Acne scarring is a significant psychologically debilitating disease affecting millions in the US, approximately 1% of the adult population in one study. Treatments for acne scars include:
- RF Microneedling
- TCA Cross
- PRP (Platelet Rich Plasma)
- PDO Threads (?)
Most of these techniques are based on trying to make the disorganized collagen in the scar to be more organized and natural. Using carefully induced tissue trauma with heat or microneedles (mechanical), the body initiates a healing process to smooth the scars.
Acne scars will often affect tissues deeper than the dermis. Fibrosis/scarring can affect the subcutaneous tissues and fat and lead to tethering of scar to the deeper structures. Lipoatrophy (fat loss) can occur as the result of the inflammatory mediators released from the acneic process. When heating from lasers and RF is applied, it is preferentially conducted through the collagen because the water content of collagen is high. Heating collagen will lead to collagen remodeling but also collagen contraction. If the collagenous attachments to the deeper tissue are not cut (subcised), there is actually potential for worsening the appearance of the scars with these heating devices.
A recent paper suggested that using a cannula to subcise acne scars is better tolerated, with less adverse events, and judged to have better results by the patients. This is Dr. Weiner’s (and acne scar expert Dr. Davin Lim’s per personal communication) preferred method of subcision vs using a Nokor needle. By subcising, the energy flow to the deeper structures is severed and harm to fat is less as is the risk of pulling some scars deeper. Placement of filler (Restylane Defyne, Bellafill) is often done simultaneously with the subcision to help elevate the scars and prevent reattachment of the scars.
Subcision has been around for decades for acne scar treatment. It is now even more important when energy devices are used to maximize the benefits of these treatments. The use of cannulas for this procedure leads to more comfort, less risks, and better satisfaction.
The Aesthetic Clinique has been designated an Acne Scar Center of Excellence by Suneva (Bellafill) and is considered an acne scar expert.
**(Subcision is also useful for treating cellulite as there are fibrous attachments from the skin which cause the dimpling.)
People chew gum to help clean their teeth after eating, freshen their breath, and even try to keep them whiter. What isn’t readily known is the havok gum chewing has on the aesthetics of the lower face.
The simple act of excessive chewing will lead to muscle hypertrophy of the masseter. Enlargement of this muscles leads to squaring of the lower face and jawline, an undesirable shape in females. The aesthetically pleasing lower face is V-shaped or Heart-shaped. Widening of the lower face is particularly prevalent in the Asian population where the women go to great lengths to slim their face with cosmetic procedures, including surgery. Gum chewing leads to similar problems which fortunately can be reversed with weakening of the masseter muscles with Botox/Dysport.
A much more problematic issue to fix is the negative side effects which occurs around the mouth secondarily to gum chewing. The movements of the soft tissue and perioral muscles is significantly more when chewing than in a relaxed state. Just as with the frown lines and crows feet, the more movement in these areas, the more wrinkles and etched in lines are created. (Ever notice Kim Kardashian doesn’t smile in pictures? It’s because she’s afraid of creating wrinkles, so she limits her facial movements.) In essence, gum chewing accelerates the aging process around the mouth and lower face. Unfortunately, Botox/Dypsort aren’t as easy a remedy for this area because restricting muscle activity can lead to eating and vocalization difficulties. However, lasers, radiofrequency, microneedling, and judicious use of Botox/Dysport can improve the perioral aging process.
Straws can also lead to upper lip lines due to excessive muscle use of the lip muscles (orbicularis oris). The recommendations to improve lower face and mouth asethetics: stop gum chewing and straw use and consider breath mints as a substitute.
It’s been the dream of generations. Hundreds of machines have failed. Now there is Emsculpt. It is now possible to strengthen your abdominal muscle muscles effortlessly and pain free. How about lifting and shaping the buttocks without squats? In fact, you can drink wine, eat a donut, or watch a movie while this is happening – NO JOKE!
The science behind the device is fairly simple to understand. The Emsculpt uses electromagnetic waves to stimulate the underlying muscle. Think of the TENS unit that is used to improve aches and pains, ON STEROIDS. The contractions are “supramaximal”, meaning more intense than a person can do on their own. During a 30 minute session, the abs/buttocks contract equivalent to a workout of 20,000 crunches/squats. The usual protocol is to have a total of 4 sessions in 2 weeks. Expect some muscle soreness the next day or 2 but there is essentially no downtime. Better yet, there is really no risks either. There are 2 handpieces for each machine. This means that 2 patients can be treated simultaneously on the abdominal area or one patient on the buttocks area.
There were 7 different sites that studied the Emsculpt. Before and after CT scans, MRIs, and Ultrasounds were taken in the study group. Results showed muscle mass increased 16% consistently. What is even more interesting is that the average fat loss was 19% and waist measurements decreased by 4 cm.
Another treatment area is the gluteal area. Using 2 handpieces simultaneously, the buttocks is treated. The settings are adjusted so as to not cause any fat destruction but just muscle hypertrophy. Other areas being treated experimentally by some physicians are the thighs and calves. The pectoralis muscles definitely can’t be treated because they are too close to the heart and the strong electromagnetic waves might stimulate the heart.
There have been anecdotal reports of enhanced athletic performance after Emsculpt treatments. Is this a new legal way to get an edge on the competition?
Contraindications are people who have pacemakers, metal IUDs, metal implants or surgical clips (close to the treated area).
Bottomline, six pack abs and brazilian butt lifts can now be obtained using the noninvasive, risk free, no downtime, Emsculpt.
Call The Aesthetic Clinique for more details, the Emsculpt headquarters of the US.
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:
- Know the major vascular structures and their landmarks
- Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
- Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
- Use cannulas whenever feasible, preferably 25/23g or larger
- Avoid boluses, small linear threads are safer
- Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
- A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
- Injection onto periosteum is safest but does not guarantee a vascular free injection
- Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
- Retrograde injections are safer than anterograde injections
- Dermal injections should be relatively safe
- Avoid deep injections in the lips. Stay superficial to the muscles
- 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
- Have on hand 6-8 vials of Hylenex
- 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.
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.
- 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
- 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.
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:
- 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.
- Pain – needles require multiple entry points to deposit the filler. Pain fibers are most prevalent in the dermis.
- 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.
“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”.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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.
- The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
- 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).
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
- The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
- 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.
- Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
- 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.
- 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.
- 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.
- 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,
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:
- Multiple treatments were required – 3 or more
- Results take weeks or months to occur
- Final results still showed volume loss in the temporal fusion line and supraorbital area
- Significant volumes of Sculptra were required
- 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.