If blanching occurs, then stop the injection. You may be injecting into or near a blood vessel. Massage the area until the skin returns to a normal

Injection Technique

Injection

1. Insert the needle into the middle to deep dermis. 2. You may stretch the skin to aid insertion. 3. The contour of the needle should be BARELY or NOT visible depending on the type of filler and the type of wrinkle being injected. 4. If you are injecting using the threading technique, then remember to apply even pressure on plunger of the syringe while slowly pulling the needle backwards. 5. Remember to stop the injection before the needle is pulled to the skin to prevent losing material out of the skin or to prevent an injection that is too superficial. 6. Superficial injection may cause a bluish hue to the skin, call Tyndall effect.

This can either be massaged deeper, squeezed out, or dissolved with

Hyaluronidase. 7. When fanning, do not completely remove the needle from the skin, angle the syringe (fanning) and reinsert the needle to the end of the hub. 8. Direction of the angling depends on the shape of the fold. 9. If blanching occurs, then stop the injection. You may be injecting into or near a blood vessel. Massage the area until the skin returns to a normal color. 10.One should always feel the resistance of the dermis as one is injecting. If the injection has too much or too little resistance, then you are likely in the wrong plane.

11.Wrinkle should be visibly lifted and filled by the end of the treatment.

Post Injection

No empty spaces or lumps should be felt along the injection. Correct to 100% – do no over or under-correct. Gently massage the injection site to contour the product with the surrounding tissue after your injection. When you feel lumps or bumps, a gentle massage between your fingers or over an underlying bone will typically flatten the protrusion.

Reassure the patient that the lump will likely go away. Arrange for a follow up in a week. If the lump is still apparent at the follow up appointment, then use Hyaluronidase. It can be difficult to judge the symmetry of your product placement immediately after the injection due to localized swelling and bruising.

This is true, especially in the lips. If you notice asymmetry and you feel that you have placed the products evenly, then it is best to invite the patient back in 1 week for re-evaluation. Any mild to moderate swelling due to localized swelling, internal bruising, and/or product placement should resolve in a few days. Offer your patient an ice pack to minimize swelling and bleeding.

Nasolabial Folds

Correction of the nasolabial fold is the most common site for correction with NASHA™ fillers. Malar fat pad moves medially and inferiorly due to loss of collagen and skin elasticity and cause the nasolabial folds or laugh lines. The Nasolabial fold is the visible line or groove from the lateral edges of the nose to corners of the mouth. Heavy cheeks due to aging or obesity may increase the depth of the lines. Depending on the age, the fold may be superficial or deep. Therefore, older patients may benefit from Perlane®.

For shallow to medium folds, use linear threading with fanning to correct the folds. Start from the inferior position and insert the needle superiorly. Inject 0.05mL to 0.1mL per injection.

Fanning is recommended up by the nose and possibly throughout depending on the level of correction visualized. Concentrate your fanning on the upper Y-shaped area below the naris and lateral to the ala. There is less movement of the facial muscles in this area and correction persists well. In this position, the nasal artery runs near, so we recommend that you pull back on the syringe plunger to make sure that no

flash of blood is seen if you feel that the injection may be too deep. Also, injecting slowly low amount of volume will also prevent intra-arterial injection.

Further down the fold towards the oral commissure, the duration of correction is shorter due to increase muscle movement. Correction may be more challenging due to the lack of underlying bone and the sagging tissue from the area of the cheekbones.

After you are finished with your injection, place a glove thumb on top of the fold and one or two fingers on the inside of the mouth. Gently mold along the injection site to feel for nodules or bumps. HA fillers are malleable and can be molded.

You may see multiple fine lines lateral to the nasolabial fold. Resist the urge to inject them as they are typically due to dynamic movement. While at rest, the lines may appear diminished, with movement, implanted fillers may be visible as cords on the patient’s face.

Oral Commissures

Lateral commissures of the mouth may begin to turn downward as one age. Patients may complain that the corners of their mouth look sad. The goal of this treatment is to fill the folds and lift the corners of the mouth. Deep depressions here may require serial puncture technique, while linear threading is preferred for shallow, longer grooves. The injection may extend down into the melomental fold in older patients. You may ask your patients to open their mouth slightly to aid your injection. Augmentation in the mouth corners typically does not last as long as in other areas. Inject 0.05mL to 0.1mL per injection.

Melomental Fold

Melomental fold (MMF) is the fold running inferiorly from the oral commissure towards the mandible. Loss of collagen and elasticity, gravity and boney atrophy causes the formation MMF. Prominent MMF gives the appearance of anger or sourness.

MMF may look like a single line when looking at the face straight on. A more three dimensional observation, by looking up towards the nose superiorly, may demonstrate a deeper groove or delta. Techniques such as linear threading or serial puncture may be inadequate for more advance folds. A scaffolding-like structure may have to be formed using fanning or cross-hatching technique.

Inject into the deep dermis vertically from inferior to superior direction. Horizontal injections should be placed from medial to lateral direction to avoid injecting the

facial vein which can be found lateral to the MMF. Layering may be required for deep MMF. MMFs benefit from thicker fillers, such as Perlane. Inject along the fold 0.05mL to 0.1mL per injection. Avoid inadvertent injections into the lip as this may cause unwanted lip enhancement or lumping in the lower lips. Remember that while most patients can tolerate injection into the nasolabial folds, MMF injection tend to be more painful.

Lips

Lip volume reach full thickness by the mid-30s. They are a defining feature of beauty and youth. As we age, vermilion border thin, corners of the mouth droop, philtral ridge and cupid’s bow flatten, and fine lines appears on the lips. Upper lip typically becomes thin and elongated, while the lower lip becomes thin and roll inwards. Activity of the orbicularis oris cause radiating perioral lines. Patients often complain about bleeding lipstick lines.

Lips are the most challenging of all the areas to fill properly. Issues to address include to following: proportional lip relative to the face, proportional upper and lower lip fullness, sharp, well defined vermilion borders, distinct Cupid’s Bow peak and philtral columns, and upturned oral commissure. Typically, the lower lip is fuller than the upper lip. The ideal ratio of upper lip to lower lip is 1 : 1.6, based on the Fibonacci proportion.

There are two distinct goals typically depending on the patient’s age.

Younger individuals typically want to enhance the size and shape of the lips. A young patient with naturally fuller lip forms may be more technically challenging. Some may bring in photos requesting specific outcomes. It is important to ask if the patient desires fuller lips or a completely different shape. Lip volume enhancement increases the height of the vermilion border and increases lip circumferentially. This may cause a “duck lip” appearance. Small volume injections are always recommended for first time treatments. Even a small volume of filler (0.1 – 0.3mL) can make a difference in appearance of the lips.

Older individuals typically want to correct or restore their lips back to where they were rather than to increase their size. Detailed consultation is required for older patients as they may not want eversion of the lips or not want their lips to look “fake”. Patients with lipstick bleeding may require additional treatments such as laser resurfacing or chemical peel. Determine the patient’s goal for the correction.

Most patients feel moderate amount of pain during the injection. HA products with lidocaine help reduce discomfort. Nerve blocks and topical anesthesia cream are

other ways to minimize pain. If you perform any nerve blocks, then it is important to work quickly after these as the numbing can distort the position of the patient’s lips. We recommend using the threading technique to minimize the number of punctures.

Injecting along the vermilion border and wet – dry junction will enhance the volume of the lips.

To increase the size of the lips, insert the needle 1-2mm away from the vermillion border towards the mucosa border to evert the lips. Injecting near the vermilion border increases size, shape, lift and contour. This will give the lips a “ski jump” like appearance where the vermillion border will curve outwards. Injections at the vermilion borders should be done with caution, as too much filler here can give your patients a “duck-like” appearance to the lips. Start with 0.05ml per injection and increase the amount depending on the level of correction desired. Injection can start from the lateral edge or the medial peak of the Cupid’s Bow of the upper lip.

Typically, injections near the vermilion border should be done prior to injections near the wet-dry border. To increase the volume of the lips, insert the needle 3-5mm away from the vermillion border near the wet-dry border to plump up the lips. This will not evert the lip edges. Start with 0.05ml per injection and increase the amount depending on the level of correction desired.

To increase the philtral column, insert the needle at the junction of the Cupid’s bow and philtral column, and advance superiorly. Try to inject a slightly greater amount of filler inferiorly to create a natural contour of the column. Inject 0.025 to 0.05ml per column.

Vertical lip lines, or smoker’s or lipstick lines vary from fine lines to deeper grooves and injection technique will vary. Injection can be directly into the lines, perpendicular to the lines, or along the vermilion border. Treat this area conservatively and use very small amounts so that the area above the vermilion border does not become swollen.

Lips are the focal point of the lower face. Therefore, mistakes are more apparent. Due to its high vascular tissue, mistakes are more likely to produce adverse events than other areas. Immediate, short-term swelling is common. Bruising is frequent. This may cause the injector to overcorrect one area in response to edema or hematoma. If the patients lips are symmetric prior to inject, then insure that equal amount of filler is implanted to maintain symmetry.

Asymmetric lips obviously require different amounts to create symmetry. Application of an ice pack after the injection can diminish these immediate complications.

Extravasation into small bumps may be visible during the injection. Massage these lumps and guide the product into the desired location. We recommend a conservative treatment with small volume injections for first time treatments.

Complication Management

HA fillers have an impressive safety record. Despite this impressive safety record, adverse events occur when injecting HA fillers. It is important to be familiar with potential complications and management.

Complication can be divided into early and delayed in time of occurrence, and minor and major in severity.

Early minor complications include bruising, pain, edema and erythema. These can occur immediately or within hours and resolve within a week. Most patients will develop at least one of these local injection site reactions, so it is important to discuss this with them. Pretreatment with anesthetic or ice prior to treatment is recommended to minimize pain in site that contains high sensory innervation, such as the lips. Avoiding anticoagulants and supplements that are not medically necessary will minimize post injection ecchymosis. Some use homeopathic ointment called Arnica in reducing ecchymosis. Helenalin, an extract of Arnica, has shown to have anti-inflammatory effects, although clinical studies are not conclusive.

Other early minor complications of asymmetry, lumpiness, or bluish discoloration are typically due to injection technique. Incorrect filler placement can cause nodules or papules. When the filler is implanted too superficially, a bluish hue is visible (Tyndall

effect). Such reactions can be treated with manual massage, aspiration, incision and drainage, or hyaluronidase.

A rare early major complication is an anaphylaxis due to an immediate hypersensitivity reaction. It is estimated that 1 in 10,000 individuals with HA report a mild to severe hypersensitivity reaction. In 2005, a patient developed angioedema-type of reaction 1 hour after Restylane injection into the lips. This patient responded to corticosteroid injection with complete resolution. It is always recommended that you should have a protocol in your office should any such emergency should arise.

Cellulitis is a complication seen with any injection procedure. Common bacterial causes are Staphylococcus and Streptococcus. Lesions should be cultured and treated with antibiotics. The use of chlorhexidine will minimize the risk of infection.

Trauma from the injection can trigger a recurrent herpetic lesion. Prophylactic antiviral treatment is recommended when injecting the lips. Also, injection should be avoided during an active herpes outbreak.

Inflammatory nodules can occur if bacteria is injected with the filler, and the HA encapsulates the bacteria within the skin. These inflammatory nodules will be red and painful. Incision and drainage should be performed, with cultures, and antibiotic, such as clarithromycin should be started for at least 2 – 6 weeks. The use of steroid can worsen the situation. Patients with diabetes, immunocompromised, chronic sinusitis, or chronic dental problems should be treated with care.

Delayed major complication is the formation of granulomas which can occur 6 months after the injection. HA fillers are rarely linked to granuloma formation, but it has been reported in 0.1% of the patients who are typically injected with permanent or semi-permanent fillers. The body mounts a foreign body reaction with fibrosis occurring at the injection site. This can be treated with steroid injections, surgical excision, or hyaluronidase.

Delayed hypersensitivity reaction can also occur. In 2009, a case report was described a patient who developed acute facial angioedema with urticarial 3 weeks after Restylane in her nasolabial folds.

The most severe, delayed complication is tissue necrosis, due to direct blockage of a vessel, compression near the vessel, or injury to the vessel. This has been reported in 0.09% of the patients who received collagen injections. The patient will experience delayed capillary refill and pain, followed by a mottled pattern of purple discoloration, and ulceration due to necrosis. This can occur in the glabellar area

due to blockage of the supratrochlear or supraorbital artery and the alar or nasal area due to the blockage of nasal arteries. This can also occur along facial and angular artery. A thorough understanding of the facial anatomy is recommended to prevent this complication. Steps such as aspiration, slow anterograde injection, constant needle motion, using small particle size fillers, superficial use, avoiding injection near vessels, and blunt tip cannulas can help reduce the risk of intravascular injection. This can be treated with massage, heat application, nitroglycerin paste (1/2 inch of 2% nitroglycerin) to vasodilate the area, and hyaluronidase to remove the filler. When nitroglycerin is used topically, the patient should be warned of the potential side effects, such as headache, bradycardia, and hypotension.

Hyaluronidase

Hyaluronidase is an enzyme that breaks down and hydrolyzes hyaluronic acid. Multiple reports have been documented on successful elimination of unwanted HA implantation. Hyaluronidase has been used to correct asymmetry, overcorrection, Tyndall effect and vascular occlusion. Hyaluronidase will dissolve the filler and reduce edema, which will help minimize occluded vessel pressure.

Hyaluronidase is diluted with saline in 1:1 ratio. Skin testing is mandatory when using hyaluronidase. Inject 3 – 5 units intradermally. A wheal formation within 5 minutes and persisting for 20 -30 minutes with localized itching is a positive skin test. Total of 10 – 30 units should be injected per 2 X 2 cm area of impending necrosis.

Please check the package insert for any Hyaluronidase product for complete instructions and warnings and contraindications.

Conclusion

During the consultation phase, collection of a thorough medical history, including medications and allergies, is essential. The injector must be aware of the techniques and understand the depth of the implantation.

A minor complication in your eyes may not be minor in your patient’s eyes. As one can clearly see, using Hyaluronic Acid based fillers offers additional options in treating any complications. Early recognition, education, treatment and psychological support will minimize any potential disasters.

A detailed consultation is a must. Educate your patients. Under-promise and over-deliver.

Dysport®Injection Training Course Certification

Learn more about Restylane® /Perlane®Injection Training Certification .