FPSAM - Roundtable 2021 - 7

Switching to the prejowl sulcus, this is the area
medial to the jowls, and the jowls are bounded by the
labiomandibular sulcus. Basically, this is the area between
the midline and the labiomandibular sulcus
(which are also called the marionette lines), and this
area tends to be a little bit depressed. It is depressed
because we tend not to have much fat in that area.
Volumizing this area will sometimes cause a substantial
amount of bruising because you detach all of
these muscle fibers, which are highly vascularized.
Having said that, this is an important aspect that needs
to be translated to the patient directly and to communicate
clearly that they may experience some bruising
in this area, but it will disappear.
Dr. Dayan: Okay, so the XPresHAn technology
may be beneficial in this area where you have a lot
of movement of tissue. But you just brought up
bruising. I would like to ask the panelists about how
they prevent adverse events, bruising being one of
them. Dr. Rosengaus, do you have a special tip, or
pearl to prevent bruising?
Dr. Rosengaus: Another good question. Normally the
bruising that I see is around the corners of the mouth,
this is the most sensitive part. Bruising is hard to avoid
and ofcourse should be communicated and explained to
patients before starting the procedure. The most successful
technique to limit bruising is the use of a cannula.
In the Restylane family, cannula is approved for
use with Restylane Lyft and Restylane Contour in the
midface and Restylane Silk in the lips. Remember, always
be very gentle with the tissues.
Dr. Dayan: Dr. Fabi, how do you prevent bruising,
and you said you use cannulas sometimes in the lip
area, and perhaps in other areas of the face where
it's indicated. Does this influence bruising for you?
Dr. Fabi: I do find that cannulas do minimize my
incidence of bruising, just because intuitively I'm
poking them three times less if I'm using something
that's about an inch-and-a-half long. I must also
mention that it's not just bruising, which we can cover
up with makeup, as much as it is also swelling, because
every time that we're poking them with the needle
we're inducing a trauma. And that's just sometimes
equally meaningful to a patient especially when
treating the lips because they're scared of looking like
a duck even if it is temporary. I also mitigate it by
inviting my patients to come in the following day for a
complimentary pulse-dye laser treatment to treat their
bruises, if for any reason they do.
Dr. Dayan: Dr. Durairaj, do you ice before you
treat, or afterward, and does that help?
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Dr. Durairaj: To prevent bruising, we offer arnica
which is a herbal homeopathic remedy and is also
helpful for swelling. I will often give patients a onetime
20-40mg dose of prednisone if I think they will
have excess swelling or if the lips have undergone a lot
of instrumentation. I often feel that cannula may create
more soft tissue trauma and swelling sometimes: so in
my hands I feel like a needle is more precise and less
traumatic. In general, I have gotten over this idea that
patients should fear bruising. I discuss this frankly
with the patient that it is a possibility in about one out
of three patients, and can easily be covered with makeup
for a few days.
Dr. Dayan: In a recently published article,
Dr. Murad Alam presents the risk for vascular occlusion
with needles versus a cannula. The researchers
noticed 77% lower odds of intravascular
occlusionwhen using cannulas, and they also noticed
a 70% lower odds of intravascular injection for
thosepeoplewho are morethanfiveyears out.
When it is feasible, and appropriate, based on
patient characteristics, anatomic location, and
other clinical factors, the article suggests that
dermatologists may consider using cannulas for
filler injection to further minimize occlusion risk.
It also mentions in the conclusion that occlusion
risk per syringe appeared decreased after the first
few years of clinical practice and was also lower
among those who more frequently inject fillers.
So, one might conclude that the researchers recognized
that there are decreased odds of intravascular
occlusion with those people with more
experience than those people using cannulas.
Would you agree with this, Dr. Cotofana?
Dr. Cotofana: Yes, I believe the article represents an
absolute reflection of what we encounter in real-life
conditions. In terms of experience, one's judgment is
more acute and accurate with increased experience.
Dr. Dayan: Dr. Fabi, why do you think experience
decreased the incidence of intravascular occlusion
and how does someone get experience?
Dr. Fabi: Well, I believe the more treatments that you
perform, no matter how experienced you are, you're
going to have complications. Certainly, we should not
shame people for experiencing complications, but we
need to find ways to minimize these complications and
have the realistic expectations that complications can
arise no matter how experienced you are. Some of the
most expert injectors have had very severe and very
significant side effects from these procedures. When I
switched from needle to cannula, I did have a significant
drop off in my complication rates. With that said,

FPSAM - Roundtable 2021

Table of Contents for the Digital Edition of FPSAM - Roundtable 2021

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FPSAM - Roundtable 2021 - IV
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