Medesthetics

OCT 2018

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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ALL HANDS 38 OCTOBER 2018 | MedEsthetics PHOTOS COURTESY OF MIGUEL ANGEL ARISTIZABÁL TORRES, MD Before-and-after Radiesse injections for volume loss usually the same day that I do the fi ller injections, I treat the area with either a Fraxel (Solta Medical) or Enlighten Picosecond (Cutera) laser to remove brown spots, stimulate epidermal turnover and even skin tone," he says. Dr. Lupo successfully used Sculptra to rejuvenate hands until encountering a "severe delayed nodule" in 2007. "Since then I have used Radiesse," she says. "For age spots, I like Fraxel Dual (thulium wavelength) best. I no longer do sclero- therapy since Radiesse hides the veins too." Dr. Torres uses Q-switched and picosecond lasers to treat brown spots. Two weeks before the laser treatment, he starts patients on topicals to prevent post-infl ammatory hyperpigmentation. He prefers CaHA for volume loss be- cause of its rheological properties (High G) and duration. Dr. Cohen treats lentigines with a BBL or Q-switched la- ser just prior to injecting fi ller and performs both treatments during the same appointment. TECHNIQUE REFINEMENTS For the fi ller procedure, Dr. Cohen often uses a 25g can- nula to deliver Restylane Lyft or Radiesse. "I generally use two entry sites about 2cm below the wrist, injecting from proximal to distal towards the fi ngers to deliver volume to the entire dorsal hand," he explains. "This is easier than us- ing multiple needle entries, and many patients prefer fewer needle punctures." He notes, however, that using cannulas is an off-label delivery technique for hand augmentation at this point. "I use cannulas virtually all the time," says Dr. Werschler. "They are safer, hurt less, bruise less and are exceptional for hand injections. My favorite is the 25g, 2-inch size. A single pilot hole placement at the extensor crease on the wrist allows placement throughout the entire dorsum down to the base of the phalanges. Additionally, the can- nula will help prevent inadvertent placement of product into the extensor tendon sheath, which is where lumps, bumps and nodules occur, regardless of the product used." Dr. Torres emphasizes the safety aspects of cannula delivery. "It is important to remember that the dorsal hand vein network that gives rise to the cephalic and basilar veins over the forearm is located superfi cial to the fascia, just below the skin; hence, the risk of vascular or structural damage is high," he says. "I recommend cannulas with a gauge of 24 or 22. Small gauge cannulas behave as needles and can penetrate these structures." Dr. Werschler also prefers Radiesse to Restylane Lyft and other HA fi llers for most patients. "Since dermal thinning is usually the primary concern and Radiesse has proven collagen-stimulating properties, it more directly addresses the actual concern than an HA-based fi ller," he explains. "I've used Restylane Lyft for hands, and it does work nicely. However, I've had patients come back with complaints of discoloration. In fair-skinned patients (who are the most likely to request hand rejuvenation) there seems to be a predilection for the Tyndall/Rayleigh re- sponse, resulting in a blue to gray discoloration, especially when [the hands are exposed to] bright sunlight. I suspect this is because of the hands' more horizontal positioning, combined with the refractive aspects of the loose aerolar tissue between the skin and underlying aponeurosis." While Dr. Werschler considers cannulas the most signifi - cant technique improvement, he also offers several other BEFORE AFTER

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