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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Page 38 of 68

GLOBAL INJECTIONS 36 JULY/AUGUST 2018 | Med Esthetics © GETTY IMAGES or other nasal surgeries are at higher risk of intravascular injuries and skin necrosis. "If you're doing off-label fi ller injection in the nose, you have to ask if the patient has had surgery in this area," says Dr. Narurkar. "Because the scar tissue can compromise the vasculature. This is less of a concern with facelifts. In fact, we do fi llers after facelifts all the time because a facelift of- ten doesn't address loss of volume. But I like to wait a good month or even up to a year after a facelift to do fi llers." Fillers actually can help alleviate one concern unique to facelift patients. "They often have signifi cant atrophy in the preauricular region because when the fl ap is elevated for the lift, the fat in the area sometimes dies, " Dr. Weinkle says. "When that happens, you see pronounced atrophy down the road, so you might choose to re-volumize that area." Dr. Percec also encourages injectors to consider the patient's tissue when selecting the best fi ller. "If you use a high G-prime fi ller—one that has high lifting capacity—in a patient who is very gaunt or who is elderly and has paper thin tissue, it is more likely to be lumpy and bumpy and look unnatural. So you want to select a more fl exible gel— something softer that will lift their tissues but not create a bumpy appearance." Conversely, she reaches for a high G-prime fi ller when treating patients with heavier faces. "A thinner or very fl exible fi ller in a patient with a heavier face and thick skin is going to be almost imperceptible," she says. Ask older patients about anticoagulant use. "Almost all of my patients down here in Florida are on some kind of anticoagulant. I do not stop anticoagulant use of any type to inject a fi ller or Botox," says Dr. Weinkle. "I explain to the patient they may have a higher incidence of bruising. But bruising is a manageable problem. I think it is very im- portant to reiterate: 'Do not stop anticoagulant use for a cosmetic procedure.'" Perfecting the Technique With so many new indications and products, ongoing train- ing is essential. Following are some basic guidelines to help injectors achieve the best outcomes. When combining toxins and fi ller, it's best to start with the fi ller injections to reduce the risk of migration of the botulinum toxin, notes Dr. Narurkar. "The rule of thumb is always do fi llers fi rst, but they can be done in the same session," he says. Start the fi llers in the midface. "We noticed during the pivotal Voluma trials that when we fi lled the midface, there was collateral improvement of both the tear troughs and the nasolabial folds—even without putting any fi ller in those areas," says Dr. Narurkar. "So we always start in the midface, then the temples, then the marionette lines, then the jaw line. At the very end, we treat the perioral area." To avoid over-fi lling, be judicious and bring patients back more frequently to slowly build up the correction they need. "I call it the building of the platform," says Dr. Percec. "We bring people back more frequently and do a little less each time. They get more natural result with less downtime." She asks patients to return every two to four weeks until the desired correction is achieved. "Once we're happy with the correction, I like to maintain it every six months," says Dr. Percec. "Even if the fi llers are still there— maybe they've lost 20 percent of the correction—I'd rather do a little touch-up at the six-month mark than a full reinjection a year or 18 months later." She encourages new injectors to take their time in intro- ducing new fi llers and areas of injection. She teaches her residents to start with one middle-range HA fi ller—Re- stylane, for example—and focus on on-label indications, such as the nasolabial folds. "Once you feel confi dent with your injection technique, move to more sophisticated areas and branch out in your use of fi llers," says Dr. Percec. "Our market is getting much more sophisticated and our injectors are getting much more sophisticated. This requires a lot more training on our part because the standards are getting higher, and we have a lot more tools in our toolbox." Inga Hansen is the executive editor of MedEsthetics.

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