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Advanced Injectors Lecture BACD Regional Meeting London June 2008. MEDICAL DISCLOSURE:. Dr. Patrick J. Treacy is a Cosmetic Doctor presently on the Specialist Register in Ireland He holds a Dip Cos. Med Dip Dermatology, U.K. BTEC Laser Technology
BACD Regional Meeting
London June 2008
2. Hand Volumisation
Biocompatible and ‘GRAS’
Generally Recognized As Safe by FDA
CaHA performs as a filler initially.
Macrophages dissolve gel carrier.
Macrophages dissolve gel carrier & fibroblasts form new collagen.
New resident tissue (collagen) anchors microspherules of CaHA.
CaHA particles degrade and macrophages metabolize microspherules.
Where is Radiesse Injected?
Inject retrograde in the mid-to-deep dermis
near the junction of the subcutaneous tissue
Miles Graivier, M.D.
Inject large volumes antegrade in the
deep dermis to level of the subcutaneous tissue
Miles Graivier, M.D.
Most injectors would agree that injectable treatments are better accomplished if the patient is kept comfortable.
This makes the experience more pleasant for the patient which will keep them motivated to return for additional treatments. It also allows the injector to stay more focused on the injection process.
I personally find significant patient discomfort to be a distraction.
Most practitioners have typically utilized some form of local anesthesia:
Infraorbital, mental, supratrochlear, or supraorbital nerve blocks
Depending upon the physician’s preference, usually 1% to 2% lidocaine with or without adrenaline is used.
The effect of topical agents is mainly limited to the epidermis to upper dermis.
The deep dermis and subdermal tissues are not anesthetized.
The patient still feels the passing of the needle and any discomfort related to the injection of the filler material.
May be quite uncomfortable.
May cause additional bruising.
Depending upon the treatment site, the nerve block may distort the area to be injected (e.g. the cheek and tear trough with an infraorbital nerve block).
Require some knowledge of the location of key facial foramina to be successful. Therefore, the efficacy of the block may be dependent on the expertise of the injector.
Directly injecting the treatment site distorts the area to be filled and can skew the injector’s judgment as to when optimal filling has been accomplished.
Anesthetizes the treatment site as the injection process progresses.
In most cases, the mixing of lidocaine with Radiesse obviates the need for nerve blocks or local infiltration.
Most patients prefer injecting the mixed product to having nerve blocks.
Some patients still will require or desire nerve blocks (sensitive patient, lip injections, etc.)
The needle entry point (at least on the face) should still be anesthetized with a topical or local anaesthetic.
Eliminates distortion of the treatment site from the local anesthetic.
I find that most of my midface injections can be done just with a topical anesthetic on the oral mucosa.
I now mix lidocaine with Radiesse for basically all of my injections.
Eliminates the immediately post injection ”burning” that some patients used to complain of.
Why mix Radiesse with lidocaine?
Provide a less-painful alternative by eliminating the pain of a block and reducing discomfort for areas that are not easily blocked
Prevent tissue distortion that may be caused by injecting local anesthetics
Adjust the cohesiveness of Radiesse to use it as a layering rather than a bulking filler
0.15- 0.2 cc of 1 - 2% lidocaine with or without epinephrine is placed into an empty Radiesse 1.3cc syringe (A).
Syringe A is connected to a 1.3 cc syringe (B) of Radiesse using a 3 Way tap (or Luer lock to Luer lock connector).
The Radiesse contents are injected into syringe A and the mixture is then “swished” back and forth several times. 10 back and forth “swishes” are needed to obtain a homogeneous product.
The mixture of Radiesse and lidocaine is then advanced back into the 1.3 cc syringe.
0.15 -0.2cc of 2% plain Xylocaine +/- adrenaline is introduced using a previous 1.3ml Radiesse syringe and a 3 way lock with another 1.3ml syringe
0.15 cc of 2% plain Xylocaine or 1% Lidocaine + Adr is introduced using a luer lock-to-luer lock connector (Baxa) and a 1 cc or 3 cc syringe
As the hands age there is a loss of subcutaneous tissue in the dorsum of the hands.
The hands become skeletonised with more prominent appearance of tendons and veins.
This can be a “giveaway” to the patient’s true age despite efforts to rejuvenate the face.
Soft Tissue Atrophy
Radiesse probably represents the best filler we currently have available for the dorsum of the hands.
Simpler, less invasive, and more natural results than fat transfer.
5 – 10 minute procedure with no anesthesia needed other than mixing lidocaine (without adrenaline).
Bolus injection into the subdermal areolar space.
Massage Radiesse to distribute it evenly.
Total Volume – 1.3 to 1.95 cc per hand
Mike Jasin, MD