Facial Rejuvenation Therapy
Neurotoxins
and Dermal Fillers
Advanced Course ©
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 email 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
Review of Manual Contents
Manual:
Section1 - PowerPoint
Section 2 - Charts
Section 3 - Suggested Readings/References
Glossary of Terms
Folder:
Supply lists
Laminated quick reference guides
FDA Approved Dermal Filler
Products by U.S. Manufacturer
Hyaluronic Acid
ALLERGAN
GALDERMA
Juvederm Ultra (XC)
Restylane-L
Juvederm Ultra
Plus(XC)
Perlane-L
VALEANT
MENTOR
MERZ
Prevelle Silk
Belotero Balance
SUNEVA
Juvederm Voluma XC
Calcium
Hydroxylapatite
Poly-L Lactic Acid
80% Purified
Bovine Collagen
and 20%
Polymethylmethac
rylate (PMMA)
Microspheres,
with 0.3%
lidocaine
Radiesse
Sculptra
Artefill
FDA Approved Aesthetic Indications
per Dermal Filler Product
Moderate to severe
facial wrinkle and
folds, such as
nasolabial folds
Lip
Shallow to deep
augmentation nasolabial fold contour
deficiencies and other
facial wrinkles
Mid face volume
Juvederm Ultra (XC)
Restylane-L
Juvederm Voluma XC
Juvederm Ultra
Plus(XC)
Restylane-L
Perlane-L
Belotero Balance
Radiesse
Artefill
Sculptra
Qualities of US Approved HA Fillers
HA
content Cross-linker
(mg/mL)
Belotero
22.5
BDDE
Restylane
20
BDDE
Perlane
20
BDDE
24
BDDE
24
BDDE
20
BDDE
5.5
DVS
Juvederm
Ultra
Juvederm
Ultra Plus
Juvederm
Voluma
Prevelle Silk
FDA Approved Neurotoxins
by U.S. Manufacturer
Botulinum Toxin
Type A
ALLERGAN
GALDERMA
MERZ
BOTOX Cosmetic
OnabotulinumtoxinA
Dysport
AbobotulinumtoxinA
Xeomin
IncobotulinumtoxinA
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)
Mechanism of Action:
Botulinum Toxin
B
D
A
C
Blocks release of Ach; without ACh release, the muscle is not able to contract.
Reprinted with permission from Arnon S et al. JAMA. 2001;285:1059-70.
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)
(Dover, et. Al. Procedures in Cosmetic Dermatology: Botulinum Toxin: 2005)
Manufacturing preparation
Storage conditions
Shelf-life (unreconstituted)
SNARE target
pH after reconstitution
Inactive gel carrier
Onabotulinum
toxinA
Abobotulinum
toxinA
Incobotulinum
toxinA
Powder
Vacuum-dried
Powder
Freeze-dried
(lyophilized)
Powder
Freeze-dried
(lyophilized)
o
o
o
o
o
-5 C or 2 C – 8 C
2 C–8 C
Room temperature
Pre reconstitution
o
o
2 C–8 C
Post reconstitution
24 months
15 months
36 months
SNAP 25
SNAP 25
SNAP 25
7.4
7.4
7.4
Human serum
albumin
500 ug/vial
NaCl - 900 ug/vial
Human serum
albumin
125 ug/vial
Lactose 2500
ug/vial
Hemagglutinin
Human serum albumin
1 mg/vial
Sucrose 5 mg/vial
Hemagglutinin
Adapted from: 1Albanese A. JAMA. 2011;305(1)89-90; 2Dressler D and Benecke R. Disabil and Rehab. 2007;29(3):1761-1768.
The Role of
BoNTA
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.
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
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
Storage of BoNTA
• Non-reconstituted product:
– Ona and AbobotulinumtoxinA: 2 - 8˚ 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
The Keys to Achieving
Ultimate Results
Understanding
Facial Anatomy and
Physiology
Custom Mapping and
Individual Treatment Plan
1 1
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
FRONTALIS
PROCERUS
CORRUGATOR SUPERCILII
DEPRESSOR SUPERCILII
TEMPORALIS*
ORBICULARIS OCULI
NASALIS
LEVATOR LABII SUPERIORUS
ALAEQUE NASI
LEVATOR LABII*
ZYGOMATICUS MINOR*
ZYGOMATICUS MAJOR*
ORBICULARIS ORIS
MODIOLUS*
DEPRESSOR ANGULI
ORIS
DEPRESSOR LABII INFERIORIS*
MENTALIS
DEPRESSOR SEPTI
MASSETER
PLATYSMA (pictured in next slide)
RISORIUS
3
5
2 4
6
7
8
13
20
17
9 10
11
12
18
15
16 14
19
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
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.
Glabellar Frown Lines
Treatment with BoNTA
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
• Abo
20-30u total (female) 30-40u total (male)
30-70 total (female) 50-80 total (male)
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
Glabellar Frown Lines
Treatment with BoNTA
• 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
(Dover, et al; Procedures in Cosmetic Dermatology: Botulinum Toxin: 2005)
Glabella
5 6
5
6 6
Dosage represented is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Photo courtesy of Jill Jones RN CPSN
Glabella
Photo courtesy of Jill Jones RN CPSN
Glabella and DAO
5
4
7 7 7
5
4
Dosage represented is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Photo courtesy of Jill Jones RN CPSN
Glabella and DAO
Photo courtesy of Jill Jones RN CPSN
Glabella & Frontalis
1
2
4
3
2
6
2
5
6
1
4
3
Dosage represented is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Photo courtesy of Jill Jones RN CPSN
Glabella and Forehead Lines
5
2
2
5 8
2
10
5
2
5
2
9
9
8
6
9
9
9
9
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
*Most significant assessment
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
Horizontal Forehead Lines
Treatment Pearls
• Injection in sub-dermal plane may prevent
bruising
• Firm, upward and outward massage to
disperse
• Optional dosage:
– Ona/Inco
– Abo
6u to 24u (1-3u per site)
20-60u (5-10u per site)
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
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
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
Faculty of Medicine, University of Toronto (2005)
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
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)
Lateral Brow Lift
• Massage in an outward and upward
direction
• For asymmetrical brow: increase dose to
more depressed side
• Optional dosages:
– Ona/Inco
– Abo
3–7 units per side
10-20 units per side
Chemical Brow Lift with BoNTA
Levator/Mueller’s muscles become very
superficial in mid pupillary line
Chemical Brow Lift
3
4
3
6
7
3
6
4
6
Dosage represented is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
Photos courtesy of Jill Jones, RN, CPSN
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
DON’T WANT!
How Can BoNTA Help These Men?
●●
●●
●
●
●
●
By raising the procerus and decreasing the intensity of
lateral frontalis elevation to create a more natural appearance
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
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”
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
• Abo
6-15 units per side
20-60 units per side
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
Crow’s Feet
Crow’s Feet
Note residual lines as a
result of ZM contraction
●
●
●
● ●
●
●
●
● ●
Crow’s feet: 4 units per site
Brow lift:
4 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
Crow’s Feet
●
●
●
●
4 units per site
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN
would be greater
Crow’s Feet
Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN
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
Lower Lids
Treatment with BoNTA
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
Lower Lids
Treatment with BoNTA
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
– Abo
1-2 units per side
No dosing available 1-11
Lower Lids
“Jelly Roll”
●
●
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
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
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
– Abo
2-3 units per side and 1-2 units across dorsum
10-20 units total
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
Bunny/Wolf Lines
● ●
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
OnabotulinumtoxinA 3 units bilateral
Additional sites: Glabella, left lateral brow lift, crow’s feet
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:
– Female:
right angle to facial bones
slight upward tilt
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
5-9 units
Medicis Inc, Scientific Department 2011
Nasal Tip Elevation
●
2 units
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
Photo courtesy of Jill Jones, RN, CPSN
Mental Crease
• Horizontal crease below the lower lip
develops as result of repeated contraction
of mentalis
• Dimpling with contraction (peau d’orange)
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
5-20 units
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
Chin
No cleft
Chin
●
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
●
With cleft
3 units per side
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
– Abo
3-7 units per side
2.5-20 per side
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
Down Turned Mouth
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
Down Turned Mouth
●
●
●
●
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
3 units lower site
1 unit upper site
Photos courtesy of Jill Jones, RN, CPSN
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
Vertical Lip Lines
Treatment with BoNTA
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
Vertical Lip Lines
Treatment with BoNTA
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-2.5-16 u; Lower 2.5-7 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
● ● ●
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
2 units each side
1 unit mid line
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
2.5-10 units per side
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
Gummy Smile
●
●
●
●
●
1 unit per side
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA Photos courstesy of Dawn Sagrillo, BSN, RN, CPSN
would be greater
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
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 10-20 units total; may titrate dose
upward according to patient response
– Treatment with Abo not recommended at this time 1-11
Horizontal Neck Lines
And then there are…..
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
Dover, et al; Procedures in Cosmetic Dermatology: Botulinum Toxin: 2005)
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 15-20 units per band
• Thicker bands may require up to 30 units per band
• A total dose of 50-100 units has been described in literature
– Abo
• 5-10 units per site for max dose 50 units per band (30-120 total)
Kane, M.A. (Jan 2010) Journal of Drugs in Dermatology.
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 1-2 cm apart
– DAO
• Dosed and injection placement as described in DAO slide
Platysma Neck Bands
Horizontal Neck Lines
Platysma Bands
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
DAO 3 units
Platysma bands 37 units total
Horizontal lines 2 units each site
Photos courtesy of Jill Jones, RN, CPSN
Platysma Neck Bands
*Above dosage is appropriate for
OnabotulinumtoxinA or IncobotulinumtoxinA
Appropriate dosage for AbobotulinumtoxinA
would be greater
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
Total units = 52 units
Photos courtesy of Jill Jones, 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
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 10-25 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 100-140 units per side in 3-4 injection sites
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
Anatomical Layers of the Skin
Epidermis
Thickness ranges
from 0.07-0.12 mm
(3 sheets of stacked
typing paper)
Epidermis
Dermis
Thickness ranges
from 1-4 mm
Papillary Dermis
Reticular Dermis
Fat Lobules
Subcutaneous
Note: Skin thickness varies by anatomic region
Facial Outline Changes
Due to Aging
“Triangle
Of
Beauty”
Triangle
Trapezoid or Rectangle
Skeletal Changes
Due to Aging
Volume Loss Due to Aging
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
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
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
Particulate HA
• Defined:
– 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
Cohesive Gel HA
• Defined:
• 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
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
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
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
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
Restylane & Perlane
• 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
1 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 4.5-9 mos
Perlane:
at least 6 months
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 4.5 - 6 month/Labeling
extended 12-18 months when a repeat treatment used
•
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
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
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
Sculptra
• Poly-L Lactic Acid:
– NOT considered a filler, but a bioactivator
– Large volume indications; requires 2-8 treatments @ 4-6 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:
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
Proper Product Placement
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
Proper Product Placement
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
Depth of Needle Placement Appearance
Subcutaneous placement
Epidermal placement
Reticular dermis placement
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
Injection Techniques
• Fanning
– Product is deposited into several pathways
from one injection site
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
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
•
•
•
•
Needle is inserted into appropriate depth of skin
Appropriate amount of product (typically .05 - .1cc) deposited
Needle removed
Procedure repeated immediately adjacent to previous location
• Tracking
• Only possible in vermilion border
• Product advances itself
Common Responses To
Treatment versus Adverse Events
• Differentiate for patient
• BOTH can be technique related or product
related
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
Early Common Responses
•
•
•
•
Swelling
Bruising
Needle marks
Remember that:
– Extent of responses vary in degree and
duration
– Technical and patient variables may influence
response
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
Example of Prolonged Bruising
Secondary to Aspirin Use
(Duffy, D., 2005)
Bruising After HA Injection
for Tear Trough Deformity
(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
Moving onto Adverse Events…
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
• Does not produce
immediate pain or
blanching
• Process is slower
• Venous Congestion
(intradermal bleeding)
• Gradual area of
darkening; dusky
appearance
Arterial Occlusion
• Immediate pain
• Blanching, followed by
darkening of tissue
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
(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
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
140
Post Injection Vascular Occlusion
Tear Trough with HA
141
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
Herpes Simplex Virus of Upper Lip
Shingles Outbreak Post Injection
Product Visibility
• Underlying causes:
– 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)
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
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
(Brody, 2005)
HA Superficial Placement:
Tyndall Effect
(Cox, S.E., & Lawrence, N., 2007)
Tyndall Effect and Treatment
Nodule versus Granuloma
Lumps/Nodules:
Granulomas:
Non Inflammatory
Aggressive Inflammatory Response
• Visible within a few weeks
• Typically due to technical
errors or placement of
specific fillers into
dynamic areas
• 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
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
Nodules Occurring in Lips
Post CaHa Injections
(Cox, S.E., & Lawrence, N., 2007)
Nodules Occurring Following
Use of Poly-L-lactic Acid
(Duffy, D., 2005)
Granuloma in Nasolabial Fold
and Oral Commissure
(Carruthers, A., & JDA, 2005)
Anesthetic Options
• Nerve blocks
– Rarely needed with new products that contain
Lidocaine
• Tissue infiltration
• Topical anesthetic
• Skin cooling
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
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
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
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”
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
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
Tear Trough Deformity
Treatment with Dermal Fillers
Anesthetic Options
• Topical anesthetic creams
• Icing
• Infraorbital nerve block (usually unnecessary)
Tear Trough Deformity
Treatment with Dermal Fillers
• 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
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
Photos courtesy of Dawn Sagrillo, BSN, RN, CPSN
HA and BoNTA
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
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 infraorbital 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
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
Cheek Augmentation
Treatment with Dermal Fillers
• 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
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
Mid-face:
Injection Planning
Use markings to
ensure symmetrical and
even placement of filler:
1. Lateral canthus to corner of
mouth
2
33
2. Upper part of tragus to alar
lobule
3. Lateral canthus to lower
tragus
1
176
MID-FACE WHERE TO PLACE JUVÉDERM
VOLUMA XC
After applying symmetry
marks:
Mark out area of depression
for injection.
1
2
1. Older patients may need
volume to be placed more
medially
2. Younger patients may need
volume to be placed more
laterally
Cheek Augmentation
Treatment with Dermal Fillers
Supraperiosteal Serial Puncture Technique
• Insert needle at 70°- 90°angle
• Advance to the periosteum
• Retract needle by 1-2 millimeters & aspirate
• Deposit 0.1- 0.2cc material or less per injection
site
• Press and mold immediately
Cheek Augmentation
Treatment with Dermal Fillers
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 .05- 0.1cc material or less per thread
• Press and mold immediately
Cheek Augmentation
Treatment with Dermal Fillers
• DO NOT inject above the inferior orbital rim
• May use 1-1.5 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
*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
– 0.1-0.2cc 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
Volume Restoration: Malar Augmentation Using
Juvederm Voluma XC
Malar
Augmentation
•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
subq
supraperiosteal
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
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
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
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
A
B
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
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
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
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 .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 Shaping
Prejowl / marionettes:
HA; BoNTA to DAO
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 .25-.5cc
for bilateral correction
• Product Selection; HA, CaHa
Ear Lobe Rejuvenation
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
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
Chin Augmentation
Treatment with Dermal Fillers
Anesthetic Options
• Topical anesthetic creams
• Icing
• Mental nerve block (usually not necessary)
Chin Augmentation
Treatment with Dermal Fillers
• 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
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
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
Hand Rejuvenation
Before
Mariano Busso, MD
Miami, FL
Immediately After
1.3 cc CaHa
Hand Rejuvenation
Before
Mike Jasin, MD
Tampa, FL
Immediately After
1.3 cc CaHa
Use of Blunt Tip Cannulas
for Dermal Filler Injections
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) 215-220
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
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
219
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
220
44
Cannula Technique
• Cannula is inserted to full length and
injection is done on withdrawal via a
threading/fanning technique
221
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
222
Temporal Region
• Insertion point- zygomatic arch
• injecting above the temporal fascia up to
the temporal fusion line
223
Malar and Submalar Region
• Injection point- Zygomatic arch
• Injection plane- deep subcutaneous space
224
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
225
Marrionettes
• Insertion point is injectors preference
• Important to add volume to the mandibular
depression due to bone loss
226
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
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