This is CME on ReachMD! The following activity From Theory to Technical Excellence:
Microinjections of Hyaluronic Acid is provided in partnership with Omnia Education and supported by an independent educational grant from Galderma Laboratories.
Prior to beginning this activity, please be sure to review the learning objections and faculty disclosures.
Your faculty for this activity Dr. Melanie Palm, medical director at Art of Skin MD in Solana Beach, California, and assistant volunteer clinical professor at the University of California at San Diego.
To see the full video demonstration or to access the slide presentation and additional resources, please visit ReachMD.com/AestheticInjections.
Here’s Dr. Palm.
Today we are conducting an educational activity, and this is really meant to help with guidance to incorporate new advanced techniques into your practice. This is meant to help provide safety measures as well as effectiveness for these advanced techniques and then some of the patient demonstrations that you will see today.
First, we are going to speak to the physiologic changes of aging, and I think we are all familiar with these. Things such as dry, thin, atrophic skin. It becomes unevenly pigmented over time. It often takes on a sallow appearance. Sometimes there is a loss of vasculature over time. This is really related to some of the physiological changes that happen to the skin in senescence. There is atrophy to the dermal extracellular matrix. There is a loss of some of the critical sugar components, such as GAGS and proteoglycans and hyaluronic acid. There is the shortening and disappearance of elastic fibers, a decrease in the content of collagen, and then, with time, the extracellular matrix has changes that consist of cell senescence, increase in reactive oxygen species, and an upregulation in proteolytic enzymes over time.
There are goals involved with microinjections. This is typically done as a series of two to three treatments done over monthly sessions and then periodical retreatment as necessary for the patient. The goals of this are really several fold. It is to increase the skin elasticity, to create a positive impact on skin surface roughness, and to enhance biosynthesis of new dermal compounds.
There are benefits to hyaluronic acid that we are all familiar with. This is a naturally occurring substance. I often tell patients that this is something that is found in our skin.
The effects of hyaluronic acid last up to 24 months. And there are common side effects that are associated with the injection of these products. They include skin rash, itching and bump-like eruptions, often acne-like in nature, redness, bruising, bleeding and swelling, which is often related to technique. Skin damage can result from improper technique or infection that occurs during the procedure, and most significant consequences that we get concerned about are things like blindness and vascular occlusion, which are very serious in nature, and a practitioner should be prepared to know how to address them immediately.
We know that hyaluronic fillers help to stimulate cellular and molecular changes in the skin. This is a study that was done in an animal model. In this rat study, a consistent increase in dermal thickness was seen over a 12-week period as you can see on the threefold picture on the left. In the other diagram, which is found on the right side of the slide, you can see several things.
In the top left, you can see that the hyaluronic filler is incorporated into the collagen matrix. In the top right, you can actually see ingrowth of both tightly wound and loose collagen fibers growing after placement of the hyaluronic acid implant. On the bottom left, with birefringence, you can see both smooth compact collagen as well as loose fibrils incorporating into the areas of filler placement. And finally, on the bottom right, with a special stain, we can actually see elastin, something that is elusive and is often hard to actually manufacture, being present and in the place close to where the hyaluronic acid was implanted.
There are best practices when we are considering microinjection techniques for our patients. In the following slides, we are going to discuss patient assessment with special attention to facial anatomy, including neurovascular bundles, anesthesia and sterile measures that are appropriate prior to injection, product selection, injection technique, preventing and managing adverse events, a maintenance plan for our patients.
The key to safety and a balanced result is really critical in a patient assessment. This occurs during consultation and during the day of treatment. A full history is necessary
There should be special attention paid to each third of the face, the upper face, the mid face, and the lower face. In particular, the anatomy in terms of arteries, veins, and neurovascular bundles are critical for minimizing complications and for the effectiveness of this treatment.
The central part of the face is at particular risk for blindness and necrosis because of the anastomosis between internal and external carotid vasculature. This must be of note and is critical during your injection procedure.
In the lower face, the key is really maintaining balance. You want to look not only from an anterior view or frontal view, but from a lateral view and appreciate the patient animation during the injection session. The chin is an area that is often neglected but is an important part of the lower face and should be considered when fully assessing the face.
A detailed knowledge of facial anatomy as I mentioned previously is critically important. In these diagrams that you can see here, you can see some of the critical internal and external carotid vasculature and how they anastomose. Once you see a demonstration of the vasculature of the face, it quickly becomes apparent how easy it is at virtually any place on the face to have a complication from a vascular perspective. I think it is critical for any practitioner to be on notice of this and consider some of these important vascular structures and neural structures when injecting in order to avoid complications.
So choosing the product for the right indication is critical in patient success, and it also allows us to avoid complications that are unnecessary. Choosing the product depends on the patient, the area of the treatment, skin quality, and a complete facial analysis.
Under rheology and the physical properties of a hyaluronic acid gel, we, in particular, like to consider the hardness of the gel, which is considered sometimes the G-complex or the complex modulus or G prime, the particle versus cohesive nature of the gel, a concentration, and, in addition, the degree of crosslinking, which often lends to the hardness of the gel.
it is important to look at factors, such as the density, the duration, and what the FDA approved the uses are for these particular gels when considering your patient and the area of injection.
As I mentioned previously, it is good to keep in mind the rheology of some of these fillers when you are considering an area of placement and augmentation with some hyaluronic acid fillers. Shear stress in filler selection plays into this rheological or the physical properties of flow and declamation of these particular fillers. We often think of the complex modulus, which is this G* as well as the G prime, which is really sort of how elastic a particular filler is.
For example, something that has a high G prime is highly complexed or tends to be very cohesive in nature is going to be a product that is more robust and is good at lifting as opposed to something that has a higher G double prime and is more viscous in nature. It is going to be appropriately placed more superficially and is going to be better at sort of melding into superficial wrinkles rather than something that has lifting capacity in the tissues.
There are various injection techniques that we employ depending on the area of injection and what we are trying to accomplish. Really, some of this is also personal preference. Linear threading, crosshatching, fanning, serial puncture, or even a combination of several of them may be used in order to receive an optimal result from hyaluronic acid injections.
But careful consideration of these injection techniques and the presence of vascular and neurovascular bundles is really of paramount importance in order to minimize adverse events.
In order to prevent and manage some of these adverse events, it is important to think of both technical errors and then errors that really arise out of reactions from interplay between the hyaluronic acid fillers and our bodies. In terms of technical errors, the volume used, the depth of injection, the location of the product, and the product choice all play a role in technical errors. In terms of inflammatory reactions, infectious agents, and really, we can minimize this through proper technique and preparation of the skin, and then immune-mediated factors that may play a role in delayed-type hypersensitivity reactions may cause inflammatory reactions related to hyaluronic acid filler placement.
It is important to keep mind of the facial anatomy during the injection, to prepare the skin properly, and to have a safety kit on hand with things such as hyaluronidase so that if you are having a vascular complication, you know how to address it immediately.
Vascular compromise and blindness are some of the most feared complications in relation to hyaluronic acid filler. There was a recent worldwide review of 98 cases that reported blindness over the past several decades, and what was found was the majority of these cases occur in the central face, and many were related to autologous fat, although every filler was represented that is currently FDA approved.
I think what is important to know is there is a learning curve involved with some of these advanced techniques. As advanced filler injectors, we really need to pay attention to technique, to the tissue at hand while we are injecting, and to do the procedure appropriately in order to mitigate some of these possible complications that can arise. Most of these cases of blindness are permanent, although there are emergent cases that have reversal and restoration of visual acuity and include injections retrobulbarly or pulsed intra-arterial hyaluronidase injections.
Maintenance plans are extremely important in discussing with patients at the time of treatment, but also at the onset of cosmetic consultation. Full correction is required, but often times this can occur over several session rather than of a mega-filler session. But the longevity of the fillers and patient parameters really determine how long the duration of the procedure is. In general, I like to reassess patients every 3-6 months and treatment touch ups usually occur at a frequency of about every 6-9 months.
In our first patient, we’re going to use a microinjection technique to address both forehead rejuvenation, as well as horizontal lines on the neck.
On my procedure tray I have gauze soaked with an antiseptic, and clean gauze, the Restylane Silk syringe, a female to female connector, and a 0.3 cc syringe of approximately 0.3 to 0.5 cc of 0.5% lidocaine with epinephrine buffered with bicarbonate is present. I admix the lido-solution with the Restylane Silk syringe to blend the product and provide a thinner product that is more easily molded into thinner tissues. From the Restylane Silk syringe I attached a 1.5 inch, 25-gauge needle and take the plunger out of the back of the 31-gauge, 3/8-inch 0.3 cc insulin syringe. I back-fill the blended Restylane Silk into the insulin syringe to give approximately 0.2cc filled product in the insulin syringe. This gives a nice hand-feel when I’m injecting, and it also provides precision and control using very small aliquots during the actual projection procedure.
Our patient is in her 40s and presents with typical aspects of some of the aging changes that we see in a female face over time. Notice that there is a deep fat pad that runs centrally and then laterally across the forehead. In youth, in women, there is a beautiful sweeping convexity but over time, there ends up being a little bit of a central indention, and we want to recreate this sweeping curve. The patient had just a little bit of topical numbing running for the past 45 minutes or so. With that, I want to mention preparation of the skin. Whatever your antisepsis routine is, it is very important to maintain.
We want to think about safety first, so I tend to be about 1 cm above the orbital rim. We know that the supratrochlear neurovascular bundle is usually emanating where we start to see that wrinkle from the corrugator muscle. We can often feel the supraorbital notch on most patients and this is where this neurovascular muscle lies.
This area here is a danger zone. By the time we get about an inch above that orbital rim, we know that we are going to be in a safe place – that is super periosteal on top of bone, and we are going to be below where these important vessels lie. If worse comes to worse in injecting this area super periosteally, you will pierce through one of the vessels and just cause a bruise. We are going to be at very low risk of cannulating one of these vessels or causing a vascular event.
I do a little poke in this area where I know I am safe. I am going down to bone, so I know I am on the super periosteum and move very slowly. Typically, I am putting about 0.05 cc of product in any singular spot, and you can see it causes a little bleeding. I do not have any sort of blanching or textural change. You can see that it is very comfortable for the patient. I am going to march over laterally a little bit during injection. Again, pulling down a bit of product on top of bone, a small little aliquot, and going very slowly. And this is a key component to safe injection.
I finish laterally. Sometimes there is a little bit of sensitivity in this region. I am going perpendicular to the surface of the skin and again placing approximately 0.05 cc of product into this area. Then I massage. If you are on the super periosteum, it just nicely glides and you’re in a relatively avascular plane, so the product beautifully smooths the region providing a nice convexity to the forehead. If we have the patient turn, we can see we are starting to get that return of volume, and you are not seeing that depression in the central forehead that occurs with atrophy of that deep fat pad of the forehead over time.
I then move to central parts of the forehead and continue over to the left side.
After I have done this, I always check to make sure that there are no areas in need additional correction. All of us are a little asymmetric and often require a bit of touchup before our final injection result is achieved at this session.
The results from this forehead injection technique for volume restoration in this area are immediate. I instruct patients to provide a full week for the results to ensure any swelling or rare bruising has subsided. The results typically last between 6 to 12 months. Most patients present for a touch up at 9 to 12 months.
Similar to the forehead rejuvenation using Restylane Silk, we are now going to explore another off-label use of Restylane Silk, this time in the lower, or actually beyond the lower face into the neck itself. I like using a sharp needle during this procedure because it allows sub scission of the tissue while simultaneously placing some of the filler in the neck line. This time I added between 0.4 cc and 0.5 cc of 0.5% lidocaine with epinephrine buffered with bicarbonate, not only for vasoconstrictive effect, but there are some superficial little veins that traverse the neck, and I try and minimize the degree of swelling and bruising. I am also trying to change the physical properties of the filler itself so that it glides, and it is smooth, and is a little diluted so that it just spreads nicely into these areas of fine lines. Then I’m going to use a little bit of manual massage to soften and smooth the blended product into place.
Let’s look at our patient. It is extremely common for patients to have these horizontal neck bands even in youth, and it is usually between two to four of these horizontal neck bands that traverse the area from sternocleidomastoid to sternocleidomastoid muscle. I usually ask the patient to tilt her chin down if I am having a hard time identifying some of these wrinkles.
Let’s start on the right side and then we will work over to the left. Please note that I bend the needle, so that I can have a tangential approach as I am working from the right side of the neck. The skin is very thin here, so a cannula is not ideal for this situation. A sharp needle is really the only approach for rejuvenating that I use for these horizontal neck lines.
I like to treat the horizontal neck bands a little more superficially than other procedures. I am holding countertraction on the skin itself and entering just almost tangential to the surface and putting a small aliquot of the Restylane Silk product in place.
Here is another fold I am going to fill. Again, some countertraction, as I am just below the surface of the skin. I like to go back and forth with the needle to subcise the wrinkle as I’m simultaneously filling. I am doing anterograde and retrograde filling during the injection, in order to create some subcision and then laying down the hyaluronic acid filler in that area, so I am simultaneously both subcising and releasing the wrinkle. Because about half of what I am placing, product wise, has the admix lidocaine, not the product itself, the product is going to settle out over time and look beautiful for a post-procedure photo in about a week.
For most patients, in terms of recovery, they may have a couple of dots where the entry points were, but it usually is not very stigmatizing. Occasionally a bruise occurs, which may take about a week to resolve.
The results following horizontal line filler treatment are best appreciated about 7-10 days post-procedure. This is typically when I invite patients back and perform follow up photography. Despite most hyaluronic acid fillers in this area having a duration of 4-6 months, the results from neck rejuvenation, in my experience often last close to a year, sometimes even longer. Maintenance regimens depend on the patients, but my typical patient repeats the procedure at about 2 years.
Now, let’s discuss on-label and a little bit of off-label use of some of these Restylane fillers for the lip area. Our patient is in her early 30s, and she has had hyaluronic acid fillers before. Notice where there is a loss of some soft tissue support in the marionette area. She received topical anesthetic for approximately an hour prior to injection.
The patient has gorgeous lips and in this younger age group, the goal is often to support the pillars of the marionette area, and smooth and hydrate the lips. Her upper lip is slightly smaller than her larger lower lip. She is Hispanic in ethnic origin and wants to be a little closer to the 1:1 ratio, which may be ideal for her facial shape and ethnic origin. But considering her face, we agreed that it is better for her upper lip to be a bit smaller than the lower lip. To support the pillars of the marionette area, I use Restylane Defyne and a micro-droplet technique. To smooth the lips, I prefer a small-particle HA product or a low concentration HA product, Restylane Silk being among the products that I use.
I start with support first. I want to support the area called the canine fossa or the piriform aperture. This is an area that we tend to get some boney protrusion over time. When you help to support this region, it brings a nice aversion to the lateral part of the upper lip.
I transferred a little bit of Restylane Defyne into these 0.3 cc insulin syringes with a 31-gauge needle. I start with the pillar of the marionette area. I am going to do the smallest poke, injecting very slowly. Be very careful, because usually where there is a fold, there could be a vessel. I use very small quantities of product, injecting slowly with these insulin syringes.
I prefer to work from the jaw line up to the oral commissure in this injection approach. As I am entering the skin, I pull the skin up a little bit and then sort of flick as I am finishing, what is sometimes referred to as a Hershey kiss technique. This is where you place more product deeper at the base, and less product as you exit the skin, creating a little bit of fullness at the base and a strut. Observe how the appearance of this area is starting to change as opposed to the contralateral side. The marionette line has softened, and the corner of the lip has begun to shift upward.
At this point, I have only used about 0.15 cc of product to support the marionette area. I am now working a little bit closer to the oral commissure, I entered perpendicularly, so we are using a depo technique.
Note again that the patient is very comfortable. There is numbing that is pre-incorporated into virtually all of the hyaluronic acids that are now FDA approved for use here in the U.S. In this case, I did not do any further admixing with a local anesthetic with the product, but I sometimes will do that depending on the physical properties of the filler that I use, and if I want a little vasoconstrictive effect, as the local anesthetic has some epinephrine in it.
Next, I will deposit a little additional product to the piriform aperture to provide support to that area, which plays a role in support of the upper lip. For this, I use Restylane Refyne.
The safest plane for injection of the piriform aperture or the canine fossa region is to be on top of bone. The angular artery could be quite close to the piriform aperture. If you can be on top of bone, the artery should be above that area in the fat.
It can be helpful for the patient to take a deep breath in and then exhale, while I do the injection technique. I’m now refluxing. I’m going to hold that for several seconds. I don’t see any reflux or blood. I’m going to slowly add a little bit of the Restylane Refyne to this area of the canine fossa as I’m watching the tissue for any signs of vascular compromise.
I entered at an acute angle, usually at about 30 to 45-degrees angle to provide support to this region. I usually do not deposit more that 0.1 to 0.2 cc of product in this area. That helps to provide some support to the nasal base and to help the lateral part of the upper lip evert. Going slowly increases the safety of these procedures for our patients, especially in high-risk areas, such as the central face. If a patient were to experience blanching, they would have immediate pain on injection that would seem out of proportion to what you were doing, and you should stop immediately, reassess the skin, and reassess the patient.
I then continue with a small little entry point just a bit inferior to that area, the piriform aperture, refluxing, not getting a positive flash, and then retrograde filling of the product. We’ll repeat the same thing on the contralateral side.
The next thing we are going to do is support and add volume to the body of the lip, and then finally add a little bit of a small-particle HA product to smooth and hydrate the lip itself.
The upper lip tends to be more sensitive to patients than the lower lip. So I typically inject the lower lip first to build patient confidence with comfort of the procedure. I tend not to inject directly into the red lip to volumize the lip body itself. Instead, my approach is to enter from around either the orbicular, or the white portion of the upper lip, or inferior to the red portion of the lower lip in order to add volume to the lip itself. You really need to be mindful of lip injection and where the superior labial artery and the inferior labial artery are located. If you create an imaginary horizontal line from the edge of the vermilion border posterior to the lip mucosa on the lower lip, that is where the inferior labial artery resides. I want to make sure that I anterior in front of that when I inject the body of the lower lip.
So, this is where I start and add a little bit to the bottom lip, in the inferior pillow of the lower lip itself. I will repeat the injection to very slowly fill the body of the lip.
Be careful, as you’re injecting the lip body, you may be in the musculature. When I want to accomplish hydration, I want to be in the submucosa of the lip. From one entry point, as I’m adding volume to the lip itself, I usually can pivot from a single access point and fill a portion of the lower lip, augmenting appropriately the indicated tubercle.
It is important to abide by the proportions of the lip. The majority of the lip volume should be in the middle half to middle two thirds of the lip, so if you drop a vertical from the alar rim down to the lip, the majority of lip volume should be in this zone. We put about 0.1 cc in that area.
I am now going to switch gears. Once we have had success with the lower lip, and patients know the lip filling experience can be comfortable, we can work on the upper lip.
Similar to the lower lip, I tend to come from beyond the vermilion border and actually access it in Orbicular, or white portion of the lip, and then from that approach, I am able to come down to the body of the lip. I tend to fill the body first and then finish any sort of vermillion border adjustment, and finally philtral column work afterwards. As opposed to the lower lip, which has two lip tubercles, there are three pillows, or tubercles, to the upper lip. Finally, I do want to add a little bit of volume here to the central pillow. I save this injection of the upper lip until last, because this area tends to be the most sensitive. I do tell patients that one is going to be a little bit spicy.
When the lateral portion of the upper lip is filled too aggressively, that is when people tend to have sort of what is referred to in layman’s terms as duck lip or sausage lip. It is important that the beautiful proportions of the lips are accented and that you are abiding by what the width of the face can accommodate for lip size. When that falls out of proportion, that is when we get into trouble with things seeming out of proportion, and lips not harmonizing with the face as a whole
Our final step is that I am going to layer on a little bit of Restylane Silk on top of the Restylane Refyne that I just used. Then, using a moderate density filler, like classic Restylane L, I will help to rebuild a little bit of the philtral columns.
Restylane Silk is a small-particle hyaluronic acid. It is used to smooth and hydrate. I do use the needle that comes standard with the filler itself. We are going to use it in the submucosal space in front of the wet-dry border to smooth the lip lines. I usually start more laterally on the upper lip and then work across. I roll the lip and I’m supplying some counter traction as I inject. In this approach, I use an anterograde and retrograde injection. You want to be as atraumatic as possible with Restylane Silk. Less manipulation is better with this product. This small-particle hyaluronic acid, if it is over manipulated, can cause more significant swelling for the patient during the recovery period, but this is typically not long lasting.
Finally, I want to do a little bit of Restylane L in order to accent the philtral columns. With that, I have bent my needle for a tangential approach. The philtral columns are not straight parallels, but the vectors should converge superiorly creating a trapezoidal-like shape. The needle enters at the tip of the cupid’s bow. I retrograde inject the philtral column, flicking the needle on exit to create a structure at the tip of the cupid’s bow. Then I repeat this technique to the philtral column on the contralateral side.
The patient has a little bit of mild-to-moderate swelling, but this will recede over the next week. It does not appear as though she is going to have any bruising. She should have a really nice hydrating effect that smooths the lips, and a subtle augmentation within about a week’s time.
Final results from this method of lip augmentation are best appreciated about a week after treatment. The most important aspects of lip augmentation are symmetry and proportion. In many patients, it is rejuvenating lost volume and support to the lip area that I favor over frank augmentation. Typical maintained intervals for lip augmentation are every 6-12 months.
In patient number 2, I first completed forehead rejuvenation. In the photo you can see her before and after approximately 1 week apart. In this ¾ view, you can appreciate an improvement in the convexity of the forehead. Where an ideal forehead should have a sweeping convexity, rather than a concavity to the upper third of the face.
In patient number 2 we also completed neck rejuvenation using blended Restylane Silk, with a bit of 0.5% lidocaine with epinephrine buffered. For her horizontal neck lines, you can see a vast improvement in both the anterior and lateral views of the neck. This is a technique that tends to be a bit longer lasting, despite shorter durations of the products that we use. In the anterior and lateral views of the neck, the horizontal transverse lines along the neck have been greatly improved through blended Restylane Silk product that was injected in an anterograde and retrograde technique using the sharp needle technique. These results typically last 6-12 months or longer.
Here you can see the before and after results from patient number 1 in which we used support with Restylane Defyne to the marionette line area. You can see a nice improvement with an upward swing of the oral commissure and support to the marionette area. In the lip area itself, I provided soft augmentation, accenting the tubercles of the upper and lower lip with Restylane Refyne, and then smoothing and hydrating the lip with Restylane Silk.
As we have just discussed, in performing some of these advanced techniques with hyaluronic acid fillers, it is important to know that there is a learning curve associated with this in order to build confidence and ensure patient safety. With practice, even some of these more advanced techniques become more understandable, better assessed, and ultimately provide superior patient outcomes.
Maintenance plans are extremely important in discussing with patients at the time of treatment but also at the onset of cosmetic consultation. Full correction is required but oftentimes this can occur over several sessions rather than a mega filler session. The longevity of the fillers and the patient parameters really determine how long the duration of the procedure is. In general, I like to reassess patients every three to six months, and treatment touchups usually occur at a frequency of about every six to nine months.
This has been CME on ReachMD. This program was brought to you by Omnia Education.
To receive your free CME credit or to view the full demonstration, please visit ReachMD.com/AestheticInjections.
Thank you for joining us.