defyne Archives | The Aesthetic Clinique

New Research Suggests that Not All Cannulas are Safe!

Cannulas, specifically, blunt microcannulas, can be used to administer fillers by advanced injectors. They a favorable over needles because they have a blunt round tip and are flexible, leading to the following advantages:

Less discomfort – one entry point can serve a large area, thus avoiding multiple dermal penetrations which is more uncomfortable.
Less bruising – the rounded/blunt tip tends to bend around blood vessels rather than nick or penetrate them.
More accurate – a recent study shows that the filler is most likely to be deposited in the area of the exit port vs a needle which has been shown to have filler travel up the shaft (back flow)
Safer – cannulas are less likely to give intraluminal vessel injections because of the blunt tip and therefor less possibilities of vascular compromise and blindness.

However, a recent publication by Drs Pavicic, Cotofana et al. has shown that #4 comes into question with certain cannulas. There study consisted of a total of 294 penetrations of the superficial temporal artery in cadavers using 22, 25, and 27 gauge cannulas and needles. The force applied to enter the vessel was measured for each. The cannulas had statistically higher forces needed to enter the vessel for the 22 and 25 gauge cannulas.

Interestingly, there was no difference in the forces when comparing 27g cannulas and needles.

The conclusion was that a 27g cannula was not safer than a 27g needle when used for filler injections. While 27g cannulas can be used, it is up to the injector to realize these are not safer than needles and to take the appropriate safety measures during treatments.

(Article: Plast Reconstr Surg. 2019 Mar;143(3):504e-512e. doi: 10.1097/PRS.0000000000005321)

What is Myomodulation?

The aging process leads to hyperactivity of the muscles of the face. This movement leads to increased wrinkles and loss of the smooth, youthful appearance of the skin. In the upper face, neuromodulators such as Dysport and Botox, do a great job at relaxing this hyperactivity. What’s trending with aesthetic providers is dampening the muscle movement but not complete relaxation, leading to a more natural expression without “freezing” the patient.

Unfortunately, the neuromodulators can’t be administered throughout the entire face. In the lower face, low doses of neuromodulators are safe for the lips, chin, gummy smile, and DAO (AKA RBF) muscles for the most part. Inhibiting the lower face too much leads to changes with expression and smiling. What can be done to control the muscles in this area? Filler!

(Side note: Hyperactivity of the lower face has been described by Dr. Weiner in gum chewers in a previous blog. It leads to accelerated aging in the lower face and should be discouraged by aesthetic providers.)

An interesting study by Dr. Nowell Solish supports this concept. Using a rather large and sophisticated machine, Dr. Solish was able to determine muscle strain in the lower face during facial expressions. He compared patients in their 50’s to ones in their 30’s. As expected, the older patients had more muscle strain than the younger patients. He then injected the older population with Restylane Refyne and Defyne, 3-4cc in the perioral area. These fillers have XPresHAn technology and have flexibility – stretch capabilities. After the injections, the older patients were restudied for muscle strain. The findings: The muscle strain of the 2 groups (older vs younger) were basically the same. The filler was able to reduce the muscle strain about 15 – 20 years!

What’s the explanation? Dr. de Maio has coined the term myomodulation. His theory is that filler placed around hyperactive muscle leads to stretching and relaxation of the muscle. While this is plausible, there is probably a better way to describe this phenomenon.

Dr. Weiner’s theory: Think of an Aston Martin that has a top speed of 230 mph or more. However, in the US, to conform to the laws and regulations, governors are placed on the car to keep its top speed at 180 (This is purely hypothetical and used for illustrative purposes only). Dr. Weiner feels the fillers Refyne/Defyne limit the full range of movement of the hyperactive muscle, akin to a governor on the muscle. Why these fillers work so well at doing this is because they can stretch and recoil (akin to a tether), leading to some, but not excessive muscle movement. Other fillers would work but with a different and less natural mechanism. Think of the non-flexible fillers as acting as a wall, and not as a governor or tether.

With the new XPresHAn fillers, Refyne and Defyne, we now have a new treatment modality for the lower face which is highly effective. Myomodulation is real, exactly what is the underlying mechanism is still debatable.

Top 5 Procedures to Improve Your Jawline in 2019

It appears that 2019 is the “Year of the Jawline”. A strong jawline is interpreted as a characteristic of strength, beauty, virility, and power. In a study of S&P 500 CEO’s, 95% were considered to have a well defined jawline. With advances in aesthetic technology and techniques, achieving that perfect profile is becoming easier, with less downtime, costs, and risks. Here are the top 5 procedures to improve your jawline:

5) Neck Lift/Lower Face Lift: With incisions placed behind the ears, this surgery can be performed with just local anesthetic. Downtime is about a week or 2. For severe jowling and platysma bands, this will give the best results.

4) Ablative Laser (Erbium/CO2) or Renuvion(J Plasma): These procedures have significant wound care for a week or more. The skin is stimulated by the heat of the laser/plasma to contract and create collagen. Healing time can take weeks and redness can persist for months. Risks include infection, scarring, hyper and hypopigmentation. Procedure is limited to the face, and can’t achieve fat reduction.

3) FaceTite: A minimally invasive procedure whereby radiofrequency is placed below and on the skin surface. Requires tumescent anesthesia only for most patients. Procedure takes about an hour, more if liposuction is added. There is minimal bruising and swelling afterwards but requires a compression chin strap for a few weeks (constant for the first 48-72 hours). The RF energy causes deep collagen stimulation and contraction as well as dermal collagen remodeling. Jowls and submental fat can be attended to with RF and liposuction.

2) Genius/Infini: Radiofrequency is placed into the dermis (and subdermis for jowls/submental) using insulated microneedles. The downtime is 2-3 days but it requires 3 treatments. The procedure takes about 30-45 minutes. Most patients require just topical anesthetic with about 5-10% opting for Pronox (Nitrous Oxide – laughing gas). Results take 3 weeks to start to become apparent and 3 months for their full effect. It is the least downtime, least invasive of the top 5 procedures, outside of #1.

1) “reJAWvenation(TM)”: Using microcannulas, filler is placed along and below the jawline to enhance and restore the profile. Typical procedure time is 10 minutes or less and there is no downtime. The amount of syringes required varies, but can be anywhere from 1-6. Multiple sessions are required for the patients with severe jowling. While there is no actual removal of fat from the jowls or submental area, these areas appear improved due to the lifting by the filler as well as camouflaging the trouble areas.

It is left up to the individual as to what procedure is right for them. Lifestyle, degree of correction desired/needed, and finances all factor into one’s decision making. Dr. Weiner is world renown for his “reJAWvenation(TM)” procedure and is known as the reJAWvenator.

(Threads are notably absent because the author believes the expense, duration, and results, don’t warrant them to be a consideration for jawline improvement.)

The Jawline – Beauty, Differences Between the Sexes, Aging, and Correction (reJAWvenation)

Nefertiti was recognized for her crisp jawline and smooth neck. Her bust is one of the most famous of the ancient Egyptian sculptures. A razor sharp jawline and well defined ascending ramus (or gonial angle) are hallmarks of beauty, both male and female. Jowling, submental fullness, blunting of the gonial angle, and an irregular jawline are all signs of aging.

While there are many commonalities between the sexes of what constitutes an attractive jawline, there are fundamental differences as well.

Males:

Broad/wide rami of mandible leading to a near vertical appearance on frontal projection
Approximately a 110-115 degree gonial angle (more acute than female)
Significant height of the body of the mandible
Wide defined, projected chin

Females:

V-shaped rami of mandible on frontal projection. A more masculine (vertical) ramus is also considered beautiful in some women (Such as Alessandra Ambrosio)
A more obtuse gonial angle of approximately 135 degrees
Shorter height along the body of the mandible
Pointed, less projected chin

There are considerable age related changes of the mandible.

Loss of bone along the body of mandible leading to loss of vertical height. This change is accelerated in an edentulous patient
Blunting of the gonial angle eventually leading to a curvilinear jawline
Narrowing of the male chin and widening of the female chin
Deepening of the gonial notch

The age related mandibular changes lead to loss of support of the soft tissue in the lower face – falling forward and downward. Jowling and submental fat is exaggerated. The upper neck skin shows more laxity as facial skin drops into the neck.

Correction of age related jawline changes with fillers- reJAWvenation

Dr. Weiner has perfected a correction using dermal fillers which he has coined “reJAWvenation”. It is based on restoring the age related loss of bone and leads to support of the lower face soft tissues. Filler is placed along the inferior border of the mandible as well as filling the gonial notch. The gonial angle is recreated. The lower aspect of the jowl is considered the new baseline and filling is made on either side to “camouflage” the jowl. Filler is also placed along the posterior aspect of the ascending ramus. The prejowl sulcus is filled, with emphasis to include the space beneath the inferior mandibular border. The chin must also be corrected to the male/female appropriate projection and shape.

reJAWvenation offers a quick (10-15 minute) correction of the age related changes to the jawline. Improvements in jowls, upper neck, jawline, and chin can be expected. There is minimal or no downtime. Even with facelifts, jawline volume is not typically addressed and needs to be corrected either during the procedure with fat grafting, or in the office, after healing, with fillers.

Deceptive Practices Used in Before and After Photos

“A picture is worth a thousand words”. It’s true, seeing a great before and after speaks volumes for a certain physician’s or practitioner’s abilities. Unfortunately, there are some deceptive practices that can trick the eyes into believing results are better than they are really are. Instagram is a showcase for the aesthetic industry, but there is no oversight as to the claims made on the photos displayed. The bullet points below will help one to develop a critical eye to discern the truth from the “fictional results”.

Lightening must be the same in both pictures. A common misleading practice is to have a dark before picture and a light after picture. In the lighter picture, wrinkles and shadows are going to be less, and fool the observing into thinking these were related to the procedure.
Angle of the neck/head must be the same in both pictures. Take a look at the nose and jaw to see if the head is in the exact same position. If the head is tilted more upward in the after picture, the neck will appear to have less fullness, less wrinkles, and be firmer. This is particularly popular in the Kybella before and after photos.
The expression must be the same in both pictures. If a patients is partially smiling in the before and not in the after, the wrinkles around the mouth and cheek will appear falsely improved.
Sculptra pictures should have at least a 3-6 month interval. Sculptra is always mixed with water or saline for reconstitution. The immediate results after injection reflect merely the effects of the water/saline and not that of Sculptra. The collagen stimulation from Sculptra will take at least 3 months to appreciate, with 6-9 months being even a better gauge of results.
Using company photos or other physician’s photos without noting this or giving the appropriate credit on their websites or posts is also a common practice.
If make-up is used, it must be similar in both photos. Too often the before has none and the after has make-up.

Perfect before and after photos are very challenging. Even when results are extraordinaire, there are often difficulties trying to capture these changes with the camera. However, purposely trying to “enhance” photos with the practices above must be pointed out to the practitioners.

Introducing the Concept of “Age Freezing”

The nonsurgical aesthetic industry has finally hit an important milestone. Using a combination of techniques, cosmetic physicians are now able to halt, and even reverse, the age-related changes which occur to one’s face. In the past, technologies would allow for turning back time for a few years but eventually, the inevitable and undeniable signs of aging would occur. As lasers, radiofrequency (RF), filler and neuromodulator techniques have improved, the aging face is a thing of the past. The concept of “age freezing”, keeping ones looks for a decade or more, is not merely a dream, but reality. More importantly, this all can be done without surgery!

Not everyone is a candidate for “Age Freezing” unfortunately. The stipulations are:

Must be a nonsmoker – There are several significant skin and health issues associated with smoker which can’t be overcome. Many procedures require healing and collagen stimulation which are inhibited by smoking.
Free of chronic debilitating disease – There are tolls long term diseases take on the body which lead to premature aging, cellular changes.
Stable weight – As Katherine Deneuve once stated, at the age of 40, you must decide between your ass or your face. If you lose too much weight, fat is lost from your face. In most instances, this can be overcome but not always. However, in patients with significant weight gains, there can be some difficulties maintaining the same look one had in the years prior.
Alcohol consumption in moderation – Alcohol can take a toll on the body in the long run when taken in excess. 1-2 drinks per day is the recommended maximum intake that the author recommends.
Healthy lifestyle and diet – Although this topic overlaps some of the previously mentioned necessities, a good exercise regime is also required. The benefits of exercise on weight, hormones, circulation all benefit the facial appearance. Obviously, a well-rounded diet full of antioxidants, vitamins, and nutrients is beneficial too. There is research to support telomere lengthening with these measures as well.

The requisite procedures for “Age Freezing” are:

Neurotoxins on a regular basis. Relaxing the hyperdynamic muscles of the face with either Dysport or Botox needs to be performed at least 3 times per year. The regularity is needed to keep the muscles weak and prohibiting them from regaining strength.
Dermal Fillers for lost volume. Fillers are the epicenter of the whole “Age Freezing” concept. Beginning in the mid 30’s, at least a cc of volume is lost per year. This is the result of fat, bone, and muscle loss. Replacing and keeping up with this process is tantamount to looking young. Large volumes are best replaced with using Sculptra, a collagen stimulating filler. It is best to recreate the foundation with Sculptra. Superficial fine tuning is best performed with a hyaluronic acid filler, such as Restylane. New techniques using blunt cannulas permitted safer, less downtime procedures. A comprehensive understanding of the aging process has enlightened our specialty as to what needs to be corrected for accomplishing age reversal.
Skin Tightening to reverse gravity. The constant downward pull due to gravity leads to skin laxity, above and beyond what is attributable to volume loss. Devices that heat up the dermis will stimulate collagen and tissue contraction. Devices vary in their ability to tighten, often with a tradeoff of more downtime/discomfort/risk for more results. Ablative lasers, CO2 and Erbium, will give the most tightening for lasers. Radiofrequency can also be used, with the microneedling RF, such as Infini, giving the best results. A new procedure called JPlasma, looks like it may have promise in significant tightening, but does have about 14 days of downtime and a month of redness.
Skin Resurfacing to improve pigmentation, fine lines, and thicken the dermis. The aging process, primarily due to sun exposure, causes skin to thin with loss of collagen and elastin. Dyspigmentation, pigmentation problems, occurs as well. Renewing the surface of the skin can be accomplished using lasers, such as the Fraxel Dual, or chemical peels. Microneedling can thicken the skin by producing small injuries in the dermis with very little downtime or risks. There may be benefit to adding PRP, platelet rich plasma, to the skin, but the jury is still out.
Skin Care is essential to achieve the optimal results from any of the above mention procedures as well as to improve one’s skin health. Retin A or Retinol should be a staple in one’s nightly regime. These products stimulate skin turnover, reversal of pigmentation problems, better hydration with hyaluronic acid stimulation, and collagen production. Blemishes/Acne breakouts are improved with these products as well.
Oral Supplements are key to good, healthy skin. Oxidants are the source of disease, cancer, aging, and skin damage. To neutralize the oxidative stress, strong anti-oxidant supplement(s) are necessary. Examples include: superoxide dismutase, fish oils, resveratrol, Polypodium leucotomos, turmeric, and glutathione. In addition, the antiaging benefits of Metformin are hard to dismiss with the current research published. Lengthening one’s telomeres with TA65 is probably beneficial as well.

One must understand that the “Age Freezing” concept is a process. It is a lifestyle, a choice. It is not a “one and done” procedure. It consists of regular visits to an aesthetic physician. There are big steps and little steps along the way. The author has dozens of “Age Freezing” patients whom look younger and better, 10 or more years after initiating treatments. “Age Freezing” will eliminated the need for future cosmetic surgery.

Dr. Steven F. Weiner’s 6 year Experience with Blunt Cannulas for Dermal Fillers

The value of volume replacement in the aging face is now universally recognized as one of the most beneficial procedures to restore youthfulness. The combination of sun exposure, aging, and genetics leads to collagen, fat, muscle, and bone loss. Reinflating the cheeks, lips, and tear troughs are routinely done by physicians across the world on a daily basis. Most of these patients will have a week or more of downtime – swelling, bruising, discomfort – but that doesn’t have to be. Blunt cannulas can minimize most of these side effects associated with filler injections and has become standard practice for Dr. Weiner for the past 6 years.

The benefits of blunt cannlas are:

There is only one insertion point to treat multiple areas. This equates to less intrusions through the skin and therefore a more comfortable procedure.
The tip is rounded and blunted. This very fact accounts for less bruising/swelling. When a blood vessel is encountered with the end of the cannula, the vessel is more likely to be gently displaced rather than punctured.
There is increased safety. A phenomenon termed “vascular occlusion” occurs when a filler is injected into a blood vessel. The filler then blocks the blood flow and can lead to necrosis (death of skin) or even blindness. It is much less likely to occur with blunt cannulas, particularly larger cannulas (23 or 25 guage), because they don’t enter blood vessels as easy as needles do.
Allows treatment in areas otherwise not easily accessible. Due to the safety of the cannulas, there are now areas of the face which are more easily treated. The superficial temporal area, supraorbital, forehead, piriform, periocular and lower eyelid are now routinely treated with cannulas whereas with needles, these areas were very precarious to inject.
Downtime is minimize. As a result of all the benefits listed above, most patients have significantly less healing time and are much happier after receiving their filler treatments with blunt “safety” cannulas.

If blunt cannulas have so much benefits, why are only 5% of the providers using them for dermal fillers? The art of using cannulas is not an easy one. Patience is required because directing the tip to the exact spot it is needed is not always easy. Remember, when the tip encounters an obstruction (vessel, ligament, collagen), it will need to traverse around it and not pierce it (as needles would do). This can be frustrating and lead to longer and less satisfactory results for the inexperienced cannula injector.

Dr. Weiner is one of the leading authorities on cannula injections of dermal fillers and has used them for over 6 years for nearly all of his injections. The cannulas provide a safe, comfortable, minimal downtime technique for volumizing the aging face, even with multiple syringes being used simultaneously.