PRE-READING COURSE MATERIAL FOUNDATION BOTOX AND DERMAL FILLERS - Module 3 - Acquisition Aesthetics
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PRE- READING COURSE MATERIAL
FOUNDATION BOTOX® AND
DERMAL FILLERS
Module 3
Dear Acquisition Aesthetics delegate,
These pre-reading documents form the lectures you will attend on the day of training.
As a CPD certified course based on theoretical knowledge, we ask that you review all
the material prior to the course date.
Please feel free to print the pre-reading modules to annotate on the day.
You will be provided with an abbreviated practical guide for your review on the
training day.
We look forward to seeing you soon and happy reading!
Yours sincerely,
Acquisition Aesthetics
2
Dermal Fillers
Treatment:
Foundation
Techniques
3
Overview
• Introduction
• The pharmacology of dermal fillers
• Specific indications / uses - Foundation and advanced
techniques
• The aesthetic benefit of dermal fillers
• Methods of administration, storage and aftercare
• Injection techniques (linear threading, serial puncture, bolus,
fanning, cross-hatch)
• Cheek augmentation
• Treatment of the nasolabial folds
• Treatment of marionette lines
• Lip augmentation
• Cautions and contra-indications
• Adverse effects
• The market - Key manufacturers and products
4
Dermal fillers - Introduction
• Injectable materials
• Treat wrinkles and deficits in
facial volume
• Mitigate signs of ageing
• Mostly Hyaluronic Acid (HA)
based
• Transformed the cosmetic
industry
• Quick, reliable and long-
lasting cosmetic enhancement
• Minimal downtime and
minimal invasiveness
5
Dermal fillers - Core principles
The pharmacology of dermal fillers
• Hyaluronic Acid (HA) is a naturally occurring component of human soft tissue
• No need for allergy testing prior to treatment
• HA has a high affinity for water
• The HA is stabilised in a carrier gel
• Behaviour defined by cross-linking technology, particle size, HA concentration etc
• Most contain Lidocaine
• Allows for incremental administration
• Temporary (longevity 6-24 months)
6
Dermal fillers - Core principles
The pharmacology of dermal fillers
HA solution HA gel
Crosslinked (BDDE)
7
Dermal fillers - Core principles
Desirable qualities of a dermal
filler:
✓ Minimal potential for adverse
reactions
✓ Non-immunogenic
✓ Predictable
✓ Durable
✓ Easy to use
✓ Reversible
8
Dermal fillers - Core principles
‘Rheology’ describes the resistance to permanent deformation of a
substance or its elasticity. This can be expressed in terms of G’
• Low G’ – low resistance to permanent deformation (softer, more fluid-like)
• High G’ – high resistance to permanent deformation (firmer, more gel-like)
Products with a
higher G’ have a
greater LIFTING
capacity
9
Dermal fillers - The Aesthetic benefits
The Aesthetic benefits of dermal fillers
• Volume enhancement
• Wrinkle reduction
• Contour / sculpt
• Rehydrate
• Restore and refine
• Smoothen and soften surface appearance
and texture
These products provide instant enhancement
and the changes can be as subtle or dramatic as
the client desires
A – Nasolabial folds F – Deep glabellar lines
B – Marionette lines G – Temporal hollows
C – Vertical lip lines H – Cheek augmentation
D – Chin wrinkles I – Orbital rim
E – Lip augmentation J – Nose augmentation
10Dermal fillers - Indications
Specific indications / uses
• Reducing wrinkles
• Correcting deep nasolabial folds and
marionette lines
• Lip definition
• Correcting age related volume loss in the
cheeks and chin, for example
• Correcting volume loss in the younger
patient e.g. tear troughs
• Enhancing facial contours
• Firming the skin e.g. hand rejuvenation
• Non surgical rhinoplasty
11Dermal fillers - Which course?
Specific indications / uses
Advanced course in Botox and
Today’s foundation course
dermal Fillers
• Reducing wrinkles • Temple hollows
• Correcting nasolabial folds • Facial contouring (cheekbone
and marionette lines formation / jawline)
• Basic lip augmentation • Chin augmentation
• Cheek augmentation • Advanced lip techniques
• Use of microcannula
• Needle techniques • Skin rejuvenation
• Hand rejuvenation
• Combination treatments
• Further management of
complications
12Dermal fillers – Advanced applications
13Dermal fillers - Paradigm shift
Note:
• Paradigm shift away from traditional
techniques towards more advanced
applications
• Practitioners are moving away from
volume replacement in the lower face
• Ever increasing popularity of
revolumisation to the midface to create
a more natural and long lasting result
• Introduction of the microcannula
technique
• Novel techniques in jawline reshaping and
chin remodelling
14Dermal fillers - Methods of administration, storage
and aftercare
• Dermal fillers supplied in pre-filled disposable glass syringes with a luter-lock
fitting
• Needles for deposition contained within the pack (2+)
• Product label is contained within the box / on syringe (exp. date, batch no.)
• The filler should appear as a clear gel and be free of particulate
• Store at room temperature (up to 25 degrees C)
• Protect from sunlight
• Do not freeze
• Do not use if evidence of damage / tampering
Single patient use only!
*Guidance relates to Galderma’s Restylane range of dermal filler
15Dermal fillers - Treatment process
• Positioning and lighting
• (Pre-treatment photographs)
• Cleanse the face free of makeup and
decontaminate with alcohol or other antiseptic
solution
• Apply topical anaesthetic (EMLA, LMX4)
• Wipe off the anaesthetic
• Prep and prime the needle / syringe
• Administer treatment to the areas of concern
• Treat bleeding points as they occur
• Massage
• Rest breaks as needed
• Post-treatment instructions
• (Post-treatment photographs)
• Aftercare
16Dermal fillers - Technique
Essential to deposit filler at the correct depth and in
the correct volume.
• Too deep - unnoticeable/ disappointing results
• Too superficial - undesirable lumps, discolouration
or granuloma formation
• Depth of administration determined by
angulation of insertion
• Aspirate prior to injecting any filler
• As a general rule, you should be able to visualise
the outline of the needle under the skin but not
its grey colour
17Dermal fillers - Technique
Injection technique
Techniques of delivery vary depending on the indication, site, product and experience
and preference of the injector.
Techniques include:
• Linear threading • Cross-hatching
• Serial puncture • Depot
• Fanning
Linear threading Serial puncture Fanning Cross-hatching
18Dermal fillers - Linear retrograde threading
• Commonly used technique
• Measure a needle length from where
you want to deposit the product to
determine insertion site
• The product is deposited in a linear
fashion as the needle is steadily
withdrawn
• Stop injecting when the needle has
been retracted 2/3rds length
• Massage to encourage continuous
‘sausage-like’ formation e.g.
nasolabial folds / vermillion border
19The linear threading method
20Dermal fillers – Serial puncture / micro-droplet
• Deeper deposition of droplets of
product with serial injections
along a wrinkle
• Sequential beads of product are
deposited individually along the
line / depression being treated
at the appropriate depth
• Massage along the treated area
to spread the product evenly and
create a smooth result
• This technique may be used to
correct fine wrinkles such as
glabella creases / peri-oral lines
21Serial puncture technique
22Dermal fillers - Fanning
• A series of small linear threads is
deposited by advancing and withdrawing
the needle back and forth to treat the
area of concern
• The product is deposited as the needle is
withdrawn
• When 2/3rds length needle has been
retracted, stop injecting, re-orientate the
needle and advance to treat the adjacent
area
• Commonly used in the upper aspect of
the nasolabial folds
23Dermal fillers – Cross-hatching
• 2 or more parallel linear threads
of product are administered
• Repeated threads of product
running 90 degrees to original
lines
• Creates a weaving effect
• Provides robust correction
• Used to correct marionette line
volume loss
24Cross hatch technique
25Dermal fillers – Bolus
Cross hatch technique
Bolus technique
• Bolus injections of dermal filler
• Injected at discrete sites
• Typically used for deep supra-periosteal
injections (e.g. cheek / chin augmentation)
• Inject slowly (boluses of varying volume
depending on treatment indication / zone)
• Remember – periosteum is innervated!
• Generally deep to vital structures
• Always aspirate prior to injecting
• Avoid blunting the needle
26Cross hatch technique
27Dermal fillers - Microcannula
The microcannula is a blunt tipped tube
with the same diameter as a traditional
needle for insertion into tissues.
Techniques using the microcannula
technique taught in the advanced Botox
and dermal fillers course include:
• Lip volumising
• Soft augmentation of the facial filling
• Wrinkle reduction
• Plumping cheeks and temple area
• Eliminating saggy skin and bags under
the eye
28Dermal fillers - Microcannula
• Flexible • Reduced downtime
• Accurate • One insertion point
• Less bruising • Wide area covered
• Less swelling
29Dermal fillers - Lip augmentation
Treatment objectives
• Today, a plump and full look to the • Natural fullness
lips is considered attractive and • Well-defined vermilion border and
desirable. cupids bow
• Good projection
• Smooth and soft appearance
• Aesthetic balance between upper
and lower lips 1: 1.6
1
1.6
30Dermal fillers - Lip augmentation
Technique
• ASPIRATE before you inject
• Treat the vermillion border first
(definition)
• Then treat the vermillion body
(volume)
• A range of injection techniques
• Consider U:L volume ratios and R/L
symmetry
• Focus volumisation to middle 2/3rd
upper and middle 1/3rd lower lip
• Be mindful of bruising
• Massage the lips
31Dermal fillers - Lip augmentation
• Definition: Linear retrograde
threading along vermillion border
• Traditional volumising technique:
Linear retrograde threading into
vermillion body (introduce needle
at wet:dry border)
• Other methods of volumising:
Tenting / vectoring, bolus (medial
and lateral tubercles),
microcannula
Product of choice: Restylane Kysse
32Dermal fillers – Cheek augmentation, marking up
Lip augmentation - Technique
Bolus administrations sites: anteromedial cheek; zygomatic
eminence and zygomatic arch
33Dermal fillers – Cheek augmentation
Lip augmentation - Technique
• Deep boluses (0.1 - 0.3mls)
are deposited just
superficial to the periosteum
(zygomatic eminence)
• High viscosity product
• May supplement with
further injections to:
̶ ‘Apple’ of cheek
̶ Zygomatic arch (up
towards hair line)
̶ Can use microcannula
34Dermal fillers – NLFs / marionette lines
• For triangular depressions at upper
limit of NLFs lateral to nares (A):
• Fanning
• +/- deep bolus in piriform fossa
• Linear retrograde threading along
length of NLFs / marionette lines (B) A
• Use bleeding points to define B
subsequent end-point (measure
length of needle)
• Inject mid-deep dermis
• Use mid-viscosity product with some
flexibility (e.g. Restylane Defyne)
35Dermal fillers - Cautions and contra-indications
Contra-indications Cautions
• Allergy • Do not inject into blood vessel
• Allergy to gram-positive bacterial • Inflammatory skin disorders
proteins • History of keloid or hypertrophic
• Allergy to Lidocaine scarring
• Active infection at the proposed • Pregnant women
treatment site • Breast-feeding
• Clients under the age of 18 (product • Patients receiving immunosuppressive
dependent) therapy
• Patients with bleeding disorders or a
tendency to bruise easily
• Anti-coagulation / anti-platelet therapy
• Recent laser treatment, chemical peel or
other therapy that induces an active
dermal response
36Dermal fillers - Complications
37Dermal fillers - Complications
Common side effects Less common adverse effects
• Temporary redness, swelling and • Embolization, thrombosis, ischaemic and
tenderness infarction. Temporary or permanent
• Temporary lumps or bumps visual impairment, blindness, stroke.
• Bruising • Damage to local tissue (discolouration,
soft tissue necrosis, abscess formation,
• Temporary itching granulomatous change and
hypersensitivity)
• Tyndall effect
• Infection
• Late onset nodule formation
Compliance with the contra-indications and cautions to treatment as stated by the
manufacturer will help practitioners avoid adverse reactions. Adequate training is also
vital to ensuring against inappropriate or superficial placement of product, which
accounts for the majority of adverse reactions.
38Dermal fillers - Complications
Visual loss
• Supratrochlear artery
• Infraorbital artery
• Angular artery
39Dermal fillers - Complications
Less common adverse effects
Tissue Ischaemia
40Dermal fillers - Hyalase
Family of injectable enzymes Less common adverse effects
Breakdown HA filler through hydrolysis
Indication: vessel occlusion and necrosis
Assessment of area must be recorded: assess for
blanching, capillary refill time, temperature of area,
pain of client (rated 1-10)
Assessment should be regular and continued with
photographic and written documentation
41Dermal fillers - Hyalase
Draw up 3-10ml of 0.9% saline, water or lidocaine Less common adverse effects
Reconstitute hyalase 1500IU with drawn up
solution
Rotate vial gently to ensure fully dissolved
Inject directly into the occlusion site and 0.5-1cm
around the periphery in a radial manner
Record injection volume and units and continue to
monitor and record for cap refill, colour,
temperature, blanching etc
Repeat if required after 20 minute assessment
42Dermal fillers - The market
Key manufacturers and products
Teoxane - Teosyal
43Biomechanics of the Restylane range
• The world’s first non-animal stabilised hyaluronic acid (HA) filler
• Crosslinker BDDE (1,4 butanediol-diglycidyl-ether) converts into gel form
• 2 unique and complementary technologies: OBT + NASHA
• 20mg/ml Hyaluronic acid
OBT NASHA
‘Optimal Balance Technology’ ‘Non-animal stabilised hyaluronic acid’
Variations in particle size and cross-linking creates gels Uniform natural entanglement of HA strands with
of different textures variations in particle size to create a variety of gel textures
44Dermal fillers - The market
Key manufacturers and products
45Dermal fillers – what to use and where
46Dermal fillers – what to use and where
47Dermal fillers – what to use and where
48Dermal fillers – what to use and where
49Dermal fillers – what to use and where
50Dermal fillers – what to use and where
51Summary
• The pharmacology of dermal fillers
• Specific indications / uses
• The aesthetic benefit of dermal fillers
• Methods of administration, storage and aftercare
• Injection techniques
• Treatment of the nasolabial folds
• Treatment of marionette lines
• Lip augmentation
• Cautions and contra-indications
• Adverse effects
• The market – key manufacturers and products
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