| beST prAcTIce | ArTIcLe
the product should be injected subcutaneously, intra- or submalar fat pad, and always above the periosteum17, 23 When the cannula technique is used for midface
.
volume restoration (Figure 5), the skin lateral to the malar area is first punctured with a needle to create a subcutaneous channel approximately 1 cm in length. Once the needle is withdrawn, a round-tipped cannula is inserted through the incision. pushing the cannula through the subcutaneous plane extends the channel, and Juvéderm VOLUMA is injected using the anterograde and retrograde technique. This step can be repeated using the fanning technique to create multiple channels to inject the required volume of product. When the injection is completed, the area should be massaged to mold the product to create a natural-looking result. To restore midface volume using the needle technique,
Juvéderm VOLUMA is injected following lines from the most prominent edge of the malar bone toward the nose and strictly inferior to the orbital rim, and always deeper than the orbicularis muscle (Figure 6). For more effective filling, the advanced injector familiar with periorbital rejuvenation may add additional perpendicular vectors for midface injections, from a point at the top of the nasolabial fold, 2 mm away from the nostril junction, fanning up to the malar eminence, and again, strictly inferior to the orbital rim. The fanning technique can be used to create multiple channels to create a heart-shape, until the desired volume of product is injected. If the subpalpebral area also needs filling, injections should be performed upwards in a fan-shaped pattern to recreate the appearance of youthful suborbicularis oculi fat pad (SOOF) and a malar pad. The product should be injected horizontally using an anterograde and retrograde technique, with continuous pressure on the piston of the syringe and always keeping the needle under the orbicularis oculi muscle4
. Anterograde deposition of Juvéderm VOLUMA will
gently dissect the tissue and minimise injury to deep facial components. When using a needle or cannula, the clinician can use an advanced technique to administer Juvéderm™ VOLUMA™ by creating multiple tunnels that cross each other in different planes (e.g. under the orbicularis muscle and under or into the malar and SOOF pads)4
. Although these injections are very deep, they are
always above the zygomaticus muscle. performing a gentle massage at the end of the injection procedure helps spread the product evenly into all the tunnels, creating a smooth, natural appearance. The cannula and needle techniques each have
advantages and limitations, but both can yield highly satisfactory outcomes. proponents of the cannula technique find it to be rapid and associated with little tissue damage; it results in possibly less bleeding and bruising than the needle technique. On the other hand, it may be somewhat less precise and associated with a potential risk of haematoma. Additionally, the cannula technique may appear more aggressive as the blunt tip must break through the subcutaneous septum, in contrast to the effect of using a sharp needle. The cannula technique may also be more difficult for new injectors to master than the needle technique, which may also offer
Figure 5 Physician- recommended technique for injecting Juvéderm™ VOLUMA™ with a cannula for malar volumisation. (Photos courtesy of Allergan, Inc., Irvine, CA)
greater precision. The needle allows control of both anterograde and retrograde deposition of material. A slight risk of haematoma formation and a higher risk of tissue trauma is associated with multiple injection sites. clinicians should decide which technique to use based on their experience and comfort level with using volumising agents and after they have undergone specific training with Juvéderm VOLUMA.
Volume recommendations Injection volumes are highly dependent on the nature and extent of the volume defect. As an example, aesthetic patients with stage 2 volume loss may need a volume ranging from 1–2 mL per side. It was recommended that clinicians begin by injecting 1–2 mL per malar treatment area in a single session and retreat as needed. patients with greater volume deficits, such as those with HIV-associated lipoatrophy, may ultimately require as much as 6–8 mL per side. regardless of the required volume, however, no more than 4 mL per midface area should be injected in a single session for any patient. In a study of patients with HIV- associated lipoatrophy, the mean total volume injected at a baseline visit was 5.3 mL ± 1.5 mL (range, 3–8 mL)16
. For the
jaw area and jowl deformities, recommended volumes were 1–2 mL per side. It was noted that the chin should receive at least 2 mL, which is appropriate for a first visit, although more than 2 mL is the typical mean volume necessary for this area. All patients should be evaluated after 1 month, at which time touch-up injections can be performed if they are deemed necessary. Waiting 1 month allows swelling and bruising to subside so that an accurate evaluation can be made. Also, it provides patients time to live with the results and assess their satisfaction with their outcomes. At that time, discussions and decisions about the use of other products can occur.
prime-journal.com | November/December 2011 ❚ 25
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