Q: What are some of the very latest innovations/advancements with regard to technique for fillers and toxins? How are these innovations augmenting the results that patients are seeing?
"Aesthetic physicians in the United States are very fortunate to have an excellent array of injectable products available and FDA-approved. While in years past this was not the case, especially with regard to the dermal fillers category, today there is a choice amongst fillers that seems to fit just about every need."We have bio-stimulatory fillers that amplify neocollagenesis, replacement fillers that slowly biodegrade, even permanent fillers that are available. For hyaluronic acid-based fillers, we have an injectable 'eraser' that can essentially melt away the product. So, all in all we have an armamentarium of dermal fillers that represent the best of the available technology worldwide. While there are products awaiting U.S. market entry post-FDA approval, now is the time to take advantage of those products which are available.
"In the injectable toxin category, there are currently three botulinum toxin type A products that are fully FDA-approved. While subtle differences between them will require injector training and awareness, when properly used, the action and effectiveness of all will be transparent to the receiving patient. Scientific debate continues to revolve around unit-for-unit potency comparisons, and only the experience of time and continued head-to-head clinical trials will resolve this issue. Regardless of the outcome of this discussion, suffice it to say that all three approved toxins are safe and effective.
"There are two relatively recent advances in the area of dermal fillers that I would like to review; injection-assist devices and cannulas. Injection-assist devices (pumps) are certainly nothing new in the world of medicine, having been used for decades in the administration of IV fluids, chemotherapy, parenteral nutrition, etc. Now they are appearing in the aesthetic marketplace for dermal fillers.
"Injection pumps have certain well-described technical advantages over manual administration to include the consistent flow of material, eliminating injector fatigue, precise variability of speed of injection, and perhaps most importantly, the change in muscle movement of the injector's hand and grip.
"When injecting in the traditional manner, the syringe is gripped in the hand while simultaneously the thumb (or palm) is delivering pressure to deliver the product. As each increment of plunger depression is achieved, the very nature of the grip and the spatial relationship of the thumb to grip vary. When holding the syringe of filler while attached to an injection pump, the type of grip changes from that of 'holding and pushing' to that of 'fine touch' motor control, similar to painting or airbrushing, and more precise as the injector's finger (usually the thumb and index finger) are the only muscles used to control the syringe.
"In evaluation of manual injector technique, it has been found that the initial delivery of product is greater than the continued flow of material, thus resulting in a 'front-loaded' burst of product at the beginning of injection, followed by a decreasing 'tail' as the needle withdraws (threading and fanning techniques). With the use of the injection-assist pump, this uneven delivery is eliminated. The flow of material is even and consistent throughout the entire injection path. Speed of injection is controlled by setting the pump's delivery rate. Patient comfort can be enhanced by slower and more controlled flow of product delivery, and with the elimination of injector muscle fatigue, the consistency of injection is maintained throughout the day. This consistency increases accuracy, reliability and perhaps most importantly, reproducibility.
"Similarly, the use of blunt-tipped cannulas (BTCs) to deliver dermal fillers continues to increase in popularity. Simply put, BTCs are mini-cannulas developed for use in facial areas for dermal filler delivery. Having a blunt tip as opposed to a sharpened bevel allows for less tissue trauma, less bruising, less bleeding, less pain and, perhaps most important of all, less risk of an intraluminal injection and subsequent tissue anoxia and necrosis. BTCs are especially useful for treating large surface areas using the fanning or threading techniques. Examples of these areas include the mid face, mandibular sweep, NLF (nasolabial folds), lateral cheek, pre- and postauricular regions and mentum.
"BTCs are not without their own challenges including unit cost, generally slower injection rates, pre-insertion tissue preparation (mapping, local anesthesia, cannula entry port stab incisions) and lack of utility for depot (temporal hollows) and small area (lips) locations. However, given these considerations, BTCs increase patient safety and that is their chief advantage.
"For even more fun and excitement with dermal fillers, try combining an injection-assist pump with cannulas. You will be amazed at the outcome. Efficiency, speed, patient comfort, injector convenience and final aesthetic outcome are all improved, plus it's safer!"