Fill Me In: An Aesthetics Podcast
On Fill Me In: An Aesthetics Podcast, Jon LeSuer NP-C and Nicole Bauer FNP-BC dive deep in the world of aesthetics. As aesthetic nurse practitioners with their own medical practices, Jon and Nicole fill you in on everything in their field.
Fill Me In: An Aesthetics Podcast
Navigating Aesthetic Complications: Bruises vs. Vascular Occlusions | Episode 26
In this episode of Fill Me In, join Jon and Nicole as they dive deep into differentiating between bruises and vascular occlusions. They discuss their personal experiences, best practices, and the importance of preparation and mentorship in handling complications. Learn how to provide quality care without causing patient panic and understand the importance of having a comprehensive crash cart ready. Whether you're a seasoned professional or a novice injector, this episode is packed with valuable insights and practical advice.
Includes a clip from Alexis Isasi MMS, PA-C on Instagram. Follow her account here: https://www.instagram.com/alexis.isasi.pa/
On Fill Me In: An Aesthetics Podcast, Jon LeSuer NP-C and Nicole Bauer FNP-BC dive deep in the world of aesthetics. As aesthetic nurse practitioners with their own medical practices, Jon and Nicole fill you in on everything in their field.
Follow Fill Me In on Instagram!
https://www.instagram.com/thefillmeinpod/
Follow Nicole on Instagram:
https://www.instagram.com/aestheticnursenicole/
Follow Jon on Instagram:
https://www.instagram.com/injectorjon/
Exhibit Medical Aesthetics website:
https://exhibitmedicalaesthetics.com/
Tox and Pout Aesthetics website:
https://toxandpout.com/
Jonathan LeSuer, MSN, NP-C
Jonathan LeSuer graduated from Le Moyne College with his Bachelor’s in Nursing in 2014 and a Family Nurse Practitioner degree in 2017. He began his career at St. Joseph’s Hospital as a Registered Nurse on a cardiac medical-surgical unit. He transitioned to the Nurse Practitioner role in 2017, working for Hospitalist Medicine, where he became the coordinator for the team’s Physician Assistants and Nurse Practitioners. In 2020, he started his career as an Aesthetic injector and quickly found out that this was his passion. On March 15th, 2022, he opened Tox & Pout Aesthetics. He is now a Master trained injector & National trainer for Allergan Aesthetics, offering Botox, Dysport, Hyaluronic acid fillers, Kybella, SkinViVe skin booster, and Sculptra. Jonathan is known for his empathy, profound bedside manner, and outgoing/warm personality. He has a deep love for aesthetics, and his patients’ confidence is his main priority.
Nicole Bauer, MSN, APRN, FNP-BC.
Family Nurse Practitioner
Nicole graduated with her Associates in Applied Sciences and began her journey as a registered nurse 10 years ago in 2014. She worked hard to combine her love for beauty with her passion for caring and healing others, attending aesthetics school while working as a hospital night nurse. After graduating as a licensed aesthetician, Nicole left the hospital where she had been for 3.5 years and began working as a registered nurse for a plastic surgeon. An experience of over 6 years that would leave her with so much knowledge and respect for the aesthetic world. It was during those 6 years that she pursued her Master’s Degree and obtained her license as a Family Nurse Practitioner, leading the way for where she is now; owning a state of the art medical aesthetic practice and being a national Allergan Trainer. Nicole takes pride in treating her patients holistically, focusing on facial balancing and enhancing one’s natural beauty. She believes education stands as the cornerstone of aesthetics and is why she is dedicated to both training others while always focusing on expanding her own knowledge as well.
Producer of Fill Me In: Joseph Ginexi
#aestheticmedicine #aesthetics #aestheticnurse #podcast #medicalfield #botoxcosmetic #filler #socialmedia #influencer #aestheticinjector
Alright guys, welcome back to another episode of the Fill Me In Podcast where we dive deeper into the world of aesthetics. I feel like it's been a minute since I've been on.
I know we missed you last week for your illness.
Thank God for Brit and Melissa for. Filling in substitute? Yes. Filling in on the fill in pod.
Oh my god. I can't, no
pun intended. Oh my God.
But guys, I am injector John, if you guys have never been on this podcast before and
I'm aesthetic Nurse Nicole, thank for joining us. Yeah.
So what did you guys talk about last week?
Last week we did all about like pre-treatments. So for your lasers? Mm-hmm. Your resurfacing, microneedling.
That's nice. Um, you know, things you should be using on the skin before and after. And just overall like home care is so important, you know? Yeah. So,
yeah. And um, this week, I mean, I feel like. This ebbs and flows, but I feel like I've gotten a lot more dms, especially from newer injectors like John, like I'm freaking out.
Like, I don't know whether I have a bruise or a vascular occlusion on my, on my patient. Mm-hmm. How do I tell the difference? And it's super, super important to know the difference because number one, we don't wanna freak out our patients. That's, that's huge. Right? We wanna make sure that we're educated.
Absolutely. Yeah. And that we can, that way we can differentiate. And honestly, if you are, say, if you're by yourself. Right. Mm-hmm. Like, I think it's really important to have like a mentor or someone that you can refer that patient to.
Absolutely. Um,
if you can't handle it yourself, and that's totally fine.
If you're newer, more novice injector, that's sometimes you don't know. Mm-hmm. But that way, you know, we don't freak out the patient and that way we send the patient to someone who does know.
Right. And it's so important to know how to care if, if they do pop up, because your patients, they're gonna just feel so much more comfortable if you're able to actually treat them.
It's becomes a problem when. You go, oh, that's a vascular occlusion, but I don't know what to do. You know? Right, right. Yes. It's so important as an injector to make sure that you educate yourself on that or have people that you can refer to.
Totally. And I mean, we've all been there. There, there's times I'm like, mm, okay.
Is that what, what's going on? Like, yeah.
Yeah. What's happening here? Yeah. Like
kind of your pit starts sweating. You're like, what's happening? You get really flushed. You're like, wait, you know? But then you're like, wait, let me check cap refill. Exactly. Lemme do some things,
but I, I had a patient recently, I did her lips.
Yeah. And then I did Skin Vive. You know, it's so funny, my past two potential occlusions have actually been from multiple treatments, but it was, uh, Voluma and Skin Vive and, uh, lip Filler and Skin Vive. Okay. Yeah. And it was her, like the corner of her mouth. It looked like a bruise, but then as I kept injecting it started to get a little too white for my liking.
Uh, very, you know, looked very dusky. Looked cold. Yeah. Um, but I did warm compress and like vigorous massage over where I did the skin Vive. And I had her stay for like 30 minutes and then it was looking warmer. I was happy with the refill. It was a little slow, but it wasn't anything crazy. 'cause I think another thing especially newer injectors tend to do is jump on that Linux.
Too quick E. Exactly. Yep. Mm-hmm. So, and then you're causing more trauma to the area, so if it is a bruise, it's just gonna. Continue to, to bruise worse. Yeah. But, so I sent her home. She's close enough where she had to come back. I texted her about four hours later. I texted her the next morning, like just kept checking up on her.
It ended up just being a bruise. Thank God.
Yeah. Yeah. But you, but you sometimes you just don't know. Right. And, and, and that's where, like you said, you don't jump on it and just do hy an exerted way. Mm-hmm. You trial, you have to kind of start critically thinking. Okay. If you know you have to be a provider.
Mm-hmm. And you have to say, okay, let's try heat and massage first. Heat is obviously gonna vasodilate. Mm-hmm. It's gonna promote blood flow and then let's reassess in 30 minutes. If the cap refill is less than three seconds, we're good to go usually. Exactly. Yep. Um. So basically for those of you that don't know the difference, a bruise, you have normal cap refill.
So in checking cap refill, um, it's just a measure of peripheral tissue perfusion, right? So basically you hold down like firm pressure on that area that you're concerned about for about five seconds. Then you quickly let go and then you want normal cap refill to return normal in about what, three seconds?
Under three seconds? Yeah. Under three.
Yeah. And then if you have any delay, if it's more than three seconds, that's when you're a little bit worried. And then you might say, okay, let's try heat. Mm-hmm. Massage and do that first, and then recheck in 30 minutes. If it's still there, then you go to your next step.
Right? Um, but normally a bruise usually occurs around the area that you're injecting pretty much sometimes right away. Um, sometimes, especially in like the. Chin shadow or supplemental shadow area. The area just looks really red at first and then it turns into a bruise. Um, but you should have normal cap refill like right away.
The whole time. Yeah, the whole time. Yeah.
Yeah. And that's something too, when I'm injecting, I. A patient may think I'm massaging, but I'm also checking. Yeah, you're checking, checking that cap refill the whole time. And yeah, like you said, the chin area, I feel like sometimes it takes 24 hours for a bruise to occur.
Really, truly occur there. Yeah. And um, you know, patients might call you the next day, like, and I always, my front desk knows if someone calls about a bruise, we never tell them, oh, bruising's normal. Yes. Let it, like, I need to see that bruise because how. Do I expect a patient to know the difference between a bruise a hundred percent.
And, you know, and an occlusion. So the other
thing too, with a vascular occlusion, things can look odd away from mm-hmm. The, the treatment area. Right. So, like, because you're affecting tissue perfusion distal to where you injected, so you're kind of like, oh, why does, why do things look weird? Mm-hmm. Like on the upper part of the face.
And that's where. Tissue or the, the vessel is occluded and it's, and it's affecting tissue perfusion distally away from where you treated.
So true. When I mm-hmm. Was at my old location, we had a surgeon in that area actually call us. He had done radius in a nose.
Mm-hmm.
And oh my God. I know for those listening radius is not fully dissolvable.
It is partially ha. But there's also a calcium component that is not fully dissolvable. It does have its own agent that is technically, you should not be
using radius in the nose. I'm sorry. Yes. There are areas, I mean, I don't do liquid rhinoplasty, but you do, right? Yeah. Yeah, I do.
Yes. Yep. And I prefer to stick to dissolvable stuff.
So Radi Radius has, its, has its place, it has its locations that I do feel like it's safe. Mm-hmm. And, but I, I, I. Choose not to use it just for purposes of, I like stuff that is dissolvable. Uh, but he did a nose and the problem was not on the nose. The modeling and all of the, um, skin color change was actually in the forehead.
Yeah.
And it's because if you think about how all the arteries are running and all things like that, like it's supplying blood to the floor, the forehead. So you're blocking that and the, you're seeing that tissue on the forehead be involved. Yeah, yeah, yeah. So yeah. So you could
be doing nasal labial fold filler mm-hmm.
But then all of a sudden. Obviously the angular artery runs parallel to the NAS labial fold, but then runs up basically parallel to the nose, and then it turns into the supra trochlear artery. Yeah, so obviously if you affect the angular artery here at the NAS labial fold, then you're gonna have modeling and impaired tissue perfusion up into the forehead and it can it.
And it progressively gets worse. Mm-hmm. Like a bruise. Like you either see it right away, it turns purple, black, and you know what I mean, right away. Um, but usually there's an area of like guiness, right? Like around where you're injecting and then distally, it's kind of red and modeled.
Yep.
And, and that's the impaired blood flow.
And that's a good way of telling the difference between a bruise and a vo.
A vo. Yep. And modeling almost looks like. Almost like a little cobweb within the skin. Yes. Like it's white, but it also has these red little cobwebs everywhere. Um, so that's, yeah, it's a very important thing to look out for. And if you're getting injected and you happen to like, look at your injector, and they're not looking here, they're looking here, it's because they're, they're checking the entire face for any changes.
You know, if we're injecting a nose, I'm looking at your forehead. If I'm injecting the laugh line, I'm looking at your nose and the forehead at the same time to make sure that nothing is. Is showing any signs
That's, that's a difference. When you're first starting, you're like, your main focus is like, okay, how much product is coming out of my syringe?
You're looking at that, you're kind of assessing, feeling the needle against the periosteum. You're, you know what I mean? You're, you're almost paying attention to other things mm-hmm. Other than the skin, right? And like the color of the skin. But as you get more experience and you get a hang of like, aspiration and all of that, and the feel of like, you know, the viscosity of that filler coming out of the needle, right?
Mm-hmm. Then you start, okay. You're injecting, but you're, I'm looking at the, the tissue rise, like the skin rise as I'm like, I'm, I'm on perio with that lift. Yeah. But then I'm also looking at the surrounding structures. The skin. The skin health. Is it still red? Is it pink? Yeah. Is it, is it blanching? If you see an immediate blanching, that's a red flag.
Mm-hmm. And then you immediately stop injecting, take the needle out, assess cap refill. And then go, you know, go along your checklist. It's checklist. Very similar to
like when you're learning to drive, like you're not just looking in the rear view mirror, you are looking at all your mirrors. You know, you're checking all your surroundings.
Yeah, that's a good way to say that.
You get there eventually. Hey guys, just popping in. If you're enjoying our podcast, please subscribe. And don't forget to follow us on Instagram injector John and Aesthetic nurse goal.
And you know, back to your, and for people that are listening that do skin ve and like I mm-hmm.
And Nicole, I'm the same way. Like I'll do like full face rejuvenation. Mm-hmm. And then I, and that's what I've been doing a lot of is full face rejuvenation, but then also adding on skin ve
Yep. At the end. Yeah. You know? Mm-hmm. And discounting
it a little bit because. Or just giving it to them. Mm-hmm. You know, especially if you're really good with your BDM rep.
Right. Um, and you could package things together. Yeah. But like we always say like, you know, your injectables only look so good as your skin looks so good, right? Mm-hmm. And for those patients getting full face rejuvenation, I really want their skin to look good. So I'll give them skin beef in conjunction with that.
And. You know, there's, I would say for the most part I've been, I've been good. But to add to your point, it makes sense. I mean, you're, you're injecting to periosteum and doing some, um, failure with your cannula depending on whether you're deeper or more superficial. Right. Depending on the fat pads that you wanna regenerate.
Mm-hmm.
Um,
but. Then you're doing skin vive and injecting it into the dermis. So it's almost like you're like sandwiching. Yep. So you're like, okay, is there some compression causing maybe some mm-hmm. Some blanching or is it like a vascular occlusion and Yeah. It's
a lot of, uh, it's, it's a lot of trauma to the area.
And I think, so I had that one by the mouth that I said earlier. Yeah. And then I also had, it was actually an employee. We do employee inject injection days and I did her cheeks. Mm-hmm. And then I went and did another employee, and then I came back and I did her skin V and
yeah.
I did the one side, it was fine.
I went to the other side and then I like looked to the other side. Just to make sure, you know, when you're doing skin ve, you're also like making sure you're not adding too much to one area. Like you're always still kind of looking at both sides. But I looked back and I was like, Ooh. That doesn't look right.
And I had, it was a very, uh, dusky area right in, in the cheek area. You wonder if it
was like the anterior facial vein
maybe. I was thinking that that's a,
that's a big vein. Vein that
right, that comes across, yeah.
Yeah.
And I was thinking like maybe the transverse artery, like it was right underneath her cheekbone it, and it was dusky a little bit purple.
But then as the the time went on, it started to model a little bit.
Okay.
Okay.
So same thing, I just massaged the heck out of it and for her and Right. I would say, and heat. Yep. And then I had her doing aspirin. Yeah. Um, we didn't do any nitro paste. We didn't do any kind of like, uh, any kind of oral medication to mm-hmm.
To increase blood flow. But besides the, the aspirin, but we did the aspirin, the heat, and the, um, gentle massage at home. She would do, and I mean, she was an employee, so I got to see her every day, thank god. Yeah. Beautiful. But, uh, it definitely took, it took about a week to fully, to fully. Kind of heal and clear.
Mm-hmm. Um, but again, no Linux. Nothing like that. And she healed completely fine. No scabbing, anything of that nature. But I think sometimes it's just a lot of trauma to the area too.
I think so too.
And it can be like a congestion or like a a, a spasm of the, of the arteries too.
Yeah. And for those listening, this is your sign.
If you do not have a crash cart, you need a crash cart. Amen. And not a cress cart, meaning someone is vasovagal and doesn't have a heartbeat. It's the aesthetic version Yes. Of a crash cart.
Yes. And, um, we, we had, um, medical art institute, we had, uh, her on the podcast. We could put a little clip of her in here.
She creates a great little crash cart with amazing the booklets and the protocols and all of that already in there. Um, so that's actually the one I purchased and then added. Any medications that I wanted on top of hers, Intuit. Uh, but you should have oral medications. You should have EpiPens, you should have all that good stuff.
Yep. But there's so many things that you might not even think of that will increase blood flow to these areas so that you have a better outcome for your patient,
one of them being Viagra.
Yeah. So, so exciting.
One of my, my new nurse that I just hired at my office, I had her, like, I was having her review the crash cart and she was like, why do you have Viagra in here?
And I said, oh, well wouldn't you like to know? Yeah, right. We have a lot of fun here just to know, but, but really vasodilates, right? Yeah. And um, but to add to your point, like, you know, doing the heat, doing the aspirin, obviously, if you're really, actually truly treating, like stuff that you do in the short term, besides using Linux right away to VAs, like say if you are running out, like say if you've done your Linux, but you're still having delayed cap refill, right?
Mm-hmm. So, and say you're like waiting on a colleague of yours to bring like boxes and boxes of their Linx, right? To your office have nitro pace, put it on the area to vasodilate the area to promote blood flow. Yeah. Um, you know, doing aspirin, doing heat, that's really important. Mm-hmm. Um, after you've done your dissolver right to the area and you finally have resolution of normal cap refill, you bring 'em back the next day, you check their cap refill again.
There's some. Some stories that we've heard of Right. That still there's some like have refilled the next day so you redo more dissolve. Yeah. Once you've had resolution doing, doing a hyperbaric oxygen chamber mm-hmm. Is really important and I, everybody should know where. The closest Hyperbarics is in your area?
Absolutely, yeah. And we have one in our area, um, so we know like where to send them. Mm-hmm. But it's amazing. It's a hundred percent oxygen. It's the number one for burns and like healing wounds. And if you do have a, a vascular occlusion and don't catch it early people will have issues with, you know.
Scarring and scarring and more issues
blistering. All of that. And oozing and stuff. So, and might, that's something
we keep on hand too, is, is wound care. So any, you know, ointments and we have one from like tics because it's supposed to bring oxygen to the area. Right. So there's topicals that you could be doing too.
And again, these are all worst case scenario.
Worst case scenarios. Yeah.
But you wanna have it on hand. Yeah. And like you said, like that hyperbaric chamber is so important. Also, having. People you can refer to. Like obviously we have our medical director that would come in, God forbid anything happened.
Yeah. Um, you know, and you have uh, we have a retinol specialist that retinol retina specialist.
Yeah, yeah. Retina. Yeah, yeah, yeah. Ophthalmologist. Yeah, yeah, yeah, yeah.
That we can refer to like these people are important because at the end of the day, we don't. We don't fully understand the eye and we need someone that does.
So,
and I think, you know, if you are, you know, especially with this field, people are going into nursing now. People are going into medical school. Mm-hmm. To become an aesthetic provider. Okay. There's no formal training in residency and also in nursing school on aesthetics. So if you are a brand new nurse and you are taking.
You're take, you're ballsy enough to just go up and open up your own practice. If you're doing that, you need to take a cadaver course before you open up your practice. You really do. You have to under understand. The structures underneath where you're injecting. Yep. Also, you need to take a complication management course because you need to have that, that crash cart mm-hmm.
Readily available so that way you, you can handle these issues, you know, without sending them out if you, I. Policy enough to just open up your practice without doing that, then you need to have a mentor or someone that you can then send, refer to that page or refer to. Mm-hmm. Or be there for you
or a very much involved medical director.
Yeah. Someone that can, yes. Yep, yep. I'm a firm believer in that things and, and help navigate you through them. Yeah. Yeah. Yeah.
A hundred percent. Because, so important. You really, you really, honestly, if you handle it well, you will not scare your patient. Right. And, and, and you'll leave them with. The confidence knowing my provider knows what to do.
Yeah. This can happen. It's, you know, I sign the consent form, it's, it can happen, right? Yep. But my provider knows what to do.
Well, and that's, again, at the end of the day, Dr. Yoland always, uh, this always stuck with me when he was like, it's only a complication if you didn't explain it beforehand, like a
hundred percent.
You have to make people aware that these are possibilities. And yeah, it's a really hard discussion to tell your patient, your tissue, your tissue could die. You could go blind again. These are all very rare things. Again, we don't do this to scare anyone, it's just that mm-hmm. It's. Potentials or possibilities.
And if you don't explain that beforehand and then it happens, of course they're gonna be pissed.
Oh my God. Of course. Yeah. You know, like
if they, if they go in knowing that this is, it's, it's, um, someone did a video on this recently actually about, um, signed consent versus informed consent. So
do you know an informed consent is I'm Alexis, a cosmetic dermatology pa and I'm gonna let you know there is a huge difference between signing a consent and being informed.
Informed consent is knowing all the risks and benefits of the procedure you're about to get. In addition to knowing any alternative options to achieve the same result.
If you're just handing them a consent form and you're not telling them what's on it and they're not reading it, that's not informed consent.
You have to mm-hmm. Have to be explaining what's on that consent form. Yeah. So we, you know, our patients watch a video, then our MAs explain it, and then we explain it. So it's like it can't be missed, you know? Um, but it's just so important to make sure that you inform your patients because if they know it can happen mm-hmm.
And then it happens, and then you're also very prepared to handle it. Right. Right. It's just that much better of a, of a patient experience.
Now Nicole, I get a lot of dms from even like new injectors, but just in general, like just patients. 'cause I mean Dr. Google, they're on Google 24 7. Mm-hmm. And they're researching things.
But one of the questions I got the other day was, can you get a vascular occlusion from skin Vive?
Mm. Mm-hmm.
Can you
Yes. It's definitely rarer. More rare. Um, yeah. But it's definitely a possibility 'cause it's still hyaluronic acid. Right? It's a very thin version. And like I said, I believe I've had two potentials that.
Have cleared themselves with me managing it, um, but did not require hynix. Uh, but it is, it is definitely a potential because it's still a hyaluronic acid filler mm-hmm. That we're placing into. Again, you're more superficial, so you would think structures aren't there. But again, everyone's anatomy is different, so Yeah.
Absolutely. Still a potential, especially
in that cheek area. Mm-hmm. I mean, obviously of the transverse facial artery, but then you also have the anterior facial vein. Mm-hmm. And think about. The depth of your vessels, right? I always, I the term van. Mm-hmm. So VAN. So vein, artery, nerve veins are closer right to the skin surface, but arteries.
Like they're right underneath.
Yep.
Where that vein is. Right.
They run together.
They run together, but they're a little bit separated. So I always tell patients, I'm like, okay, with skin, at least for me when I'm injecting, I'm thinking, okay, you know, obviously you can bruise them. There's veins more superficial.
Right. Um, off label. I do do skin vive with cannula. I've been doing a lot of cannula lately, especially, Ooh. Smile lines and also doing, um, the supplemental shadow, like
Okay. Yeah. All,
all of those like vertical and diagonal lines mm-hmm. From like stomach sleeping and side sleeping. Right. Like obviously I'll use velo there too.
Like sometimes I'll, I'll, um, um, put velo into a bet insulin syringe. Yeah. And then I'll do that micro drop technique through there. Right. Whatever. And very superficial. And then massage the hell out of it before they go home. But. I'm using a lot of, um, skin Vive, um, and I'm making sure I'm, I'm superficial, I'm in the dermis.
I always tell patients with, um, anytime I use a cannula, I'm using skin Vive. I am kind of doing sub precision with it, so Right. There's a higher chance of bruising mm-hmm. With the patient. Right. So I like to definitely premedicate my patients with arnica, have them taken two days before. I'm like, you know, telling them before a, you know.
Start taking your arm off. Don't get that. Get it on Amazon or go to go to Wegman's or shop. Right. I have no idea what's shop. I passed a couple Shop Rites, but I was down in we're
we are definitely shop. Shop, right? Heavy over here. You are,
but you, you have a Wegmans down there. We
do, yes. Melissa loves Wegman's.
Oh, yep.
I'm a, I'm a whore for Wegmans. I just, I love Wegmans.
I grew up on ShopRite. I can't get, I can't get with Wegmans. No. And
ShopRite is great, but the Wegmans subs are better. I'm sorry. Sorry. Um, but
sorry, that was our off topic. Uh, I'm
sorry. Yeah. But anyway, our, our
squirrel moment.
But, but seriously, if you are listening and you're not utilizing Skin Vive, just try it.
Ask your all that's credible rep person samples. Incredible. And try it. Yeah. It's really, really great. And to use it off label. Mm-hmm. Um, especially like the peri oral lines, those, those vertical lines. Like obviously you can do like Ian Skin Resurfacing or CO2 or Moxie, right? Mm-hmm. If you have Moxie to really help to stimulate the collagen to resurface the skin, that's great.
But, um, skin Bee is a wonderful product. Yeah. Yeah. I think
it's been incredible. And although. Adverse events like occlusions are still possible. It's sure. It's more rare with something like skin div. I would, it is because I would say it's so, it's like water. Yeah. Yeah. It's literally like
water, but still Yeah.
Have that Linux on hand.
Yes, exactly. Um, how about, um, how about, I know a, a big topic is PDGF. Mm-hmm. How about PDGF? Can you get an occlusion with that?
You cannot, you are safe with PDF because you are so pgf bb. Right. Um. You reconstitute it with bacteria static saline and PDGF is, it's just water. It's just water.
It's sa Right? Very, very liquid. It very liquidy.
Yeah.
So you're mixing it with saline. Mm-hmm. So you cannot get avascular occlusion with it, which is wonderful. And it's really great because especially if you're using PDGF in the under eye area. Mm-hmm. Obviously cannula, there's still a small, small risk.
Right. Like a 25% risk. Right. But, um, especially if you're using needle and you're going to bone. There's that chance, you know, the infraorbital frames there or the arteries there. But just to rest, rest assured that you're not gonna be causing an occlusion, right? So you don't have to worry about that. The other thing too, s Sculptra.
Mm-hmm. Sculpture's a big one too. Um, s Sculptra, I use a lot in my practice
and recently that, that post went very viral online.
What post was it? The
girl, the girl that had the sculpture in her temples. Oh, I know. Yeah. Mm-hmm. Yeah.
And I just, it's just, there's such a small, small chance of that chance of it causing it.
Mm-hmm. But like I, and I've done sculpture now for five years and I use it everywhere. I mean, and I'm using it for skin rejuvenation. Mm-hmm. Some violent restoration, but more skin rejuvenation. Um. I'll do needle to periosteum in the temple. Now I'm doing more juven. Voluma. Yeah. Like, you know, just because now that we
have the indication, yeah.
Right? Mm-hmm. It's
instant gratification. It's really restoring volume. But I'm using sculpture more for skin rejuvenation, but I'm still doing it into the hairline too. Mm-hmm. I, I have not run into that yet. Yeah. Of causing a vascular occlusion and my eyes from using it. Maybe they're not reconstituting it enough.
And you have to, or they got the, the foam right? Little, yeah. Yeah, the foam, the little particles. Mm-hmm. Um, and you're, you can't have those particles in the syringe. You really have to shake it. And when, when you're drawing. A sculpture up into the three CC syringes, or five cc, whatever you normally use.
You want to go all the way down to where that cloudy liquid is, and then stop drawing it up once you've reached that foam.
Mm-hmm.
And then always just check your syringe. You want it just to be a cloudy liquid. You don't want it to have any particles.
Yeah, you shouldn't see any big particles in there because those will
clog your needle number one.
Or your cannula, whatever you use. But also, or an
artery.
Or an artery I guess. But I guess in my eyes, if that does happen and you do have delayed cap refill with s sculptra, you need to flood the area with bacterial static saline. Right. Or Right. Try to flush it out. Yeah. And flush it out. Yeah. And, and try to hit that, you know, that, um, the artery that you think that you occluded
right.
And flush it well.
I, um,
and massage. Heat massage. Right?
Heat massage. Yep. And then all the other, like things like Viagra, things that will help. Mm-hmm. You know, nitro past nitro paste. Yeah. Bring, bring blood flow to the area. Um, you just, when I brought up the temple story, so there was a, there was a. Posts online that were very viral of a poor woman that had sculpture into her temples, but it actually affected both temples.
She got an occlusion on both temples. Um, but it just made me think back to a couple years ago, we had a patient receive jawline filler and I mean, he had multiple syringes over months. Sure. Probably, probably almost over a year, but I'm pretty sure it was like 12 or 14 syringes.
Mm-hmm.
And, um, he ended up so.
The injector was not able to get down to bone anymore because there was so much product uhhuh. So, uh, she was aspirating but kind of free floating instead of switching to a cannula, which you had mentioned just before. Cannulas do keep you a little bit safer. It's still possible to penetrate into an artery with a cannula, but much less likely than if you were to be using a needle.
Um, so instead of switching to a cannula, she was kind of free floating with that needle and, and aspirating, but just kind of, you know, crossing your fingers. 'cause when you're not on periosteum, you are kind of. You know, there's nothing to sit on. Uh, but we do believe it was a facial artery that she ended up injecting, um, Voluma into.
And it's crazy.
He called a couple days later and it was modeling, but it was um, kind of following that facial artery, you know, the nasal
labial fold like up. Yep.
And, um, up through the cheek a little bit. And it was all kind of modeled through here. So we had 'em come in. Obviously. Another great thing is a lot of these companies have people they can refer you to too, by the way.
So like obviously we had a surgeon on staff, like we were fine, but we. Always call our MSL, which is your medical assigned liaison. Yeah. Um, and they get you in touch with other like oculoplastics and people like even Leslie Fletcher, like these, there's people out there that can kind of help you navigate these situations as well.
Yeah. Um, but we did a total, I think it was like four or five visits and we did a total of almost 20 vials of Linx. Yeah. Um, nitro paste. We did, uh, he did start to get a little bit of breakdown kind of right through this area. Yeah. So we, we did do, um, like a. Silicone base, like wound gel. Oh, yeah. Uh, he, he did not scar like we were able to clear the whole thing.
But it goes to show that it, it, it's a journey. It's not like you just put Hylan in there and it's done. No, no. You know, we, we had to see him for, I. Days and weeks and, and it took 20 vials of Linx just flooding that area. Yeah. Over multiple days. And
for those of you that don't know, um, Linx, it permeates the arterial wall.
Mm-hmm. So even if you are not actually getting your needle right into that artery. It's still going to permeate through the artery and it will make its way in.
Yep, yep. So you don't have to. Yeah. 'cause there are techniques online that you'll see that, like phishing techniques and stuff where you're aspirating until you see blood and then you're replacing the, um, the Linux, but it technically can permeate through.
So you don't have to, you know, you flood the area and then massage. So, yeah.
So anyone who's listening, so basically, like if you're a brand new injector, if you're opening up your own place right? You don't have a lot of training, which is fine. I mean, like we said. Mm-hmm. There's, there's no, you don't learn this in nursing school.
Right. In a residency. Right. Or in PA school. So you have to,
yeah, you have to seek it. Yep.
Right. Um. Just make sure that you become friends with someone who's more experienced in your area that knows how to deal with complication management. Use them as a mentor, um, and then. Get yourself booked for a complication management course.
Um, go to a conference. Usually at every conference there's like a mm-hmm. Lecture about complication management, right? Yep. Yep. Um, we were fortunate at our Allergan train the trainer just recently for Temple. Like they did a whole, yeah, like it was great. It was amazing. Yeah. Um, so that was great. And that's why we love Allergan so much.
Right.
And they give you protocols Now. That was something that we do a lot of us kind of were asking for too, because you go to these trainings. Yeah. And you know, you're kind of, your early answer is Linx and they're kind like a hundred percent. Oh, well I don't really know what that means, you know? Right.
So it's nice to be able to give them. Other things they can utilize and, and the y Yeah.
Now how many, um, so when you order Linx on on mm-hmm. McKeson or wherever you get it from, we get it from McKesson. Um, one box of Linx has four vials.
Yes. Yep.
Um, right. So like if you're ordering it, if you're new, you're wondering, one box has four vials.
I like to have four to five boxes at all times. Yeah, me too. In my fridge. Um, so around like 20 to 24 vial,
vi. Yep. Mm-hmm. And that's, that's exactly what we do as well. And then we also have. Injector friends close enough where Yeah, it'd be like a 20 minute drive for me, but I, I could call them and I know they would Oh yeah.
They would share their, their stock with me, so that's so important too. Yeah. Community over competition always, because at the end of the day, always you, you'll need them. One day you will trust me.
Yeah. Always remember, like seriously, I always say like competition either brings out the best or the worst in people.
Mm-hmm.
Right. You know what I mean? And you want it to bring out the best in you. Yeah. You know, a hundred percent if you're in it just to be the best and say like, fuck everybody else. Like, no. Yeah. You should not be doing it for that reason. Right. You should be doing it 'cause you love it and you have a passion for it.
Exactly.
Um, but the ones who are succeeding right. Are collaborating. Mm-hmm. Collaborating at the top. Yep. That's what we always say.
No, a hundred percent.
Yeah. Um, oh, one other thing mm-hmm. Is, and you and I both don't carry it in our practice, but a lot of people do. We kind of brought it up earlier, but Radis.
Mm mm-hmm.
Um, obviously great product guys. It's a great product. It's used. Big time in this world. Yep. Um, both with hyper dilute radius meaning, so it's kind of like s sculptra stimulating, um, collagen production, elastin production within the skin, restoring some natural volume loss. Um, but the thing was.
Threes is that there's no really reversal for it. Mm-hmm. Um, which is a little bit scary, um, for me and Nicole and Yeah. And I like to have, you know, right. Products to solvable
agents. Yes. Yeah, exactly.
Yeah. Um, and Nicole, you're saying, what, what is the product that's used to like soften sod, sodium
theos sulfate?
I believe it is. Okay. Yeah. So it does technically have an antidote, but it's only to soften the filler. So if there's like nodules or stuff. They can use that to soften the nodule. Yeah. But it won't, it won't fully dissolve like Hyaluronidase or Linx can do for Right. For ha. Yeah.
Right. And of course, like if you're a very experienced injector watching and you're listening to us, and we are wrong on this, please like, yeah, please let us know.
Let us know. Know, I comment, and you know, a lot of the time
too, people still use Hy Linux on radi DS because it is an HA component. So it's only, I think it's only 30% calcium, so it's not a large component of it that's, that's not dissolvable. Um, and also just flooding with saline if there's a nodule and things like that.
I've heard, I've heard success with that too. So, yeah, again, it's a product that we don't work with, but, uh, there's definitely, it has its place in our, in our field obviously percent. It's a very popular product. It's just very, it, you know, you use sculpture. I don't do sculpture or Radius, um, but. I use, I use Skin Viva a lot for.
For a lot of those things, but
we love it. Um, all right. Well this was a lot of fun. Yes. This is a great episode. Yeah. I hope this was good for people. We get so many dms and questions about a VO versus bruise. I mean, I can't tell you now, you know, in other injectors in the field messaging me, like for advice and things like medical advice.
So, um, we wanted to air this for you guys and to have this be a resource for you. Mm-hmm. So I hope this was helpful.
Yes, absolutely. I know, and I think it's nice when you share your own stories 'cause oh
my God, yes. When it
happens, you're like, oh my God, how, how did that happen to me? But it can happen to any of us, no matter you experience, you feel the worst injector, right?
Yep. It just, you just feel like,
yeah.
Always goes straight to the ego.
It does. It does. And then you're like, oh God, you worry about that person then telling the other person, oh, I went to so such and such place, I got a vascular inclusion. And they're gonna be like, I don't wanna go there. Right, right. You know?
And so it's just, but. It just comes down to how you handle those situations. Mm-hmm. Right? Mm-hmm. Super important. And if you're,
if you're able to care for it and you're able to clear it, and if you're not, do you have the right pathways to set your patient up for success? So a
hundred percent. And the patient feels like they're number one through that whole process,
right?
Yep. That's all that matters. That's all that matters. Yep. And, um, you know, Julie Kaplan is a really good one to follow on this. Love her. Yeah. And she, um, she also did a lecture that I attend. I attended on complications and she said too, you know, apologize, like we are told so often to not apologize 'cause it makes you seem guilty.
Oh yeah. But at the end of the day, you know, this is your patient, it's their face and yeah, it's something that. It, we have no control over, but it's still mm-hmm. You know, we still are sorry that it happened to you. You know? My god. Of
course. Of course. And
that compassion can go a lot further than like, you know, this could have happened, like to anyone.
It's not me a hundred percent. You know? So it's just the way you approach the situation too. Yep. But she's a great one to follow for any kind of complications. Botox complications, filler complications. She's a really good one too, but
she's the real one. Mm-hmm. Julie Kaplan is a real one.
Yeah. Yeah. I love her.
Mm-hmm.
Um, but thank you guys so much for tuning in to another episode of the Fill Me in Pod. Thanks for joining.
Yes. Bye guys.
Bye. See you next time.