restylane Archives | The Aesthetic Clinique

Does Radiofrequency, RF Microneedling, or Lasers Affect Hyaluronic Acid Fillers?

While there are number of studies suggesting that lasers and RF do not affect fillers, a recent article by Dr. Weiss opened up the debate again. In his paper he stated that biopsies showed evidence of heating around the filler. It did not evaluated the changes in the filler volume over time. He concluded that the filler was at risk to be affected by the heat. Dr. Davin Lim’s recently published study contradicts Dr. Weiss, and showed with RFM, there was no affect on fillers (biopsy proved) at multiple different energy levels.

The heat from RF Microneedling reaches approximately 65-75 C for 100 msec to up to 3-4 seconds depending on the device and parameters used. This is the “hottest” version of RF delivery used in aesthetics. This compares to the sterilization process of the fillers at the (Galderma) manufacturing plant of 110-120 C for 15-20 minutes.

Lasers can heat the tissue to a higher level, up to 100 C, but again, it is for milliseconds at best.

Conclusion: There should be no concern regarding placement of HA fillers with RF Microneedling or lasers, at any level of the dermis or subcutanous planes on the same day. Furthermore, there will be no effect on previously placed HA filler. As a side note, PMMA has to be heated to 160 C to cause changes to it’s structure. While the exact temperature is unknown for calcium hydroxyapatite, it is significantly higher than HA, so it too is safe from RF and lasers.

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)

2019 UPDATE: State-of-the-Art Acne Scar Treatments

Acne scarring has significant debilitating effects on one’s overall self-worth and confidence. Millions in the US are affected. There have been improvements in techniques and energy devices in past few years which have led to better outcomes for acne scar treatments.

Subcision – This is process of breaking up deeply tethered scar bands associated mainly with atrophic/rolling scars. Subcision has be performed for acne scars for decades and just using this procedure alone has proven to lead to significant acne scar improvements. Recently there have been a couple publications suggesting that cannula subcision had better outcomes, less downtime, and less discomfort than the traditional method of using a Nokor needle. A cannula has a blunt tip so it is also safer – less chance for cutting a nerve or blood vessel than the knife-like edge of the Nokor needle. In the study, both patients and the performing doctor rated the results better when using the cannula. Subcision is particularly important, in Dr. Weiner’s opinion, to be performed prior to any energy device for tethered scars. This is based on the fact that RF and laser will preferentially travel through collagen – which is high is water content – than fat or most other tissue. Scars are predominantly collagen, so it makes sense to cut the connection of the scar to the deeper tissue. Through personal communication with Dr. Davin Lim, biopsies he performed have shown scar band that reach the deeper fat pads from tethered acne scars. Transmission of the energy through the scar can theoretical lead to collagen contraction and deepening of the tethered scar. Sometimes fillers are placed at the time of the subcision to improve the volume loss associated with the scarring. Some hypothesize that putting a “spacer of filler” might improve results as well. Dilute lidocaine during the initial passes allows for this procedure to be well tolerated.

TCA CROSS – TCA (Trichloroacetic Acid) is a chemical peel used to improved acne scarring by placing minute quantities in the scar using a toothpick. CROSS stands for Chemical Reconstruction of Skin Scars. The most common use of this procedure is for ice pick and small boxcar scars. The process of causing a controlled chemical burn, allows for the body to heal from the deepest part of the scar towards the skin surface. This makes the scar smaller in diameter and shallower. Usually a series of 3-6 treatments are needed, with 3-4 weeks between treatments. There will be some mild scabbing for a few days which needs to be kept moistened for best results. Risk include widening of the scar or post inflammatory hyperpigmentation (PIH).

Radiofrequency Microneedling – This technology (RFM) has been available in the US for about 6 years and has revolutionized acne scar treatment. Using needles which are insulated, energy is delivered into the scar tissue directly and bypassing the epidermis, for the most part. The insulation protects the skin surface from heating so darker skin type individuals are at much less risk of PIH (post inflammatory hyperpigmentation) vs a laser treatment. The needles allow for deeper penetration than lasers as well. Overall, downtime is less than ablative lasers in most individuals (when insulated needles, proper technique, and appropriate settings are used). With acne scarring affecting darker skin types disproportionately, this is an excellent alternative to lasers. The Genius has recently been FDA approved and is now the “best of bread” RF microneedling device. There is now impedance feedback from the needles which allows for improved and exact energy delivery. The resistance in the tissues being treated is measured and this is important because throughout one’s face, there are differences, as well as between different individuals. Also, as tissue are heated or subcised, the resistance changes. Prior to Genius, there was no idea of how much energy was being delivered. There is now an accurate total energy for each pulse and a cumulative total. Other improvements include needle design-sharper, stronger motor, and feedback regarding quality of each pulse fired.

There is a myth that needs to be busted. Deeper does not mean better for acne scars.

The needles must stay within the scar for best results. If the needles go beneath the dermis, there is a risk for heating the fat and fat loss. Let it be known that the actual depth of the needles in most RFM devices is less than the settings, and becomes less accurate, the deeper the settings are. There is inherent resistance of the skin to penetration and many needles aren’t sharp enough or motors aren’t strong enough to get to the desired levels in the time required. This has also been addressed with the Genius and it’s depths are very accurate after extensive testing.

In addition, higher energy levels on any device which doesn’t monitor impedance, can actually result in very little energy delivered. Once the tissue is heating beyond a critical level, the resistance becomes so high that energy output cuts off. However, when higher energy levels are desired when using the Genius, the energy is adjusted to the increasing impedance and it is successfully delivered.

Fillers – Fillers are a very integral part of improving acne scars. They are extremely useful for the atrophic scars and the lipoatrophy associated with these scars. The aging process leads to dermal thinning and fat atrophy, which makes the acne scars appear worse, even if active acne has long been controlled. Fillers need to be injected deeply for correcting large areas of volume loss and superficially in minute quantities for focal defects. A hyaluronic acid filler will give about 12 months of improvement vs Bellafill which can give near permanent improvements. Bellafill does require a skin test to see if one has a allergy to the bovine collagen (0.5% chance) which needs 3-4 weeks to determine. There is some who feel fillers in areas of subcision will prevent re-adhesion of the scars. Most failures from other treatments are related to not recognizing the need to fillers to improve the acne scars.

Lasers – Erbium/CO2 ablative lasers still are beneficial for acne scars but have more downtime and risks vs RFM. Deeper skin imperfections are not improved with lasers and require fillers. These devices are best reserved for more superficial scars, mainly boxcar scars. Non ablative lasers are less affective but safer and in the author’s opinion give very minor results.

Microneedling – Also know as “Collagen Induction Therapy” CIT, has become popular in recent years. There are rollers available for home use and then there are medical grade devices which go to depths of 2mm or deeper and create thousands of penetrations per second. Rollers should be not be used at home for 2 reasons – questionable sterility at home and they tear tissue more than the in-office devices. Often these treatments are combined with topicals and PRP. It is highly recommended to not use any products on the skin which would normal not be injected. There have been many cases of infection and granulomas from these practices. Even when done in the office with PRP or amniotic membrane products, the efficacy of this procedure is minimal, and should be reserved for only mild acne scarring.

PRP/Amniotic membrane products – There is some date to support that better results and faster recovery with less side effects if PRP or amniotic membrane products are used during acne scar treatments. There is a movement more towards amniotic/placental products and away from PRP because there are more growth factors/healing properties in these vs PRP.

LLLT – There is a plethora of studies to suggest that using low level laser light (LLLT) is beneficial to results and healing times. The most researched device is Healite, and this should be performed immediately following all acne scar procedures which use energy devices. It calms the skin and improves circulation.

Acne scarring procedures are continuing to improve as technology and techniques evolve. One must understand that results require months to fully appreciate and multiple treatments (3-5 or more) are often needed to optimize results. Expectations need to discussed with providers/patients so that all are on the same page as to what one can achieve with treatments.

Dr. Weiner is an Acne Scar Center of Excellence designated by Bellafill and is a specialist on acne scars. He is a lecturer and trainer for Bellafill. He has become one of the leading authorities on Radiofrequency Microneedling and travels the globe lecturing on this technology. He performed the FDA trails for the Genius. He recently authored a chapter on RF Microneedling which soon will be published in the Facial Plastic Clinics of North America. He also wrote a recent chapter on Radiofrequency Safety and Complications which will be part of a book titled “Complications in Minimally Invasive Facial Rejuvenation: Avoidance and Management” by Paul Carniol, MD

How to Minimize Risks of Vascular Occlusion and Blindness During Filler Injections

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

Know the major vascular structures and their landmarks
Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
Use cannulas whenever feasible, preferably 25/23g or larger
Avoid boluses, small linear threads are safer
Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
Injection onto periosteum is safest but does not guarantee a vascular free injection
Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
Retrograde injections are safer than anterograde injections
Dermal injections should be relatively safe
Avoid deep injections in the lips. Stay superficial to the muscles
An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
Have on hand 6-8 vials of Hylenex
Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.

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.

Proper Sterile Technique is Critical for Optimal Dermal Filler Results

In surgery, sterile technique is “the law”. Any break in sterility places the patient at risk for a potentially life threatening infection. It is the duty for the surgeon(s), scrub tech, and circulating nurse to self report or call out any suspected or potential contamination risk. Immediate actions are taken to remedy the situation and to limit the risk to patient.

Why should dermal fillers be treated as anything differently? They shouldn’t! Fillers are semipermanent or permanent implants, and they must be administered in aseptic technique. The majority of injectors are not trained as surgeons and therefore don’t fully comprehend what sterile technique entails. Granulomas, one of the more serious complications from fillers, have now been traced to biofilms. Biofilms are latent bacteria that somehow get activated and present as infection or granulomas, months to years after the initial injection. Most often biofilms are deposited in the tissues during the initial injection procedure. Clearing infections or granulomas takes weeks or months to clear and often entails antibiotics, steroids, 5 FU, and hyaluronidase (if a hyaluronic acid was used).

The following guidelines should serve as a reference for physicians and nurses to minimize infectious complications during dermal filler injections.

The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
Never inject someone with a current/ongoing infection. Even if the infection is not in the area of the dermal filler, bacteria can seed the filler from distant areas through the bloodstream (bactermia).
If a patient is in the process of getting dental work or even dental cleanings, hold off on injections until after the work has been completed. Bactermia is well documented during dental cleanings. It is recommended to wait at least 2 weeks after fillers to get dental cleanings. The areas of filler placement will initially have increased blood flow (hyperemia) so it is best to wait until this settles down.
Skin should be prepped for injection with chlorhexidine, with Hibiclens being the preferred form by the author. Although isopropyl alcohol (70%) is effective in killing bacteria and fungus, it is only effective for seconds and becomes ineffective as soon as it evaporates. Hibiclens kills germs on contact and will give persistent bactericidal effects for at least 6 hours, and up to 24 hours. It will bond with the skin even after washing to give continued killing effects. Isopropyl alcohol doesn’t give this lasting bactericidal effect, so anytime after the initial cleaning that an unsterile glove touches the skin, that area is now contaminated. (Hibiclens must be kept out of the eyes because it can burn the cornea). Technicare is also a great antiseptic but the author doesn’t have experience with it. Too many patients are allergic to Betadine for it to be used routinely.
Do not use tap water when applying Hibiclens or to clean the face after completion of the injections. There are several bacteria, fungi, as well as mycobacterium in water which can seep through the injection ports and cause infection.
If the filler is prepared by mixing lidocaine or saline, this must be done in a sterile fashion. The female/female connector used to connect the 2 syringes together must not be reused. It can only be used for the current patient and cannot be sterilized for use on other patients. The tops of all the solutions used must be wiped with an alcohol wipe. Routine use of blending fillers opens up more avenues for filler contamination and must be done with the strictest of sterile technique. If any of the solution vials becomes unsterile, all future filler patients using that vial will become infected.
Blunt tip cannulas can be used for multiple injection sites ON THE SAME PATIENT and are not intended to be used for multiple patients. When changing the cannulas between syringes, they should be recapped first. It is not sterile technique to lay the cannula on an unsterile tray or even a sterile drape when uncapped. After a syringe of filler is removed from its sterile packaging, the areas touched with the exam gloves become “contaminated”. Therefore, the sterile drape is not a sterile field anymore, once the syringes is placed on it. Best practice is to cap the syringe every time it is laid down.
Blunt cannulas are much longer than needles and must be kept sterile throughout their entire length. The cannula is contaminated if anywhere along its length it touches non sterilized skin, gloves, or hair.
It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
Unless the gauze used during the procedure is specifically labeled as sterile, it is not, and introduces another route of contamination. Gauze that comes in sealed pull away packs and labeled as sterile is best to use. The author will take unsterile gauze, place in autoclave packs, and place in the autoclave to obtain sterility.
Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
If ice or devices for vibration are used to control discomfort, these should be cleansed with Hibiclens prior to applying to the skin. In addition, the areas where these were applied should be “re-sterilized” prior to injections.
When the procedure is complete, sterile water or saline on sterile gauze should be used to clean the patient. Again, if tap water is used, this can seep through the injection ports and lead to infection. Also, when soaking the gauze, best practice is to pour the water/saline over the sink onto the sterile gauze so as to keep the remaining fluid in the container sterile. By tipping the water/saline onto gauze that is covering the top, there is risk of contamination going back into the container.
Make-up should not be applied to the skin until the morning. At this point, the injection ports have all healed and there is no risk of contamination.
Dental procedures, even cleanings, should be postponed for at least 2 weeks.

Although the details above are fairly lengthy, any break from any step will lead to a possible source of granuloma or infection in the future. Strict sterile technique will lead to better outcomes and happier patients,

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.

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.