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that it’s been used in Asia for a long time for total body treatment. We use it in a controlled way. Most of our medicines are originally derived from botanicals. But while they are botanicals, it doesn’t necessarily mean they’re not toxic. They can be. More work needs to be done looking at safety in all topical applications.
QI
have found that the appearance of HA in the tear trough area changes depending on the patient’s water content and degrades over time, as the chain links are getting shorter and the molecular weight is reducing. What is your experience with the duration and longevity of HA in the periocular area? Dr Michael Kane: Injecting superficially is a high risk, high reward technique— HA in the lower lids changes during the day. The area looks different from when patients wake up to when they go to bed at night. But this is why I prefer to use a more superficial technique with less volume. If I have injected a large amount of material, I will see more of a change.
Q I tend to inject superficially in the infraorbital area. But I find that I cannot avoid bruising in that area—patients almost always bruise. Are there any other techniques you can suggest to help us avoid bruising? Dr Michael Kane: If you’re injecting superficially and getting bruising, you’re too deep—you’re not injecting superficially enough. Almost the only time I get a bruise is when I’m injecting through the orbicularis muscle. If you’re not injecting that far down, it’s unusual to get a bruise. When the compounding pharmacy mixes up the products, they can put some
phenylephrine in which causes a little blanching. When I tried this, I didn’t notice an appreciable change in the amount of bruising. You shouldn’t be getting bruising if you’re superficial. I don’t think the resulting vessel constriction does enough to prevent bruising.
Q When I’m performing a periocular injection, I always mention the potential risk of blindness on the consent form. The patient always comes back with: “That sounds serious. How often does it occur?” I don’t have an answer for them other than, “It’s very rare, but it’s serious and you should know about it.” How you deal with the issue when you’re discussing it with the patient? Dr Michael Kane: I don’t think there are any confirmed cases of blindness after HA injection around the orbit. One German article on periorbital injection had one patient with eye pain following injection. The patient had a fundoscopy which showed a small plug of what appeared to be HA in an artery in the retina but it passed and there was no change in visual acuity. Many cases of collagen, triamcinolone and fat injections have caused blindness but not HA. Millions of patients have been injected without one case of blindness that I am aware of.
Q What is your approach to the periocular area? Dr Michael Godin: I have a more standard approach, right on the bone. I want to feel the needle on the bone, keeping under the muscle to avoid swelling and bleeding. I feel my way along the bone with a 30G 1” needle, injecting in a retrograde fashion slowly and using the thinnest HA I can find along the rim. You see the area fill immediately. It is a nice effect and lasts a long time—about twice as long in that area than in other areas in the face. Dr Derek Jones: I used to use the same technique; a 30G 1” needle, dropping down and along the periosteum and doing a linear retrograde technique. But now I use a 32G half inch needle, injecting small threading injections in the suborbicularis oculi plane above the trough. I tend to get a more controlled injection and better correction with that.
Q How When treating Asian skin, we need to stop melanogenesis at its production site with inhibitors while removing excess that is caught up in the cuticle body language www.bodylanguage.net
many points along the rim would you inject? Dr Derek Jones: Around four or five points, injecting 0.05ccs. Some people prefer Restylane there, as it’s a more particulate product which lays down better.
But I use Juvéderm and results are good.
Q Do you find it necessary to massage the area after deep injections? Dr Derek Jones: I always massage. Hyaluronic acids are very hydrophilic polymers. When you inject them into tissue, they will absorb water, especially in a thin-skinned area like the lower eyelid. So you must not treat to optimal correction. You have to take the swelling into account. This is probably one of the main reasons we see poor results—we’re filling up to optimal correction and send them away. But they start absorbing water and come back a week later with sausages underneath the eyes, so we have to remove the HA.
Q When you mix adrenaline and lidocaine in the syringe, how do you maintain sterility as well as getting an even distribution of product in the syringe? Dr Derek Jones: You use a sterile technique adding 10% volume. With a 1cc syringe, you take 0.1cc of 2% Lidocaine, with or without epinephrine. I prefer epinephrine because it creates a vasoconstriction and prevents purpura. Using a female-to-female adapter, you make sure there is no air in the column and perform at least ten full revolutions back and forth. It mixes nicely as long as you follow the sterile technique. I am not aware of any infections associated with this type of mixing. There is controversy as to whether or not the epinephrine does anything beneficial. But if there is anything I can do to prevent bruising, I will do it. I think the epinephrine helps. Dr Michael Kane: I agree. In the future, I think most people will gravitate towards a mid-level injection in the lower lid. It’s not as high risk as the superficial injection and it gives you a better result than the deep injection under the muscle.
Q In
the tear trough, the traditional approach is to inject deep and then laterally, followed by going superficially as you inject medially. Is there any problem with that? Do you inject laterally? Dr Derek Jones: I inject deep the whole way along the periosteum. However, many people are treating tear troughs when there is more deficit in the mid-face. It is imperative that you correct the midface deficit before you go up into the tear trough; otherwise, you will be over-corrected in some places and under-corrected in others. 55