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Inject 10-50 units at a time. More is not indicated.

After 2-5 days, re-evaluate and re-inject if needed.

If new filler is needed to fill the void, wait 2 weeks before the injection to avoid breakdown

LESSON 1: Protocol for Impending Embolization with Risk for Necrosis

01. Hyaluronidase—10 50 units mixed 50/50 with 0.9% saline. Inject into the area and massage gently to disperse
02. Nitroglycerin Ointment 2% applied to the overlying area
03. Aspirin 525mg daily with food
04. Warm compresses and massage
05. Topical Dermacyte (Oxygen cosmeceutical) QID
06. See patient daily. If no improvement, repeat regimen and add a Medrol Dosepak
07. Refer to a Plastic Surgeon if no improvement seen

The post MODULE 7: HYALURONIDASE appeared first on Learn @ Aesthetic Medical Partners.

LMX-5 is 5% Lidocaine in a lisosomal encapsulated system, may be superior (LMX4 is OTC)

BLT-Benzocaine, Lidocaine and Tetracaine. This is usually compounded at a local or regional
compounding pharmacy. Applied 15-45 minutes prior to the procedure. Apply like icing with a Q-tip.

Cetacaine-benzocaine, a mi no benzoate and tetracaine. Rapid onset. Runny at body temp.

LESSON 1: Treatment Techniaues

Remove make-up and cleanse area with alcohol prep pad or other antiseptic.

Apply/perform appropriate anesthesia, if required Warming the syringe in your hand prior to injection may reduce the injection pressure needed.

Determine appropriate injection technique.

The depth of the needle should be high dermis for superficial lines, mid-dermis for more substantial wrinkles, and deep dermis for heavy folds.

Good rule of thumb
01. For mid-dermis placement, the contour of the needle should be visible, but not its color.
02.Better to err on the side of injecting too deeply if unsure, as superficial injections can leave surface irregularities.
✓ Blanching—indicates vascular compression
✓ If blanching is seen, then the provider should immediately stop injecting and massage the skin until normal color is returned.

Methods of Filler Implantation

✓ Serial Puncture

✓ Linear Threading

✓ Fanning

✓ Crosshatching

✓ Layering

✓ Microdroplet

✓ Ferning
✓ Push Ahead

✓ Tower Technique

✓ Liquid Threadlift® (ArqueDerma®)

Multiple punctures to implant small amounts at a time.

Smooth or mold after filler injected

Easiest technique, and often preferred by beginners Needle enters the skin at desired depth, a small amount of filler is deposited, and the needle is withdrawn.

LESSON 2: Linear Threading

Treatment Techniques Fanning and cross-hatching techniques are variations of the linear threading technique, Used when placing a larger amount of filler more deeply.

Treatment Techniques

FANNING

mplant layers of product at different levels to improve the wrinkle.

Avoids a “blob” of product in one area

Lends to different products—placing a firmer product (Juvederm Ultra Pl us-XC, Restylane lyft, Radiesse) deep then softening the more superficial layer with a softer product (Juvederm Ultra-XC, or Restylane)

Push-ahead Technique:

01. Insert the needle and inject as you advance the needle.

02. Should only be used in areas where

vessels cannot be embolized.

03. Great technique in lips that have been treated previously (vermillion border)

Lip Enhancement

Ensure comfort. Recumbent position is recommended

Adequate pain control

Clean the lips with mouthwash or something that does not taste bad

Several enhancement technique are possible

After Care

Ice to area frequently for remainder of day.

Explain that swelling/bruising are to be expected.

Prophylaxis offered if applicable-Valtrex, Famvir or Acyclovir
NSAIDS post-op (only) if necessary for pain or swelling
Explain signs and symptoms of infection
Make sure that patient understands that with a temporary product, touch ups will be needed, and estimate how soon the patient can anticipate needing to come back.

If considering any long term filler, use a temporary filler first to demonstrate results.

Bruising

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Allergan

FDA Approved: November 2015

Injected into Submuscular /Subdermal plane

lml prefilled syringes

Vycross technology—90 % LMWHA+10%HMWHA

Hyaluronic Acid Cohesive Gel

01. Trade Name: BELOTERO Balance 02. Merz Aesthetics: 866-862-1211 03. FDA Approved: 11/16/11 04. Injected into Mid-deep dermis 05. lml prefilled syringes, $240 06. Cohesive Polydensified Matrix Technology

LESSON 1: Semipermanent Fillers

Calcium hydroxylapitite | Trade Name: Radiesse (Merz)

FDA approved 2006 for treatment of facial wrinkles and folds.

Not for lip augmentation

Longevity: 12+ months

Subdermal injection

This filler “improves” over time I 1.5ml-$562

LESSON 2: Permanent Fillers

✓ Trade Name: Silikon 1000, Vitresil

✓ Indicated for retinal detachment, not FDA approved for cosmetic use but is used off-label

✓ Longevity: Permanent

silicon oil

✓ Polymethylmethacrylate (PMMA)

✓ Trade Name: ArteFill, Bellafill

✓ Suneva Medical, Inc., 858-550-9999

✓ Suspended in bovine collagen, so must be allergy tested

✓ Contains 0.5% Lidocaine

✓ FDA approved 2006 for nasolabial folds

✓ FDA approved 1/2015 for acne

✓ Longevity: Permanent

LESSON 3: Autologous Growth Factor

✓ PRP/platelet rich fibrin matrix (PRFM)

✓ Trade names: Selphyl (UBS aesthetics) and

✓ MyCells (Kaylight Corporation), harvest PRP

✓ Patient’s blood is drawn into an anticoagulant in a specialty tube or prep pack

✓ After centrifugation, the platelets and fibrin form a matrix.

✓ PRP is injected to stimulate cell proliferation.

✓ Volume is increased and the skin is

✓ Rejuvenated by targeted tissue regeneration.

✓ Selphyl $1100/$700 per kit (Check current pricing in your area), harvest-buy centrifuge then disposables

What Is Hyaluronic Acid (HA)?

01. HA is a naturally occurring substance that, in the skin, forms the fluid matrix in which collagen fibers are embedded

02. is negatively charged and bindsenormous amounts of water, giving skin its supple, resilient quality

03. The amount of HA in the skin decreases with age, resulting in reduced dermal hydration and increased wrinkling

HA Physiochemical Attributes

✓ The half-life on natural HA in tissue is only 1-2 days. KB W

✓ HA molecule are chemically cross-linked, forming more stable macromolecules which have the same biocompatibility as native HA, but are water-insoluble.

✓ ‘Shear-thinning’ gels: Under pressure of injection, gel can pass through a relatively small gauge needle, but removal of the shearing force causes increased viscosity.

✓ Viscosity also decreases with warmer temperature.

Classification Methods

01. Source of HA

03. HA concentration

02. Method and degree of cross-linking

04. Particle size NOT

Suggested For:

01. Dynamic rhytids

02. ‘Ice pick’ and other non- distensible scars

03. Widened surgical scars

04. Actinic damage of lips

05. Extensive facial rhytids

SIDE EFFECTS

Herpetic outbreak – prophylaxis recommended.
infection good aspectic technique a must
Swelling/Bruising – common, self-limited. Ice
recommended post-op. Avoid ASA/NSAI Ds prior to injection.
Nodules (depending on product injected)
Respond to massage, or to local injection of corticosteroid and massage.

Tenderness – will resolve in 1-5 days
Pain – Recommend good topical anesthetic or dental block.
Erythema Itching

Consultation

Assess expectation_ silk purse from a sow”s ear. Attempt to determine if expectations are reasonable
Medical History_ make sure there are no contraindications to treatment
Medications- ASA”s, NSAID”s should be avoided prior to the treatment. Accutane avoid treatment Untill off for six month
Use manual strecthing of skin to demonstrate how well a particular perceived imperfection may or may not respond to filler.

Supplement begining with “g” Ginger, Ginko, Garlic, and fish oil as this can thin the blood as well
Assess patience pain tolerance

May use ice, topical anesthetic or nerve block

Be sure patient understand the results are temporary
Explain treatment and risk and determine level of understanding
Have patient sign informed consent
Pre procedure photographs recomended

The post MODULE 5: Hyaluronic Acid Volumizer appeared first on Learn @ Aesthetic Medical Partners.

Where is Collagen Found?

01. Collagen is a natural protein that provides structural support.
02. It is found throughout the body in skin, muscle, tendon, and bone. Fibers of collagen are woven together, like threads in fabric.
03. It forms a framework into which new cells can grow. Collagen provides the texture, resiliency, and shape to skin.

LESSON 1: What Weakens Collagen?

In addition to being a natural part of aging, other factors weaken the collagen fibers:

01. Exposure to the environment (esp.sun)

02. Injury

03. Heredity04. Lifestyle

Why Injectable Fillers?

The way your skin looks is directly related to the way your skin is supported.

Collagen is the naturally occurring component of skin that is part of the support structure of skin. Wrinkles form when this natural collagen layer thins during aging.

Injectable fillers are implanted in the skin directly into the areas where collagen has weakened.
Depressions in the skin can be raised to the level of the surrounding skin. Thus, lines and scars can be minimized.

LESSON 2: Why Not Collagen Creams?

Creams and moisturizers work only Creams and moisturizers work only on the skin’s surface as a temporary barrier to help retain water.

Injectable products are paced in the skin to replace what has been lost. Although, they don’t reverse aging they do make aesthetic improvement.

LESSON 3: Temporary Injectable Fillers

o Bovine Collagen—Zyderm/Zyplast (No longer in the market) to njection

•  Foreskin Fibroblast Culture

• CosmoDerm/CosmoPlast

Culture

• Cymetra, Dermalogen, Fascian o Lc

The post MODULE 4: Injectable Dermal Fillers appeared first on Learn @ Aesthetic Medical Partners.

Avoid the area less than 1 cm above the orbital rim over the iris. Diffusion of the toxin into this area can cause ptosis. With Dysport®, avoid the area 1 1/2 cm above the brow.

Glabellar Region “Frown Lines”

By paralyzing the Corrugator muscle and parts of the Procerus muscle, the frown lines are arrested and the effect of the muscles lifting the brows dominates.

Additional Glabellar Injection Patterns

Treatment softens the vertical glabellar furrows.

BTXa injected into the glabellar region causes the frontalis muscle to dominate. 

(Can help with older clients or those with low set eyebrows.)

Failure to include the glabella when injecting the forehead can cause lowering of the brow

(Neanderthal appearance)

Stacking

Trio

Diamond

LESSON 1: Glabellar Landmarks

Commonly used landmarks lie about 1 cm above the medial ends of the eyebrows, directly over the glabellar furrow, in the middle of the bridge of the nose and usually also in the medial belly of the glabellar fold.

Horizontal Forehead Lines

Recommended Dose:  12-20 Units

Since the frontalis muscle is responsible for 

elevating the eyebrows and wrinkling the 

forehead, paralyzing this muscle can lower the

forehead and the eyebrows.

Because of this, the glabellar region should always be treated first or at the same time in order to raise eyebrows 

LESSON 2: Sites To Avoid

Injections of toxin in the lateral forehead region.

The ‘Bermuda Triangle’ area of the forehead is to be avoided, since paralyzing this area can cause a ptosis of the eyelid.

Lateral Canthus Lines “Crows Feet”

Injection in the ‘crows feet’ area are frequently performed intradermally rather than in the belly of the muscle and are quite effective.

Recommended dose: 4-12 Units per side

Start injections about 1 to 1.5 cm lateral to the orbital rim.

Injection pattern is individualized to client.

LESSON 3: Row’s Feet Caution

The provider must be careful when treating clients with loose, baggy skin on their lower lids, since this provides a path for BTXa to migrate into unintended areas.

Botulinum Toxin After Treatment

Explain to the client that effect is not immediate – they should expect to begin to see results in 5-7 days. Follow up or advise in 14 days and take ‘after’ photos

– Stay upright for 3-4 hours after treatment

– No vigorous exercise for 24 hours

– No makeup for 12 hours

– No extreme hot or cold for 48 hours

– No hats/headbands for 4 days

– No laser, waxing, microneedling, facial treatments for 14 days

Side Effect And Complications

– Local injection pain
– Bruising (5-10%)
– Pressure sensation above the upper lid/lower forehead
– Lid/Brow ptosis (5%)
– Diplopia (very rare)
– Headache, “flu”, hearing impairment (<1%)
– Numbness in forehead

The post MODULE 3: Botulinum Toxin A Treatment appeared first on Learn @ Aesthetic Medical Partners.

– Once reconstituted, store refrigerated
– Ideal use is within 24 hours – this follows manufacturer’ specifications but clinical effectiveness has been shown to 30 days.

LESSON 1: Reconstitution

• Use 2.5 ml sterile saline or bacteriostatic 0.9% sodium chloride per 100 unit vial (or the
  appropriate volume for the desired dilution)
• Use preservative-free 0.9% saline or 0.9% bacteriostatic sodium chloride
• Do not shake vial! Make every effort to avoid foaming.

Botulinum Toxin Storage

Botox + Jeuveau:
– Prior to reconstitution, keep refrigerated.
– After reconstitution, keep refrigerated or on ice.

Xeomin:
– Prior to reconstitution, keep room temperature.
– After reconstitution, keep refrigerated.

Syringes

1 ml Syringe with 0.1ml increments. TB—with detachable needle Norm-Ject or Exel 26048—with detachable needle. Allergy—with attached needle

Insulin Syringes—with attached 50-52g 5/16″ to %〃 n(
(5/10ml), 50 unit (l/2ml), 100 unit (lml)

UniTox Syringe—with attached 50g 5/16″ needle must use 2.5ml
saline in a 100 unit vial dilution. Increments are 5,10,15 and 20 units
Comfortox Syringe

LESSON 2: Client Selection

Basic points – all risks and complications have bee clearly stated/explained
If client is unsure have them wait.
BTXa cannot replace psychotherapy.
Assess expectations – if unrealistic, safer to avoid treatment
Judge facial condition!

Botulinum Toxin Indications

01. Most of the folds and wrinkles in our face are the result of traction of underlying mimetic muscles on the skin, ptosis of the fat pads and loss of collagen.

02. Muscles are in a dynamic balance.

03. Treatment should affect specific muscles while sparing the surrounding muscles.

Indications

1. Horizontal forehead lines
2. Glabellar folds “frown lines”
3. Lateral canthal lines “crows feet”
4. Fine wrinkles on bridge of nose “bunny lines”

Main area of treatment is upper half of the face.
Lower half of face and neck treated less frequently and considered higher risk along with bunny lines.

LESSON 2: Neurotoxin: Contraindications

Allergy to any components of the toxin preparation, (i.e. albumin/egg allergy)

Generalized impairment of muscle strength (i.e. Myasthenia Gravis, Eaton-Lambert syndrome, ALS)

Antibiotic therapy shortly before or after treatment (Aminoglycosides (gentamicin) intensify effect, others can lessen effect.)

Clients planning Lasik surgery

Blepharoplasty (plastic surgery operation for correcting defects, deformaties and disfiguration of eyelids)

Treatment with ASA, NSAIDS or Anticoagulants one week prior to treatment

Infections of the eyelids or of other intended injection sites.

Serious preexisting disease

Pregnancy and for the duration of breast-feeding.

Blood donors – can’t donate after Botulinum toxin A for a period of time determined by the blood bank.

Preparing The Client

Take before photographs + after photographs 2 weeks after treatment to help resolvecomplaints such as “I can’t see any difference” or “It’s worse now than it was before”.

Inform client verbally about treatment and potential complications

✓ Multiple Photos of Different Angles

✓ Hair Away From Face

✓ Remove ALL Makeup

✓ Solid Background

✓ Clear Shots of Injection Area

LESSON 3: Botulinum Toxin A Treatment

Always make sure informed consent
is signed and medical history forms
are filled out completely

Document status prior to treatment (describe in chart, as well as photo)

Cleanse injection site using alcohol wipe or product similar to Hibiclens

Evaluate anatomy in upright position.

Inject Botulinum toxin with client in upright position.

Ask client to contract targeted muscles BUT the needle is inserted in the belly of the muscle while relaxed.

The needle is inserted into the muscle and BTXa is injected.
Beware tapping periosteum may dull needle.
Dermal wheal (bleb/intradermal) could be done in most areas.

The post MODULE 2: Facial Muscle Anatomy appeared first on Learn @ Aesthetic Medical Partners.

Today’s presentation will include the use of Botulinum Toxin A in the FDA approved Glabellar, Crow’s Feet, and Forehead areas (on a botulinum toxin A)

In addition, areas of the upper face that are not included in the FDA indication will be shared.

These injections are considered off-label use and within accepted and published standards.

LESSON 1: Botulinum toxin A therapy

Alan B. Scott
(1960’s) attempted to find an agent to use on eye muscles for strabismus. First used in 1978 on humans.

Carruthers and Carruthers
(Canadian physicians) did joint dermatological-ophthalmologic research starting in 1987 with Alan Scott.

LESSON 2: Pharmacology

Three step process

01. IRREVERSIBLE binds topresynaptic terminal of motor end plate

02- Internalized into axon by endocytosis

03. Cleavage of SNARE (receptor) proteins resulting in inhibition of neurotransmitter release

SNARE proteins N-ethylmaleimide sensitive factor attachment protein receptor

Each serotype binds to a specific residue of one of the

docking proteins Botox=SNAP-25 Jeuveau=SNAP-25

Dysport=SNAP-25 Xeomin=SNAP-25

Mechanism of Action

Light chain blocks fusion of neurotransmitter
vesicle with nerve membrane by cleaving SNAP-25 with Type A

Botulinum Toxin A Mechanism of Action

Before Botulinum Toxin A: Endplate sits upon muscle fiber
The Botulinum Toxin is internalized via receptor-mediated
endocytosis
Botulinum Toxin A binds to nerve terminal

The endplate expands and collateral axonal sprouts emerge. Sprouts subsequently retract and are eliminated; parent terminal is II  I  I re-established

BOTOX
(on a botulinum Toxin A)
MANUFACTURER: ALLERGAN
ONSET: 5-7 DAYS
APPROVAL: FULL FACE + THERAPEUTIC
FINAL RESULT: 14 DAYS
SHIPPING: BUSINESS ONLY + ON DRY ICE

Dysport (abobotulinum Toxin A)

MANUFACTURER: GALDERMA
ONSET: 5-7 DAYS
APPROVAL: FULL FACE + THERAPEUTIC
FINAL RESULT: 14 DAYS
SHIPPING: BUSINESS ONLY + ON DRY ICE

1. Ratio of diffusion differs from Botox®
   2. Specific training for Dysport® is
   recommended to prevent inappropriate injection/diffusion. Medicis has a DVD and online videos on reconstitution/injection at:

Xeomin (Incobotulinum Toxin A)

MANUFACTURER: MERZ
ONSET: 5-7 DAYS
APPROVAL: FULL FACE + THERAPEUTIC
FINAL RESULT: 14 DAYS
SHIPPING: BUSINESS OR RESIDENTIAL
SHIPPING: ROOM TEMPERATURE

1. Ratio of diffusion is similar to Botox.
2. However, package insert cautions that the units of biological activity cannot be compared orconverted to other botulinum toxin products using other assay methods.

LESSON 3: Antitoxin

An antitoxin is available if overdose or mis-injection occurs.
Contact your Local or State Health Department to process a request for antitoxin through the CDC. If you do not receive a response within 50 minutes, contact the CDC directly at 770-488-7100.
Antitoxin will not reverse Botulinum toxin induced muscle weakness already apparent by the time antitoxin is administered.

Alternatives to Injectables

Surgery Laser
IPL Topical Skin Products Microdermabrasion

Medical Needling Radiofrequency
LED Light Treatments Microcurrent Toning Chemical Peels

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