PEER-REVIEW | INJECTABLES | hide the unsightly extensor surface blood vessels. The
microcannula technique on the dorsum of the hand is to place the pilot in the distal mid-hand and to use this lone portal to encompass the entire extensor surface of the hand. As you can see (Figure 6), the microcannula can literally glide over blood vessels without penetration using the wiggle progression technique with excellent results using the 1½” microcannula.
Figure 7 (A) Hinderer’s Lines delineating classic injection zone. (B) Pyramid vertical fan technique minimises injections
Pyramid vertical fan technique The traditional method of injecting Juvederm Voluma is to demarcate Hinderer’s Lines, the two lines that cross the mid-face highlighting the malar prominence of the cheek. Hinderer’s lines divide the cheek into four distinct zones which should be injected sequentially in order to give the most efficient lift to the cheek. Line number one is from the lateral canthus to the oral commissure and line number two is from the tragus of ear to upper alar lobule of the nose. These result in the classic four injection sites: the zygomatic arch at sites 1–2 which anchor and lift laterally; the anteromedial zone at site 3; and finally, the submalar zone at site 4. Injections are then made using needles perpendicular to the skin placed supra-periosteal in sites 1–2; and above the periosteum, but into the subcutaneous tissue in the remaining sites. The needles are injected with one single retrograde infusion and immediately removed to inject the next site, not unlike the placement of tent pegs to support canvas. The fanning technique has the advantage for injections
Figure 8 (A) Before and (B) after cheek treatment using Juvederm Voluma with TSK by Air-Tite microcannula
Figure 9 (A) Before and (B) after neck treatment using Juvederm with Air-Tite Microcannula
that are horizontal to the plane of the skin of a single painful entry point encompassing a much larger fan area. Consequently, the author believes the same may be accomplished using a fan that was vertical to the plane of the skin. ‘The pyramid technique’ is simply to insert a pilot needle perpendicular to the skin, and then fan the microcannula vertically in the shape of a 3–4 sided pyramid for greater structural anchoring ability and to minimise injections. Beginning microcannula users find it far easier simply to inject the cheek using hypodermic needles, but with few exceptions, the author now uses microcannula in this area. With Juvederm Voluma, it is essential to inject sequentially as numbered with traction from the lateral-superior aspect to the medial-inferior aspect to anchor the skin so less product is needed medially. This technique also requires enough massage over the injected areas to maintain a smooth appearance.
Figure 10 (A) Before and (B) after chrinkle treatment using Juvederm Ultra Plus and Voluma with TSK by Air-Tite microcannula
30 ❚ January/February 2015 |
prime-journal.com
Neck technique Microcannula may also be used to inject cosmetic fillers into neck wrinkles, but a great deal of extra care must be taken to avoid the plethora of blood vessels endemic in this area. The author uses a surgical marker to delineate the horizontal grooves with a 1½” microcannula to inject very superficially to avoid any cannulation of blood vessels, then repeats the process until the entire length of the groove is filled. Before injection, it is important to aspirate back on the syringe to further reduce the risk of injecting into a blood vessel. Repeat the process again until the entire length of the desired wrinkle is completed. Sculpting cosmetic filler in the neck is particularly difficult
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