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 firstname.lastname@example.org
About Dr. Rihani:
Dr. Rihani is considered one of the top injectors in the Dallas Fort Worth area. Specially trained in head and neck surgery, he is a double board certified facial plastic surgeon. His dedication to education is evidenced by performing trainings across the country on injectable fillers and dysport to his peers and lecturing at national conferences.
Original content copyright 2020 by Facial Plastic Surgery Institute, PLLC