PEER-REVIEW | INJECTABLES |
Figure 14 (A) before and (B) after Frontalis Juvederm treatment using TSK by Air-Tite Microcannula
Overcorrection will occasionally require the use of the enzyme hyaluronidase, which may be used judiciously to sculpt any hyaluronic acid filler. Of course, the wiggle progression technique is indicated for greater safety to minimise any chance of embolization.
Crow’s feet (orbicularis oculi) technique This traditional Botox® treatment area can also be injected with Juvederm Ultra Plus XC for longer lasting results using the long microcannula double cross- hatched fan technique. Cosmetic fillers may be a better and less expensive option, especially for those with large crow’s feet muscles, which may require excessive Botox units four times a year.
Glabella technique This is a high risk injection area where necrosis and stroke20
have been reported after the accidental
cannulation of small calibre vessels branching from supratrochlear arteries, which have minimal collateral circulation21
. The resulting necrosis often leads to when no longer hidden by involution in loose skin
folds after cosmetic filler volume correction. The author’s chosen entry point is ½” to 1” below the
tear trough with pilot placement medial and lateral to the inferior orbital nerve. Restylane is then fanned up to no more than 50% correction, typically stopping just below the bony orbital rim. Correction of more than 50% usually results in grossly abnormal swelling — especially the day after injection from water absorption — so the author prefers to make corrections in lessor stages.
ulceration and ultimately scarring. Nevertheless, static glabella lines may give rise to the connotation of anger even when no such emotion exists. This may be circumvented with the conservative application of Juvederm Ultra in greater safety using microcannula and the wiggle progression technique in place of the needle.
The frontalis technique applies to
both static and dynamic wrinkles and is used most aptly when Botox
cannot be used due to the likelihood of brow ptosis.
The author’s technique is to place the pilot from above
the two vertical lines (i.e. ‘the elevens’) and to carefully tunnel with the microcannula below the dermis. Upon any resistance or pain, simply redirect the microcannula below the dermis. Upon reaching the desired end point, aspirate the syringe to minimise the risk of injecting filler into blood vessels and upon finding no blood in the syringe, slowly inject retrograde on the way out intentionally under-treating and under-filling to avoid the compression of blood vessels.
32 ❚
Figure 15 (A) Before and (B) after cosmetic filler using the long microcannula double cross- hatched fan technique for liposuction scar
January/February 2015 |
prime-journal.com
Frontalis technique The frontalis technique applies to both static and dynamic wrinkles and is used most aptly when Botox cannot be used due to the likelihood of brow ptosis; the horizontal wrinkle is too proximal to the levator palpabrae superioris muscle with the risk of eyelid ptosis; the cost of Botox is prohibitive due to the large size of the occipitofrontalis muscle; or Botox is simply ineffective because the wrinkle is static instead of dynamic and can only be treated with cosmetic filler. The process is to place a pilot needle at one end of a horizontal wrinkle, insert the microcannula using the wiggle progression technique, and to repeat this sequentially until the entire length of the horizontal line is treated.
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