MAR 2014

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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DETAILS periosteum increases the risk of intravascular cannulation of blood vessels and resulting necrosis and embolization, so I recommend aspirating the syringe before injecting VOLUMA. Then wait three seconds to allow the lidocaine to take effect before completing additional injections. Allergan recommends VOLUMA be placed a certain way to exact the greatest G' lifting ability: VOLUMA is injected supra-periosteal in injection sites 1 and 2 upwards to subcutaneous depth, much like a tent pylon holding up a pup-tent. Having tried the traditional approach as well as the pylon, the pylon wins hands down in delivering the greatest cosmetic fi lling for a given amount of VOLUMA. For injection, I now exclusively use TSK Laborato- ries' Air-Tite STERiGLIDE MicroCannula instead of the traditional needle, because the blunt-tipped cannulas are less likely to penetrate blood vessels, nerves and muscle, resulting in far less bruising, swelling and pain. The Micro- Cannula has a blunt tip with a tiny port near the end where cosmetic fi ller is extruded—and the tip is tapered for easier entry, with the port close to the tip for better placement precision. Beginners may experience an initial learning curve to insert the cannula smoothly without repeated and painful efforts to enter the Pilot opening, but once the technique is mastered, I know of no injector who regressed back to the traditional needle. For VOLUMA, I use a larger 21-gauge 1-inch pilot needle to create an opening through the dermis, and then introduce the 27-gauge 1½-inch STERiGLIDE MicroCan- nula through it. I inject enough VOLUMA to suffi ciently lift to 100% of the desired volume correction at the base of our chosen sites, instead of the usual horizontal superfi cial dermal/SQ junction fanning technique. Typically, I do a vertical fan with a single pilot hole for each site, which I call the Pyramid Technique (photo 2). Instead of a straight up and down pylon or tent peg shape, I prefer to introduce the Pilot needle at the tip of the pyramid and fan downwards just above the periosteum in the shape of a miniature pyramid. This technique seems to maximize stability at the base, without creating a palpable presence superfi cially. After aspirating the syringe, I inject retrograde as I withdraw the cannula to permeate VOLUMA into multiple tissue layers to create a more stable foundation. Finally, without removing the cannula from the subcutaneous plane, I fan downwards to repeat the process twice more at equal intervals to complete the pyramid. A fourth equidistant fan may also be added. After the injections, I massage and mold the VOLUMA to the shape desired for maximal aesthetic effect. Alternatively, one may use a traditional needle instead of the blunt-tipped cannula, though I would make sure to use a 27-gauge 1-inch needle instead of the 27-guage 1½-inch needle included with VOLUMA to better reach the perios- teum. The traditional needle has the advantage of penetrat- ing more readily so you do not have to create a tunnel (as with the microcannula), but the risk of cannulation is higher with the needle, and I fi nd it causes more pain, swelling and bruising. I would also aspirate carefully before any needle injection using only minimal massage, as this will markedly increase patient bruising and swelling. 24 MARCH 2014 | Med Esthetics I inject retrograde as I withdraw the cannula to permeate VOLUMA into multiple tissue layers. Photo 2: The Pyramid Technique maximizes stability at the base to fi ll out the cheeks and improve nasolabial folds and the tear trough area. Photo 1: Hinderer's Lines are used to highlight the four distinct injection zones. PHOTOS COURTESY OF GARRY LEE, MD D e t a i l s M E D 3 1 4 . i n d d 2 4 Details MED314.indd 24 2 / 1 1 / 1 4 3 : 5 0 P M 2/11/14 3:50 PM

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