CSF 2018 Recap: Tips, Tricks and Pearls Pt. 2

Advanced Level Use for Neurotoxins and Fillers:

• Dr. Suneel Chilukuri treats the horizontal upper lip rhytids with BTX, 1 in columella and 1 inferior to the lateral aspect of the nose on the upper lip just above the line.
• Dr. Corey Maas’ tip to avoid medial brow droop: avoid patients with laxity that need frontalis to keep their eyebrows up. Grab corrugator, stay medial and treat below the brow.
• When do you combine Neurotoxins and Fillers? Dr. Nick Lowe suggests when treating Mentalis dimples, do BTX BEFORE filler, not on the same day.
• Dr. Suneel Chilukuri suggests treating the Depressor labii inferioris with a half unit BTX and injecting the 2 spots below the widest part of the mouth if your patient has a congenital asymmetric mouth.Repeat in 4 days or do each spot all at once.
• Dr. Hema Sundaram likes to dilute BTX 100u with 5cc drawn into 10 syringes and apply small amounts to the whole face to decrease sebum, decrease pore size, decrease sweating and increase turgor.

Jet Volumetric Remodeling with Dr. Daniel Cassuto

• Jet Volumetric Remodeling (JVR) is a needle-free, proprietary technology that simultaneously delivers kinetic energy and a healing compound, enabling a controlled, deep micro-trauma profile effect for dermal remodeling.
• The nanoscopic jet entry to collagen fibers promotes regeneration below the inflammatory threshold. You can deliver any injectable you wish through this device without a needle.
• When you combine this technology with hyaluronic acid, doubling collagen is reproducible. The hyaluronic acid promotes regeneration of lasting and regenerating collagen.
• JVR is more precise than anything you do manually. Many things can be injected this way, including hyaluronic acid fillers. Dilution of HA should be 5-10 times more than a filler as far as the concentration is concerned. You can inject depth from 6 mm to 0.6 mm.
• Useful treatment for striae, acne scars (faster than subcision), stretch marks and burn patients.Reference in Derm Surg 2015.

Fractional Laser Treatments with Dr. Jill Waibel

• Is a non-surgical facelift possible? Dr. Waibel shows a reliable epidermal and dermal microscopical removal case where more than 100 patients were treated 1-2 times with a micro-core needle. The patients showed 5% skin removal with a minimal downtime of 3.8 days. The results were outstanding. The wounds healed without scarring and there was signs of overall improvement and satisfaction.
• You can do fractional surgery for immediate tightening of loose skin! Dr. Waibel showed an impressive under-chin treatment resulting in no scars with 1.5mm punch BXS in a grid. She is working on an automatic device that does the hole punching grid for you.
• When treating burn scars, Dr. Waibel rubs polylactic acid over fractionated treatments. This consists of 6cc water +2cc Lido with Epi dilution.
• Treat patients with the right technologies and choose your tools scientifically!

Using the Fraxel 1927 NM for Treating Melasma with Dr. Nick Lowe

• Pre-Laser Treatment plan:UVA/UVB photo protection daily is a must. He recommends prescription 5% hydroquinone as well as non-prescription products such as niacinamide, licorice extract, antioxidants and retinoids. During the RX program, the patient should take an oral tranexamic 250 mg bid. This is a clot stabilizer, so it’s imperative your patient has a good medical history. The 250 mg is a much lower dose than used elsewhere medically.
• Observe short contact therapy with Cysteamine.
• Take two tablets of Heliocare in the morning about 30 minutes before sun exposure with a full glass of water for benefits to last all day.

Managing Complications with Dr. Daniel Cassuto and Dr. Julie Woodward

• Be cautious of infection. Before you begin injecting, remove makeup well due to sterility issues. If a nurse or assistant transfers fillers into smaller syringes, there can be an increased risk of infection.
• A sharp needle can easily perforate a vessel or nerve. However, a blunt tip cannula cannot easily perforate a blood vessel or nerve. Dr. Cassuto recommends 22g or 23g cannulas over 25g or 27g cannulas for a less traumatic, less flexible and less painful needle. A 27g needle will not show visible bruising when the patient is dismissed from the office, but will show up 48 hours after subcutaneous injection.
• When injecting with a cannula, advance the cannula VERY, VERY SLOWLY and inject only retrograde. Embolism can be caused by reckless, frantic undermining movements!
• Dr. Julie Woodward suggests when dealing with the inferior labial artery, to stay away from the midline. The labial artery is never in vermillion. Stay subcutaneous! Treat vascular occlusion with hyaluronidase injected daily for three days and aspirin.
• Do not inject without having hyaluronidase on hand in office.
• Dr. Woodward says if blindness from fillers occurs, perform a retrobulbar hyaluronidase injection or defer to an oculoplastic surgeon (which should be performed within ~100 minutes.) It should be noted there was some panelists who questioned whether it is helpful to inject retrobulbar or if more harm can be done.

ICYMI: Part 1 featured the latest from the science of living a long healthy life, negotiating contracts, PRP for hair loss, dealing with psoriasis and the bowel and much more!