Speaker 1: 00:11 Okay. So let’s, let’s talk a little about, uh, the different techniques for dermal fillers, dermal filler techniques. There’s, there’s a specific technique that you’re going to use when you’re doing these types of injections. All right, so let’s, let’s go over this a little bit. First of all, we’re going to be practicing this afternoon. So what we’re doing now in practice, you may not have to do when you’re in your own practice. For instance, we may mark the area right now with a surgical pen right ? This is done right now for practicing, right? One of the things that you’re going to do after you’re done with your, after you’re done with your history and physical, you want to have your person sitting upright, okay? What, what do you want to do? Unlike Botox, Botox, you can have your personal lying down. You could have them sitting up.
Speaker 1: 00:48 It doesn’t really matter with fillers, you want to see the area that you’re going to inject. You want to see the defect, okay? The area. If you have your person lying back, gravity is gonna pull the skin back and you’re not going to necessarily see where you want to inject. So pretend she’s sitting down. What do you want to do is if you turn your head like this, okay, can you bring your head up a little? It is, you want to focus, you want to be very, um, very meticulous with what you’re doing. You want to take a close look and you want to see the defect, alright? And you’re coming in close, well, you don’t want to do is you don’t want to push the skin back like this. I see that a lot. You don’t want them lying down because you’re going to, you’re not going to see the fold.
Speaker 1: 01:23 All right? And what we’re doing with these syringes, what we’re doing with the needle is we’re doing threads. It’s called linear thread threading, linear threads. And what you’re doing is you’re advancing your needle and syringe right into the fold, okay? And then you’re laying the product down as you’re pulling out, okay? And that’s called the linear thread. Okay? So the main thing I wanted to show you was was that, and I also just wanted to show you that when you have your person, make sure that they’re sitting upright as opposed to lying down. Cause if they’re lying down it’s, it’s a little bit more difficult to see what you’re doing. All right. Usually what I do, again, this whole procedure is only gonna take you about five minutes. Start with one side. If the product has lidocaine, what’d you do is then you go to the other side while the product is kicking in on this side, you start to work on that side and you do a thread here.
Speaker 1: 02:05 Then you do a thread here. Then you’d go to the other side and then you do a thread here and you keep going back and forth until you’re done. When I usually do is is I use about two thirds of the Syringe, the remaining one third. That’s usually when I stop, I give the patient a mirror, all right. And I have them look and usually they’re going to say, well, maybe can you do a little bit more over here or can you do a little bit more over here? And then I work with them and I finished it up. Don’t give them the mirror right from the beginning because you’re going to be working on this side and you’ll do one thread and they’ll right away. So what about over here? You forgot over here. So do the best you can do, do it the way you think it should be, but leave a little bit left and show them the result.
Speaker 1: 02:41 And then usually they’re going to say, well, can you also work on this area and do a little bit more here? Yeah. Now let me just go over with you. I mentioned this a little bit earlier, how to hold the syringe. The reason why this is important is because this is going to help you with your depth of penetration and it is important at you’re injecting this the correct depth because if you’re too superficial, you’re going to end up with lumpiness and it’s not going to look. It’s not going to look good at all. If you end up to deep, what’s going to happen is nothing necessarily dangerous about it. You’re not going to necessarily have a bad effect. It just, you’re going to waste the product because it’s too deep and you don’t see the result, right? I see a lot of people holding the syringe like this.
Speaker 1: 03:19 Okay, if you hold a syringe like this, chances are you’re going to end up too superficial and just practice that are on your own. You’ll see what I mean. So you’re coming in like this, you’re almost too superficial. All right? If you’ll hold the syringe like this, and I see this a lot, I see a lot of doctors and nurses holding the syringe like this, right? It maybe it’s good for certain other injections, but for this it becomes very, very deep. The injection. So you’re , you’re coming over here, your depth, your angle is just going to be too deep, right? So try not to hold the needle and the syringe like this. The best way to do it is to hold it the traditional way, which is like this and almost by default, if you come in next to the person, you’re almost going to have the correct depth without even knowing it.
Speaker 1: 04:02 Of course, we’re going to, we’re going to practice it. I’m, we’ll look very closely to make sure that your depth is correct, but try to start off the right way by holding the syringe like this. The other thing that you want to do is once you advance your syringe, your needle, you want to tilt the needle back a little bit and you want to look to see the outline of the needle. That’s what you’re looking for, and that’s going to give you an idea of if you’re too deep or if you’re too superficial, is bring back the needle and look. If you see the color, if you’re, or if you see the serial number to that needle, you are way too superficial. Okay, so, so take it out, reposition and try again. If you bring it back and you’re not seeing anything, then you’re too deep.
Speaker 1: 04:37 You do want to see a little bit of an outline of the needle. Okay, so let’s talk a little bit about the different techniques that you can use for lips. How do we inject those? Anybody? Now, obviously that’s why you’re here for the course today, but anybody started doing any of this, you know, injecting lips or had it done or seen it done. It’s really not that difficult. What I’m going to tell you as a couple pearls. I think that that are going to help a lot. One of the things I see when I watch people doing lips is they have a really hard time, you know, grabbing the person’s lip and palpate because it’s so slippery. The technique that we’re going to teach you this afternoon is you don’t even have to hold the lip like that. All right? First of all. You come from the side.
Speaker 1: 05:15 All right? And the idea is you’re going to go around the vermilion border all the way around the side. So you’re coming in from the side and you’re injecting the lips like this. Okay? So just to give you a quick summary and then we’ll go into more detail later. There’s actually three different things that you could do with the lips. Okay? One is you can go completely around the lip border, all right? And that’s, that’s very effective. That’s going to create a nice shape, particularly patients that have very, very thin lips. It’s going to really enhance the border, all right? And their lips are going to stand out and chances are that’s all you need to do. You’re not even, you won’t even need to do anything more if the person has very, very thin lips, you can add volume by going directly beneath that border that we just mentioned and going into the lip and adding a little bit of filler right in there, right?
Speaker 1: 05:59 That’s going to add volume. There’s a third technique that we do a lot and it’s very effective. And what this is going to do is this was going to eat avert , the lip. All right? So what I’ll do for instance in the bottom lip, if, if you were to do it on a botom lip and I could show you here is it’s going to cause this lip to drop down like this, okay? To avert or to plump out a little bit. The way to do that, and we’re going to practice this a little bit, is you’re going to place, you’re going to make your injection along the wet-dry border of the lip, all right? And you’re going to do that very evenly and very smoothly. So you dropped the lip down like this, okay? And you’re injecting right across like this, right along the wet dry border.
Speaker 1: 06:37 Okay? And when you do that, this person is going to, this person is going to do that. Okay? So just like that. Okay. It’s going to avert the lip. Um, that’s really, that’s a quick little, you know, five minutes summary. Obviously we’re going to get in some more detail, but I just wanted to point out, you know, essentially what you’re doing is you’re injecting along the vermilion border is one way as long one way. You don’t have to do all three techniques. Okay? Sometimes you can end up just doing what I, what I mentioned about the vermilion border. The other ways is sometimes if the person wants just a little bit and they just want you to avert their lip, let just do along the wet-dry border. The other thing is important is is you’re the sculptor. You’re the person who’s who’s responsible for the outcome.
Speaker 1: 07:19 And whenever you see patients walking around or people walking around and they, they don’t look natural, it, it’s sometimes it’s because the patient walked into the doctor’s office or whoever and said, you know what? I just want you to work on my upper lip. I don’t think that I really need too much anywhere else. Just put a little bit on the upper lip and that’s fine. Your patient , you could could tell you what they want, right? But it’s important for you to understand that what’s going to create the best aesthetic or the best cosmetic appearance. Right? The bottom lip is typically more plumped than the top lip. The bottom lip should be more plump. Okay? So even though the patients asking for just a top lip, you want to make sure that you can do that, but you want to make sure that the bottom lip is still more plumped than the top lip.
Speaker 1: 07:58 Otherwise you’ve got that unusual appearance where the top is very thick. Okay, so they could tell you what they want and everything, but you need to come back with with their recommendations. Okay, so this is, this is a specific technique for injecting the lips and some, some people call this the push through a technique, right? As you know, with fillers really with a lot of other things, when you make your injection, you typically advance your needle and then you, you lay down a thread of product as you’re pulling out, right? That’s typically the way that you do these types of injections in the nasal labial fold area as called linear threading, and you could do the same thing in the lips. Okay? Where you could advance along the vermilion border. All right? You advance your 30 gauge, half inch needle and then you depress your plunger and you lay the product down as you’re coming out.
Speaker 1: 08:43 That’s called the linear threading technique and that’s fine and you can do that. There is another technique that I like. It’s called the push through technique. And the way this works, it’s, it’s really, it’s really nice when you actually do this is you enter along the side. Okay. Just like you normally do with, with this, you enter on the side and you’re, you’re pressing, you’re depressing your plunger and you’re laying down the product as you’re going forward. And what you’ll see is the product is going to come out and it’s going to, it almost looks like it’s following it’s own path, but it’s not. It’s following the, the canal that’s in the vermilion border and it’s following through that. So what you’re going to see is, is you advance the syringe and needle and you press the product and it fills in ahead of where you’re going, right?
Speaker 1: 09:25 Then you take the needle out and you put a little bit more forward and you press it and it advances through the canal that you’re going into. Okay. And they call it the push through technique. And I like to do that a lot. It’s, it’s very, very effective there. Okay. So we’re here and I’m probably medical training and we’re going to do a demonstration of a dermal filler and we’re going to inject marionette lines. Okay. So there’s a, there’s a very specific technique we’re going to talk about a couple of different things when we actually do the technique. One is, is there a traditional linear threading? Okay? Which we kind of talked about already. And that is when you’re advancing your syringe and your needle and you’re, you’re laying down a thread of product. The other techniques. So the nice thing about demonstrating marionette lines is that you can actually do a couple of different techniques, two or three different techniques.
Speaker 1: 10:06 One is the linear threading, which we do a lot in the nasal labial fold where you advance the needle and, and, and um, syringe forward. You lay your product down and you come out. The other technique is fanning technique. And what you’re doing with that is you just advance your needle and you’re moving the needle like this as you are laying down product. And a lot of these techniques are said you don’t have to do multiple injections and enter the pierce the skin multiple times. You want to be able to pierce the skin once and fan it like this and you’re going to cover a bigger area than just the linear threading. The other technique, which we may or may not do right now depending is cross hatching and what that is is you make your linear thread here and then you come across, take the needle out and you come across that way and it just covers the area, you know a little bit much better.
Speaker 1: 10:52 Actually, I’m going to kind of pass this around a little bit. It comes with a 30 gauge needle, okay? You want to make sure that when you screw on your cap that it’s, you know, you’re screwing it on tight enough. I don’t know if you ever had the, and it happens if you’re not careful where you are screwing the cap, it wasn’t tight enough and then it pops off. Okay? So try to make sure that you screw it up. There’s always a little air bubble in there. It’s not dangerous or anything, but just kind of push that through. But anyway, that’s, that’s pretty much your sort of what your syringe looks like. It almost looks like it just air in there, but that’s your product. It’s a viscous hydronic acid. Okay. So what we’re gonna do is we’re going to just work a little bit.
Speaker 1: 11:32 We’re not going to, it just going to, we’re looking for a subtle change and just for the demonstration purposes right now we’re not going to overly, you know, overly do too much. So we’re gonna just inject a little bit right over here and right over here. All right. The corners of the mouth. It’s a nice technique because it does a couple of things. It fills in that area. It could also bring that up a little bit. What’s the other technique that you could use if you inject? I’ll give you hand. You injecting the, the DAO muscle, the depressor anguli oris right. And that’s a, you’re injecting botox here and that brings the corner of the mouth up just a little bit. So if you use that in conjunction with this, yes, you get a very, very nice result. Okay. First thing you do is try and make this area nice and clean. Okay? Okay, good. Let’s do this side over here.
Speaker 2: 12:18 Good.
Speaker 1: 12:20 The only thing when you were injecting lips, this is not quite lips, but it’s close to it. You’re going to see that the patient’s, you know, asking for water and licking her lips because it’s very, very hydrophilic. These products and they’re, and they’re drawing water molecules in right from right from around the area. So it’s going to dry that area, which has, you know, it’s not a problem or anything, it’s just that’s what it does. Okay. Always have your gauze right, right next to you. Cause this way in case it bleeds a little bit, you know, you just dab it. Worst thing in aesthetics is you don’t want any blood dripping on the patient or anything like that. It messes up their clothing and it’s a little sloppy too. Okay. So can everybody see, okay, so let’s start over here and try to, when you come in, you’re coming in from the side.
Speaker 1: 13:01 Don’t approach them with the needle and syringe. You don’t want them to see that. Try to work from the side and then you come in and you talk to them like this and the syringe and needle are over here. All right. And then you let them know. So what I’m gonna do is I’m just gonna inject right over here a little bit. There’s also lidocaine in this product too. So, and then what I’ll do is as the lidocaine is kicking in and I’ll go to this side and work on that, and then I like to go back and forth. It takes, you know, kill some time you talked to a person, makes it feel a little more comfortable. Okay. So just a little stick, right? Debra, you had a little more? Yeah, that’s it. Perfect. Everybody’s watching. Okay. There we go. Is that okay? Hopefully not to too much. And then just nice and slow.
Speaker 2: 13:44 There we go.
Speaker 1: 13:47 Take your time. Okay. Now the fanning technique is where you’re coming in like this and you’re just turning the syringe.
Speaker 2: 13:57 Okay.
Speaker 1: 13:57 Just like what we’re doing right now as you pull out..there you go. Open your mouth for a second.
Speaker 2: 14:04 Perfect.
Speaker 1: 14:07 That’s it. That’s it. And then you could see a little bit already. I didn’t do very much. I only did about 0.1. Okay. But you could already see you see that plumped out. Don’t get too, you know, too aggressive. Don’t put too much in there. Just a little bit. People typically want to have a natural look. All right? So that’s the better look, the natural look. All right, so let’s do a little bit more. All right. We’re going to do linear threading and we’re going to do the fanning technique. So since the idea is you want to get it here, you enter a little bit lower. So let’s enter right here. And she’s definitely a good patient because she’s not moving around or anything and everybody’s looking. They can see that that fanning technique, right? Good.
Speaker 2: 14:54 Yeah,
Speaker 1: 14:54 come on up. Good. Nice. Look at that, you guys. Can you zoom in on that? Okay. She did not need much at all there. I want to go to the other side. That may be all she needs. Open your mouth for a seconds and always check. You know, sometimes it comes if you’re not careful, will come through on the other side, which is okay. You just want to make sure that you’re molding and palpating around. She’s not even bleeding much at all. Okay, so now let me work on this side a little bit here and then when I’m about two thirds done with the procedure, that’s when I’m going to give her a mirror and I’m going to have her look and then she’s going to say, well, maybe you forgot to do this area over here here so kind of point out. Okay, so now turn your head a little bit this way. No, we go and always kind of figure out a way to to brace your hands are in there. We talked about that yesterday except don’t, don’t brace your hand. I always see people burying the, the tip of their finger in the top of their nose and making them comfortable. You know? So just like this through nice and comfortable. We go little poke right there.
Speaker 1: 15:58 There’s, yeah, there’s local anesthetic. There’s lidocaine in here. So the local, the nerve block we were talking about is with a is when you’re doing lips.
Speaker 2: 16:06 Okay.
Speaker 1: 16:09 Okay. And then we stopped opening mouth for a second. The idea here is you’re not molding it around you just gently palpating to make sure that it’s smooth, that you’ve covered the area nicely. Okay. That’s really all you want to do here. So now I’m going to go and again a little bit more. Yeah. Uh Huh. Exactly. So let me, let me fan a little bit more here. You’re also, you’re also looking at the plunger to see and make sure that the product is coming out and how much and how fast it is. When people ask me to, what’s the dosage? It’s visual, you know, it’s not 0.2 CC’s or three milligrams. It’s, it’s what you see as the dosage. There you go, that’s coming out ice. n
Speaker 1: 16:58 Yeah, that’s coming out really good. Okay. Open your mouth again for a second. Yeah, that’s nice. And then remember we talked about earlier when you explain to your patient, you know this, this is a very hydrophilic products. What’s going to happen is you’re going to feel this product here for a couple of weeks. Eventually it’s going to, you’re not going to feel it and you’re probably going to think, hey, I thought the doctor said that probably was going to last, you know, six months. I don’t feel it anymore. It’s been replaced with water molecules. That’s how this works. It draws in water molecules and that’s mainly the effect that you’re getting to filling effect. It’s from the water. So you’ll feel this for a couple of couple of weeks at least. And even myself, I had this recently, I could still feel it, um, but much less than when I had it about a month ago. Okay. That said. So I’m just going to keep doing a little bit more here alright and then I’ll go back to the other side as long as you guys are following along,
Speaker 2: 17:59 There we go. Perfect. Let’s go to this side here. Good.
Speaker 1: 18:10 Usually deep , by the way, deep marionette lines, you know, you can end up using two juvederm ultra pluses. Okay. This is prevail silk. This is a little bit of a less viscous, you know, layman’s way of saying it would be thinner product, but that’s a less viscous product. On something like this, I would normally like to use the juvederm ultra. Plus it’s thicker. It’s going to fill it better. You know, here we might have to use two or three syringes, but normally I would probably use one juvederm ultra plus for both sides.
Speaker 2: 18:53 Yeah. That’s really about it though. Good, good, good. That’s coming out really nice. Okay. Open your mouth again. Yup. Perfect. That’s really is. That’s really all there is to it. Okay. Let me go back and in here just any questions or anything. What do you guys think so far? We’re going to be practicing this right now. I said it is immediate.
Speaker 1: 19:20 Yeah, that’s really true. I mean, botox is a great procedure to do, but you know, you don’t get to see the third, the patient’s reaction right away. You got to wait a little bit. This is so immediate. They’re usually very, very happy happy up there.
Speaker 2: 19:35 How’s the pain?
Speaker 1: 19:36 Pretty good. Pretty good. Oh, you mean for her? I thought you meant. Yeah. Yeah. She’s uh, she’s, she’s actually, she seems to be tolerating it pretty well. It’s, it’s a little uncomfortable. How do you feel?
Speaker 3: 19:46 How’s it feel? You can feel the initial stick and then you feel it. Plumping, which is a bit of an odd sensation, but at this point that the whole, this whole, like the corner area of my mouth is totally numb.
Speaker 2: 20:01 This has lidocaine in there. [inaudible] can’t feel my mouth. Oh, I did touch the face. Okay.
Speaker 1: 20:11 Okay. I’m going to keep going here. You guys can do a little bit more.
Speaker 2: 20:18 There we go.
Speaker 1: 20:23 Every time. When you go next, each side, do you go a little bit lower? Filling up? There’s no rule or anything on that. It’s just, it’s just wherever, wherever you’d see that you can use a little bit of product.
Speaker 2: 20:38 Okay. Now let me see where I want to put the remaining amount. Can you turn your head a little bit? Okay. Now the other way. Alright. I think I’m going to go right. I’m going to go right over here this little bit. I’m gonna put right here. There we go. Okay, good. Now, let me just put some alcohol there and then you are good. And try to clean them up. Nice. You know, before they look in the mirror and make sure they’re not, they’re not leaving your office with any blood or anything. Did you have any makeup on? I guess I took it all off. Okay. How soon can she appliy a makeup product? Um, there’s, there’s no specific number, but as soon after, you know, as long as there’s no blood or bleeding or anything like that.