juvederm Archives | The Aesthetic Clinique

What’s More Accurate – Cannulas vs Needles For Dermal Fillers?

There is an ongoing debate among injectors as to what method of injecting fillers is more accurate. The needle pundits state that the needle can inject in any tissue, at any depths. While this is true, is the filler actually placed where they think it is? Cannulas aficionados argument is that cannulas will stay in the plane which they are placed, and are therefore more accurate.

In a paper titled “Precision in Dermal Filling: A Comparison Between Needle and Cannula when Using Soft Tissue Fillers.” by Pavicic, Frank, Cotofan, et all, the debate was studied. There were 10 cadavers studied for supraperiosteal injections. The filler injected was radiopaque. Needles were placed in position using a perpendicular transcutaneous approach. The cannulas were placed in a similar position in the supraperiosteal plane. Using fluoroscopy, the injected material was analyzed in the horizontal and vertical planes.

The results show that in over 60% of the needle injections, the material changed planes (became more superficial) and this was not found in the cannulas group.

The conclusion was that cannula filler placement is more precise because the filler remains in the plane of the intended implantation much more so than needle placement.

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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)

Cannulas Were Approved by the FDA for Restylane Silk….Finally!

On October 12, 2017, Galderma was notified by the FDA that Restylane Silk was approved to be administered using blunt microcannulas. Galderma deserves a huge “high 5” for stepping out of the box in recognizing the improved patient outcomes and safety benefits of cannulas. No other dermal filler in the US has been approved for use with cannulas, it is a “First for Fillers”. Galderma is researching other areas for cannula use and expect approval in 2018 for another 1 or 2 indications.

What’s the big deal with cannulas?

The traditional method to administer dermal fillers is using a needle. Unfortunately, there are many side effects and risks using needles. These include:

Bruising – sticking a needle into a highly vascular organ, skin, will lead to bruising a majority of the time. This is corroborated by the FDA studies for all the US approved fillers.
Pain – needles require multiple entry points to deposit the filler. Pain fibers are most prevalent in the dermis.
Vascular Occlusion Risk – when a blood vessel is cannulated with a needle and the filler is injected directly into the vessel, occlusion of the vessel occurs. The sequelae of such event can result in skin necrosis, eye injury, or even blindness.

Cannulas have a blunted, rounded tip which is less likely to injure blood vessels than a needle is. When the cannula brushes up against a vessel, it is deflected away, in distinction to a needle which will often pierce the vessel. When a vessel is traumatized, a bruise will occur.

To use cannulas, a small pilot hole using a needle is required. Unfortunately, completely eliminating needles is not possible. However, after that entry is performed, the cannula can be placed through the dermis and into the subcutaneous tissue or deeper fat compartments. The areas below the skin surface are generally less innervated and are more comfortable to place filler.

The most important quality of cannulas is their safety. By design, they are much less likely to result in placement of filler within the lumen of a blood vessel. The rounded tip eludes lumens of blood vessels whereas needles don’t offer that protection. Although vascular occlusion is possible with cannulas, it is much less likely when compared to the risks associated with needles.

Dr. Weiner has been an advocate of injecting dermal fillers with cannulas for the past 6 years, since 2012. He has become one of the most experienced cannula users in the US. He has been chosen by Galderma to use his cannula experience to “Train the Trainers” in the use of cannulas for Restylane Silk in the lips.

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.

Dermal Filler Providers Must Also Be Proficient With Hyaluronidase

The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.

There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.

The reasons to dissolve HA filler are:

Poorly placed filler giving an aesthetically poor result
Where too much filler was placed
Filler that is infected
Filler is forming a granuloma
Filler is causing ischemia/vascular occlusion
Filler is causing visual changes or blindness

The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.

It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours.

Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.

The Latest Trend “Prejuvenation” – Preventative Rejuvenation

It’s been touted for years by the aesthetic physicians – “Prejuvenation” – starting maintenance treatments in one’s late teens or early twenties. The Kardashians have popularized these minor cosmetic tweaks to stay youthful and refreshed with visits to their Beverly Hills physician, documented regularly on “Keeping Up with the Kardashians”. There is increasing pressure to get that perfect selfie for Instagram or to look cool and attractive on a “Snap”. Unfortunately filters don’t work well with videos unless you want to look like a cute puppy. Doctors are in agreement (for any disease process) that it is much easier to treat problems in their early stages than to reverse them after they have spiraled out of control. Small preventative treatments early on, can maintain and even enhance one’s looks for many years and avoid invasive surgical procedures in the future. The question is, which procedures should be considered for Prejuevenation?

Neuromodulators: These wrinkle improving injections take less than 5 minutes and have no downtime. Millions of these procedures are done each year and it is the most popular cosmetic procedure performed worldwide. Most often these are used in the younger population in the frown lines (glabella), forehead lines, and crows feet. Treating these areas before the lines set in at rest, known as “etched in” lines, is one of the fundamental concepts of Prejuvenation. (Suggestions: Dysport, Botox)

Dermal Fillers: Dermal fillers made from hyaluronic acid (HA) are used to improve the minor volume loss which occurs with age. In the more athletic patients, fat loss can be appreciated in the face as well as throughout the body. Supple enhancements can be added to the mid cheek and around the eye to stave off this premature volume loss. HA fillers are also used to plump up the lips to create a youthful appearance. (Suggestions: Restylane Refyne, Restylane L, Restylane Lyft, Sculptra)

Chemical Peels: To keep the skin in top notch shape and to reverse early sun damage, chemical peels can exfoliate the superficial layers of skin. This renews the texture and pigmentation and leaves a youthful and glowing quality to the skin. (Suggestions: Illuminize, Vitalize, ZO 3 Step Peel)

Skin care: Great skin care is the basis for good looking skin. Most would agree that some type of Retin A or Retinol is essential for maintaining youthful skin. These products lead to increased turnover of the skin cells, improve dyspigmentation (pigmentation problems), thicken the skin, and create a more hydrated skin. Sun protection with an SPF should be part of one’s daily regime. It is also highly recommended to apply growth factors to the skin to reverse the aging process. (Suggestions: ZO Skin Health, Lifeline Stem Cell Skincare)

Prejuvenation is a trend that is here to stay. Preventative maintenance will prolong the need for more aggressive corrections in the later years. With short, no downtime procedures such as neuromodulators, chemical peels, fillers, and a good skin care regime, youthful, natural appearances will persist for years. Stay ahead of the curve with Prejuvenation.

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.

The Temples Shouldn’t be Ignored When Filling the Face

The ideal facial shaped has been described as “heart shaped”, “V shaped”, or “Upside Down Egg”. A youthful face draws attention to the upper face and eyes. With aging, the lower face becomes “heavier” and more dominant, as laxity and volume loss set it. Instead of round or oval, the shape of the face becomes closer to square. The underlying cause for these changes is primarily loss of fat, muscle, and bone.

The upper face’s width is determined primary by the temples. Fat pads in this area are particularly susceptible to atrophy associated with aging and exercise. To reestablish the youthful facial shape, it is essential to reflate the temples. There is a contiguous fat pad in the preauricular area which follows similar volume loss as the temples and should be volumized simultaneously. When the lateral cheeks are given filler, the temporal deficits become exaggerated and more obvious. Patients must be counseled on their temples whenever cheeks injected.

Besides the overall facial shape change, the benefits of filling the temples are the lift given to the surrounding tissues. The brow, and upper eyelid will be elevated with temporal filler. Placement of filler along the orbital rim and lower forehead further enhances this effect. The ideal temple should be convex in a women and slightly concave in the male.

The filling of the temples is reserved for the experienced injector. Dr. Weiner’s choice for this area is Sculptra because of its safety and natural appearance. The only downside to Sculptra is that when placed along the bone in the deepest aspect of the temporal fossa, a large volume of product is needed for complete correction. To finish corrections after the deep Sculptra placement, a superficial layer of HA filler (Restylane, Juvederm) can be safely placed using large bore cannulas. The filler is placed immediately below the dermis in the subcutaneous layer or just below the superficial layer of the temporalis fascia.

To reverse the signs of aging and restore the upper face dominance, temple volumization is required. It must be considered for patients that have brow and eyelid heaviness as well. This is an area that is difficult to treat with higher than average safety risks, and should be reserved for the most experienced injectors.

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Commonly Asked Questions About Lip Filler Problems

My lips are swollen, lumpy, and a little uneven, when will they get better? This is the most commonly asked question on Realself.com. The lips take about 7-10 days to settle down after getting filled. Restylane Silk will swell the most of all the fillers. Juvederm, and Restylane are the most commonly used fillers and the swelling and lumps will all even out gradually over the first week. Sometimes there is asymmetrical swelling, and that usually evens out too. Elevating the head of bed will help lessen the swelling. Unless there is bruising, ice will not change the swelling, nor will antihistamines. The swelling is most often related to the HA filler absorbing water from the surrounding tissues. On an extremely rare occasion, the lips and surround tissues swell abnormally, and this is called angioedema. This most often occurs in people that take a blood pressure medicine that is in the “ACE inhibitor” family. If this occurs, immediate attention is needed by your doctor or the emergency room.
I’m very bruised, when will it go away? Bruising is related to technique, not the filler itself. Bruising can take up to 10 days to go away. Early bruising can be treated with a laser (VBeam or Excel V) to decrease the duration to 2 or 3 days. It is best to stop all supplements, anti inflammatories, fish oils, vitamin E, or all other medications that can thin the blood a few days before injections if possible. Aspirin takes 12 days to get out of the system. Cannulas help minimize bruising as does careful technique, but bruising isn’t always avoidable. Arnica will help bruising too.
My upper lip is very full, is this normal, I look like a fish or duck? There is an art to filling the lips. The upper lip should be smaller than the lower lip by the golden ratio of phi, 1:1.6. If the doctor does not abide by normal anatomic ratios, the lips look done and abnormal. It does not happen to most people and is unrelated to the product injected. It is poor technique by the injector. In ethnic people, sometimes a 1:1 ratio does look normal, but never when the upper lip is larger. Click here to learn about perfect lip anatomy.
Can the corners of mouth be turned up, I always look sad? The corners of the mouth can be lifted with properly placed filler. Also, an injection with a neuromodulator such as Botox or Dysport can be injected into the depressor angularis oris, DAO, to relax the muscle pulling the corners down. Often, support is also needed in the above the upper lip in the triangle of volume loss near the corner. Also, injection into the corner (commisure) is needed.
I’m not happy with my lips after injection, what can I do? First thing is to discuss with your injector. After waiting the 10 days, lips that still have bumps, look odd, or are uneven, can be dissolved with hyaluronidase. This is not a precise procedure, so fine tuning is not possible. Most often, one treatment is needed but sometimes 2 are needed. Sometimes a little filler can be added to make things more symmetric. Asymmetries are very frequently noticed after injections by patients, but after careful review of photos, were present before the procedure too.
I have severe pain, days after the injection. Pain should not be present after about a day or 2 from the procedure. This needs to be discussed with your injector. Concerns would be possible injection, or herpetic outbreak. Severe overfilling can cause this too.
What can be done for my upper lip lines, “smokers lines”? Upper lip lines, “smokers lines”, are some of the hardest wrinkles to treat. This occurs even in non smokers and is mostly a volume related problem. Best treatments include filler placed horizontally in the white lip or ergotrid (with cannulas), a fine bead of filler along the vermilion border, and a small amount in the lip body. Adding Botox in small amount help too. Don’t expect elimination, just improvement. Longer term solutions are laser resurfacing with ablative lasers, Infini, or dermabrasion.

Video of Dr. Weiner discussing the most commonly asked questions about lip filler from RealSelf.com

What is Vascular Occlusion or Vascular Compromise from Dermal Fillers?

Dermal fillers of becoming the fastest growing area of aesthetic enhancements. In general, the procedure of injecting the filler is safe, with very little downtime, and with visible results. However, there is a rare, but extremely significant potential risk, that patient’s, medical staff, and providers need to always be aware of: Vascular Occlusion or Vascular Compromise.

What is Vascular Occlusion or Vascular Compromise? This is caused when the dermal filler is either injected into an artery or around an artery to the point that the blood flow is reduced or completely stopped. The area of skin or other tissues that are supplied by the affected vessel will start to die without the necessary blood supply. Almost always, if this complication occurs, there will be an immediate blanching (paleness, tissue turns white) when the blood flow is interrupted, often in areas far away from the actual injection. Recognition is key to a favorable outcome. If this occurs, the injector must stop immediately and take measures to resolve the problem. Pain is usually associate with vascular occlusion. There have been cases reported that occurred 12-24 hours after being injected but almost always it occurs immediately.

If no treatment is initiated to improve the vascular flow, the skin will start to appear dusky, a bluish tint, with fine reticulations (lace like) to areas WELL BEYOND THE SITE OF INJECTION. This occurs within 24 hours. If still no therapy is done, the skin will start to die, turning black, and sometimes there is an associated infection. At this point, scarring will likely occur and surgery is often needed to remove dead tissue and/or to close the wound.

If there is a recognized vascular event, several steps should be initiated.

Hyaluronidase, an enzyme that dissolves Hyaluronic Acid, should immediately be injected in the area, and into the vessel if possible. Some doctors advocate using hyaluronidase even if the filler is not an HA filler because it will dissolve the naturally occurring hyaluronic acid hopefully improving blood flow.
Massaging the area will help mostly if the filler is externally pushing on the vessel. This might move the filler away from the vessel to re-establish flow.
Blood thinners will allow the blood to flow thru a smaller vessel or to go around a blockage. Aspirin and possibly heparin are recommended by most physicians.
Vasodilators such as nitroglycerin are also recommended by most physicians. There is a question as to whether this might allow the blockage to travel further down the vessel.
For severely vasacular compromised tissue, hyperbaric oxygen treatments are beneficial.

Administering dermal fillers with blunt tip cannulas will minimize the chances of a vascular event. The fact that the ends of the cannulas are rounded, makes it very difficult to enter a vessel, particularly with the larger cannulas. To the author’s knowledge, there have been no reported events of vascular occlusion with cannulas larger than a 27g. There is still the possibility of causing external pressure on vessels, but this seems to be a low risk, and mainly associated with fillers that expand, like the HA fillers.

The areas prone to vascular events are areas of the face that are called “watershed areas”. These are areas where there is poor collateral blood supply. These areas are:

Glabella
Under the eye
Nose and around the nasal ala (nostrils)
Nasolabial folds
Upper lip

The catastrophic complication of blindness from dermal fillers is also a form of vascular occlusion. This is when a bolus of dermal filler is injected into an artery in such a way that it travels back to the vessels supplying the retina. Not only does the injector have to be within an artery, but he/she has to exert a force of injection that overcomes the blood pressure (retrograde flow) in the vessel. This is an extremely rare occurrence but unfortunately is almost universally irreversible.

Prevention is key to avoiding a vascular event with dermal fillers. The safest fillers are the HA fillers which can readily be dissolved with hyaluronidase. Cannulas should be used in all high risk areas in the author’s opinion. If using needles, aspiration to see if the tip is within a vessel should be done before all injections in these areas. Careful counseling of patients and staff is needed to recognize a potential event early to get the best possible outcome.

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