I want to wish a happy new year to every physician using medical spa. I hope our treatments in aesthetic medicine this year, to be more effective and satisfactory.

My question is: What if thrombosis or necrosis appear after an accidental injection of hyalyronic acid filler in a nein or artery? how can we treat or prevent this possibility?
The same stands for granuloma formation.
(I use Restylane for most of my patients).

You do not want to wait until necrosis occurs as it is too late then and you will treat it like a wound. The most likely spot to have necrosis is when injecting the glabellum. Many feel that the problem in most cases is not that you injected directly into the artery but that too much pressure has been placed on the vessel. Yes, injecting directly can cause it as well.

When injecting this area make sure to watch for vascular compromise. The are will turn white. If this occurs, immediately lay the patient down and massage the area. Hopefully this is all you will need to do. If not improving, then you may want to apply nitro paste to the area and continue to massage. Next if necessary you can inject hyaluronidase into the area.

One way to prevent this vascular compromise is to be careful and not over inject directly over the artery. Remember, it is more likely to be pressure on the artery than directly injecting into the artery. When injecting you also want to inject ante-grade and retrograde. In the past it was always taught to inject retrograde (when withdrawing the needle). The theory is that if you inject the HA ante-grade the HA will push the vessels out of the way and you will be much less likely to hit or enter a vessel. You will hopefully have less bruising as well.

As far as granulomas, you should not get them with the HA's. Tell me more of what you mean by granulomas and I will hopefully be able to help. Have you tried Juvederm yet? I like it a little better it is softer than the Restylane. I have done a lot of lips and every single woman I have used both Restylane and Juvederm on prefer the Juvederm. I also think the Juvederm flows a little easier through the needle. I do think it seems to last a little longer but not a huge difference.

There are 3 good videos that you can watch on injection techniques on www.thederm.org. They cover lower, mid and upper face injection techniques.

I hope this helps.

I was under the impression you do not inject in the glabellum for restylane? That it is mainly for nasal labial folds and lips

No, you can use it about everywhere. Perlane has been released for your deeper injections. I have switched to Juvederm Ultra and Ultra plus. I keep the restylane on hand as a few patients still want to use it.

LH and anybody else,
What is your technique for injecting nasojugal grooves, cheeks, and under eyes? I have been doing Juvaderm in these areas with good results but sometimes when the patient follows-up it looks odd when they smile.(A "blob" appears to move up-hard to explain) It seems to happen more when I do the cheeks or eyes. Have you experienced this? I am going as deep as I can-down along the orbital bone. I am going to check out www.thederm.org as you suggest. Any thoughts would be appreciated!
Happy New Year!

I always put it down on the periosteom in these areas. If it is sub-muscular it will not move like that.

LH & LA MD
when you say down on the periosteom for these areas, did you mean the cheeks as well? I've been using radiesse for the cheeks and going to the deep dermis/subcutaneous - i haven't had anyone come back complaining of filler movement but could it be a matter of time and if so, why haven't I heard about it from my rep or at other courses?

I did do my one eye myself for experience, which was unnerving & difficult with my hands shaking from the lido with epinephrine, but I did make sure I hit periosteum first before injecting. At first, I thought it looked very "youthful" to be rid of the hollow eye. Now I realize I have slight undereye bags which I didn't before when I looked hollow. I don't mind the bags and no one else would notice but it made me wonder if patients would be aware of the tradeoff and therefore to be on the safeside, I'd undercorrect my patients.

Has anyone used hyaluronidase to correct such deep injection sites and is the skin laxity more prominent once the filler is dissolved?

There are 2 schools of thought on the treatment of the nasojugal creases. LH likes the deeper plane. I prefer the more usual, more superficial level of injection - but you have to be careful not to overinject, and just do a little at a time, and sit the patient up & re-evaluate frequently.

If you get a prominent area, then a couple of weeks post-injection you can easily dissolve it away with hyaluronidase, if necessary. This occurs < 5% of the time.

Actually, I do stay in the dermis when injecting the NJG but go submuscular at the infraorbital rim and the zygomatic process. I also go deep along the jaw line.

Is anyone injecting intraoral Radiesse. Works like a dream. No bruising, minimal swelling!

Are you talking about lips or NLF's, mwrn? Radiesse is infamous for lumps when injected into the lips....

mwrn,

What areas are you using the intraoral technique on? I have heard of people doing this but have not seen anyone do it. It does make sense though. I have heard of someone doing the ifraorbital and zygomatic regions using this approach.

absolutely not the lips. I mean the zygomatic for awesome cheeck bones.

Have you tried the infraorbital area as well?

yes, great results. I use a leur lock and mix some lido 1% back and forth. When you inject, use your middle finger on the zygo. notch and place your needle just a head of that area. Iject SLOWLY. Inject small amounts in a row and massage gently just enough to bring it all together. My pts. ove it

I'd like to hear more about your technique for creating cheek bones....typically how many cc's of Radiesse do you use for each side? Where do you aim for maximum cheek prominence? Tips for shaping?

LH, i have tried nothing but restylane.
By granuloma, i mean the formation of a palpaple (or even visible sometimes) mass in the injection site of the product a few months after the implantation.
Thanks for the precious help!

Anyone had patients who developed lumps after injecting Radiesse in the nasojugal groove?
How do you manage the lump in this region if the patient presented 3 months after the treatment?

I know some are injecting with saline to try to "washout" the product.

If there is any inflammation you can do intralesional steroids but be very careful as it can cause atrophy of the skin.

Another option if you can see white through the skin or intra-orally you can use an 11 blade or 20g needle and make a small incision and remove some of the material.

I would try the washout technique first.

Could anyone share on the concentration and dosage for using Hyaluronidase to dissolve HA in the tear trough area?

Can anyone give details about using the luer lock technique to mix lidocaine with filler before injecting? I just attended a class where an instructor did this and the model who was being injected loved it. Said very comfortable. SP

We frequently mix lidocaine with an injectible filler. Purchase luer lock adapters without a stopcock. Draw up .2ml of 2% xylocaine without epi in a 3ml non safety syringe, remove the needle and screw on (tightly) the luer lock adapter. Next, remove the protective cover from the filler product. Place the filler syringe on the other end of the luer lock adapter and gently "swish" the contents of the filler into the lidocaine syringe. Gently repeat this until the product is homogenous. Once the filler syringe is full there will be some remaining product in the other syringe, this of course can also be injected. Remember, that you have now increased the volume of the solution injected but not the actual amount of product. I have the product number for the luer lock at my office and will post that tomorrow.
Hope this helps.

I am in the Memphis, TN area. I have been injecting Botox and HA's for about 2 1/2 yrs and started injecting Radiesse in the last 6 months. We get excellent results with Juvederm which we find more comfortable for our patients than Restylane. We have developed very good protocols for evaluating what and where injections are needed. Trainers for Radiesse disappointed us. We really didn't need instructiing, the rep was impressed with our results. The instructor was insistent that we inject using her technique which caused unneeded trauma to the tissue. We continued to use our technique which our patients are extremely happy with. 95% of our patients have no bruising, very small amounts if any of swelling , they can usually leave our office and meet friends for lunch without them knowing what they have had done. Contact me if anyone is interested in training. Bad injectors hurt everyone!!

I also have a procedure for mixing and using Hyaluronidase that makes it very easy if you have not used this before. There are definite trade offs for smoothing the trough and some things that improve results greatly if done first. If not careful, you will create a dam that blocks the flow of fluid from draining from that area.

We do not add any lidocaine to our fillers before using. With our technique, patients are very comfortable.

DianaCo,

What is your Hyaluronidase technique? Are you for real OR are you just trying to sell your injection training?

DianaCo,

When you mention you do not add lidocaine to Dermal Fillers are you referring to actually not adding to the filler syringe or not using a dental block. Presently we are using a lidocaine block, but on some patients we just use a topical BLT and have also found a 23/7 (L/T) works very well.

I would be glad to share our written policy regarding Hyaluronidase. Email me at dede5267@mac.com and I'll forward it to you. And no I am not trying to just sell training. I have worked hard to gain the comfort in using these injectibles and am proud to say that my clients love the results. Ice is what I use prior to and immediately after injecting, Lidocaine is not needed. Ice works well in chin, NSFs, cheeks, troughs, lips and noses.

DianaCo,

How long do you ice prior to injection and after injection. Do you ice in between your threads of filler? Do you do about .05 cc per thread? Do you do linear threading or serial pucture? Do you use 27 gauge or 30 gauge needle? How many syringes do you use for a typical nasolabial fold, marionette line, pre-jowl sulcus, tear trough, infraorbital area, cheek, etc?

Can anyone post a product number/company that produces the Luer lock used for mixing filler and Lido. I am having a problem locating one. thanks

CosMedics,

Baxa makes the Leur Lock connector. I order it through a local distributor PSS.

http://www.baxa.com/NursingProducts/IVAccessories/ProductDetail/?id=644091AC-3048-7B87-70C13B8B788D7DC9

Has anyone had complications from Radiesse where they became hospitalized with a carotid artery dissection? Also 4 vials were used on a first visit.

It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

I am in the Memphis, TN area. I have been injecting Botox and HA's for about 2 1/2 yrs and started injecting Radiesse in the last 6 months. We get excellent results with Juvederm which we find more comfortable for our patients than Restylane. We have developed very good protocols for evaluating what and where injections are needed. Trainers for Radiesse disappointed us. We really didn't need instructiing, the rep was impressed with our results. The instructor was insistent that we inject using her technique which caused unneeded trauma to the tissue. We continued to use our technique which our patients are extremely happy with. 95% of our patients have no bruising, very small amounts if any of swelling , they can usually leave our office and meet friends for lunch without them knowing what they have had done. Contact me if anyone is interested in training. Bad injectors hurt everyone!!

I also have a procedure for mixing and using Hyaluronidase that makes it very easy if you have not used this before. There are definite trade offs for smoothing the trough and some things that improve results greatly if done first. If not careful, you will create a dam that blocks the flow of fluid from draining from that area.

We do not add any lidocaine to our fillers before using. With our technique, patients are very comfortable.

08.20 | DianaCo
DianaCo,

What is your Hyaluronidase technique? Are you for real OR are you just trying to sell your injection training?

08.21 | MDR
DianaCo,

When you mention you do not add lidocaine to Dermal Fillers are you referring to actually not adding to the filler syringe or not using a dental block. Presently we are using a lidocaine block, but on some patients we just use a topical BLT and have also found a 23/7 (L/T) works very well.

08.21 | SBJ
I would be glad to share our written policy regarding Hyaluronidase. Email me at dede5267@mac.com and I'll forward it to you. And no I am not trying to just sell training. I have worked hard to gain the comfort in using these injectibles and am proud to say that my clients love the results. Ice is what I use prior to and immediately after injecting, Lidocaine is not needed. Ice works well in chin, NSFs, cheeks, troughs, lips and noses.

08.22 | DianaCo
DianaCo,

How long do you ice prior to injection and after injection. Do you ice in between your threads of filler? Do you do about .05 cc per thread? Do you do linear threading or serial pucture? Do you use 27 gauge or 30 gauge needle? How many syringes do you use for a typical nasolabial fold, marionette line, pre-jowl sulcus, tear trough, infraorbital area, cheek, etc?

08.23 | JEE
Can anyone post a product number/company that produces the Luer lock used for mixing filler and Lido. I am having a problem locating one. thanks

02.6 | CosMedics
CosMedics,

Baxa makes the Leur Lock connector. I order it through a local distributor PSS.

http://www.baxa.com/NursingProducts/IVAccessories/ProductDetail/?id=644091AC-3048-7B87-70C13B8B788D7DC9

02.6 | Boots
Has anyone had complications from Radiesse where they became hospitalized with a carotid artery dissection? Also 4 vials were used on a first visit.

08.12 | Kelli Egan
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

08.13 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

10.10 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

When you mention you do not add lidocaine to Dermal Fillers are you referring to actually not adding to the filler syringe or not using a dental block. Presently we are using a lidocaine block, but on some patients we just use a topical BLT and have also found a 23/7 (L/T) works very well.

08.21 | SBJ
I would be glad to share our written policy regarding Hyaluronidase. Email me at dede5267@mac.com and I'll forward it to you. And no I am not trying to just sell training. I have worked hard to gain the comfort in using these injectibles and am proud to say that my clients love the results. Ice is what I use prior to and immediately after injecting, Lidocaine is not needed. Ice works well in chin, NSFs, cheeks, troughs, lips and noses.

08.22 | DianaCo
DianaCo,

How long do you ice prior to injection and after injection. Do you ice in between your threads of filler? Do you do about .05 cc per thread? Do you do linear threading or serial pucture? Do you use 27 gauge or 30 gauge needle? How many syringes do you use for a typical nasolabial fold, marionette line, pre-jowl sulcus, tear trough, infraorbital area, cheek, etc?

08.23 | JEE
Can anyone post a product number/company that produces the Luer lock used for mixing filler and Lido. I am having a problem locating one. thanks

02.6 | CosMedics
CosMedics,

Baxa makes the Leur Lock connector. I order it through a local distributor PSS.

http://www.baxa.com/NursingProducts/IVAccessories/ProductDetail/?id=644091AC-3048-7B87-70C13B8B788D7DC9

02.6 | Boots
Has anyone had complications from Radiesse where they became hospitalized with a carotid artery dissection? Also 4 vials were used on a first visit.

08.12 | Kelli Egan
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

08.13 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

10.10 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

02.6 | Boots
Has anyone had complications from Radiesse where they became hospitalized with a carotid artery dissection? Also 4 vials were used on a first visit.

08.12 | Kelli Egan
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

08.13 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

10.10 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

08.13 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

10.10 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

08.13 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

10.10 | cosmo
It is not uncommon to use 4 syringes and sometimes more. I have NEVER heard of a carotid dissection. Nor have I injected filler in the neck. The carotid is not accesable from the usual face injection sites or by the standard needle used for filler . May want to see if the patient had facial surgery or previous injury to face. Good luck

I use Radiesse on daily basis in my Comsetic Laser and Vein Clinic and never had complications, even after using 6 vials in one visit. Anyway, I will research into the subject and post my reply in case I find something interesting.