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The Art of Injecting – Part 3

This three part series is meant as a guide for beginner or intermediate injectors looking for new concepts or interested in advancing their techniques. These concepts apply for injectable fillers as well as with Botox/Dysport. I also invite my patients to review these topics in order that they can be knowledgeable about their treatments. These are concepts that I frequently reference when performing trainings. I perform my own injections of filler and botox in my Southlake and Fort Worth, Texas offices.

The Art of Injecting – Part 3: Draw Attention Upwards (Towards the Eyes)

Avoid the Nasolabial Trap

I blame “FDA approved marketing” for the seemingly incessant obsession over the nasolabial folds and here’s why. When filler companies first began getting FDA approval for fillers, the facial folds – most commonly nasolabial folds – were the first indications to gain approval. As a result, a flood of fillers were now considered safe for this indication, and subsequent FDA approvals allowed rapid influx of products for this same indication. Avoiding legal ramifications of promoting off-label uses of fillers, this FDA approved use of fillers were mass marketed directly to patients.

To this day, we continue to have patients that come in for correction of nasolabial folds as their primary concern. As I tell my patients, it is normal for a baby to have nasolabial folds. What isn’t present on a baby are the hollows above the nasolabial folds from volume loss in the cheeks and mid-face. Therefore, for natural correction, I strive to achieve correction of this volume loss to elevate the nasolabial folds with a tent-pole effect.

 Volumize to Lift, not to Drop

Volume in the lower face should be used sparingly in areas that are gravity dependent and not adherent to bone. This includes areas like the lips and lower cheeks – which can hang lower with weighed down with filler. Areas along the bone can be filled in ways that provide support and use a cantilever-effect to lift areas that need lift.

Over-volumization of the lower face can lead to a monkey appearance if around the mouth or a masculine appearance if it causes squaring of the jaw line. Do not make this mistake! Lift, Don’t Drop!

How can I bring attention to the eyes?

This is my not-so-secret way of keeping things looking natural. I always ask myself this question while injecting, “What is distracting me from the eyes?” I then ask, “Will injecting the distraction make it less distracting or more distracting?”. If the answer is that it will make it more distracting, then you’re probably focusing your attention on the wrong area and may want to consider moving upward to the next closest region and ask that question again.

Inject Safely

This could be its own 3 part series, but the point is always use safe injection techniques or a nice result is useless. Complications can ruin an otherwise nice result. Act fast if there is any evidence of vascular compromise and flush with large amounts of hyaluronidase. If there are issues or questions, feel free to reach out regarding this topic. That’s all I will say on that topic for now.

Well that wraps it up! I hope that this series was helpful for injectors out there. Feel free to let me know what you think or if there is anything you would like to know about the topic!

Happy Injecting!

Jordan Rihani, MD

All original content, copyright 2018 Facial Plastic Surgery Institute, PLLC

The Art of Injecting – Part 2

This three part series is meant as a guide for beginner or intermediate injectors looking for new concepts or interested in advancing their techniques. These concepts apply for injectable fillers as well as with Botox/Dysport. I also invite my patients to review these topics in order that they can be knowledgeable about their treatments. These are concepts that I frequently reference when performing trainings. I perform my own injections of filler and botox in my Southlake and Fort Worth, Texas offices.

The Art of Injecting – Part 2: Know Your Products

Hyaluronic fillers have been FDA approved for treating wrinkles since around 2005. Since that time, the hyaluronic acid filler market has exploded in popularity with companies like Allergan, Galderma, and Merz leading the charge. The demand for new, longer lasting, more natural results has sparked a barrage of newer products with new technologies. The field of filler types has also expanded with different filler types like Poly-L-Lactic Acid and Calcium Hydroxylapatite. Similarly, Botox used to be the only player in the neurotoxin market, but now we are seeing the emergence of Dysport and Xeomin as well.

So what do we make of this rapidly expanding product market as injectors? How do we decipher the good from the bad?

Not All Fillers Are Created Equal

It is important to remember that as an injector, fillers have strengths and weaknesses. Therefore understanding the chemical strength and elasticity of each product on the market is crucial to being a top injector. Concepts of G’, viscosity, and cohesivity are important to understand. Basic knowledge of rheology may be helpful for intermediate and advanced injectors to help further their understanding. Simply put, Voluma and Restylane Lyft, for example, are created for structure and strength – which is great for cheek support, but would not be great for someone desiring a soft lip filler.

These same concepts apply for our neurotoxins – Botox, Dysport, and Xeomin. They may break down to the similar botulinum toxin, but due to purification methods, some patients experience differences in time of onset, total effect, and sensation. I see this often in my patients and is why my office offers all neurotoxins.

An Artist Must Know Which Paintbrush to Use

This metaphor is used by one of my close friends and mentors and I agree that you cannot effectively paint your best picture with a single paintbrush. Understanding which brush you would need for clouds or leaves of a tree or blades of grass allows you to create that perfect picture. If you are trying to use a product for something other than what it was designed for just because you may be more comfortable with it, you probably aren’t getting your best results!

Know the Feel and Pressure of Each Syringe

Since products have different viscoelastic properties, it is natural to understand that the feel of the injection is going to be different. A filler with a higher G’ may be harder to inject through a similar size needle, for example, but the syringe may come with a larger needle to accommodate for that difference. For this reason, I usually take syringes when injecting them for the first time and simply watch the product and the speed and pressure needed to extrude it.

When the needle is under the skin, you cannot really tell the exact amount of filler being used and therefore you need to rely on proprioceptive feedback and experience. So take the time to inject a spare syringe ex-vivo to help yourself. The last thing you would want to do is accidentally inject a large bolus into someones lip and need to deal with the irregularities that would cause.

Explore New Products

This seems obvious, but injectors that have been injecting for some time may not feel the need to step outside of their comfort zone. As a result, you may be missing out on new technologies and products that are more optimally suited for the needs of your patients. With the release of Restylane Refyne and Defyne last year, we were able to experience new flexibility in fillers that had not previously been available. As a result, my patients are experiencing more natural correction of smile lines.

Inject! Inject! Inject!

If you are performing injections, the more you can inject the better! Experience helps to develop feel for products and makes you more comfortable achieving you and your patient’s goals. If you are a beginner, don’t get discouraged, just work up through your comfort zone and rely on those with more experience to help guide you. Working in a busy cosmetic surgery metropolis like DFW, I have the fortune of having plenty of colleagues to bounce off ideas and techniques and even challenging cases.

Thank you for your attention. Be sure to check out Part 1 of the Art of Injecting if you haven’t already. Part 3 will be coming soon.

Any feedback or questions? Feel free to email me at jordan@rihanimd.com

Original content copyright 2018 by Facial Plastic Surgery Institute, PLLC

The Art of Injecting – Part 1

This three part series is meant as a guide for beginner or intermediate injectors looking for new concepts or interested in advancing their techniques. These concepts apply for injectable fillers as well as with Botox/Dysport. I also invite my patients to review these topics in order that they can be knowledgeable about their treatments. These are concepts that I frequently reference when performing trainings. I perform my own injections of filler and botox in my Southlake and Fort Worth, Texas offices.

The Art of Injecting – Part 1: Symmetry over Size

Symmetry over size has been something I recognized early in my injection career and is something I feel is not always emphasized. Always inject for symmetry over volume. Patients come to my office wanting to look “better” not “bigger”. To make them look better we must understand that our eyes are attracted to symmetry – whether we realize it or not. As a trained injector, it is important to be able to recognize lack of symmetry in order that we can correct it.

Step 1: Perform Facial Analysis to recognize symmetry.

This is the most important step. If you do not recognize that one cheek has a volume deficit compared to the other or that it sits slightly lower on the face, then it is impossible to correct it! Take the time to take pictures prior to touching a patient and study/review them.

Step 2: Review treatment goals with your patient, including pointing out asymmetries you are planning on correcting.

Although many patients may not recognize a lack of symmetry between the two sides of their faces, they should be noted prior to starting in order that you can show them where you are planning on using the products. For example “I will be using more product on your right side, in order to even the appearance of the two sides”. This allows them to feel comfortable if you are working more on one side or using more product. This also helps them understand why they may have more swelling on one side after the injections if you had to use more product

Step 3: Fill the deficient side first

In some patients, they may come to me desiring cheek volume. If they have significant flattening of one side compared to the other, it would be a mistake to put equal volume in both cheeks. Clearly this would have done nothing to address the fact that one side is more flat. Instead, you should start injecting filler on the side that needs more volume and correct to the level that the cheek volumes are equal. From that point, you can then add the volume that patient is desiring.

If I am using one syringe for a patient’s cheeks, it is not uncommon for me to inject 2/3 of the syringe in one side and the other 1/3 on the other side. As long as you can achieve that symmetry, the patients will notice the improvement right away.

Step 4: After asymmetry has been corrected, add desired volume

Only after both sides have been “evened” out to the extent possible, do I start adding desired equal volume. This prevents further distortion or more assymetry as a result of starting on the larger side, for example, and using too much product on that side, and then not having enough to catch up on the already deficient side.

Summary:

Patients notice improvements in symmetry, and although not always a drastic change, patients will be happy with their results. As injectors we have the responsibility to make our patients look better – not just add volume because they tell us to! And always remember – Keep It Natural!

Thank you for reading.

Jordan Rihani, MD

copyright 2018, Facial Plastic Surgery Institute, PLLC

Injectable Fillers in Southlake and Fort Worth – What I am using now

Dr. Jordan Rihani provides a recap of some of the current fillers that are out there and what he is currently using in his Ft Worth and Southlake offices. We use a variety of fillers including Juvederm, Restylane, Voluma, Vollure, Restylane Refyne, Restylane Defyne, Belotero, Radiesse, and more. Each patient has an individualized treatment plan and algorithm based on their needs and goals.

Is there a way to make Botox last longer?

 

Injecting Botox or Dysport every three months can be a bit of an inconvenience for some of my patients. So what kind of options do we have and what impacts the length of duration of Botox and Dysport? I inject my own patients in my Fort Worth and Southlake, Texas offices and get asked a number of these questions daily.

  1. Increase the dose – There is evidence that higher dosages of Botox and Dysport can result in longer duration of action. There are trials using twice the dosage which can show duration of action closer to 4-5 months in about 60 percent of patients. This may or may not be worth the added cost.
  2. Metabolism plays a role in duration of Botox/Dysport. For patients that exercise daily and participate in high intensity exercises, neurotoxins may last a shorter period of time. Extreme examples may be 2-3 weeks, but on average in my practice these patients can have a length of duration of around 6 weeks. Decreasing frequency or intensity may not be worth the trade-off, but is considered an option.
  3. Product resistence. This is a real phenomenon that we see in our practice. Patients may become resistant to one product or the other, but the alternative therapy may last longer or be more effective. The reasoning behind this may have to do with the proteins that allow delivery of the botulinum toxin. Trying Dysport if you are showing decreased response to Botox, or vice versa is an option.
  4. Next Generation Botox? There are new products on the horizon, although a year or two out. One promising agent is Daxibotulinumtoxin which may last up to 6 months from preliminary data. Check out our Daxibotulinumtoxin page for more details/updates.
  5. Nerve Destruction. There are methods of permanently cutting or damaging the nerves that travel to the forehead or glabella (corrugators or frown lines). These methods are performed using a radiofrequency probe which can locate and weaken the nerve.

If you have any questions please let me know by emailing me at jordan@rihanimd.com 

-JR

The Botox Browlift

How do you lift the brow with Botox?

This is a common request I receive from patients and is something not all injectors know how to assess properly. I want to outline proper assessment of brow position and how to avoid the much feared brow drop.

Step 1 – Assessment

Whoever is performing your injections should be assessing your brow position with your eyes closed! This is the most important part of the initial Botox/Dysport consultation. If they are not doing this, your chances of having a dropped brow are significantly higher. People naturally lift their brows when their eyes are open. Only when we close our eyes and really relax our forehead can the true brow position be assessed.

If your brow position sits below the rim of the eye socket with your eyes closed, Botox/Dysport should be used very conservatively in the frontalis muscle to prevent brow drop.

 

Brow Position with Eyes Open

 

Eyes Closed, Forehead Relaxed

 

Actual Brow Position (Where brows will fall if frontalis movement is eliminated)

Step 2 – Anatomy

Botox works by weakening muscles. If you weaken the upper forehead (frontalis) muscles, you will not get a brow lift, your brow will drop. The injector actually must weaken the muscles that pull down the brow. These muscles are the muscles BETWEEN the eyebrows (the 11’s, corrugator and procerus muscles) and along the OUTSIDE OF THE EYES (crows feet, orbicularis oculi). This allows decreased pulling of the eyebrows downwards and allows the frontalis muscle to lift the brow.

Step 3 – The Final Result

When the frontalis muscle is able to lift the brow, there is still upper forehead movement and wrinkles present, but the brow is now in a higher position. Again, this is the common misconception and something I educate my patients about. If you eliminate all horizontal forehead wrinkles then you will be dropping your brow down to the natural position of your brow (where it is with your eyes closed and your forehead relaxed).

Step 4 – Less is sometimes more

If you can understand these concepts, then you are steps ahead of many people that receive Botox/Dysport as well as many injectors! As my patients get older, I actually use less Botox in order to preserve a higher brow position.

Step 5 – Find someone you trust

If all this sounds rather confusing, then don’t worry! Find someone experienced that you trust to perform your injections. Preferably someone with a strong background and understanding of the facial anatomy and how it functions.

Lastly, are there surgical options to correct a low brow?

For patients with a low brow, the best correction that can both raise the brow and eliminate forehead wrinkles is a Browlift. This can be done through an endoscopic approach in most cases. Endoscopic browlifts are done through small incisions in the hairline and have minimal downtime. Most swelling and bruising is gone within 1-2 weeks.

Any questions? Don’t hesitate to email me: jordan@rihanimd.com

 

Post Rhinoplasty Expectations

Answering commonly asked questions about rhinoplasty surgery. Do I use nasal packing during surgery? What is the post operative visit like and is it painful?

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