PRIME North America Jan/Feb 2015 Volume 3

| INJECTABLES | PEER-REVIEW

Temple technique This is a treatment area which is growing in popularity as we all age. Previously, the author used Sculptra® with success in the temporal fossa, but now often uses Juvederm Voluma mixed with 1.0 cc of lidocaine per syringe for smoothness. Again, the author uses the long microcannula double cross-hatched fan with the wiggle progression technique with care to aspirate to prevent cannulation.

I believe that the next

frontier in non-invasive cosmetic medicine will be in the

combination of microcannula

introduced cosmetic fillers with synergistic modalities — such as laser, radiofrequency,

microneedling, PRP, stem cells, and microcurrent.

Buttocks and body techniques Although cosmetic fillers are traditionally thought of for injection to the face, the author believes there is no reason to not use it off-label in other appropriate body areas. Figure 15 shows application made in the upper thigh to correct a groove created from a surgeon’s excessive liposuction. The long microcannula double cross-hatched fan technique was used with Juvederm Ultra Plus.

Future trends and conclusions With the ebbing of the Great Recession, we are beginning to see the re-emergence of interest for cosmetic procedures, particularly non-invasive ones which tend to be less costly procedurally and with minimal downtime. The American Society for Aesthetic Plastic Surgery notes that non- surgical procedures increased in 2013 by 13.1% in the US with 9.5 million procedures22

. In particular, hyaluronic acid

cosmetic filler procedures increased a tremendous 31.5% in the US over the same time period22

. Moreover, we can

now create results which were once thought unachievable (see Figure 16) using cosmetic fillers alone. On the horizon, we are beginning to use platelet-rich

plasma (PRP) in aesthetics though there is no specific FDA indication and benefits to date are more anecdotal than documentable. I believe that the next frontier in non-invasive cosmetic medicine will be in the combination of microcannula introduced cosmetic

References

1. Zeichner JA, Cohen JL. Use of Blunt Tip Cannulas for Soft Tissue Fillers. J Drugs Dermatol 2012; 11(1): 70-72

2. Sherman, Richard, MD. Avoiding Dermal Filler Complications. Clinics In Dermatology 2009; 27: s23-s32

3. Glogau R, Kane M. Effect of Injection Techniques on the Rate of Local Adverse Events in Patients Implanted with nonanimal Hyaluronic Acid Gel Dermal Fillers. Dermatol Surg 2008; 34: S105– S109

4. Tzikas TL. Evaluation of the Radiance FN Soft tissue Filler for Facial Soft Tissue Augmentation. Arch Facial Plast Surg 2004; 6(4): 234-239

5. Merriam-Webster Online Dictionary and Thesaurus. Available at: http://www. merriam-webster.com/dictionary/ cannula [Last assessed 10 December 2014]

6. Prosotu Cannula and Needle

Solutions. Available at: http://prosotu. com/cannula-and-needles/ [Last accessed 10 December 2014]

7. Chesnut C, Hsiao J, Beynet D. New Uses for Fillers. Cosmetic Dermatology 2012; 25: 176-182

8. Niamtu J, III. Filler Injection with Micro-Cannula Instead of Needles. Dermatol Surg 2009; 35(12): 2005-2008

9. Fulton J, Caperton C, Weinkle S, Dewandre L. Filler Injections with the Blunt-tip Microcannula. Journal of Drugs in Dermatology 2012; 11(9): 1098-103

10. Hexsel D, Soirefmann M, Porto MD, Siega C, Shcilling-Souza J, Brum C. Double-Blind, Randomized, Controlled Clinical Trial to Compare Safety and Efficacy of a Metallic Cannula with that of a Standard Needle for Soft Tissue Augmentation of the Nasolabial Folds. Dermatologic Surgery 2012; 38(2): 207-14

11. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S. Blindness Following Cosmetic Injections of the Face. Plast Reconstr Surg 2012; 129(4): 995-1012

12. Cattin T. A Flexible Microcannula for Soft Hyaluronic Acid Fillers Improves Patient Comfort. Journal of Cosmetic Surgery & Medicine 2011; 6(1)

13. Hamman M, Goldman M. Mimimizing Bruising following Fillers and Other Cosmetic Injectables. J Clin Aesthet Dermatol 2013; 6(8): 16-18

14. Garcia R, Garcia A. The Use of Microcannulas in Facial Volume Restoration Treatment with Poly-L-Lactic Acid. Surg Cosmet Dermatol 2011; 3(1)74-6

15. Cohen J, Berlin A. Integrating Cannulas into Your Filler Practice. The Dermatologist 2012; 20(6

16. Smit R. Rejuvenating the Periorbital

Area: Lower Eyelid, Tear Trough, and Mid-Face. Injectable Treatments. PRIME 2013; 3(2). Available at: https://www. prime-journal.com/rejuvenating-the- periorbital-area-lower-eyelid- %E2%80%A8tear-trough-and-mid-face- %E2%80%A8/ [Last accessed 9 December 2014]

17. Brody HJ. Use of Hyaluronidase in the Treatment of Granulomatous Hyaluronic Acid Reactions or Unwanted Hyaluronic Acid Misplacement. Dermatologic Surgery 2006; 31(8 Pt 1):893-7

18. Funt D, Pavivic T. Dermal Fillers in Aesthetics: an Overview of Adverse Events and Treatment Approaches. Clinical, Cosmetic and Investigational Dermatology 2013; 6: 295-216

19. Sharad J. Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and Their Outcomes.

Journal of Cutaneous and Aesthetic Surgery. 2012; 5(4): 229-238

20. Bailey S, Cohen J, Kemkel J. Etiology, Prevention, and Treatment of Dermal Filler Complications. Aesthetic Surgery Journal 2011; 31(1): 110-121

21. Glashofer M, Cohen J. Complications from Soft-Tissue Augmentation of the Face: A Guide to Understanding, Avoiding, and Managing Periprocedural Issues, in Injectable Fillers: Principles and Practice (ed D. Jones). Oxford, UK: Wiley-Blackwell, 2010. Published online 10 March 2010, doi: 10.1002/9781444315004.ch10

22. Cosmetic Surgery National Database Statistics. American Society for Aesthetic Plastic Surgery (ASAPS). Available at: http://www.surgery.org/sites/default/ files/Stats2013_4.pdf. Page 5 [Last accessed 9 December 2014]

prime-journal.com | January/February 2015 ❚

fillers with synergistic modalities — such as laser, radiofrequency, microneedling, PRP, stem cells, and microcurrent. The challenge today is how to best integrate these together. What we are seeing is a convergence of technologies in which our incremental advances in non- invasive cosmetic medicine may one day produce results which begin to rival — what we can only see today — with plastic surgery.

Declaration of interest Air-Tite National Director of USA

MicroCannula Instruction and Physician Instructor for Allergan, Medicis, and Eclipse Aesthetics, USA

Opening image © David ‘Spike’ McCormack, Figures 1-2,

5–16 © Dr Garry R. Lee, 3 © David ‘Spike’ McCormack, 4 Diagram © Dr Garry R. Lee, image © Shutterstock

Key points Microcannula are

replacing hypodermic needles for the injection of cosmetic fillers

Microcannula decrease the bruising, swelling, and pain associated with cosmetic filler injections

Microcannula are

thought to be safer than needles by reducing the risk of cannulation of blood vessels

It is essential to select

the appropriate type of pilot needle, microcannula, and cosmetic filler

Physician and nurse

training in basic and advanced microcannula techniques are critical to success

Figure 16 Non-surgical results with only Juvederm and Restylane cosmetic injections

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