How to Minimize Risks of Vascular Occlusion and Blindness During Filler Injections

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor  and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

  1. Know the major vascular structures and their landmarks
  2. Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
  3. Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
  4. Use cannulas whenever feasible, preferably 25/23g or larger
  5. Avoid boluses, small linear threads are safer
  6. Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
  7. A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
  8. Injection onto periosteum is safest but does not guarantee a vascular free injection
  9. Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
  10. Retrograde injections are safer than anterograde injections
  11. Dermal injections should be relatively safe
  12. Avoid deep injections in the lips. Stay superficial to the muscles
  13. An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
  14. Have on hand 6-8 vials of Hylenex
  15. Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.

The Jawline – Beauty, Differences Between the Sexes, Aging, and Correction (reJAWvenation)

Nefertiti was recognized for her crisp jawline and smooth neck. Her bust is one of the most famous of the ancient Egyptian sculptures. A razor sharp jawline and well defined ascending ramus (or gonial angle) are hallmarks of beauty, both male and female. Jowling, submental fullness, blunting of the gonial angle, and an irregular jawline are all signs of aging.

While there are many commonalities between the sexes of what constitutes an attractive jawline, there are fundamental differences as well.

Males:

  • Broad/wide rami of mandible leading to a near vertical appearance on frontal projection
  • Approximately a 110-115 degree gonial angle (more acute than female)
  • Significant height of the body of the mandible
  • Wide defined, projected chin

Females:

  • V-shaped rami of mandible on frontal projection. A more masculine (vertical) ramus is also considered beautiful in some women (Such as Alessandra Ambrosio)
  • A more obtuse gonial angle of approximately 135 degrees
  • Shorter height along the body of the mandible
  • Pointed, less projected chin

There are considerable age related changes of the mandible.

  • Loss of bone along the body of mandible leading to loss of vertical height. This change is accelerated in an edentulous patient
  • Blunting of the gonial angle eventually leading to a curvilinear jawline
  • Narrowing of the male chin and widening of the female chin
  • Deepening of the gonial notch

The age related mandibular changes lead to loss of support of the soft tissue in the lower face – falling forward and downward. Jowling and submental fat is exaggerated. The upper neck skin shows more laxity as facial skin drops into the neck.

Correction of age related jawline changes with fillers- reJAWvenation

Dr. Weiner has perfected a correction using dermal fillers which he has coined “reJAWvenation”. It is based on restoring the age related loss of bone and leads to support of the lower face soft tissues. Filler is placed along the inferior border of the mandible as well as filling the gonial notch. The gonial angle is recreated. The lower aspect of the jowl is considered the new baseline and filling is made on either side to “camouflage” the jowl. Filler is also placed along the posterior aspect of the ascending ramus. The prejowl sulcus is filled, with emphasis to include the space beneath the inferior mandibular border. The chin must also be corrected to the male/female appropriate projection and shape.

reJAWvenation offers a quick (10-15 minute) correction of the age related changes to the jawline. Improvements in jowls, upper neck, jawline, and chin can be expected. There is minimal or no downtime. Even with facelifts, jawline volume is not typically addressed and needs to be corrected either during the procedure with fat grafting, or in the office, after healing, with fillers.

 

Cannulas Were Approved by the FDA for Restylane Silk….Finally!

On October 12, 2017, Galderma was notified by the FDA that Restylane Silk was approved to be administered using blunt microcannulas. Galderma deserves a huge “high 5” for stepping out of the box in recognizing the improved patient outcomes and safety benefits of cannulas. No other dermal filler in the US has been approved for use with cannulas, it is a “First for Fillers”. Galderma is researching other areas for cannula use and expect approval in 2018 for another 1 or 2 indications.

What’s the big deal with cannulas?

The traditional method to administer dermal fillers is using a needle. Unfortunately, there are many side effects and risks using needles. These include:

  1. Bruising – sticking a needle into a highly vascular organ, skin, will lead to bruising a majority of the time. This is corroborated by the FDA studies for all the US approved fillers.
  2. Pain – needles require multiple entry points to deposit the filler. Pain fibers are most prevalent in the dermis.
  3. Vascular Occlusion Risk – when a blood vessel is cannulated with a needle and the filler is injected directly into the vessel, occlusion of the vessel occurs. The sequelae of such event can result in skin necrosis, eye injury, or even blindness.

Cannulas have a blunted, rounded tip which is less likely to injure blood vessels than a needle is. When the cannula brushes up against a vessel, it is deflected away, in distinction to a needle which will often pierce the vessel. When a vessel is traumatized, a bruise will occur.

To use cannulas, a small pilot hole using a needle is required. Unfortunately, completely eliminating needles is not possible. However, after that entry is performed, the cannula can be placed through the dermis and into the subcutaneous tissue or deeper fat compartments.  The areas below the skin surface are generally less innervated and are more comfortable to place filler.

The most important quality of cannulas is their safety. By design, they are much less likely to result in placement of filler within the lumen of a blood vessel. The rounded tip eludes lumens of blood vessels whereas needles don’t offer that protection. Although vascular occlusion is possible with cannulas, it is much less likely when compared to the risks associated with needles.

Dr. Weiner has been an advocate of injecting dermal fillers with cannulas for the past 6 years, since 2012. He has become one of the most experienced cannula users in the US. He has been chosen by Galderma to use his cannula experience to “Train the Trainers” in the use of cannulas for Restylane Silk in the lips.

Action II Erbium Laser for Resurfacing and Bella V Vaginal Rejuvenation

Lutronic has added a new laser to it’s armamentarium and it is called the Action II. There are several different applications for this laser which include: fractional laser resurfacing, the “Shining” laser peel, skin lesion ablations, and the “Bella V” procedure for vaginal rejuvenation.

Erbium lasers are ablative lasers, they cause ablation of the tissue treated. This means that there will be vaporization of the treated skin. The Action II is a fractional laser, so only a “fraction” of the area treated will be ablated. Studies show that fractional lasers are safer and provide improved recovery times when compared to total (100%) ablative lasers. Comparing an erbium laser to a CO2 laser (which is also ablative), the erbium will have less coagulation of the tissue – less heat is transmitted to the surrounding tissues. The clinical result is that there is less crusting, less wound care, and faster healing with the erbium vs the CO2 laser.

  • Fractional Laser Resurfacing: The Action II uses a stamping handpiece that has approximately 15% coverage (15% of the skin is ablated) per pass. Depths are controlled by varying the energy as well as the pulse stacking. Typically patients will receive between 1-2 passes. The procedure takes about 30 minutes to complete. Only topical anesthetic is needed and patients are very comfortable throughout the procedure. Wound care which includes soaks and specialized creams is required for about 4 days. There is minimal to no crusting with this laser. More than one treatment might be needed to get optimal results.
    • Indications: Treating deep wrinkles, sun damaged skin, pigmentation, and laxity
  • Shining Peel: This is a very superficial laser resurfacing with minimal depth and can be done without topical numbing creams. It takes about 15 minutes and is meant to have almost no downtime. It causes a rejuvenation of the skin
    • Indications: Treat superficial wrinkles, minor pigmentation, enlarged pores
  • Surgical Handpiece: This is a microfocused beam to treat very small skin lesions. No anesthetic is needed.
    • Indications: Treat sebaceous hyperplasia, seborrheic keratosis, actinic keratosis, benign nevus, skin tags, warts
  • Bella V: This handpiece/procedure is used for vaginal rejuvenation and stress incontinence. The handpiece is insert to the vagina. It has a unique 360 degree treatment zone as the laser is pulsed. There are 2 pulses, a shorter ablative or subablative pulse, followed by a longer nonablative (heating) pulse. The handpiece is gradually withdrawn about 0.5cm and another pulse is fired. The is done throughout the entire vagina and introitus and then repeated. If there is a component of stress incontinence, the area of the tissue around the urethra is treated more aggressively. The entire procedure takes about 10-15 minutes and no topical anesthetics are required. (At this time, external vaginal treatments are performed using the ThermiVa at the Aesthetic Clinique.)
    • Indications: vaginal laxity, vaginal atrophy, decreased moisture, stress incontinence

Deceptive Practices Used in Before and After Photos

“A picture is worth a thousand words”. It’s true, seeing a great before and after speaks volumes for a certain physician’s or practitioner’s abilities. Unfortunately, there are some deceptive practices that can trick the eyes into believing results are better than they are really are.  Instagram is a showcase for the aesthetic industry, but there is no oversight as to the claims made on the photos displayed. The bullet points below will help one to develop a critical eye to discern the truth from the “fictional results”.

  1. Lightening must be the same in both pictures. A common misleading practice is to have a dark before picture and a light after picture. In the lighter picture, wrinkles and shadows are going to be less, and fool the observing into thinking these were related to the procedure.
  2. Angle of the neck/head must be the same in both pictures. Take a look at the nose and jaw to see if the head is in the exact same position. If the head is tilted more upward in the after picture, the neck will appear to have less fullness, less wrinkles, and be firmer. This is particularly popular in the Kybella before and after photos.
  3. The expression must be the same in both pictures. If a patients is partially smiling in the before and not in the after, the wrinkles around the mouth and cheek will appear falsely improved.
  4. Sculptra pictures should have at least a 3-6 month interval. Sculptra is always mixed with water or saline for reconstitution. The immediate results after injection reflect merely the effects of the water/saline and not that of Sculptra. The collagen stimulation from Sculptra will take at least 3 months to appreciate, with 6-9 months being even a better gauge of results.
  5. Using company photos or other physician’s photos without noting this or giving the appropriate credit on their websites or posts is also a common practice.
  6. If make-up is used, it must be similar in both photos. Too often the before has none and the after has make-up.

Perfect before and after photos are very challenging. Even when results are extraordinaire, there are often difficulties trying to capture these changes with the camera. However, purposely trying to “enhance” photos with the practices above must be pointed out to the practitioners.

 

Proper Sterile Technique is Critical for Optimal Dermal Filler Results

In surgery, sterile technique is “the law”. Any break in sterility places the patient at risk for a potentially life threatening infection. It is the duty for the surgeon(s), scrub tech, and circulating nurse to self report or call out any suspected or potential contamination risk. Immediate actions are taken to remedy the situation and to limit the risk to patient.

Why should dermal fillers be treated as anything differently? They shouldn’t! Fillers are semipermanent or permanent implants, and they must be administered in aseptic technique. The majority of injectors are not trained as surgeons and therefore don’t fully comprehend what sterile technique entails. Granulomas, one of the more serious complications from fillers, have now been traced to biofilms. Biofilms are latent bacteria that somehow get activated and present as infection or granulomas, months to years after the initial injection. Most often biofilms are deposited in the tissues during the initial injection procedure. Clearing infections or granulomas takes weeks or months to clear and often entails antibiotics, steroids, 5 FU, and hyaluronidase (if a hyaluronic acid was used).

The following guidelines should serve as a reference for physicians and nurses to minimize infectious complications during dermal filler injections.

  1. The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
  2. Never inject someone with a current/ongoing infection. Even if the infection is not in the area of the dermal filler, bacteria can seed the filler from distant areas through the bloodstream (bactermia).
  3. If a patient is in the process of getting dental work or even dental cleanings, hold off on injections until after the work has been completed. Bactermia is well documented during dental cleanings. It is recommended to wait at least 2 weeks after fillers to get dental cleanings. The areas of filler placement will initially have increased blood flow (hyperemia) so it is best to wait until this settles down.
  4. Skin should be prepped for injection with chlorhexidine, with Hibiclens being the preferred form by the author. Although isopropyl alcohol (70%) is effective in killing bacteria and fungus, it is only effective for seconds and becomes ineffective as soon as it evaporates. Hibiclens kills germs on contact and will give persistent bactericidal effects for at least 6 hours, and up to 24 hours. It will bond with the skin even after washing to give continued killing effects. Isopropyl alcohol doesn’t give this lasting bactericidal effect, so anytime after the initial cleaning that an unsterile glove touches the skin, that area is now contaminated. (Hibiclens must be kept out of the eyes because it can burn the cornea). Technicare is also a great antiseptic but the author doesn’t have experience with it. Too many patients are allergic to Betadine for it to be used routinely.
  5. Do not use tap water when applying Hibiclens or to clean the face after completion of the injections. There are several bacteria, fungi, as well as mycobacterium in water which can seep through the injection ports and cause infection.
  6. If the filler is prepared by mixing lidocaine or saline, this must be done in a sterile fashion. The female/female connector used to connect the 2 syringes together must not be reused. It can only be used for the current patient and cannot be sterilized for use on other patients. The tops of all the solutions used must be wiped with an alcohol wipe. Routine use of blending fillers opens up more avenues for filler contamination and must be done with the strictest of sterile technique. If any of the solution vials becomes unsterile, all future filler patients using that vial will become infected.
  7. Blunt tip cannulas can be used for multiple injection sites ON THE SAME PATIENT and are not intended to be used for multiple patients. When changing the cannulas between syringes, they should be recapped first. It is not sterile technique to lay the cannula on an unsterile tray or even a sterile drape when uncapped. After a syringe of filler is removed from its sterile packaging, the areas touched with the exam gloves become “contaminated”. Therefore, the sterile drape is not a sterile field anymore, once the syringes is placed on it. Best practice is to cap the syringe every time it is laid down.
  8. Blunt cannulas are much longer than needles and must be kept sterile throughout their entire length. The cannula is contaminated if anywhere along its length it touches non sterilized skin, gloves, or hair.
  9. It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
  10. The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
  11. Unless the gauze used during the procedure is specifically labeled as sterile, it is not, and introduces another route of contamination. Gauze that comes in sealed pull away packs and labeled as sterile is best to use. The author will take unsterile gauze, place in autoclave packs, and place in the autoclave to obtain sterility.
  12. Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
  13. If ice or devices for vibration are used to control discomfort, these should be cleansed with Hibiclens prior to applying to the skin. In addition, the areas where these were applied should be “re-sterilized” prior to injections.
  14. When the procedure is complete, sterile water or saline on sterile gauze should be used to clean the patient. Again, if tap water is used, this can seep through the injection ports and lead to infection. Also, when soaking the gauze, best practice is to pour the water/saline over the sink onto the sterile gauze so as to keep the remaining fluid in the container sterile. By tipping the water/saline onto gauze that is covering the top, there is risk of contamination going back into the container.
  15. Make-up should not be applied to the skin until the morning. At this point, the injection ports have all healed and there is no risk of contamination.
  16. Dental procedures, even cleanings, should be postponed for at least 2 weeks.

Although the details above are fairly lengthy, any break from any step will lead to a possible source of granuloma or infection in the future. Strict sterile technique will lead to better outcomes and happier patients,

Update – A Better Way (Than Sculptra) to Enhance Temples is Using Cannulas and Refyne

A couple years ago, I wrote a blog that stated deep injections along the periostium using Sculptra were the best way to enhance temples suffering from volume loss. I would like to update everyone to a newer technique I have perfected that gives better results.

Although the Sculptra temple injections are safe and long lasting, there were deficiencies:

  1. Multiple treatments were required – 3 or more
  2. Results take weeks or months to occur
  3. Final results still showed volume loss in the temporal fusion line and supraorbital area
  4. Significant volumes of Sculptra were required
  5. Needle injections inherently lead to more bruising than cannulas

The temporal fossae is a very large space and when Sculptra is injected in this area, there is tremendous spread of the product due to its watery consistency.  In addition, the deep temporal fascia is a thick and unyielding tissue plane that resists lateral movement from filler placed deeply.

My current preference for volumizing the temples uses large (23g) cannulas and a diluted HA (Refyne) dermal filler. I use large cannulas because they are safer than the smaller cannulas and needles for preventing vascular occlusion. I have found that the larger cannulas navigate the numerous veins in the temples well with minimal discomfort.  My entry point is the zygomatic arch, about 1 cm posterior to the brow. The plane of injection is between the superficial temporal fascia and the deep temporal fascia. This is the exact area where the temporal fat pad is situated and where fat loss occurs.  Surrounding areas such as the superior orbital rim, supraorbital area, forehead, and hairline can all be injected from the temporal approach. By diluting the Restylane Refyne with 1cc of saline and 1cc of lidocaine 1%, the thinner product is able to distribute very evenly throughout the plane of injection. Refyne’s high tissue integration and low swelling properties makes this the optimal filler for this area. I have found that a total of 1-2 syringes of the filler is needed to achieve correction in most patients. Massaging at the time of injection and periodically afterwards by the patient will give the smoothest results. A follow up in 3 weeks is typically made to make final touch ups if needed.

Techniques must constantly be re-evaluated and refined to achieve the optimal and safest results for our patients.

 

The Next Big Thing….Nanofat

Aesthetic physicians are constantly striving to find the best procedure/device to turn back time. This time, it is actually a procedure which has been used for decades, but with some modifications. Fat grafting is a procedure that harvests fat from one part of the body and then injects the fat into another area. It has been used to volumize the aging face, hands, and even breasts. Benefits of fat grafting in repairing slowing healing wounds and radiated tissue have shown there are additional qualities to this procedure other than just volume. It turns out that fat contains stem cells and growth factors, more than any other tissue in the body, even more than bone marrow. The component of the fat that contains the stem cells and growth factors is called the “stromal vascular fraction”, also know as SVF.

When digging down into the research, an interesting finding has been discovered. It turns out that most of the fat cells injected don’t actually survive. What actually happens is that the stems cells (Adipose Derived Stem Cells – ADSC) injected along with the fat cells (SVF) leads to new fat cell production.

So here’s the new modification of the procedure. There is new a way to separate the SVF from the fat, without affecting the viability of the stem cells. This process creates the so called Nanofat, a highly concentrated solution of stem cells and growth factors.

It is a process of using filters and screens which takes less than 15 minutes to perform. It turns out that fat cells make up about 80% of the volume of the fat extracted during the harvest. The filtration system leads to destruction of the fat cells (which don’t live anyways) and leads to a much thinner solution which can be injected using smaller cannulas or needles than typical fat grafting procedures.

It turns out that Nanofat actually contains little to no viable fat but is the popular term for the SVF derived from fat. To even further “energize” the Nanofat injections, PRP or PRF is mixed with the solution. This process gives additional growth factors which benefit in the fat production and overall repair and rejuvenation of the areas treated.

Nanofat injections are often combined with fat grafting which is modified from the classical method. It has been found that the inconsistent “take” and lumpiness of fat grafting is related to large size and nonuniformity of the fat harvested. To overcome these hurdles, the harvesting process is now done with smaller cannulas and the fat is pushed thru filters to make uniformly smaller sized fat globules.

Nanofat is useful to treat:

  1. Crepey skin around the eyes
  2. Superficial lines and wrinkles
  3. Smoker’s lip lines
  4. Thin, atrophied skin
  5. Severely sun damaged skin (in combination with other procedures)

The use of Nanofat, with or without fat grafting, requires a minor liposuction procedure to harvest the cells. This is done completely under local anesthesia. Only syringes are used as suction and the cannulas used are much smaller than typical liposuction. There will be some downtime of swelling, bruising, and redness, that typically lasts a few days or up to a week (longer in a minority of patients). Full results require about 9 months to fully appreciate – the time required for new fat and skin cells to be generated.

We now have a completely natural way to rejuvenate and reverse the affects of aging, using stem cells derived from fat cells – Nanofat. The process of isolation of the stem cells and growth factors from fat has become an extremely viable option with a 90 minute procedure.

Dermal Filler Providers Must Also Be Proficient With Hyaluronidase

The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.

There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.

The reasons to dissolve HA filler are:

  1. Poorly placed filler giving an aesthetically poor result
  2. Where too much filler was placed
  3. Filler that is infected
  4. Filler is forming a granuloma
  5. Filler is causing ischemia/vascular occlusion
  6. Filler is causing visual changes or blindness

The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.

It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours. 

Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.

Introducing the Concept of “Age Freezing”

The nonsurgical aesthetic industry has finally hit an important milestone. Using a combination of techniques, cosmetic physicians are now able to halt, and even reverse, the age-related changes which occur to one’s face. In the past, technologies would allow for turning back time for a few years but eventually, the inevitable and undeniable signs of aging would occur. As lasers, radiofrequency (RF), filler and neuromodulator techniques have improved, the aging face is a thing of the past. The concept of “age freezing”, keeping ones looks for a decade or more, is not merely a dream, but reality. More importantly, this all can be done without surgery!

Not everyone is a candidate for “Age Freezing” unfortunately. The stipulations are:

  1. Must be a nonsmoker – There are several significant skin and health issues associated with smoker which can’t be overcome. Many procedures require healing and collagen stimulation which are inhibited by smoking.
  2. Free of chronic debilitating disease – There are tolls long term diseases take on the body which lead to premature aging, cellular changes.
  3. Stable weight – As Katherine Deneuve once stated, at the age of 40, you must decide between your ass or your face. If you lose too much weight, fat is lost from your face. In most instances, this can be overcome but not always. However, in patients with significant weight gains, there can be some difficulties maintaining the same look one had in the years prior.
  4. Alcohol consumption in moderation – Alcohol can take a toll on the body in the long run when taken in excess. 1-2 drinks per day is the recommended maximum intake that the author recommends.
  5. Healthy lifestyle and diet – Although this topic overlaps some of the previously mentioned necessities, a good exercise regime is also required. The benefits of exercise on weight, hormones, circulation all benefit the facial appearance. Obviously, a well-rounded diet full of antioxidants, vitamins, and nutrients is beneficial too. There is research to support telomere lengthening with these measures as well.

The requisite procedures for “Age Freezing” are:

  1. Neurotoxins on a regular basis. Relaxing the hyperdynamic muscles of the face with either Dysport or Botox needs to be performed at least 3 times per year. The regularity is needed to keep the muscles weak and prohibiting them from regaining strength.
  2. Dermal Fillers for lost volume. Fillers are the epicenter of the whole “Age Freezing” concept. Beginning in the mid 30’s, at least a cc of volume is lost per year. This is the result of fat, bone, and muscle loss. Replacing and keeping up with this process is tantamount to looking young. Large volumes are best replaced with using Sculptra, a collagen stimulating filler. It is best to recreate the foundation with Sculptra. Superficial fine tuning is best performed with a hyaluronic acid filler, such as Restylane. New techniques using blunt cannulas permitted safer, less downtime procedures. A comprehensive understanding of the aging process has enlightened our specialty as to what needs to be corrected for accomplishing age reversal.
  3. Skin Tightening to reverse gravity. The constant downward pull due to gravity leads to skin laxity, above and beyond what is attributable to volume loss. Devices that heat up the dermis will stimulate collagen and tissue contraction. Devices vary in their ability to tighten, often with a tradeoff of more downtime/discomfort/risk for more results. Ablative lasers, CO2 and Erbium, will give the most tightening for lasers. Radiofrequency can also be used, with the microneedling RF, such as Infini, giving the best results. A new procedure called JPlasma, looks like it may have promise in significant tightening, but does have about 14 days of downtime and a month of redness.
  4. Skin Resurfacing to improve pigmentation, fine lines, and thicken the dermis. The aging process, primarily due to sun exposure, causes skin to thin with loss of collagen and elastin. Dyspigmentation, pigmentation problems, occurs as well. Renewing the surface of the skin can be accomplished using lasers, such as the Fraxel Dual, or chemical peels. Microneedling can thicken the skin by producing small injuries in the dermis with very little downtime or risks. There may be benefit to adding PRP, platelet rich plasma, to the skin, but the jury is still out.
  5. Skin Care is essential to achieve the optimal results from any of the above mention procedures as well as to improve one’s skin health. Retin A or Retinol should be a staple in one’s nightly regime. These products stimulate skin turnover, reversal of pigmentation problems, better hydration with hyaluronic acid stimulation, and collagen production. Blemishes/Acne breakouts are improved with these products as well.
  6. Oral Supplements are key to good, healthy skin. Oxidants are the source of disease, cancer, aging, and skin damage. To neutralize the oxidative stress, strong anti-oxidant supplement(s) are necessary. Examples include: superoxide dismutase, fish oils, resveratrol, Polypodium leucotomos, turmeric, and glutathione. In addition, the antiaging benefits of Metformin are hard to dismiss with the current research published. Lengthening one’s telomeres with TA65 is probably beneficial as well.

One must understand that the “Age Freezing” concept is a process. It is a lifestyle, a choice. It is not a “one and done” procedure. It consists of regular visits to an aesthetic physician. There are big steps and little steps along the way. The author has dozens of “Age Freezing” patients whom look younger and better, 10 or more years after initiating treatments. “Age Freezing” will eliminated the need for future cosmetic surgery.

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