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Why are Blunt Microcannulas the Obvious Choice for Dermal Fillers?

Dermal fillers are becoming increasingly popular worldwide. Contouring of the face, restoring volume loss, enhancing features such as lip plumping can all be obtained with very little downtime. Just 15 years ago, surgery was the only way these enhancements could be performed. There are some minor complications associated with fillers such as pain, bruising, swelling which are fairly common (>70%) and some major risks such as vascular occlusion, blindness, and stroke which are much less common.

The most common method to administer fillers is using the needle which is packaged with the product. While needles are very easy to use, in the author’s opinion, they are more risky and lead to more downtime versus the blunt microcannula technique. Microcannulas were introduced to the United States about 8 years ago from Europe. These were a smaller version of the already widely cannulas which were used for fat transfer. When compared with a needle, cannulas are more flexible, longer, and their tip is more rounded. The following advantages are found with cannulas:

Fewer dermal penetrations – cannulas are introduced through only a small number of pilot holes.
Less discomfort – the dermis contains more pain fibers than the deeper tissues. The injections with cannulas are below the dermis, so discomfort is less.
Less trauma to tissues/less bruising – because of the rounded tip, the cannula is less likely to nick blood vessels leading to less bruising and swelling.
Faster procedure times – With an experienced cannula user, placement of filler is done very quickly and efficiently. (Cheek/tear troughs <5 minutes per side, lips <5 minutes)
Less vascular occlusion risks – While cannulas aren’t 100% safe, the risks of injecting into a blood vessel are less because entering a vessel is more difficult with the rounded tip and flexible shaft. This is true for the larger gauge cannulas such as 22, 23, and 25. Recent studies by Dr. Pavicic and Cotofana have shown the 27g cannulas have the same force needed to enter a vessel as a 27g needle and therefore should not be used.

Galderma recognized the advantages of microcannulas and became the first company to get FDA approval for their use with Restylane Silk in lips in 2017, and for Restylane Lyft for the cheeks in 2018. While less than 10% of providers use cannulas in the US, there is a push by the top injectors to encourage their widespread use.

Dr. Weiner has been using microcannulas since 2012 and is one of the most experienced cannulas injectors in the US. He is one of the leading trainers for Galderma, particularly for their cannula trainings. He is available for private trainings in off label use of fillers – face/body. There are shadowing opportunities as well as week long internships opportunties. For inquires, please email: info@theclinique.net or steve@stevenfweiner.com

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.

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.

Creating the Perfect Lips with Restylane Silk

Lips before treatment with Restylane Silk

Dr. Weiner Lip Enhancement, Restylane Silk

Lip Enhancement with Restylane Silk.

Enhancing lips has become a very popular cosmetic procedure. Most of the press has been negative because of the abundance of poorly performed injections, particularly on celebrities. Instead of improving ones looks, and sensuality, they become a turn off, negatively affecting one’s attractiveness if not done properly. A slew of new terms for these lips has arisen: “Fish Lips”, “Sausage Lips”, “Trout Mouth”. Patients go into the doctors office with aspirations of “Angelina Jolie” lips and leave with “Lisa Rinna’s” lips. Unfortunately, the bad outcomes of these celebrities and close friends, scares off a number of interested women, fearing they too will end up like Goldie Hahn from the “First Wife’s Club.”

Fortunately, with an experienced injector, and the newly approved filler Restylane Silk, cosmetically attractive lips are well within reach for most clients. Restylane Silk’s advantage lies with it small particle size. This enables the injector to more precisely place the filler, for better contouring, and with less chance of leaving lumps or bumps. Also, because it is superficially placed, there is less bruising and less discomfort during injections. It’s not just the filler though, it takes the skilled eye, technique, and knowledge of an experienced injector to get the lips just right.

Knowing the esthetically correct dimensions and landmarks of the face goes back to Leonardo Da Vinci, in the 1400’s. He recognized the golden ratio, phi, that equals 1.618. Throughout the face, he saw that relationships between spacing and dimensions of the face, and all were related to the pi ratio. In the lips, the golden ratio is found between the upper and lower lip, with the upper to lower lip ratio being 1:1.618. In African Americans, this can be close to 1:1 and Asians are somewhere in between. Several other aesthetically appealing features of the perfect lips are:

Prominent tubercles in the middle of the upper lip, and either side of the midline on the lower lip
A strong cupid’s bow and philtrum
Corners of mouth that are neutral or turn up slightly
Very little red lip visible on the lateral 1/3rd of the upper and lower lip
The length between the columella and space between the lips should be about 1/2 of the length from the space to the chin
The peak of the cupid’s bow is continuous with the philtrum
The upper lip should project more than the lower lip when visualize on a lateral view
A “Paris Curl”, lips curling up at their vermillion borders
Phi ratio: length between cupids peaks: length between corner of mouth and cupids peak

What goes wrong with lips that look obviously done or unattractive? The simple answer is that ratios and landmarks are ignored. Several common errors are: upper lips that are bigger than lower lips, lower lips that project more than the upper lip, tubercles (or other landmarks) that are obliterated, and no attention to the cupids bow. Also, enhancing lips to the “age appropriate size” is part of the art of an experienced injector. Selecting the appropriate filler is important too. Fillers other than Restylane Silk, are too thick to be added superficially in the lips without the risk of being noticeable or palpable. Silk can be injected just beneath the surface of the lip and not be perceptible. Fine tuning is much easier with this technique rather than the deeper injections that have more associated bleeding, bruising, and swelling.

The take home messages are that achieving desirable, sensuous lips requires a skilled injector with a keen awareness of natural ratios and landmarks. Using the newly approved FDA filler for lips, Restylane Silk, allows for greater control and results that can’t be achieved with the other, more viscous, hyaluronic acid fillers.

(In the older patient: It is very hard to restore lips to their youthful state when there is severe volume loss, multiple upper lip lines, and loss of the normal curvature of the lips. The lip muscle in a young lip forms a “J”, creating a natural curl in the lip. In some patients, this elongates into an “I” shape, making it difficult to create the natural shape with a filler injection without it appearing abnormal. In these patients, the author gradually enhances over several months and this seems to lead to better outcomes.)

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Why are Blunt Microcannulas the Obvious Choice for Dermal Fillers?

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

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

Creating the Perfect Lips with Restylane Silk

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