2011;305(1)89-90; 2Dressler D and Benecke R. Disabil and Rehab. 2007;29(3): 11

The Role of BoNTA 12

Reconstitution of Ona/Abo/Inco botulinumtoxinA
Base Your Decision on These Clinical Considerations Patient discomfort Patient appearance Dispersement of product Beneficial or increasing the risk of a complication? While Ona and Abo and Inco botulinumtoxinA are all Botulinum toxin type A, due to manufacturing differences, the dispersion of the three products may differ. Calculations of units per site *IncobotulinumtoxinA vial MUST be inverted after reconstitution to assure dissolution of all toxin. More fluid means more discomfort More fluid means more obvious injection sites 1cm from point of injection using a 2.5cc dilution Concerning calculations of units/site Ability to accurately deliver a specific number of units into each injection site crucial to dependable repeated effects Ability to adjust or duplicate desired dosage accuratelyBOTOX® Today we will be reconstituting with 1cc yielding 10u/.1cc Each line on an insulin syringe is 1 unit Botox is packaged as a vial containing 100 units of freeze dried Botulinum Toxin, Type A, appearing as a “circle” of white powder circling the bottom of the vial. It must be reconstituted to make it a liquid in order to be injected. The injector must decide upon the ideal amount of reconstitution fluid.

Syringe Selection Ideal syringe and needle*
Maximum comfort for patient No waste of product Ease of use Inexpensive *depends on the amount of diluent used We will be using a 1cc dilution today; we will also be using a 30 unit syringe; show it to them at this point and explain that with a 1cc dilution 1 line equals 1 unit; fill the syringe and you have 30units; 14

Handling of Reconstituted BoNTA
Minimal agitation post reconstitution Drawing up product with syringe that has a non detachable needle: Remove rubber stopper Protect the sterility of the stopper Touch only the outer rim of the stopper Place stopper with sterile inside facing upward Draw up product directly from vial Replace stopper in vial top Minimal agitation post reconstitution See ASPS Consensus Recommendations for discussion Many clinicians do this; no reported incidents of infection Reference Kebby Industries vial decapper 15

Storage of BoNTA Non-reconstituted product:
Ona and AbobotulinumtoxinA: ˚ C. Can be frozen, but not necessary IncobotulinumtoxinA: room temperature Reconstituted product: (all BoNTA formulations) DO NOT FREEZE Store at 2 - 8˚ C Per manufacturer package insert BoNTA should be used within 24 hours after reconstitution Clinically shown to be effective at 1 month post reconstitution when bacteriostatic saline is the diluent and if kept under proper conditions Stress that using the product within 4 hours was never about efficacy, but about the risk of contamination when using preservative free diluent.

The Keys to Achieving Ultimate Results
Understanding Facial Anatomy and Physiology Custom Mapping and Individual Treatment Plan

1 1 3 1. FRONTALIS 2. PROCERUS 3. CORRUGATOR SUPERCILII 4. DEPRESSOR SUPERCILII 5. TEMPORALIS* 6. ORBICULARIS OCULI 7. NASALIS LEVATOR LABII SUPERIORUS ALAEQUE NASI 9. LEVATOR LABII* 10. ZYGOMATICUS MINOR* 11. ZYGOMATICUS MAJOR* 12. ORBICULARIS ORIS 13. MODIOLUS* 14. DEPRESSOR ANGULI ORIS 15. DEPRESSOR LABII INFERIORIS* 16. MENTALIS 17. DEPRESSOR SEPTI MASSETER PLATYSMA (pictured in next slide) RISORIUS 5 4 2 6 7 8 9 10 17 11 12 13 18 20 15 14 16 19 HAVE THEM locate EACH OTHERS MUSCLES; describe the characteristics of each muscle- orientation of fibers, function, superficial or deep, ; describe the anatomical variances among patients 13 * = do not inject

The Aging Brow Ptosis of the medial and lateral brow caused by the effects of gravity and loss of skin elasticity Development of glabellar frown lines—repeated contraction of corrugators, procerus and depressor supercilli horizontal forehead lines—repeated contraction of the frontalis Patient looks in mirror and precisely identifies any and all areas of face and neck causing dissatisfaction Goal is to introduce every patient to all you can do for them without criticizing their appearance or looking like a sales person. 19

Glabellar Frown Lines Treatment with BoNTA
Procerus Superficial, vertical oriented muscle fibers Evaluate need for multiple injection sites “J” or “L” shaped lines, bunny lines on level with medial canthus Can inject IM, but at 70° angle Mark injection site by making an imaginary line from each inner eyebrow to contralateral canthus to create an “X” eyebrow Lateral post injection massage Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.

Corrugator Supercilli Injections should be low on forehead and deep into muscle Medial head: inject directly at 90° into belly of muscle Tail: inject at 90° just medial to contraction (dimpling of skin) Optional dosage: Ona/Inco u total (female) u total (male) Abo total (female) total (male) Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.

To achieve an arch of the horizontal brow Inject into tail of corrugator Inject orbicularis oculi (OO) laterally at temporal fusion line and/or just medial to this point, avoiding the mid pupillary line Dosage selection dependent on Existing asymmetry Intensity of muscle contraction Thickness of skin Massage of procerus will disperse BOTOX® into the depressor supercilli Massage of corrugator supercilli can increase risk of eyelid ptosis The levator and mueller’s upper eyelid muscles become very superficial in the mid pupillary line; some patients may actually have a “canal” at the supraorbital artery and nerve foramens that lead to the upper eyelid; botox can descend this canal and cause a ptosis Dosage selection dependent on: Asymmetry More depressed brow needs more BOTOX® for elevation Intensity of muscle contraction Stronger muscle needs more BOTOX® to decrease contraction Thickness of skin Central vertical line requires higher dose than the “11” line formation (Dover, et al; Procedures in Cosmetic Dermatology: Botulinum Toxin: 2005)

Glabella Photo courtesy of Jill Jones RN CPSN 23 5 5 6 6 6
Dosage represented is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Photo courtesy of Jill Jones RN CPSN 23

Glabella Photo courtesy of Jill Jones RN CPSN 24

Glabella and DAO Photo courtesy of Jill Jones RN CPSN 25 5 5 7 7 7 4 4
Dosage represented is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Photo courtesy of Jill Jones RN CPSN 25

Glabella and DAO Photo courtesy of Jill Jones RN CPSN 26

Glabella & Frontalis Photo courtesy of Jill Jones RN CPSN 27 2 2 2 1 1
4 4 6 5 3 3 6 Dosage represented is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Photo courtesy of Jill Jones RN CPSN 27

Glabella and Forehead Lines
2 2 5 8 8 5 2 10 2 5 5 9 2 9 9 9 9 9 6 6 Photo courtesy of Dawn Sagrillo, BSN, RN CPSN Dosage represented is appropriate for OnabotulinumtoxinA (black) & AbobotulinumtoxinA (red) *Softening to frontalis due to diffusion of a 1cc dilution of abobotulinumtoxinA injected to the corrugators/procerus

Horizontal Forehead Lines Assessment
Evaluation Hooding of upper eyelids (excess fat and/or skin)* Brow position Low orientation Line curving around the lateral brow with brow elevation (comma) Height asymmetries (document) Width of forehead 12cm or greater = wide brow (at risk for “spock” or “mephisto” brow) Discuss rationale for site and dosage selection Hooding and low set brows may make the pt keep the frontalis contracted by habitp immobilizing the frontalis will add to the problem caused by the underlying issue *Most significant assessment 29

Horizontal Forehead Lines Treatment Pearls
Injection Techniques Inject 2-3 cm above brow to prevent ptosis of brow Low set brows/hooding of upper eyelids treatment options: Chemical and/or dermal filler brow lift Decreased frontalis dosage More superior placement of injection sites Inject glabella (depressor muscles) at same time to prevent ptosis Wide brow treatment options: Lateral injections to prevent “Spock” or “Mephisto” brows (1 – 2 u per site) Leave up to 1 cm vertical strip of functioning lateral frontalis Superior frontalis acts as a brow depressor Mephisto is a demon in german folklore and appearance includes sinister brows Keep injections 2-3 cm above brows to prevent ptosis…Lowest point is midline between brow and hair line Decreased frontalis dosaging decreases the risk of further brow depression Consider chemical and/or dermal filler brow lift to decrease need for persistent frontalis contraction If low brow then inject low dose only medially 30

Horizontal Forehead Lines Treatment Pearls
Injection in sub-dermal plane may prevent bruising Firm, upward and outward massage to disperse Optional dosage: Ona/Inco 6u to 24u (1-3u per site) Abo u (5-10u per site) Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology. 31

Horizontal Forehead Lines
Sites represented are appropriate for 40 units of AbobotulinumtoxinA Photo courtesy of Lovely C. Laban, ARNP, MSN

Horizontal Forehead Lines
1 2 2 2 1 Dosage represented is appropriate for AbobotulinumtoxinA Photo courtesy of Jill Jones RN CPSN 33

Brow Lifts BoNTA Primary Concern is lid ptosis
Caused by BoNTA migration into the levator Prevented by: Injecting in Orbital portion of OO Injecting 1cm above the orbital rim Orbital Palpebral Ciliary Levator is deep to the OO and distal to orbital rim, becoming more superficial at the mid pupillary line. Faculty of Medicine, University of Toronto (2005) 34

Medial Brow Lift Treatment with BoNTA
Assess for medial brow depression (“sinister” brow) Target: medial brow depressor muscles Primary: procerus Secondary: corrugator supercilli, depressor supercilli Dose and technique as for glabellar frown lines Need medial, lateral or both? Undesirable medial brow depression may be relieved with procerus injection 1-5 mm elevation 35

Lateral Brow Lift Treatment with BoNTA
Target muscle: Orbicularis Oculi (OO) Most depressive point on OO is where muscle fibers change directions (horizontal to vertical) To locate, have patient wink very tightly and look for where the lines start to change orientation (horizontal to vertical) Massage in an outward and upward direction to avoid frontalis and OO difusion 36

Lateral Brow Lift Massage in an outward and upward direction
For asymmetrical brow: increase dose to more depressed side Optional dosages: Ona/Inco 3–7 units per side Abo units per side 37

Chemical Brow Lift with BoNTA
Levator/Mueller’s muscles become very superficial in mid pupillary line 38

Chemical Brow Lift 3 4 3 3 6 7 6 4 6 High dose in procerus because of medial ptosis; double injections into medial corrugator due to very high recruitment (evidenced by high lines); assymetrical lateral corrugator and obicularis occuli dosing due to lower left brow Dosage represented is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photos courtesy of Jill Jones, RN, CPSN 39

Lateral Brow Lift and Crow’s Feet
5 ● ● 5 5 5 5 Dosage represented is appropriate for OnabotulinumtoxinA Photo courtesy of Jennifer Kauffman, NP-C

How Can BoNTA Help These Men?
DON’T WANT! How Can BoNTA Help These Men? ● ● ● ● ● ● ● ● 2-3 units 2 cm above brow By raising the procerus and decreasing the intensity of lateral frontalis elevation to create a more natural appearance 41

Brow Lift BoNTA Potential Complications
Frontalis-Brow ptosis/heaviness Treat Brow depressors Lower dosing and higher placement with future treatment Glabella-Ptosis of upper eyelid due to diffusion into orbital septum, affecting levator muscle Alphagan P .15% or Iopidine Visine Glabella--Levator and mueller’s muscles become very superficial in the mid pupillary line of the upper eyelid. Therefore, the mid pupillary line injection is the most likely to cause a ptosis Alphagan administered 1 gtt affected eye TID 42

Periorbital Aging Aging causes a loss of skin elasticity and fat volume in the infraorbital area resulting in lengthening of the lower eyelids and formation of infraorbital hollows Repeated contraction of the orbicularis oculi causes the development of crows feet and possibly infraorbital “jelly roll” 43

Crow’s Feet Treatment with BoNTA
Injection placement: 1cm above the zygomatic arch 1cm lateral to the orbital rim 2-4 injection sites per side 2nd lateral row of sites if lines extend laterally Superficial injection may prevent bruising and diplopia Massage injection sites away from eye Best results with injection sites close together, above lateral canthus Optional Dosages: Ona/Inco units per side Abo units per side Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.

Crow’s Feet 45

Crow’s Feet Note residual lines as a result of ZM contraction ● ● ● ●
Crow’s feet: 4 units per site Brow lift: units on R, 3 units on L *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photo courtesy of Jill Jones, RN, CPSN 46

Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN
Crow’s Feet ● ● ● ● 4 units per site *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN 47

Crow’s Feet Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN 48

Lower Lids Treatment with BoNTA
Indications “Jelly roll” appearance when smiling/squinting Negative appearance of small eye opening Asymmetry of eye opening Provides a more “western” appearance to Asian eyes by “rounding out” the almond shaped eye No improvement for excess skin and fat Appearance of excess lower lid fat can worsen with this treatment Hypertrophy of the lower Orbicularis Oculi causes a “jelly roll” appearance when smiling/squinting; not present at rest; must distinguish this from a fat bag 49

Potential Contraindications Poor snap test Dry eyes Scleral show History of lower lid swelling, as with allergies Previous lower eyelid surgery Lower lid blepharoplasty without canthoplasty Co2 laser resurfacing Previous lower eyelid surgery will increase risk of lag opthalmus/ectropion Must have a brisk return to resting position or will result in lag opthalmus LL swelling will worsen post lower lid injection due to decreased pumping action of OO Adjust dosage to correct asymmetry Increasing aperture will increase scleral show Assess for dry eyes; Opening eye aperture will increase tear evaporation and worsen dry eyes 50

Injection Technique Injection site 3mm below ciliary margin and below tarsus Lateral to mid pupillary line Superficial (intra-dermal) Patient positioned upright, head steady, eyes looking upward Massage laterally Optional dosage: Ona/Inco 1-2 units per side Abo No dosing available 1-11 51

Lower Lids “Jelly Roll”
● ● Not excess fat/skin; only bulges with smiling which means it is hypertrophic muscle. Pt also had lateral brow lift and glabellar injections and crow’s feet injections. 2 units on R; 1 unit on L *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photo courtesy of Jill Jones, RN, CPSN

Periorbital Aging BoNTA Potential Complications
Crow’s Feet – bruising, diplopia, ectropion, and asymmetrical smile Inject more superficially in the future Keep injections 1cm above the zygomatic arch Lower Lids – ectropion, dry eyes, scleral show, malar edema Do not inject lower lids in the future Lower lid lymph edema (typically disappears in 2-3 weeks) Antihistamines Massage and/or ice Crows—diplopia--due to medial migration & resulting paralysis of lateral rectus muscle, ectropion, or drooping lateral lower eyelid, and asymmetrical smile (migration into ZM) 53

Bunny/Wolf Lines Evaluation
“Crinkle” across nose with frowning/smiling Lines are oblique and just lateral to the nasal dorsum Injected glabella area is immobile Nasalis continues to contract, forming lines below area of immobility Considered the “BOTOX” sign post glabellar injection with BOTOX® Lines are oblique and just lateral to the nasal dorsum, resembling whiskers of a bunny or wolf

Photo courtesy of Terri Harper, MSN, APRN, FNP-C
Bunny Lines Pre Glabella Injection Smooth Post Glabella Injection Remaining Crease Photo courtesy of Terri Harper, MSN, APRN, FNP-C

Bunny/Wolf Lines Treatment with BoNTA
Injection Technique Targeted muscles: Nasalis Bilateral just lateral to nasal dorsum Avoid the nasofacial groove to avoid the LLSAN Intradermal at 20-30° angle Aim medially toward nasal dorsum Massage toward the nasal dorsum Optional Dosage: Ona/Inco units per side and 1-2 units across dorsum Abo units total Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.

Photo courtesy of Jill Jones, RN, CPSN
Bunny/Wolf Lines ● ● OnabotulinumtoxinA 3 units bilateral Additional sites: Glabella, left lateral brow lift, crow’s feet *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photo courtesy of Jill Jones, RN, CPSN

Nasal Tip Elevation Treatment with BoNTA
Evaluation Indications: Droop of nasal tip with smiling Hyper animation of nasal tip with speaking Downward nasal tip angle on profile Horizontal rhytid between nose and central top lip Ideal nasal tip angle on profile Male: right angle to facial bones Female: slight upward tilt Angle of the nose takes precedence over correcting horizontal rhytid 58

Nasal Tip Elevation Treatment with BoNTA
Injection Technique Intra-muscular at mid line directly beneath the septum Angle needle slightly upward toward the nasal spine No massage Optional Dosage: Ona/Inco 2 units and titrate up as necessary Abo units Medicis Inc, Scientific Department 2011 59

Photo courtesy of Jill Jones, RN, CPSN
Nasal Tip Elevation ● Pt also had botox; sites: forehead, glabella, lat lift, crow’sx feet, top and bottom lip, DAO 2 units *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photo courtesy of Jill Jones, RN, CPSN 60

Mental Crease Horizontal crease below the lower lip develops as result of repeated contraction of mentalis Dimpling with contraction (peau d’orange) 61

Chin Treatment with with BoNTA
Inject at the mandibular junction, IM at 45° - 90° angle 1 to 3 sites, depending on mentalis contraction Must avoid injection into Orbicularis Oris, DAO, DL Massage: direct pressure post injection Cleft Inject on either side of cleft Without cleft Inject mid line Optional Dosages: Ona/Inco 2-6 units Female; 2-8 units male Abo units Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology. Avoid orbicularis oculi, depressor anguli oris, depressor labii 62

Chin No cleft 63

Chin ● ● With cleft 3 units per side
*Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater 64

Down Turned Mouth Treatment with BoNTA
Muscle: Depressor Anguli Oris (DAO) Techniques to Consider 1cc dilution if using Ona/inco botulinumtoxinA Inject on a trajectory with the naso-labial groove low at the mandibular junction Intramuscular at a 90° angle Injection just beneath the subcutaneous fat Massage: press area post injection Optional Dosages Ona/Inco 3-7 units per side Abo per side Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology. Goal: Elevation of the corners of the mouth by allowing for more efficient contraction of lateral lip elevators. Smoothing the skin of the lateral chin. Alternate techniques to locate DAO Bite down on back teeth and identify medial border of the masseter muscle and inject 1 thumb width medial to its border Measure 1cm lateral to oral commissure and 1cm downward from that point 65

Down Turned Mouth 66

Photos courtesy of Jill Jones, RN, CPSN
Down Turned Mouth trajectory *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater 3 units per side Photos courtesy of Jill Jones, RN, CPSN 67

Down Turned Mouth ● ● ● ● 3 units lower site 1 unit upper site *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photos courtesy of Jill Jones, RN, CPSN 68

Vertical Lip Lines Treatment with BoNTA
Injection Technique Injections placed so as not to compromise lateral oral competence Intradermal Massage injection sites Initial injections should be symmetrical Consider injecting lower/top lip separately initially Increased dilution may improve result due to increase in spread of effect Intradermal to decrease excessive muscular compromise Consider injecting lower/top lip separately in order to allow for patient adjustment to change in mobility Adjust if asymmetrical contraction is observed on follow up Lateral injection could compromise lateral oral competence (may result in drooling)

Injection Technique Mid line injections: Avoid cupid’s bow in older patients Mid line injections for more youthful patients Augmentation: Upper lip : Inject low across vermilion border Lower lip: Inject in midline of vermilion border to give a “pouting” look Mid line injections: Avoid cupid’s bow in older patients (results in increased flattening of area) Mid line injection into cupid’s bow with excessive mid line contraction in more youthful patients (to avoid “beak” effect) Augmentation: Upper lip augmentation: Inject low across vermilion border Lower lip augmentation: Inject in midline of vermilion border to give a “pouting” look Line Reduction: Upper lip: injections spread evenly across lip; Lines radiating upward toward nose; 2 sites: 1 above the other-situated on a horizontal line mid way between the vermilion border and superior border of the OO Lower lip: where contraction is observed Optional Dosages: 4-10 units per lip

Injection Technique Line Reduction: Upper lip: spread evenly across lip Lower lip: where contraction is observed Optional Dosages: Ona/Inco 4-10 units per lip Abo Upper u; Lower u Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.

Vertical Lip Lines

Vertical Lip Lines ● ● ● ● 1 unit per site *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photos courtesy of Jill Jones, RN, CPSN

Vertical Lip Lines/Augmentation
● 2 units each side 1 unit mid line *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photos courtesy of Jill Jones, RN, CPSN

Gummy Smile Treatment with BoNTA
Evaluation Abnormal visibility of gum line Upper lip retraction when smiling

Gummy Smile Treatment with BoNTA
Injection Technique Target muscle is the LLSAN Injection site: Piriform fossa at nasal labial groove just lateral to mid alar border 45° to 90° angle Intramuscular No massage Optional Dosages Ona/Inco 1 unit per side; titrate 1 unit at a time per side Abo units per side Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology. Allows for lengthening of upper lip to decrease excessive exposure of gingiva with smiling

Photos courstesy of Dawn Sagrillo, BSN, RN, CPSN
Gummy Smile ● ● ● ● Note improvement of nasolabial folds; not good to do for this purpose if patient doesn’t have a gummy smile ● 1 unit per side *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photos courstesy of Dawn Sagrillo, BSN, RN, CPSN

The Aging Neck Horizontal neck lines are caused by flexion of the neck muscles, but may also be due to Excess folds of skin Sun damage Have patient exaggerate flexion of the neck (contract platysma) If lines deepen with flexion of platysma, improvement possible with BoNTA Platysmal bands develop as the muscle separates with age BoNTA will not help loose bands that do not extend with contraction Treating the lateral bands at the uppermost palpable band can tighten the neck line 78

Horizontal Neck Lines Treatment with BoNTA
Target Muscle: Platysma Techniques to Consider Injection sites spaced 1-2 cm apart Inject just above each targeted neck line Inject intra-dermal (raising a skin wheal) at a 10-15° angle Massage post injection Optional Dosages Initial treatment Ona/Inco units total; may titrate dose upward according to patient response Treatment with Abo not recommended at this time 1-11 79

Horizontal Neck Lines 80

And then there are….. 81

Platysma Bands Treatment with BoNTA
Injection Technique Muscle: Platysma Techniques to Consider: Inject 1-1 1/2 cm apart along the band Grasp muscle band between the finger and thumb IM injection No massage Goal:Smoother appearance of neck; tighter mandibular line Dover, et al; Procedures in Cosmetic Dermatology: Botulinum Toxin: 2005) 82

Platysma Bands Treatment with BoNTA
Optional Dosages: Ona/Inco 3-10 units per site Highest dose at top and decrease as descend the neck Thinner bands respond to units per band Thicker bands may require up to 30 units per band A total dose of units has been described in literature Abo 5-10 units per site for max dose 50 units per band ( total) Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology. 83

Nefertiti Lift Treatment with BoNTA
Target Muscles: Platysma DAO Techniques to Consider Platysma lateral bands Dosed as described in medial platysma injection slide Injection sites spaced 1-2 cm apart Ona/Inco 2 units along mandlibular border lateral to the DAO and medial to masseter cm apart Dosed and injection placement as described in DAO slide 84

Platysma Neck Bands 85

Horizontal Neck Lines Platysma Bands
DAO 3 units Platysma bands 37 units total Horizontal lines 2 units each site *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Photos courtesy of Jill Jones, RN, CPSN 86

Platysma Neck Bands R lateral band 8 units on top;6 units below R mid line 8 units on top; 5 units below L mid line 8 units on top; 5 units mid; 4 units below L lateral band 8 units *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater Total units = 52 units Photos courtesy of Jill Jones, RN, CPSN 87

Photos courtesy of Dawn Sagrillo ,BSN, RN, CPSN
Platysma Neck Bands Photos courtesy of Dawn Sagrillo ,BSN, RN, CPSN

Masseter Hypertrophy Evaluation Square jaw or a wide lower face
Common in people of Asian descent Patients with bruxism may also have masseter hypertrophy On exam, prominent masseter will be palpated Bruxism is more commonly known as teeth grinding.

Masseter Hypertrophy Treatment with BoNTA
Injection Technique Palpate the masseter as the patient bites down on the back teeth Inject IM into the bulk of the muscle Toward the mandible in the lower mass of the muscle Avoiding the upper masseter (toward the zygoma) Ona/Inco 25 units per side Evaluate at 2 weeks; May add u at that point if necessary Ona max dose is 75 units; results are typically seen for 6 months Larger doses (50-75u) may cause buccal weakness Abo units per side in 3-4 injection sites Larger doses (50-75u) have been reported to cause low incidence of buccal weakness or fatigue after vigorous chewing Ahn, Horn, Blitzer ; Arch Facial Plastic Surg May/June 2004

Masseter Hypertrophy Before 25u each masseter At 10 weeks *Above dosage is appropriate for OnabotulinumtoxinA or IncobotulinumtoxinA Appropriate dosage for AbobotulinumtoxinA would be greater At 2 weeks; 15 units added each masseter Photos courtesy of Linda Gilliland PhD, ARNP

The Role of Dermal Fillers

Keys to Providing Successful Dermal Filler Treatments
Thorough understanding of skin anatomy and aging process Thorough comprehensive consultation Proper patient selection Proper filler selection Proper injection technique Appropriate combination of treatments We will talk about the layers of the skin on the next slide; talk about the difference between Sagging versus wrinkling; is the patient a wrinkler or a sagger or a combo? Injection of products into each layer will correct a specific issue Aging process Loss of elasticity of skin Loss of volume (fat atrophy, bony resorbtion) Must conduct a thorough consultation. Communication is key in identifying what does the patient see as their aesthetic problem, not what you see. Identify each patient’s pattern of aging Clearly identify patient’s aesthetic goals Must be able to select appropriate filler for each cosmetic issue Each dermal filler is intended for injection into a specific level of the dermis Products are intended to be injected into the Superficial papillary layer of the dermis or into the Deep reticular layer of the dermis Layering of dermal filler products, depositing product into the deep as well as the superficial level of the dermis may be necessary for total correction Injections into the deep RETICULAR layer of the dermis volumizes and provides support and removes folds and depressions that cause shadowing effect Injections into the superficial PAPILLARY layer of the dermis smoothes surface irregularities such as creases/wrinkles (rhytids) BOTOX® Cosmetic: 1) extends the life of dermal fillers when injected into the same anatomical region 2) eliminates or reduces dynamic lines and can decrease the amount of filler needed for fine line correction

Anatomical Layers of the Skin
Epidermis Thickness ranges from mm (3 sheets of stacked typing paper) Epidermis Dermis Thickness ranges from 1-4 mm Papillary Dermis Reticular Dermis Epidermis is the layer you see All fillers must be beneath the epidermis Papillary--Zone immediately underneath epidermis Derivation of tactile sense Diffuse vascular network Radiates heat to the skin’s surface Reticular--Thicker, deeper layer of dermis Extends to the subcutaneous tissue Contains wealth of arteries and veins Pressure receptors and sweat glands Fat Lobules Subcutaneous Note: Skin thickness varies by anatomic region

Facial Outline Changes Due to Aging
“Triangle Of Beauty” In youth, most of the fullness of the face is in the middle third. Fullness becomes more apparent in the lower third of the face with aging Triangle Trapezoid or Rectangle

Skeletal Changes Due to Aging
Skeletal changes include: Accentuation of underlying skeletal deficiencies & asymmetry of facial bones Malar atrophy & submalar hollowing due to absorption of zygoma bone Chin protrusion and sinking around the mouth due to mandible absorption VERTICAL ARROWS ON PHOTOS SHOW THE DRAMATIC DEGREE OF FLATTENING OF THE MID FACE & FOREHEAD AND ELONGATION OF THE EYE SOCKET AND CHIN PROTRUSION DUE TO BONY ABSORPTION.

Volume Loss Due to Aging
Fat absorption, bone loss, dermal thinning

Longevity of Correction Factors Contributing to Absorption of Product
Characteristics of product Molecule size Percent of active ingredient* Cross-linking agent Viscosity of product Characteristics of individual/injection technique Metabolism Mobility of treatment site Depth of product deposit into the skin (deeper = more product needed) *most significant factor CROSS LINKING MAKES A PRODUCT LAST LONGER, BUT CAN INCREASE SENSITIVITY, SO A DELICATE BALANCE MUST BE MAINTAINED BETWEEN THE RIGHT AMOUNT OF CROSS LINKING AND TOO MUCH CROSS LINKING. A FAST MASTABOLISM AND MOBILITY OF AN INJECTION SITE MAKES A PRODUCT ABSORB FASTER THE DEEPER A PRODUCT IS INJECTED, THE MORE PRODUCT IT TAKES TO SEE A VISIBLE RESULT ON THE SURFACE

What Is Hyaluronic Acid (HA)?
Naturally-occurring linear polysaccharide (sugar) Identical chemical structure across all species No need for skin allergy test Short life span in natural form (4 days) Cross-linking extends life span Enzymatic degradation Naturally occurs in body Manufactured Hyaluronidase for HA products 99 99 99

How to Differentiate HA Fillers
Raw HA typically is sourced from the one manufacturer Specific characteristics and variables make each HA filler unique Total HA concentration Soluble HA added or not (lubricant) Average molecular weight (MW) of HA (length of strands) Degree of cross-linking or cross-linker used Varying particle size Gel / Fluid HA ratio Gel hardness (G’) Extrusion force and viscosity Degree of gel swelling post injection One source of the raw HA, each manufacturer takes that HA and manufacturers it in a way to produce the commercially available product they desire. You don’t need to go through each individual specific characteristic, but just sum it all up by saying “These specific characteristics make each filler unique. These characteristics can effect the longevity of the product, the feel of the product to the injector, as well as post injection anticipated normal skin reactions.” 100 100 100

Particulate HA Defined: Process:
Sieved (“particulate”) HA gels – Restylane & Perlane Individual particles of cross-linked hyaluronic acid dispersed in a soluble HA lubricant Process: Raw HA cross linked and formed into gel blocks HA gel blocks are passed through sizing screens to create particles of a single size Sieved means that the HA was pushed through, or sieved, through a screen to make the product consist of particles suspended in a gel carrier. Perlane has larger molecules of the sieved HA. The products do not stay cohesed, so this can be an advantage in certain areas where you want a “flatter” correction. 101

Cohesive Gel HA Defined: Process:
Non-sieved HA gels – Belotero Balance & Juvederm No particle sizing occurs during manufacturing Process: HA is cross linked and made into a cohesive, homogeneous mass Different particle sizes Creates a more cohesive gel Think of sieved as “lumpy” mashed potatoes and non-sieved as whipped potatoes. This does not make a product better than another, just different. The behavior of sieved or non sieved may have an effect on which product a practitioner decides to use for a specific indication. 102

Distinctions of Cohesive Gel versus Sieved HA
Behavior of each type once injected Smooth Remains in the shape it was injected in Lift Softness on palpation Sieved Spreads from point of injection Slight firmness on palpation Practitioner must decide which type provides ideal correction for particular sites of injection Think of sieved as “lumpy” mashed potatoes and non-sieved as whipped potatoes. This does not make a product better than another, just different. The behavior of sieved or non sieved may have an effect on which product a practitioner decides to use for a specific indication. 103

U.S. FDA Approved Products

Juvederm Ultra and Ultra Plus
Non-animal derived Hyaluronic Acid (HA) gel FDA approval for mid-deep dermal injection for treatment of moderate to severe facial wrinkles/folds such as n/l folds 2 syringes per box ( .4cc or 1cc ) Chemical makeup: Ultra: 24mg/ml HA less viscous Ultra Plus: 24mg/ml HA 20% more viscous than Ultra due to higher degree of cross-linking Injection Plane: Ultra: mid to deep reticular dermis Ultra Plus: deep reticular dermis Longevity of correction: up to 12 months with initial treatment Juvederm ultra 24mg HA Juvederm Ultra plus 24mg HA—crosslinked at higher rate than ultra making it more viscous and longer lasting Note: longevity estimations based on anecdotal reports and FDA approved statement

Juvederm Ultra XC and Juvederm Ultra Plus XC
Identical to original formulations in packaging, chemical composition, injection technique and longevity Lidocaine .3% in a powder form added by manufacturer Powder form ensures that the physical characteristics and longevity of the product are unchanged Patients report 90% reduction in pain Patients report 90% reduction in pain

Juvederm Voluma XC Non-animal derived Hyaluronic Acid (HA) gel
First HA filler FDA approved for Mid Face Volumization FDA approval for deep supraperiosteal and/or subcutaneous injection for treatment of age-related volume deficit in the mid face (cheeks) on adults over 21 2 syringes per box (1cc) Chemical Make up: 20 mg/ml of tightly cross linked HA (short chain) HA using Vycross Technology (high G’) Injection Plane: Sub Cutaneous Plane/ Supra Periostial Depot Longevity of correction: up to 2 years with maximum fill NOT to be placed in mobile areas (ie: lips, hands) or for nasal sculpting or glabella What is Vycross techonology: It is a method that creates more effective cross linking because of short HA chain lengths. The G’ is very high (highest among its competitors) and the cohesivity is lower. Smoothness is still intact.

Restylane & Perlane Restylane 1 syringe per box (.5cc, 1cc or 2cc)
Non-animal derived Hyaluronic Acid (HA) with molecules suspended in a gel carrier FDA approval for mid-deep dermal injection for treatment of moderate to severe facial wrinkles/folds such as n/l folds Restylane 1 syringe per box (.5cc, 1cc or 2cc) Perlane syringe per box (1cc, 2cc) Chemical makeup: equal percentages of HA/ml Restylane particle size smaller Perlane particle size larger Injection Plane: Restylane: mid-deep reticular dermis Perlane: deep reticular dermis Longevity of correction: Restylane: 4-6 mos; up to 18 months/1 touch up at mos Perlane: at least 6 months Restylane has 20mg/ml of HA and a smaller particle size Perlane has 20/mg/ml but has a larger particle size Refer students to charts Note: longevity estimations based on anecdotal reports and FDA approved statement

Restylane-L Perlane-L
Identical to original formulations in packaging, chemical composition, injection technique and longevity Lidocaine .3% added by manufacturer Patients report 90% reduction in pain

Prevelle Silk Non-animal derived Hyaluronic Acid (HA) molecules suspended in a gel carrier FDA approval for mid dermal injection for treatment of moderate to severe facial wrinkles/folds such as n/l folds 1 syringe per box (.9cc) Chemical makeup: 5.5mg HA Crosslinked with Divinyl Sulfone Contains .3% Lidocaine Injection Plane: Mid reticular dermis Longevity of correction: Up to 4 months

Belotero Balance Non-animal derived Hyaluronic Acid (HA) gel double cross-linked with BDDE FDA approval for mid-deep dermal injection for treatment of moderate to severe facial wrinkles/folds such as n/l folds 1 syringe per box (1cc) Chemical makeup: 22.5mg HA Injection Plane: Mid to deep dermis but may be injected more superficially Longevity of correction: typically month/Labeling extended months when a repeat treatment used The way it integrates into the tissue makes it less likely to cause a Tyndall effect when injected more superficially than the other Has. Note: longevity estimations based on anecdotal reports and FDA approved statement

What Is Calcium Hydroxylapatite (CaHa)?
Naturally occurring mineral form of calcium apatite Belongs to group of phosphate minerals known as apatites Composed of calcium, phosphate and hydroxide Major component of bones and teeth Pure hydroxylapatite powder is white 112 112 112

Radiesse Chemical makeup
CaHa active ingredient (70%) + glycerin and water gel carrier (30%) FDA approval for mid dermal injection for treatment of moderate to severe facial wrinkles/folds such as n/l folds & for lipoatrophy due to HIV Vacuumed packed in foil pack; 1 syringe per box (.3cc, .8cc, or 1.5cc) 1 kit per syringe for adding Lidocaine to product Injection Plane: Deep reticular dermis or dermal/subcutaneous junction Longevity of correction: 12 months or longer Limitations Not recommended for use in superficial rhytids, lips or tear trough RADIESSE ACTS AS A FILLER AND BIOACTIVATOR GEL CARRIER ABSORBS IN 3-4 MONTHS AND THEN THE CAHA TRIGGERS THE TISSUE TO PRODUCE MORE COLLAGEN LIDOCAINE IS NOT ADDED TO PRODUCT BY THE MANUFACTURER BECAUSE IT CAN CHANGE THE CHARACTERISTICS OF THE PRODUCT IF IT IS ADDED WELL IN ADVANCE OF INJECTION, AS WELL AS IT LEAVES IT UP TO THE INJECTOR HOW MUCH LIDOCAINE TO ADD; MOST PRACTITIONERS ARE ADDING 0.2CC TO 0.3CC PER A .8 OR A 1.5CC SYRINGE. Note: longevity estimations based on anecdotal reports and FDA approved statement

What Is Poly-L Lactic Acid (PLLA)?
Synthetic Polymer from the Alpha Hydroxy Acid family Byproduct of sugar fermentation 40 ‐ 60 Micron Particles Irregularly Shaped “Spikey” i.e. sharp edges under scanning EM Used in dissolvable sutures and implants for decades Biodegradable and biocompatible Breaks down into C02 and water Nontoxic effects on biological function Stimulates the fibroblast cell to produce collagen Gradually restores volume to targeted areas 114 114 114

Sculptra Poly-L Lactic Acid: NOT considered a filler, but a bioactivator Large volume indications; requires week intervals FDA approval for up to 4 injection sessions that are scheduled about 3 weeks apart for correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles 2 vials per kit; powder that must be reconstituted prior to injection with 6-8cc sterile water 1-2cc Lidocaine, plain or with epinephrine Injection Plane: Subcutaneous tissue Longevity of correction: Up to 2 years (maximum results seen at 6 mos post final treatment) Limitations: Not recommended for use in superficial rhytids, lips or tear trough Stimulates collagen matrix production in a series of treatments Reconstitution of product Reconstitute with 5-7cc of sterile water and let vial stand at room temperature for 2 hours Agitate suspension immediately prior to use Add 1cc lidocaine (with or without epi) immediately prior to injection Manufacturer states reconstituted product can be stored at room temperature (up to 86˚ F) Indications Generalized loss of volume, as in facial wasting/lipoatrophy deformity in HIV, or aging Cheek augmentation Process Patient will typically need 3-6 treatments scheduled 4-6 weeks apart Injection Technique Must be subdermal Use only retrograde threading Inject only small.01cc threads of material at each pass Cross hatch threads Typical sites of use: Cheeks Mental grooves Temporal fossa Post instructions Massage 2 times a day x 7 days

Proper Placement of Each Filler
Epidermis Not appropriate for fillers Papillary Dermis Reticular Dermis HA products (not Voluma) CaHa Subcutaneous CaHa (at junction) PLLA Juvederm Voluma

Proper Product Placement
Papillary Dermis Needle Angle: 10-25 ˚ Appearance of needle under the skin: Hint of color, no reflection Resistance: Will feel resistance against the needle Immediate reaction of skin to injection: Immediate blanch Belotero can be injected into the papillary dermis with less risk of Tyndall effect than other Has. When you press the needle that is extended its entire length under the skin in the papillary dermal layer, the skin will pucker with the needle.

Reticular Dermis Needle Angle: 45-90˚ Appearance of needle under the skin: shape of needle, no color Resistance: Will feel resistance against the needle Immediate reaction of skin to injection: Delayed or no blanch Where all HA products on market today are intended to be injected

Subdermal Plane Needle Angle: 45-90˚ Appearance of needle under the skin: Generalized elevation of entire area Resistance: No resistance against the needle Immediate reaction of skin to injection: No blanch This would be Sculptra and maybe Radiesse

Depth of Needle Placement Appearance
Subcutaneous placement Epidermal placement subQ: elevates entire area Epidermal: will see product through skin; no product goes here Reticular: where MOST products are intended to be injected; will see elevation of skin that drapes around the SHAPE of the needle, but will not be able to color of needle Reticular dermis placement 120

Injection Techniques Threading
Needle is inserted into appropriate depth of skin Needle is advanced the entire needle length, maintaining consistency in depth Product is injected as needle is withdrawn (retrograde) Procedure repeated the length of desired correction Overlap end to end threads Threading: Needle is inserted into appropriate level of the skin, advanced to maximum point, and product injected as needle is withdrawn (retrograde). Ideal sites: vermilion border/vermilion, N/L folds, marionette lines, tear trough, cheek/chin augmentation, brow lift, nasal contouring

Injection Techniques Fanning
Product is deposited into several pathways from one injection site Fanning: Product is deposited into several mid dermal pathways extending from one insertion site Ideal for N/L groove, marionette lines, large surface areas 122

Injection Techniques Cross hatching
Multiple adjacent threads are laid down in area of defect in one trajectory Perpendicular threads are laid across initial threads Adds significant volume Cross hatching: Series of parallel threads of product, followed by placement of additional series of parallel threads above or below and perpendicular to first series. Ideal for areas requiring larger volumes.

Injection Techiques Tenting Lay down foundation above the periosteum
Continue to layer into subcutaneous layer (aka: “tenting”) with the goal of restoring natural contours Medial cheek – inject in subcutaneous space Lateral cheek – supraperiosteal and subcutaneous Dose Mild – 0.5cc – 1cc per side Medium – 1cc -2cc per side Severe – 3+ cc per side

Injection Techniques Serial Puncture Tracking
Needle is inserted into appropriate depth of skin Appropriate amount of product (typically cc) deposited Needle removed Procedure repeated immediately adjacent to previous location Tracking Only possible in vermilion border Product advances itself Serial Puncture: Needle is inserted into appropriate level of the skin, deposit of product injected into skin, needle removed and procedure repeated immediately adjacent to previous location. Ideal for superficial injections. Tracking: Needle is placed into appropriate level of the skin, needle position stabilized, plunger depressed, product advances itself. Only applicable for the “canal” of vermilion border 125

Common Responses To Treatment versus Adverse Events
Differentiate for patient BOTH can be technique related or product related Explain to patient what MAY be expected vs. true complications that MAY occur. We will first look at RESPONSES to treatment

Factors Influencing Patient’s Response to Treatment
Needle gauge required for viscosity of product Multiple puncture technique Rapid injection technique Location of product placement Aggressive massage Patient’s inherent response to injury Oral anticoagulants in meds, nutritional supplements and food Generally, placing dermal fillers is a minimally traumatic event. Needle gauge required can contribute to extent of trauma. More viscous product or larger particle size requiring larger diam needle can cause larger epithelial tear or puncture,greater disruption of dermal structures (capillaries) resulting in more signif edema and stimulation of inflammatory cascades. Fast inj more traumatic than slow. Placement above or below mucles such as lips, TT’s can have higher intensity and propensity for swelling due to vascular nature. Pts respond to “trauma” within a range of bruising/swelling inherent to their natural tendencies. Meds, supplements & food can exacerbate the normal response to trauma.

Early Common Responses
Swelling Bruising Needle marks Remember that: Extent of responses vary in degree and duration Technical and patient variables may influence response The extent of these responses fall along a bell curve in a range of magnitude and duration expected for the type of filler. Consider also technical and patient variables that can accentuate or detract from these adverse events.

Management of Treatment Responses
Swelling Ice Antihistamines Temporary immobility of area Transient painless bruising or discoloration Direct pressure Cold compresses Arnica Montana Bromelin BBL or Q switch laser ABT has an Arnica Forte that contains arnica, bromelin and vit c all in one capsule Mention Sinnech and Vitamedica as examples of brand name Arnica preparations

Example of Prolonged Bruising Secondary to Aspirin Use
Severe bruising lasting several wks after augmentation with silicone. Pt forgot to d/c ASA before tx. (Duffy, D., 2005)

Bruising After HA Injection for Tear Trough Deformity
Photo shows 5 days following injection (Procedures in Cosmetic Dermatology. (Cox, S.E., & Lawrence, N., 2007)

Asymmetry Following Injection
Temporary post treatment swelling may obscure assessment & final outcome Volume miscalculation Pre-existing asymmetries: may be impossible to completely correct Refinement at follow up visit if true asymmetry exists Make note of amounts of product used per side (I.e., lips)

Moving onto Adverse Events…
Now to step into the ring with discussion

Hypersensitivity Incidence with bovine collagen 3% (Artefill)
Incidence with HA is .02% and often self resolving Symptoms Pain Redness Swelling at injection sites

Signs of Vascular Occlusion
Venous Occlusion Arterial Occlusion Does not produce immediate pain or blanching Process is slower Venous Congestion (intradermal bleeding) Gradual area of darkening; dusky appearance Immediate pain Blanching, followed by darkening of tissue These are signs/symptoms related to venous occlusion.

Management of Vascular Occlusion
Action FIRST Stop injection Immediate pressure and icing ONLY if hematoma suspected Hyaluronidase to dissolve HA Massage Warm compresses If blanching/dusky appearance continues, apply 2% nitroglycerine paste to the skin Sloughing may occur within 2 days to 1 week manage with gentle wound care Most wounds will heal without scarring Hyaluronidase injection will dissolve unwanted HA Massage to dissipate product. Post-massage erythema may develop and indicate resolution of occlusion. Priority is to re-establish circulation to the ischemic tissue. Primary surgical repair is always a last resort if wound won’t heal secondarily. Collagen products have a “procoagulant effect” that can result in propagation of occlusion. Speculation of the cause in glabellar region include: vasc. Compression or poor collateral circulation of supratrochlear vein. Most feared complication is blindness due to retinal artery embolization and has been reported with a variety of fillers. Apply 1/2 to 1 inch of ointment to glabella and adjacent forehead (within 3 cm of affected area) Occlude with Saran wrap Spread into thin, uniform layer Leave on for 12 hrs, then remove for 12hrs; continuing cycle until clinical improvement noted Continue treatment until improvement noted and/or as pt tolerates Hyperbaric Oxygen is recommended if impending necrosis suspected (Narins et al, 2006)

Necrosis Extremely rare less than 0.001% worldwide (Narins et al, 2006) Reports with every type of filler At risk locations: Glabella and forehead Nasolabial groove Acne scars (i.e., cheeks) Lips AT RISK LOCATIONS: angular artery/nasolabial groove. DEFINITION: Death of living cells or tissues due to ischemia (lack of blood flow) and is non-reversible. Glabella and forehead: because of arterial plexus; nasolabial groove-because of angular artery; acne scars because of decreased vascularization; lips because oflabial artery Not related to product See Vascular Anatomy Diagram in “General Information” section of manual

Causes of Necrosis Pressure occlusion of cutaneous vessels
Emerging hematoma; will not cause arterial occlusion but can still result in necrosis of overlying dermis Excess product volume Cannulation and direct injection into vessels resulting in occlusion and ischemia (Carruthers & Carruthers, 2007)

Post Injection Ulceration and Scarring to Glabella with ZyPlast
(Duffy, D., 2005)

Post Injection Necrosis Naso-Labial Folds with HA
2nd photo is approximately 2-3 months post injection

Post Injection Vascular Occlusion Tear Trough with HA
Patient received a HA 0.1cc to medial cheek; The patient complained that she felt a “zing” to her nose at the time of injection; (would indicate contact with the infraorbital nerve). Injection was stopped and everything looked good at that time. The photo is from 3 hours post treatment; can see the tell-tale sign of a vascular occlusion of the lacy blanch/redness across the effected area. Patient was seen immediately and treated with Hyaluronidase, Nitropaste, warm compresses. No resulting sequelle.

Infection Occurrence rate is rare
Prevent by appropriate pre-injection skin cleansing Biofilms Post injection antibiotic ointments shouldn’t be routinely used History of oral herpes Consider prophylactic treatment with antiviral prior to filler tx Do not inject in presence of active herpes or bacterial infection Bacterial infection should be suspected where there is prolonged erythematous papules/nodules at the treatment site (Neosporin, Polysporin, Bacitracin-#2 contact allergen in U.S.) can be sensitizing and cause sensitivity and pruritis Herpes outbreak: at greater risk, those that have outbreaks once a year or have had occurrence in last 6 mo. More concerned about outbreaks in the specific area of treatment.

Herpes Simplex Virus of Upper Lip
Photo shows 5 days following injection (Procedures in Cosmetic Dermatology.

Shingles Outbreak Post Injection
Had marionette lines, NLF’s, lips. Outbreak started several days later. Reported no Hx of cold sores.

Product Visibility Underlying causes: Exhibits as noninflammatory
Malposition of product (superficial placement) Excess product Exhibits as noninflammatory Appearance Opaque products: white or papular HA products: light blue or steel gray, “glass-like” (Tyndall effect) Non-inflammatory nodules should lower the suspicion for infection.

Product Visibility Management Massage area to disperse product
Incision with needle (i.e., 25g) to attempt to express product (this is possible as long as the product is visible) QS 1064 nm laser also reported to be effective for HA visibility Hyaluronidase (HA only) Temporarily decreases viscosity of intercellular cement, promoting diffusion and absorption Source for hyaluronidase is bovine testicles. It is a soluble protein enzyme acting at site of injection to breakdown and hydrolyze HA Most successful treatment for Tyndall Effect, according to literature

Hyaluronidase Considerations
Off-label use for all brand names Some elect to perform skin test and wait 15 minutes proceed if no reaction Inject directly into area of undesired product Dosing ranges 5-20 units per site Resolution has been noted within 24 to 48 hours of injection Dilute with NaCl to increase dispersion and decrease tissue reactivity Off-label application QS 1064 nm laser also reported to be effective for HA visibility. Hylanex and vitrase are the two most popular brands (Brody, 2005)

HA Superficial Placement: Tyndall Effect
(Cox, S.E., & Lawrence, N., 2007)

Tyndall Effect and Treatment
After tx wth hyaluronidase

Nodule versus Granuloma
Lumps/Nodules: Non Inflammatory Granulomas: Aggressive Inflammatory Response Present several months to years following injection at ALL implantation sites at the SAME time Excision rarely indicated as borders are seldom defined Without intervention, may increase in size, persist and then spontaneously resolve Visible within a few weeks Typically due to technical errors or placement of specific fillers into dynamic areas Granulomas are due to sudden stimulation of memory of macrophages “stimulus” may trigger immune memory of the macrophages to induce sudden foreign body reaction With sculptra it is not always in every area; incidence related to dilution of product and skin thickness

Granuloma Management Oral and intralesional steroid
Used in association with antibiotics such as minocycline, which target granulomas Reports state that non-inflammatory fibrotic nodules have responded to treatment with intralesional triamcinilone Alone or in combination with 5-FU May require excision Triamcinilone is a steroid. 5-FU is a chemo agent

Nodules Occurring in Lips Post CaHa Injections
(Cox, S.E., & Lawrence, N., 2007)

Nodules Occurring Following Use of Poly-L-lactic Acid
The lesions resolved spontaneously over several months. (Duffy, D., 2005)

Granuloma in Nasolabial Fold and Oral Commissure
Seen in a 46 y/o female appearing 3 years after ARTECOLL treatment (Carruthers, A., & JDA, 2005)

Anesthetic Options Nerve blocks Tissue infiltration Topical anesthetic
Rarely needed with new products that contain Lidocaine Tissue infiltration Topical anesthetic Skin cooling This procedure will be reviewed in the hands on portion of the class. Make your patient comfortable- it is recommended to provide some level of local anesthesia This reduces patient pain and anxiety about their procedure and makes the experience more enjoyable – provide total anesthesia to an area being treated by anesthetizing the main trunk of a nerve (similar to dental blocks – anesthesia injected just under the skin around the entire area being treated (EMLA, Caine Tips, etc.)- helps primarily with pain associated with needle sticks(Ice, Zimmer Chiller)- temporary anesthesia

General Dermal Filler Post Treatment Instructions
Provide Guidance Regarding: Avoiding Manipulation of treatment sites Makeup application Activity restrictions/limitations Skin care use Laser and IPL treatments Microdermabrasion or chemical peels or massage can shift product Needle insertion sites must be closed prior to makeup application Consider potential for swelling, bruising HA, retinoic products can cause irritation Heat dispersement may increase product absorption; clinical studies ongoing with varying opinions.

Glabellar Frown Lines Treatment With Fillers
BoNTA first consideration followed by dermal filler only if necessary Filler treatment Consider potential for vascular compromise due to occlusion Do NOT overfill Retrograde injection only Product selection: HA Inject product directly into the line at a 10-15˚ angle An immediate blanch and wheal should be observed with proper placement of CD® 1 or 2 If products extrude through pore, rotate needle ¼ turn; still extrudes then withdraw needle and reinsert Allergan Medical’s package insert recommends against injection into this site with CosmoPlast® or Zyplast®

Horizontal Forehead Lines Treatment With Fillers
BoNTA first consideration followed by dermal filler only if necessary Filler treatment Dermal fillers if BoNTA is used does not eliminate all lines Deliver low volume Use small gauge needle Use light weight HA product If a person has pre existing brow ptosis, caution should be taken with botox dosing; filler can be used to fill in residual lines.

Periorbital Aging Aging causes a loss of skin elasticity and fat volume in the infraorbital area resulting in lengthening of the lower eyelids and formation of infraorbital hollows Repeated contraction of the orbicularis oculi causes the development of crows feet and possibly infraorbital “jelly roll” This is a repeat slide from the BoNTA section however it is important to review with trainees first point as it relates to dermal fillers 159

Lateral Brow Lift Treatment with Dermal Fillers
Inject outside of supraorbital rim Lateral brow towards mid pupillary line Threads within, superior, and inferior to hair of brow Linear threading/fanning-mid to deep dermis Massage laterally 30/31/32g, 1/2” needle (HA); 28/29 (CaHa) Amount of product: .25 to .5cc total Product Selection: HA, CaHa After botox, filler is adjunct for maximum elevation/correction of asymmetries Blend product into surrounding tissue Anesthetic options are topical and or ice

Tear Trough Deformity Treatment with Dermal Fillers
Indications: Naso-jugal fold (medial tear trough) Lateral periorbital depressions Lower lid fat atrophy (bags) Pre injection marking Patient position should maximize visualization Inject only outside of infraorbital rim Product placement subdermal or submuscular (just above periosteum) 30/31/32g ½“ needle or blunt tip cannula

Anesthetic Options Topical anesthetic creams Icing Infraorbital nerve block (usually unnecessary) Patient position-head straight, eyes diverted upward Consider pre injection marking; area of tx; orbital ridge Product placement subdermal to avoid vascular plexus, visibility and/or lumpiness of product Some use blunt cannula to decrease embolization Consider 32g ½” needle to decrease trauma, bleeding/bruising and patient discomfort Massage treatment area with a Q-tip to “smooth out” product

Injection Technique Options: Linear threading and fanning Serial depots at orbital rim Combination Massage and blend product into surrounding cheek tissue Typical amount of product: .5cc to 1.5cc total for bilateral injection Product selection: HA Patient position-head straight, eyes diverted upward Consider pre injection marking; area of tx; orbital ridge Product placement subdermal to avoid vascular plexus, visibility and/or lumpiness of product Some use blunt cannula to decrease embolization Consider 32g ½” needle to decrease trauma, bleeding/bruising and patient discomfort Massage treatment area with a Q-tip to “smooth out” product

Tear Troughs and Lateral Brow Treatment with Dermal Fillers
HA 1.2cc to medial and lateral tear trough and brow bone Photos courtesy of Deb Thomas RN, M.P.M

Tear-Trough Lateral Orbital Depressions
HA and BoNTA Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN

Pre/Post Tear Trough HA and BoNTA
Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN

Tear Trough Deformity Post Treatment Expectations
Potential for bruising Temporary contour irregularities Potential need for refinements at two weeks Continuous icing of areas for 24 hours Restriction of exercise/strenuous activities for 48 hours Potential need for refinements/additional product at two weeks post-treatment slight contour irregularities until “settling” of product occurs

Complications of Tear Trough: Dermal Fillers
Vascular occlusion is a medical emergency Be aware of signs/sx of occlusion Prevention Retrograde threading or serial deposit at supraperiosteal level Do not overfill Do not inject at inner canthus Avoid angular artery

Complications of Tear Trough: Dermal Fillers
Pronounced or prolonged bruising Ice and direct pressure to bleeding Avoid needle placement at midpupillary line Bruise cream Arnica and Bromelin Laser treatment may reduce longevity Malar edema Blindness (RARE) Due to occlusion of retinal artery

Facial Aging in the Mid Face
Aging causes a loss of volume in the mid face due to descent and loss of mid-facial fat and bone resorption Deepening of nasolabial folds Lengthening of the lower eyelids Infra-orbital hollows Loss of malar prominence Treatment of malar and infra-orbital areas: Restores volume and accentuates underlying bone structure Attempts to recreate the “Triangle of Beauty” *Some indications presented are not approved in US

Mid Facial Aging Treatment Special Considerations
Increased risk of bruising Vascular occlusion of infraorbital artery Risk of infraorbital nerve damage Potential for contour irregularities Ice and the use of lidocaine with epi may decrease bruising. Locate the infraorbital ridge prior to injecting, as the foramen is usually 8mm inferior to the ridge. Refinement treatments are often required with midfacial augmentation

Mid Facial Aging Evaluate patient to determine area of deficit
Medial flattening of the cheek Mid cheek at the mid pupillary line Lateral to the mid pupillary line May need all three areas augmented Treat cheeks before tear troughs and n/l folds as this may decrease the amount needed for correction in those areas Goal: to achieve a blending between the lower eyelid, n/l fold and cheek *Some indications presented are not approved in US

Cheek Augmentation Treatment with Dermal Fillers
Anesthetic Options Topical anesthetic creams Icing Modified infraorbital nerve block Rarely necessary Local infiltration Will cause distortion Modified infraorbital nerve blocks for patient comfort and vasoconstriction, if using epinephrine; small aliquots of local infiltration to augment block Local infiltration can distort the area; need to wait until this subsides to inject

Pre-treatment marking Product Placement: HA – mid-deep dermis, subq or supraperiosteal (always with Voluma) using a 27g, 28g or 30g 1/2” to 1” needle CaHa – subdermis or suprperiosteal using a 28g 5/8” needle PLLA – supraperiosteal or subq using a 25g 1 1/2” or 26g 1” needle or blunt tip cannula Injection techniques Serial depot Fanning Threading Cross-hatching Amount of product ranges: .5cc to 1.6cc per cheek Product selection: HA, CaHa, PLLA Fanning and threading approaches and cross-hatching to further volumize the area Pre treatment marking areas of desired treatment (malar implant sizers may be used)

Cheek Augmentation Serial Puncture Technique
Mark area to be treated Identify infra-orbital notch and mark Select and mark injection sites within the treatment area Avoid infra-orbital notch Stay inferior to infraorbital rim This is an alternative technique provides easy delivery of small amounts of product It is very important to stress avoiding the infraorbital notch due to the risk of nerve damage. Also stress the importance of staying inferior to the infraorb rim.

Mid-face: Injection Planning
Use markings to ensure symmetrical and even placement of filler: Lateral canthus to corner of mouth Upper part of tragus to alar lobule Lateral canthus to lower tragus 1 3 2 3 176 176

MID-FACE WHERE TO PLACE JUVÉDERM VOLUMA XC
1 2 After applying symmetry marks: Mark out area of depression for injection. Older patients may need volume to be placed more medially Younger patients may need volume to be placed more laterally

Supraperiosteal Serial Puncture Technique Insert needle at 70°- 90°angle Advance to the periosteum Retract needle by 1-2 millimeters & aspirate Deposit cc material or less per injection site Press and mold immediately Stress the importance of delivering small amounts and deep placement of product with this technique.

Retrograde Threading Technique Insert needle at 30°- 45° angle into selected plane Deep dermis or subcutaneous (HA-Restylane, Perlane, Juvederm) Subcutaneous (HA-Voluma, Sculptra, Radiesse) Advance to full length of needle Aspirate Deposit cc material or less per thread Press and mold immediately

DO NOT inject above the inferior orbital rim May use syringes/side, depending on product Amount may vary for each side Area should be free of nodules and feel smooth Expect swelling Do not overcorrect Molding and pressing are preferred to rubbing the skin. *Some indications presented are not approved in US

Mid-Face Volumization Using Juvederm Voluma XC
Patient marking of proposed sites Zygomatic arch, anteriomedial, submalar Prep skin Use a ½ - 1 1/2 inch needle or blunt tip cannula Subcutaneous in medial and submalar (‘tenting’ technique to build vertical scaffolding under skin in medial cheek) Supraperiosteal depots in zygomatic arch cc per bolus (not to exceed 0.3cc) Change needle if contacts bone Start injections laterally and move inward Average volume is 1.6 cc for cheeks Stop if patient experiences a shooting pain Our experienced colleaque in Canada feels that some of the other ideal off label laces for placement of Voluma is temples, chins, jaw shaping, and NLFs. using Chlorhexidine Gluconate prior to injection

Volume Restoration: Malar Augmentation Using Juvederm Voluma XC
Supraperiosteal and subcutaneous May use cannula in the sc plane Inject slowly Stop if patient experiences a shooting pain Immediate gentle massage post injection Ice for bruising Volumizing procedures require somewhat greater skill than more superficial dermal filling procedures, specifically that injections should be placed into the deep dermis or above the peri-osteum, and should be placed under the obicularis oculi, but strictly above the zymgomaticus. subq supraperiosteal 182

Complications of Mid Facial Aging Treatment
Bruising Arnica, Bromelin, Bruise Cream, possible laser tx Infraorbital nerve damage Avoid the infraorbital foramen Contour irregularities Evaluate at 2-3 weeks and adjust as needed Ice and the use of lidocaine with epi may decrease bruising. Locate the infraorbital ridge prior to injecting, as the foramen is usually 8mm inferior to the ridge. Refinement treatments are often required with midfacial augmentation

Facial Lipoatrophy Pre-treatment marking Fanning and Cross-hatching
Product Placement: CaHa deep dermis or subdermal; 28g 5/8” needle PLLA subcutaneous or supraperiosteal or 25g 1 or 1/2” or 26g 1” needle or blunt tip cannula Amount of Product: CaHa 1cc to 2 cc per cheek PLLA up to 2 vials per treatment, 3-8 treatments, separated by 4 weeks Product selection: HA; CaHa, PLLA Bioform and dermik have assist programs for qualifying pts according to reported income; call company for more details

Mid Face Volume Replacement
PLLA 2 sessions 2 vials total to temple, malar, submalar, NLF, jaw line Photos courtesy of Deb Thomas, RN, MPM

Lower Facial Aging Nasolabial Folds, marionette lines and prejowl sulcus are developed with the descent of the facial tissue and loss of elasticity and volume. The vermilion lose volume with age and the vermilion border loses definition. Vertical lip lines develop secondary to repeated contraction of the orbicularis oris. The corners of the mouth turn down as result of volume loss as well as activity of the DAO.

Nasolabial Folds Treatment with Dermal Fillers
Techniques Threading Fanning/Cross-hatching Consider fanning into the fold Ideal site for layering of products Releasing dermal attachments creates a pocket for the filler LLSAN does contribute to depth of NLF but primary treatment with BoNTA not recommended Patient position should be upright so the shadow of the depression can be seen Threading technique provides smoothness of area of correction Fanning of product at N/L groove towards the base of the alar ridge and all the way down the line gives the area more support and makes the area appear smooth Cross-hatching to provide additional foundation and support Layering example: Radiesse™ for deep foundation HA for filling CD® 1 or 2 for fine line removal Photos used by permission Inamed 2004

Marionette Lines/Oral Commissures Treatment with Dermal Fillers
Techniques “Triangle” technique (photo A) “K” technique (photo B) Augment lateral vermilion border (photo C) Fanning from inferior fold towards oral commissure Correction to any observable chin depressions Releasing dermal attachments creates a pocket for filler Product Selection: HA, CaHa; BoNTA to DAO Fanning from inferior fold towards oral commissure (as in N/L groove treatment) Injections just medial to depression Cross hatching adds further support Do not inject into the lateral mound of the fold B A C

Nasolabial Folds/Marionettes
HA 1cc n/l & 1cc marionettes Photos courtesy of Jill Jones, RN, CPSN

Perioral Rhytids Treatment With Dermal Fillers
Treatment options: Vermilion border augmentation Direct injection of rhytids Parallel threads perpendicular to rhytids above vermilion border Product selection: HA BoNTA will reduce pucker Augmenting vermilion border can eliminate fine lines that lie in direct contact with border. Lines radiating away from border will need direct injection CD®1: ideal for very shallow lines, thin skinned areas, and older patients with thinning dermis CD® 2: ideal for deeper lines/creases, younger patients

Vermilion Border/Vermilion Treatment With Dermal Fillers
Note pre-existing asymmetries Maintain proper lip proportion Upper lip 40% lower lip 60% Techniques: “Tracking” - only possible in vermilion border Serial retrograde threading Grasp the lip between your thumb and fore finger, or stretch the vermilion taut Deposit product in reticular level of the dermis BoNTA for further eversion of vermilion Threading: inject retrograde (as needle is withdrawn)-consider 30g 1” needle for border HA products may also flow into top lip and vermilion and appear as clumps with tracking and may give a “ducky” look Botox can also extend the longevity of the correction

Don't Want!!

Vermilion Border/Vermilion Treatment With Dermal Fillers
Grasp the vermilion border between your fingers, or stretch the vermilion taut Augment the philtral columns of the cupid’s bow Augment oral commissures Immediate post injection massage Product selection: HA To augment the philtral columns of the cupid’s bow: Thread the needle from the peak of the cupid’s bow straight up toward the columella of the nose. Firmly pinch the skin on either side of the needle to form a “canal” for product. Inject retrograde Place a q tip in the depression of the cupid’s bow and fold the skin around it for a few seconds to further form the philtral columns. To augment oral commissure patient opens mouth beginning on the lower lip, inject into the vermilion border advancing the needle towards the eye, threading product upward toward the most lateral aspect of the upper lip Massage the area immediately using a double sided technique.

Male Lip Augmentation Vermilion HA 1cc Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN

Lip Augmentation (note pre-existing lip asymmetry)
Vermilion border: HA Vermilion: HA Photos courtesy of Jill Jones, RN, CPSN

Lips and Oral Commissures
HA .8cc to philtral columns, border, wet/dry, oral commissures Photos courtesy of Deb Thomas RN, M.P.M

Lips and Oral Commissures
HA to philtral columns, border, wet/dry, oral commissures Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN

Mandibular Contouring Treatment with Dermal Fillers
Indications Pre jowl depressions Lateral jowl depressions Not appropriate for extreme laxity and descent of tissue Pre treatment marking Fanning and threading techniques Elliptical pattern with feathering of the endpoints Amount of product ranges from: .5cc to 1.5cc Product selection: HA, CaHa, PLLA Mandibular contouring may be incorporated with treatment of marionettes

Mandibular Shaping Prejowl / marionettes: HA; BoNTA to DAO Risk of Bruising is increased in this area due to increased vascularity. Photos courtesy of Jill Jones, RN, CPSN

Mandibular Shaping Prejowl, marionettes, cheeks, preauricular:
CaHa; BoNTA to DAO Photos courtesy of Jill Jones, RN, CPSN

Earlobe Rejuvenation Treatment with Dermal Fillers
Techniques Linear threading Fanning Serial depot Indications Thinning and/or wrinkled earlobes Elongated pierce holes Requires small amounts of product cc for bilateral correction Product Selection; HA, CaHa When treating an elongated piercing inject distal to the piercing

Ear Lobe Rejuvenation HA .2cc per lobe
Ideal area to use small amount of left over product HA .2cc per lobe Photos courtesy of Deb Thomas RN, M.P.M

Mental Crease Treatment with Dermal Fillers
Very porous – frequent extrusion of product during injection May need layering of products Undermining to release dermal attachments Product selection: HA BoNTA into mentalis Consider undermining to release dermal attachments; aids in ideal product placement by making a pocket for the product

Chin Augmentation Treatment with Dermal Fillers
Indications for treatment Recessive chin Asymmetry Pre treatment marking Product placement HA mid-deep dermis using a 30g 1/2” needle CaHa deep dermis or subdermis using a 27g 1/2” to 1” or 28 g 5/8” needle

Anesthetic Options Topical anesthetic creams Icing Mental nerve block (usually not necessary)

Injection Techniques Serial depot Threading Fanning Cross-hatching Amount of product ranges from .5cc to 1cc Product selection: HA, CaHa Increased potential for bruising in this area

Acne Scars Treatment with Dermal Fillers
Techniques Undermining fibrotic tissue of central scar Serial depot Begin in the center of the scar, inject product into the reticular dermis at a 45 ˚angle Pre treatment marking Post injection massage May require series of injections Increased risk of vascular compromise Product selection: HA, CaHa, Poly-L Lactic Acid Undermining fibrotic tissue of central scar using a needle in a windshield wiper action immediately pre treatment to create a dermal pocket can aid in placement of product; if attachments are too adherent then the product will go around the defect and it will look worse Photos used by permission Inamed 2004

Acne Scars Photos courtesy of Deb Thomas RN MPM

Hand Rejuvenation Treatment with Dermal Fillers
Restores the volume lost with aging and makes the prominent dorsal vessels less obvious Anesthesia: Topical Injection Technique While tenting skin, needle is placed in areolar plane between subcutaneous and superficial fascia layers Release skin and slowly deposit material (will see large lump of product through skin) Products HA, CaHa Typical Volume 1.5-2cc per hand Many practitioners use both topical and add the lidocaine to product; others don’t use the topical

Hand Rejuvenation Three techniques utilized for depositing product:
Inject entire syringe as bolus in center of dorsum of hand Inject several smaller boluses of equal amounts across the dorsum of hand Linear threading with HA Avoid injection into or near: Extensor tendons and their synovial sheaths Retinaculum Muscles Bend of the wrist Knuckles Immediate post injection, vigorous massage in all directions to disperse Patient makes a fist Ointment or Arnica Gel to decrease irritation of massage Many practitioners use both topical and add the lidocaine to product; others don’t use the topical

Hand Rejuvenation of Radiesse® Before Immediately After 1.3 cc CaHa
Mariano Busso, MD Miami, FL

Hand Rejuvenation Before Immediately After 1.3 cc CaHa Insert video
Mike Jasin, MD Tampa, FL

Use of Blunt Tip Cannulas for Dermal Filler Injections
We will cover this ONLY in lecture, but it will not be included in the hands on portion, due to time required to utilize the technique. We will add this to the MASTER’S LEVEL COURSE, coming out 2nd quarter 2013 and advanced courses with 5 or less students. Participants may also elect to take a coaching session in their own facility.

Cannula Usage Not a new concept
Have been used for fat injections for years They are more flexible than fat injection cannulas to allow for better contouring around the facial structures

Advantages Minimized bleeding and bruising
Less patient discomfort and needle phobia Faster recovery Decreased risk of intra-arterial injection and adverse events Facial Plast Surg Clin N AM 20(2012) It is theorized that the cannula does not cut though tissue, but glides along the natural tissue connections with minimal damage. The blunt tip is thought to displace blood vessels rather than lacerate them, thus reducing bruising and edema. Studies not done to support this but clinical experience does.

Specfic Features Flexibility, unlike a rigid cannula
Blunt tip with a precision laser-cut lateral side port for product extrusion Fits on any Leur lock syringe Made of stainless steel

Availability of Cannulas
Cannula available through Merz or Surgical Solutions Inc.

Blunt Tip Cannula Technique
Pretreatment photos, skin cleansing, markings Anesthesia Topical anesthetic 20 minutes prior to treatment Ice Inject insertion sites with .2cc xylocaine with or without lidocaine You may apply ice to the insertion site to further improve comfort level. 45

Cannula Injections Make an entry point with a needle that is slightly larger that the size of the cannula Insert cannula through the entry point into the hypodermis It is helpful to stabilize the area with the fingers to assist in the entry of the cannula. 44

Cannula Technique Cannula is inserted to full length and injection is done on withdrawal via a threading/fanning technique The cannula may meet some resistance while passing through in the tissue. This is normal as you are breaking through the fibrous septums. 221

Cannula Use: Precautions
Landmark insertion points carefully Potential for an intravascular injection remains Must watch the plunger as product filler flow is increased Risk of vascular occlusion from product placement

Temporal Region Insertion point- zygomatic arch
injecting above the temporal fascia up to the temporal fusion line

Malar and Submalar Region
Injection point- Zygomatic arch Injection plane- deep subcutaneous space 224

Nasolabial Folds Prep skin Palpate for facial artery
Mark insertion site Infiltrate and make entry point with hypo Insert cannula and glide to nasal angle Fan along angle

Marrionettes Insertion point is injectors preference
Important to add volume to the mandibular depression due to bone loss

Mandibular Contouring
Mark out facial artery -sits in front of the masseter muscle Be aware of the location of the parotid gland Deep injection along mandible towards earlobe 227

BoNTA and Fillers BoNTA glabella, frontalis, DAO, crowsfeet, upper lip
CaHa 2 syringes cheeks, NLF. HA 2 syringes lips, cheeks, brows Photo courtesy of Lovely C. Laban, ARNP, MSN

BoNTA and Fillers BoNTA glabella, frontalis, lateral brow, crowsfeet, DAO CaHa 1 syringe cheeks, marionettes, NLF, HA 2 syringes NLF Photo courtesy of Lovely C. Laban, ARNP, MSN

Facial Rejuvenation Therapy Neurotoxins and Dermal Fillers Advanced Course © 1.

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Facial Rejuvenation Therapy Neurotoxins and Dermal Fillers Advanced Course © 1.

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