JUL-AUG 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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GLOBAL INJECTIONS PHOTOS COURTESY OF VIC NARURKAR, MD; BACKGROUND: © GETTY IMAGES glabella because people have asymetrical muscles—they may be stronger on one side," adds Dr. Weinkle. "You can't inject cookbook. You have to watch the muscle activ- ity before marking the injection points." Study the patient's dynamic face not only prior to injec- tions but during treatment, suggests Dr. Percec. "I watch how the face moves as the patient talks, and then have them express things like a grimace, a snarl or a big, open- mouth smile," she says. "If you're trying to fi ll something that is only visible during animation, you have to have the patient animate to see it as you're injecting." Understanding the Products With so many HA fi llers now on the market—each with its own characteristics—practitioners must become versed in the different products. "In 2004, we had Restylane. Now we have 12 HA fi llers in our cupboard and we're about to have more," says Dr. Weinkle. "To be the most skilled in- jector, it's important to recognize the signifi cant variability among the products." Today, injectors may use three or four different fi llers plus toxins in one patient, and patients regularly come in for touch-ups or retreatment. This raises the concern of potential complications due to product layering or mixing. "We know very little about how these fi llers interact with one another," says Dr. Percec. "Even if they are all HA- based, they all behave differently and their cross-linking technologies are all slightly different. So the question is, when we layer these one on top of the other, do the fi llers interact with each other and/or the tissue in a way that has a negative effect or a benefi cial effect?" Dr. Narurkar regularly uses a combination of HA fi llers in his patients and has also combined different classes of fi llers. "I've used HA fi llers to create more defi nition in patients who already had Sculptra. Similarly, we've had patients with Radiesse followed with an HA fi ller, and there haven't been any issues. But none of this has been studied objectively. This is all anecdotal. "Complications occur," he continues. "But often you don't know what prompted them." Infection is the main concern when you have multiple injection sites and multiple treatments performed over years, says Dr. Percec. "Early on, injectors were a little too cavalier. They would use an alcohol wipe and not make patients take their makeup off, which I believe increases the risk of developing biofi lm and potential infection," she says. "Overall, the more product you inject, the higher the likelihood of introducing bacteria." The sheer volume of fi ller being implanted into the face also raises some concerns. "If patients already have product in their faces and are prone to infl ammation or transient infections, such as sinusitis, or undergo dental procedures—that transient bacterial load or viral load can infl ame the HA fi ller," says Dr. Percec. Similarly, seasonal allergies can activate the fi ller and cause infl ammation. "These fi llers are dynamic in the sense that tissues respond and interact with them, and we're just at the beginning stages of learning how that affects patients," says Dr. Percec. "In the past, a patient would get one syringe of Restylane or Juvéderm in their nasolabial folds, and there was very little likelihood that something was going to happen. But when you have all these different areas of the face being injected on a more frequent basis, you're going to see different kinds of biological behavior." Specifi c Concerns Some patient-specifi c concerns are well documented. For example, patients who have undergone rhinoplasty 34 JULY/AUGUST 2018 | Med Esthetics BEFORE AFTER This 55-year-old patient received treatment with 1mL of Juvéderm Ultra XC at initial treatment and 0.5mL Juvéderm Ultra Plus XC at touch-up in the nasolabial folds; 1.1mL of Juvéderm Ultra Plus XC in the marionette lines; 0.4mL of Juvéderm Ultra Plus XC in the oral commissures; 2.9mL of Juvéderm Voluma XC in the midface; BOTOX Cosmetic: 20U in glabellar lines, 24U in crow's feet lines; and LATISSE (bimatoprost ophthalmic solution) 0.03% as part of the HARMONY study.

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