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
High-Risk Injection Zones in Aesthetics | Episode 33
In this episode of Fill Me In, Jon and Nicole discuss the high-risk areas of injecting, emphasizing the importance of technique, safety, and advanced training. Learn about the crucial zones where complications like vascular occlusion and tissue necrosis can occur, including the glabella, forehead, nose, and other areas. The hosts also share expert advice on safety protocols, the importance of aspiration, and real-life experiences to help injectors navigate these risky zones with confidence. Join us for an in-depth and educational session that’s perfect for both new and experienced injectors.
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This episode features a Reel from Dr. MJ Rowland-Warmann. Watch the full Reel on her Instagram: https://www.instagram.com/dr_mj_smileworks/
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.
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Producer of Fill Me In: Joseph Ginexi
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Alright guys, welcome back to another episode of the Fill Me In podcast. I'm injector John, and
I'm aesthetic Nurse Nicole.
And we are gonna be talking about high risk danger zones. Mm-hmm. For injecting today, which is a new one. We haven't, well we talked about it a little bit the other episodes, but yeah, we've
done, well, we've done like complication management and stuff, but I feel like we've never really focused on high risk areas.
Yeah.
Um, we both definitely treat some. Considerably high risk areas we do.
And like I treat an area that I feel like is more risky than,
than the area I treat. An area that
you treat and I won't treat your area.
I, and I'll treat your area. I, well, I know, which honestly, like
Nicole, just do it like, I don't know.
I know.
Oh, so we're gonna, we're gonna dive into that today. We're gonna
dive into that. I know it like won't make sense, but I think it will make sense for those listening. Maybe not.
Who else? Yeah. Yeah. I think it's, this one will be more for our injectors, but
Yeah. Yeah. Well, it's so funny too because I feel like, um, obviously we're Allergan trainers and like when we are at trainings, we can't do off-label areas, right?
Right. So. You know, so many people inject the piriform. Mm-hmm. But like we can't in trainings because it's off-label.
Right. Right. You know? Right. Yep.
Um,
but there's so many questions that get asked that, you know, we can't, there's so many questions. Yeah.
Yeah. It's tough.
But that's why this episode will be good.
It'll be so good. Yeah.
We can talk about all those things and then when that happens again, we can be like, please refer to episode. Whatever of the film po.
So, Nicole, like what would you identify or describe as a high risk area?
So, high risk areas are areas that are more likely to have complications. So like a vascular occlusion, which can cause tissue necrosis, which would be tissue death, uh, blindness, things of that nature.
Mm-hmm. Um, a lot of the. Areas that we treat on a day-to-day basis, it can happen. It's just more low risk, you know? Mm-hmm. Our highest risk areas are gonna be like your glabella region, your forehead, nose, laugh lines. Mm-hmm. Um. That's what I would consider high risk. I mean the chin, technically those vessels are so small, they, I guess they are a little bit easier to occlude.
But I would say your highest risk areas are gonna be like forehead, glabella, nose,
and you'd think almost temple, but it's really not actually. Yeah, it's like on the lower. Mm-hmm. Like right on the spectrum. Yeah. Think for high risk,
I think. I think. Definitely it should be considered high risk because of the anatomy in that area.
Mm-hmm. Um, because God forbid if you hit that temporal artery, you're gonna have a major issue. But, um, I feel like now with the training and um mm-hmm. You know. Basically it was FDA approved for use in that area. When you have an area like that, you get more training, more research on it, so it, it, you feel a little bit safer treating it.
Mm-hmm. You know, where other areas, like the nose and forehead, they're not approved areas. So you don't, you don't have that research or, yeah.
Temple's actually like the fifth on the list actually of like high, high risk areas, but basically, and I think too,
it's, it's because probably too, it's easier.
Because it's only too anatomical. You have that true, you know?
Yeah.
Rather than the nose is so many small little vessels. Same thing with like the glabella in the forehead,
and when we say high risk, like meaning for like vascular compromise and stuff, it's just because there's. Underlying vasculature there.
Mm-hmm. Like an artery or something. So you just have to make sure that you're practicing like safer techniques. Right. Right, right. You're aspirating, even if you're at bone, always aspirate. Mm-hmm. Honestly, if you're using a cannula and you're in a danger zone aspirate. Right. You know you wanna sleep at night.
Mm-hmm. And you wanna make sure that your patients are safe at all times. Right. And you wanna make, and what does it
take? Like an extra 10 seconds to aspirate it does not even just do
it. Yeah, yeah. Yeah. And it will save your day. Mm-hmm. If you have like a 20. To 25 patient day.
Mm-hmm.
Something like that happens.
You're gonna have to cancel your next five patients, if not maybe your whole day just to take care of that patient. Exactly. Yeah. Um, but. The area that I actually treat, um, which is high risk, is the glabella. Mm-hmm. Filler, which I think all of us would understand this, like when patients come in and they sometimes wait too long to get Botox, um, and they've already had this like deep crevice in their 11 or, or in their glabella area.
Mm-hmm. You know, Botox will only do so much. It'll help not make it deeper. It might soften it a little bit over time, but sometimes people still see, like, especially when they turn their head like this deep crevice and it just bothers them. Yeah. Or it'll have that patient say, the Botox isn't working.
It's just not working. It's not the Botox. And you're like, Botox isn't a wrinkle eraser. Right. You know, it's. The Botox is doing its job. You can't furrow your brow or make an angry face. Um, but I'll do filler there. But what I do is I use a cannula and I usually make a little poke about literally the center of the forehead, mid, halfway through.
Mm-hmm. Um, and I'll make that little port, and then I'll use a 25 gauge, one and a half inch cannula, and I use Juvederm Velo there just because Velure is so versatile, it draws less water. Um, it, it feels honestly like. This area, it's very, very soft, which is nice. But you have the supra artery and you have the supraorbital artery that's there, and it, so it's a very, it's a higher risk area.
There's a lot of little. Um, ca uh, arteries that stem off of those arteries, right? Mm-hmm. So obviously it is higher risk if you're doing that area. You should be more, um, more experienced, I would say, and definitely have done cadavers and, you know, just, yeah, I have a true understanding
of where those vessels lie.
Yeah, I actually, so. When you said forehead, I thought you meant how, you know how people are treating the dips of the forehead down. Yes. Yes. So some people are actually placing filler right along the, the forehead to kind of round it out. It's, it's huge in, I think like Korea and places like that. In Asia.
Yeah. Asia. Yeah. So like. I don't do that obviously, but I will treat the, the 11 lines. Um, but I do velo or skin Vive actually. Mm-hmm. And I put it into a BD syringe, so like an insulin syringe. And I very, very superficial, like, almost like the fern technique, uh, hit, hit right along each line just to support.
So like, basically I pinch the skin. Look at that. We can really see it on me today.
Oh my gosh. You cracked me up.
I pinch the skin and I see where it's folding, and then I'll go right along and drop it and then mm-hmm. As I pinch, make sure that it supports the tissue, but mm-hmm. My thing there is, if I'm superficial, I don't feel like I'm deep enough to be penetrating an artery there.
But again, technique, advanced training, because you may think you're superficial, but you might not be superficial.
Yeah. You know? Oh, for sure. So it makes like such a big difference though, I will say. Mm-hmm. Like if you end up. Doing glabella filler there? Definitely use, I mean, at least for me, I use a cannula.
I feel safer. I'm aspirating for five seconds even with it. Um, I always say like, in crevices like that, and also like even in the labial mental crease mm-hmm. Down here, underneath, I feel like vessels love a crevice. And they'll sometimes hide there. So sometimes, like, you know, when, if you're listening in and you're an injector, just make sure you're extra cautious and little crevices, because that's where sometimes vessels lie.
Yeah. Um, and you could run into some issues, so just make sure, um, that you aspirate. I, there was one patient that I was doing their, their 11 filler and I was injecting. I went right down and I was, I hadn't even aspirated yet, but I was going down, being very gentle and all of a sudden blood just shot right up.
And I was like, oh, yep. Oh. It was a butt hole clench. Yep, for sure. You know, and I'm like,
oh, you know, and then I'm just slowly, yep. And they're like, is everything okay? You're like, yeah, everything's fine.
Yes. And of course I'm talking to the patient, they're great. Yep, I'm fine. I was just like, okay,
yeah,
perfect.
Like pull it out. We hold pressure and it's so strange. Patient didn't bruise, nothing happened. Wow. I went back, changed my position and I was okay. Yeah. Um, but it definitely scares you, but Oh yeah. You know, especially if the blood is just rushing up a syringe like that, you know, you're in an artery just because of that pressure.
I was say,
that's when, you know, and that has happened to me in a temple before, so that is actually why I don't do a lot of cannula in the temple anymore. I don't either. I do needle to bone. Yeah. I'm like all needle to bone, which again, advanced technique definitely need. Experience there. Yeah. But um, I, same thing, and it was the last pass I had like 0.1 of the filler left and this was when I did, I was, do I usually do velo or Voluma here?
If I'm doing a cannula, I usually do velo or I'll dilute Voluma, which is off label. Yeah. Um. But I had like point, one of it left and I was like, oh, there's like a little divot. I just wanna hit it. I go back in and I just, I, I hit a little like resistance. So I gave a little push and my syringe just started filling crazy with blood, like I didn't even have to aspirate.
Mm-hmm. It just started filling, and again, it was a cannula, it was a 23 gauge cannula. So, yeah. When you, when you're in a vessel, you'll know.
You'll know. Yeah.
Yep.
Yep.
But, uh, the area that I treat that John does not treat, and actually a lot of, there is a lot of controversy around this and there is a viral video right now that I'll see if Joey can throw in here for you guys.
Um, about it. Is the nose filler,
what is going on with this nose? She had a non-surgical rhinoplasty three days ago, and now it's red, hot, swollen, and painful. This is an infection. This could have gone extremely badly. This is an especially risky complication because it's in the so-called danger triangle of the face.
Infections of this area can result in cavernous sinus thrombosis and death, so this must be taken extremely seriously.
Um, and a lot of the times, either it's people that have. A, a hump, you know, or if you wanna lift the tip a little bit more, or I do it in people with, similar to how, if you could point about the glabella lines not going away with Botox.
People that scrunch and have this Yeah. Horizontal line. A lot of the time it's because they're lacking support in the bridge of the nose. So I'll go down to bone and I'll, I'll pop some filler there. Um, same thing. I never do more than 0.3 to 0.4 in a session. I always separate my nose fillers into two sessions, because the more you do, the more chance you have of compression.
Mm-hmm. Mm-hmm. And a compression, um, injury is basically when you put a lot of filler and it's sitting on a vessel, so it's basically blocking the flow. So it's not a true occlusion, but it is because it's, it's occluding that, that blood flow, uh, without being in the vessel. But
yeah.
Um, any who I put it into.
D syringes again, the ins, insulin, syringes and me are best friends. I use them for like, yeah. Every, all my high risk areas too. Mm-hmm. Just because I feel like you, sorry, I just dropped my shoe. Uh, I feel like you, you are a little bit more precise with them. Mm-hmm. And you can also do very small amounts of product.
So like mm-hmm. Point three of product in a big syringe is, it doesn't seem like a lot, but when you put it in BD syringes, you have like six BD syringes to work with, you know? Yes, yes. So, um, I always aspirate in the nose too. Always, always, always. And I start in the bridge. So technically the bridge is gonna be your safest place in the nose because those arteries should be, you know, what should be traveling on each side
right here too, honestly.
Mm-hmm. I will tell you. Mm-hmm. Here, I, I do cannula there.
Okay. Yeah.
I'll make a poke here. Go and I'll just, you go down, come down to there where I am uncomfortable. Mm-hmm. And I think a lot of people are, it's from that hump down Down Yeah. Where I just get really nervous. Yeah. And I, and I'd rather them go to someone like you who does it more frequently.
Yeah. All the time. Yeah. Yeah. And I
think, again, it's, I started with a plastic surgeon and he taught me. Yeah. And I just feel like it's like, it's how you're trained. You know, if you, if you've never done it before, of course you're gonna be terrified. Yeah. You know? Um, but I will say, this is where I do majority of the product.
And then from here down. Very, very small amounts. I'll come. So I'll start up here on the bridge and then I'll come to the tip and I'll do probably about 0.05, so less than 0.1. Right at the tip, I, I enter from the bottom of the tip and I come up in, I drop 0.05 and then I come out and then I'll do very tiny, like little aliquots if, if I need to kind of tracing up onto the bridge.
Got it. Again, more superficial, you're saying?
You're saying central? Central, always central. Yeah. I don't do
any, there's like one patient that she had, um. A rhinoplasty. Now that's something I wanna touch on too. If you've had any kind of surgical procedure on the nose, you're not technically a candidate for nose filler because it's gonna change how the vascularity is and it's already so intertwined there.
If you've had surgery, who knows what it looks like under there. You know, it change the anatomy. It's like getting a
facelift, like when you do filler sculpture on someone who's got a facelift. Yep. You just gotta be careful. Exactly.
You just have to be careful. So I have a patient that has like a surgical like divot here, and I'll do again, very small.
Superficial little blebs kind of right through there. Yeah. Uh, but I never, like I said, put more than like 0.3 to 0.4 in one sitting in a nose, and majority of that is gonna be on the bridge. Good to
know.
Yeah. But you know, that's, uh, cadavers and all of that, and it's just, again, how I was trained. And if you're not trained in it, I, I would not suggest trying it, you know?
Yeah.
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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 call
another like higher risk area, which. Is piriform. Mm-hmm. But I fricking love paraform. Oh God. Like who doesn't love paraform? Oh my God. Such a difference.
Makes such a difference. It makes such a
difference. So with the
midface when you're treating Yep. Um, the cheek, it's just such a difference.
Explain to the people what the piriform area is.
The piriform aperture is literally, if you draw a triangle from that, your na over to your fold, usually where that creases or you smile.
So you like when you smile, you draw a little line, and then it forms a triangle and you draw it up. Right? Mm-hmm. To the corner of the nose, you do a little injection to bone, so to the piriform to bone there, and basically that is the deepest part of the nasal labial fold, right? You start like the oral commissure kind of adjacent to it.
You follow that nasal labial fold up to the corner of the nose. That's literally where the piriform is, and that's where it's deepest, and that's where it accentuates that nasal labial fold. So when before even treating or filling a nasal labial fold, I, we. A lot, you know, and on a uni Nicole too, you treat the piriform aperture and then I'll go up into the anterior medial cheek mm-hmm.
And I'll follow the cheek along and it makes such a huge difference in the midface. Yeah. And a lot of times when you treat the piriform to bone, um, you don't even have to treat the nasal labial fold, right? Mm-hmm. It el lifts it. Sometimes you do. And I'll do like a, an injection kind of midway through the NAS labial fold, and I'll do cannula and I'll.
My cannula just, oh yeah. And I'll go right underneath that, that nose there. Yep.
Yep.
And it's really, really pretty.
Yeah. And you have to be careful there too. So it is high risk because of the fact that the facial artery kind of travels up. It, it basically enters Yeah. Into that area at that top one third, and then it, it travels up and turns into your angular artery.
So yeah, you gotta be careful there too. A lot of people do suggest doing ultrasound prior to, I don't personally, I have an ultrasound machine. Uh, but I just feel like for the amount of times that. It would, it would show something. Yeah. You know, you're already aspirating, you're down to bone, so you're right.
You're as safe as you can be there to begin with. Uh, but if you have the time to use the ultrasound, it never hurts, obviously. And if you have the training, uh, my ultrasound I really use for more of dissolving or I. Like emergency situations, you know? Right. Um, but yeah, the piriform, it's a great injection because actually what happens too over time is we lose bone and everything starts to kind of sink this way.
And that's why we get kind of wide through here too.
It's great to do, um, like I'll do in the right patient, do Voluma there to bone. Mm-hmm. I will do. Um. Velo to bone. Yeah. It really just depends on your anatomy. I the same, yeah. If you're super, super thin, like, you know, more gaunt than you're gonna lose, use something softer.
Mm-hmm. But if you have thicker skin, you know, something like that, that you need to make more of a profound impact than something like Voluma is really beautiful. Yep. Um, and then obviously when you're doing nasal labial folds, I usually use valor. Mm-hmm. Um, deeper, deeper folds like ultra or ultra plus, you know, sometimes I'll use, but yeah, I, I feel like we need to get away.
From like not treating the nasal labial fold. In general, I feel like we went through this whole thing. Oh yeah, definitely. Obviously treat the cause and do the piriform to bone first and do the cheek first.
Right.
And maybe address the under eye before treating the fold. Because a lot of times when you're treating those areas, it does lift it and provide that support and lessen the appearance in nasal labial fold.
Um, that should be your last resort to fill. Yeah. In these labial fold. How many times am I gonna say that word?
Oh my god. No. I wanna see if I can find a picture of me, because I. Have obviously done my nasal labial folds with valor multiple times.
Yeah.
Um, but yeah, here it is. Some people just need it because they have an etched line, like,
oh yeah, yeah.
I,
if I, if I only did those lifting mm-hmm. You know, uh, injection points, that etched line would still be there. And of course when you smile, there's still gonna be something. I mean, this picture's from 10 years ago, but still my forehead. Looks the same now.
I can't with you. Oh my God.
Also, honey,
we gotta Botox it.
No
lips. Look at that.
Uh, crazy.
I'm dissolving my lips next week.
Are you really? Mm-hmm. Starting fresh.
Starting fresh. We love it. Yeah. I'm excited. God, that's great. But yeah, I like you said, we got, we, I think that was social media fear mongering. Like do not treat your laugh lines. Like sometimes you really need to, sometimes you do start and like, yeah, if you only treat here, and especially on someone that's like.
Gaunt or like really heavy in the face. If you only treat here, you are gonna make them look. Mm-hmm. So wide in the lower face.
The other thing I wanna talk about is sculpture. Mm-hmm. A little bit because, um, I love sculpture in the piriform mm-hmm. And the cheek, like I, I. Do this technique, which I know a lot of injectors do, um, where I call the sandwich method.
Mm-hmm. So basically I am placing filler to periosteum, to bone, sorry, not filler. S Sculptra. Mm-hmm. Um, to periosteum to bone, which there's also fibroblast activity on bone. So it's really important to remember to place your sculpture on bone as well, and not just. Subdermal, superficial. Mm-hmm. Or more superficial.
Um, so I'll do a piriform injection with s Sculptra and I'll do probably like 0.05 injections of s Sculptra along the periosteum on the cheek. But then I'll also do more superficial subdermal injections of um. Uh, of sculpture as well. Mm-hmm. And it kind of sandwiches it, so you'll get, you'll get collagen production more superficially, but then also deeper as well.
And it provides such a nice support for the skin and also for the skin to, to, to hold that filler be better too.
Yeah. I was gonna say too, like doing deep with that superficial, you're getting that glow, but then you're also getting that, that support to the tissue that it really genuinely needs, where if you're only subdermal, you might not get that support.
Right.
You know? Yeah. It's nice.
Yeah. It's
better. Yeah. And it's long lasting. It lasts two to three years, which I love. Yes. Um, I think sculpture's a great alternative for patients too, that are so filler obsessed. Mm-hmm. Or they're like chasing, constantly chasing things. Yep. When they come back, they know we're gonna do sculpture today.
Yep. You know, it's gonna give you, um, what you're looking for, but you know, if we keep. Filling. Filling. Filling. We're just gonna end up too puffy. Mm-hmm.
You're gonna look crazy.
Yeah.
Yeah. Sculpture's something we carry now. Yay. Because we brought gab on. Gabs been doing sculpture from like day one, but obviously me and Melissa never really Yeah.
Dabbled in it. So that's something we now offer, and we have our P-D-P-D-G-F training on July 1st, so I'm so excited. So excited. I love that. For you, it,
it's just such, such a game changer. Yeah. Yeah. Bio stimulation along with filler, it's green. Mm-hmm. It
makes
such a difference, especially when harmonica comes.
I'm
excited for that. Oh my god. I know, I know. Um, can't wait. Another high
risk area is tear troughs.
Yes. Yes.
So how do you do tear troughs, Nicole? So
I have a little bit of a. Different technique depending on the person. Mm-hmm. So on someone that I can truly see the groove and I feel like their ligament really isn't too, too tight, I will do a cannula.
But if you have someone that has a really tight groove, you can't really, like, almost me, you can see today. 'cause I have no makeup on. Like, you see how my hollow kind of. Curves, like someone that has a more straight down hollow, I feel more confident using a cannula on someone like me. I, I put it into BD syringes.
Mm-hmm. Sponsor me insulin.
Yep, yep,
yep. Insulin syringes. But I put it into those small insulin BD syringes and I will. Actually chase the ligament right at the like orbital rim. Mm-hmm. Um, and that's a technique that I learned from Dr. Zurich at, at, uh, his injection anatomy that weekend course, uh, years ago.
But it's, the thought behind it is if you're placing the filler directly into the ligament, you're gonna have no migration over time. If you're using a cannula and you're potentially in the muscle every time they blink, every time they animate, it can. Potentially move that product around. And that's why we see that kind of like, I like to call it pooling or like, you see that pools popping issues with lymphatic drainage.
Yeah. Yes. Yeah. Yeah. So if you're, if you're using small amounts and you're getting it targeted directly into the ligament, you technically will have better longevity. It'll, it'll just look better over time. So I would say a lot of the time I am doing that BD technique, unless it's a true, just like straight.
Hollow that I can easily pop into. Yeah.
Yeah. No, I feel the same way. I feel like I love doing under eye filler, but it's just finding that right candidate mm-hmm. Is so important. Yeah. Like I feel like especially in the younger patient, a lot of patients come in that are younger in their late twenties, thirties, and.
They're just not there for filler. Mm-hmm. Or it's more dark circles or thin skin or, but, or you have that more mature patient that just has thin crep skin that wants tightening. And those are great candidates for either P-R-P-P-R-F Easy Gel or PG PDGF. Right. Which is wonderful. Just toe collagen, elastin, and to help tighten that skin.
But I would say. I normally, when I'm doing under eye filler, I'm using a cannula, right? Um, I'm right between the ORL or picis retaining ligament and that zygomatic, zygomatic cutaneous ligament, right? Mm-hmm. Mm-hmm. Um, which, you know, and I'm down to bone deeper injection. Mm-hmm. Never superficial when I'm doing.
Um, under eye filler. Yes. Yes. With cannula. Mm-hmm. Uh, so I'm deeper in the tear trough like I am with PDGF injections. For those of you that are asking and DMing me about the depth of p dgf always deeper. Mm-hmm. Um, and then like you, especially like in the outer mm-hmm. Like lateral orbital rim. Yep. I will put volbella in a beatty insulin syringe, and I'll go to bone.
Mm-hmm. And I'll place little aliquots along that lateral orbital rim, or like you said, even anterior. Yes. Yeah. Into that sweet spot. Mm-hmm. Where sometimes it's needed.
Yeah. You just need that little lift. Yeah. Yeah. Yep. Yep. Yeah. And you said Bel I always use Bel there. I don't, uh, put anything else in the under eye region.
Yeah. I used Restylane Classic and nothing against Restylane Classic. Mm-hmm. Or Restylane Eye. Now I think it's, I, yeah. I like, I
bright or something. I, I like maybe is Yeah, God, they're probably
make laughing at us, the wrestling people. Um, but I like maybe, um. It's nothing against that product. I just prefer Ella.
Yeah. I do feel like when I use Restylane, I did get a little bit more tling. Okay. And I don't know if that was just technique because that I started using Restylane when I first started, so that might've just been user error. Sure. But with Volbella, I feel like I just don't see that as much. I have done skin Vive under the eyes quite a few times actually.
And I do, I do like that too. Um, but I'm excited to start, uh, dabbling with the PDGF under the eye. I think I'm gonna do mine first. Be my own Guinea pig here, let Melissa gap do. It's
just, I mean, do you see mine? Yeah. I mean, yeah. I've only done one session. I needed to do my second. That's so bad. No, they look incredible.
You And it still looks
natural. Oh yeah. Like that's the bigger thing, you know, like, and I feel like that's another thing too, like patients will chase like they want no hollow there. Like that's not normal. We have to have something there, you know?
And I find too, like with my patients that are older, that have bags.
Mm-hmm. But like Crepiness, I find it doesn't cause more puffiness good. Especially when you inject deep. Mm-hmm. If you inject superficially. You could have a little bit of puffiness and you can cause some issues with lymphatics. Mm-hmm. So just make sure you're deeper with the PDGF. Are you using
cannula with the PDGF?
Yeah. Still? Yeah. Okay. But just very deep in there.
Yep. Mm-hmm.
Like dragging, dragging on bone basically.
Yeah. Literally when I'm ta once I hit bone, I change that direction. I just up right on bone. Yeah. And, you know, just glides right up. Yep. Um, and then I'm fanning. Mm-hmm. I'm kind of going up right up to here.
Coming back. Fanning. Fanning
Okay.
Fanning. And sometimes if I'm able to come all over, go all the way over.
Okay. Yep.
If not just putting a 30 gauge needle on it mm-hmm. And going right to bone and putting a couple droplets there. Okay, perfect. Yeah. But yeah, I just avoid. Um, the superficial cause of the angiogenesis and the redness, but yeah, honestly, whatever, if you cause a little bit of it, you want it.
Yeah. It's a little bit of downtime. It's not a
bad thing. Yep. I get
it that way. I, yeah, I ended up just fine, so Yeah.
Yeah. You healed fine. It just took longer. Just a little bit longer. Yeah. Yeah. But if you explain that in your consult and. The potential of how long you can take. Yeah. And you guys
can have concealer.
I don't. Oh yeah.
We're allowed to wear makeup. Well, you could. You're allowed to. Technically I'm allowed to.
I'm free will, but I don't want to,
so that's just me. Yeah. You don't wanna wear concealer. I don't blame you.
Yeah. Yep.
So you, als also mentioned the, um, submental crease. Yeah. Uh, definitely that mental crease area.
I think I'd have to go back in my notes, but again, doc, I love Dr. Zurich's course. Like if any injectors out there, I feel like if you're like, if you're like anywhere from like one to three years in, I think that's a really great course to go to because mm-hmm. It's advanced enough. Um, and you still. You still don't know everything.
I mean, obviously we're eight, almost eight years in. We don't know everything either, but I'm just saying it's, it's definitely really good if you're in that like one to three year range. Mm-hmm. But his course, I learned so much in the cadaver aspect and mm-hmm. I think it's like, it's a crazy number. I think it's like 70% of something of people's, um.
Uh, inferior labial artery actually lays in that mental crease instead, instead of, instead of that lower lip. So that's something where just switching to a cannula and popping in right next to the crease and just going right across it, it's gonna keep you and still aspirating because you can,
And I feel like when I'm doing lips and I'm like, you know. I don't know, providing that support of my hand. Mm-hmm. And I'm going, whatever I can sometimes feel. Mm-hmm. That pulsate, like the pulsation from the artery there. So, yeah, no, I know what you mean.
Yeah, so that's why like even with the cannula always aspirate.
Of course. You know, as long as you know how to take care of these things, your patients are always gonna be okay. Oh yeah. It's just, yeah. You know, just there's ways to avoid it. And when it's happened to you, you, you learn those ways, right? Yep. But that's another, that's another area. And then the, the, um.
Submental arteries are kind of like a little bit off from the midline down here. Mm-hmm. And that's why too, when you're using needle, you wanna be very careful there too, because again, not only can you pop into them, but you can also cause that compression too. Yeah.
Just aspirate. Mm-hmm. And always when in doubt aspirate.
Yeah. What would you say the biggest bolus is? That you'll safely you, you feel comfortable doing?
Um, in the temple. Mm-hmm. I do 0.5 ml.
Mm-hmm.
Um, which that is a protocol per Allergan. Yes. Um, but I do, I do 0.5. Mm-hmm. There, um, piriform no more than 0.3.
Okay. That's me too. Yep.
The chin. I've done 0.3.
Okay.
Sorry if that's too much. I know people usually say 0.2. Yeah. In the, yeah. Mine 0.2
in the chin, but, okay. Yeah. And
just some people I'll do 0.3, like today I had someone who I did, I was watching the skin rise. Mm-hmm. And it was like, perfect. And it was 0.3, and then I went over, it was 0.2. Point two, whatever.
Yeah.
Yeah.
Um,
sometimes too, I'll do like a 0.2 and then I'll do like a little Hershey kiss, like just keep injecting on my, on my way out. Yeah.
Which, that is more advanced, I will say. Mm-hmm. Mm-hmm. So make sure you know your anatomy and just. You know. Yeah. He Linux, god forbid. Yep. But I know a moving needle's, a safe needle, they always say, yeah.
Yes. Um, gon angle mandible. Mm-hmm. I usually do point twos back there, the cheeks point twos, and then when I go more lateral. Point 0.1. Yep.
That's how I am too. And sometimes, like all the way back, it's like a 0.05 point. Not even one A 0.1. Yeah. Yeah. In the gonio angle, I'll actually do 0.3. Point two. Point two.
Okay.
Yeah.
Nice.
But yeah, my highest, my highest bolus is the temple Uhhuh. Yeah.
Yeah. Um, a lot of people are scared to inject the, um, gon nal angle or like that, the jawline or posterior, um, mandible just because first off, it's, I know it's so hard to find that gon nal angle sometimes and like, you know, you wanna find just that right angle to pop it and give that nice like sharp little angle there.
Yeah. But whenever I'm teaching. Jaw line back there. I'll do like the, that three, like three or four injections. Mm-hmm. You know, back through here. Like 0.2, 0.2 or 0.3, 0.2, 0.2 0.2. And just follow the, um, the shape, the shape of the jaw. Mm-hmm. But then we'll find that little, um, mandibular notch there and we'll mark that as the danger zone.
We don't do needle to bone there. Mm-hmm. And then, 'cause people are always like, oh, we do that. But then there's like that little mis disconnect here. Right. You miss that. Yep. But you have to use. Do cannula there. Cannula, yep. Yeah, just to harmonize it.
The reason we do cannula in that area is because if you think about how the facial artery comes up through that agonal notch, it's deep.
Yeah. So it's gonna be laying on that bone. And some people, it really will, my God. It's like some people have a notch that is like. Oh my God. Two inches deep. Yeah. But so if you use a cannula and you stay superficial and you just lay, I'm one of those people, are you? Yeah. Yep, yep. Yeah. Mine's so small, but if you, if you stay superficial and lay with a cannula, you're gonna be so much safer because you're not gonna be in the same plane as that, as that artery that, so that's why we do it that way.
The, the bolus is in the back with needle and then switch to cannula.
But just saying if something happens and you think that you cause a vascular occlusion mm-hmm. At the angular artery, right? Mm-hmm. Infra or S mm-hmm. S You can find that little notch Yep. And inject into it. Mm-hmm. So it flows. So it flows right through and will dissolve that clot
because this is gonna be the easiest part of that facial artery to find.
And that facial artery is gonna connect to all of those little branches. Right? Yep. Exactly. And the member two Linux is permeable. So even if you can't find the artery, just flood the areas because it will, it will make its way in. Mm-hmm. It will find its way there. Exactly. Now, unfortunately, if, God forbid, you have a patient that goes blind, which is more common if you're gonna be treating in the forehead and the nose areas, um.
You know, that is typically permanent, unfortunately. Mm-hmm. But the best things that you can do is like vigorous ocular massage. Yeah. Um, so you really wanna, it's like taking your thumb and you are like really pushing back and forth on that eye. Yep. Um, and, and you wanna be doing that for a good amount of time and always have a, a retina specialist that you can refer to.
Um, and if you don't, I would send them. To like an ER and just make sure that they have an ophthalmologist or somebody on call that you can refer to. Uh, but yeah, unfortunately the, the vision is the hardest thing to treat. Yeah. And if it does happen, you might not have resolution of that.
Yeah.
Yeah.
Um, so I think like the biggest, obviously, like if you're listening and or tuning in, the biggest takeaways with this, and we could talk about this like so much more.
Oh yeah. I feel like there's so many different patient situations. Yeah. Everyone, everyone's anatomy is so different and
technically every area is a risky area. It's just that there's more areas that are higher risk, which is what we talked about today.
Exactly. Um. Because of like the blindness and things like that, right?
Mm-hmm. Um, but basically quick action, so like mm-hmm. Just know the signs of the vascular occlusion, right? Yes. Always check cap refill. Mm-hmm. You know, if you have any delayed cap refill. Mm-hmm. That's a, obviously a warning sign. If there's an area that's white or dusky right? Like, doesn't look like it's getting.
Oxygen, then that's a like, obviously a danger area.
Yep.
Um, so just know how to recognize ischemia, which is a lack of oxygen to the area. Um, so if there's any prolonged blanching, just. Start your Linux, stop injecting, evaluate your patient, you know, apply heat, um, or do nitro pace or to have the patient take aspirin and you know, start your own protocol.
I know when Michelle Duran visited, um, Syracuse, she is, um, an injector in Allergan trainer out of I think, Boston. Mm-hmm. Do you know her?
Yes. Love her.
Oh my God. She has. At her practice a um, code called Code Blanche.
Mm-hmm. Okay. Love that. Which I think is so great. So
she just goes, I have a code blanche.
And she'll say, and everybody just stops what they're doing.
Yep. Her
front automatically calls like her next two or three patients to reschedule.
Mm-hmm.
And then they start the whole protocol and each Oh,
that's great.
Each person has their own role in the code blanche. Yeah. Like the hospital, because I think she said like.
A lot of her employees came from the ICU or the er. So they're like, they're just, so, that's how their brains work. It's how their brains work. Yep.
Yep. So that's
kind of cool.
No, I actually love that because that one time I've had a few occlusions in my, my time and all were resolved. No issues, no scars, nothing.
Yeah. But, um. The one time I thought I had one with skin, Vive. 'cause I had done the lips, I did her chin and then I finished with skin Vive in the whole area. And I think I just aggravated, I think it was like a, a spasm rather than an actual occlusion. But I, and I've talked about this on previous episodes.
Yeah. But I, I came out of the room and I said to my assistant, I'm like, I think I have an occlusion in there. And the patient heard me say that out in the hallway. You know, you think you're being quiet, but you're never being quiet. And, uh, when my assistant went back in the room to just give her a heat pack to hold onto it.
Um, and she did a little bit of massage to the area. The patient said to her, she's like, oh my God, do I have an occlusion? Like I heard her say, and she was like, no. Oh my gosh, no. We're just making sure that, you know, it's, you know, we're just taking a look at it. But it's like, you know, if we have code blanche, you're not gonna make them panic, you know?
Right. Yeah. Like using a different term so that your patient doesn't panic. Yeah. Right. Um, I wanna actually too, just a little bonus for some people. Um, talk about what's on my crash cart.
Yep.
Um, great. So definitely aspirin. I give that to anyone that I think may potentially have an issue. Um. We do it for a couple of days, if, if I'm seeing them back.
Mm-hmm. It's something that they're gonna take for a few days. The Nitro bid or the Nitro pace, like you talked about, um, prednisone, because prednisone can be great if they're, if they're also having a lot of inflammation, it can bring that inflammation down or allergic
reaction. Mm-hmm.
Um, 2% Lido without epi.
Um, that can be really good just for comfort. Um, or if you're having to give a lot of Linx, you can mix it into the Linx.
Yep.
Um. Normal saline is same, same thing just to dilute if you need to dilute. And then also normal saline's really good if you used a Kaha product. So like a radius or something like that?
Yeah, you, you know, there are components of those products that are hyaluronic acid, um, but it's not fully hyaluronic acid. So there is evidence showing if you just flood it with saline, it may help. Dilute it and mm-hmm. And move the product along. Um, timolol drops for the eyes, um, that reduces intraocular pressure.
So I do have that in my crash cart. God forbid if someone is experiencing blurriness or blindness. Mm-hmm. You wanna throw those in the eye?
Mm-hmm.
Um, Viagra, we've talked about this before.
Oh yeah. Yep.
It induces vasodilation and Viagra is actually a really important one. Not only if you're suspecting necrosis, but also if you're suspecting any kind of ocular.
Mm-hmm. Um, vision changes because it helps vasodilate the little tiny vessels in the eye. Mm-hmm. And then this, I'm gonna butcher the name of this one, but this is a good one for the eyes too.
Acetazolamide.
Okay. Yeah. Maybe
that, maybe that, maybe I said it right.
I think you said it right. Yeah.
But so that's, um, it causes higher oxygen concentration in the body. Great. So that's gonna help with the permeability and the, um. The pressure as well. And the list goes on and on. Obviously Hy Linnex is on there, EpiPens is on there, but I've just felt like those are some that people might not really know about.
Um, and then obviously wound care, I also have a rebreather bag because that's really important. If you're having an ocular issue as well, the rebreather can help. Um, whatever puts Is it, is it, um. Carbon dioxide, it helps reduce carbon dioxide. It helps again, reduce ocular pressure. Okay. Yeah. So if they're, I think they
talked about that at the train the trainer or something.
Yeah. Yeah.
It's, so it's, you just have them breathe in and out of a paper bag.
Yeah.
That can help too. And then obviously I have, um, hyperbaric chamber. Retina specialists, all those people to refer out to, God forbid, wound care. Yeah. All that. So,
yeah, definitely know, like even if you, it's not like a, a, a vascular occlusion.
Mm-hmm. Just someone who has, like, if you have lasers, someone who just has a bad burn or something like that mm-hmm. You can always refer them to a local hyperbaric, um, yes. Oxygen chamber, um, uh, like office. Mm-hmm. Which is great. So know that, um, have an ophthalmologist and, mm-hmm.
Yeah. Great. And um, always if you suspect anything, always call your rep because especially Allergan, they have MSLs, this medical science liaison.
You can call them and be like, this is what's going on. If they can't help you, there are, um, doctors and nurse practitioners and physician assistants that they actually keep on staff that they can, uh, just hook you up on a phone call. You could FaceTime if they're in your area. Some of them might even come to you.
Yeah. But some of them are even facial. Facial oculoplastic surgeon. So if you're really mm-hmm. Thinking you have a major issue, get right on the phone with your rep. They'll get you in touch, and then they'll get you in touch with somebody like that.
Yeah. And they're great for like your off-label questions too.
Mm-hmm. Stuff that you're, you know, your BDM, you're, you can't answer. Right. You know? Yep.
Yep. Absolutely. Well, good. I love it.
This was a great episode. Yes. I hope you guys enjoyed this. This is very educational. Mm-hmm. And, um, yeah. Love it. Love it.
Yeah. Thanks for listening guys. And if
you're listening and you haven't done a cadaver course, do a cadaver.
Yes.
Okay.
Mm-hmm.
Definitely do it. It's so useful. And, um, every, every face is different, so it's really nice to know your underlying anatomy. Yep. Um, so you know that you're injecting safely and efficacious.
Right. So, yeah, we try to do one at least every year. It's funny. Yeah. Every time you do it, you, you see something different.
You see something different and you learn something different. Yep. And like something else absorbs into your brain. Mm-hmm. Because it's just a lot, like after you do your first, you're gonna be like, oh yeah,
yeah.
It's just overwhelming. How do I memorize all, everything? Right, right, right. And then it's
so funny that it's just like the back of your hand, like, you know?
Yeah. Yep. Left to your fourth or fifth cadaver, you're like, okay.
Yeah. Yes. So funny. All right, well thank you guys for tuning into this week's episode of the Filmy End Podcast. We hope you enjoyed it. Till next time, bye bye.