What are the steps to preparing the skin before aesthetic treatments? How do you ensure that the area is clean via aseptic non touch technique (ASNTT)?
Preparation before injection:
1. Clean skin by removing makeup with micellar wipes thoroughly
2. Open up sterile pack. Spray clinisept onto gauze
3. Wash and dry hands
4. Don sterile gloves
5. Clean face with gauze thoroughly. Let area dry before repeating. Clean face at least 4-5X including underneath jaw
6. Remove gloves and don new sterile gloves before procedure
What is SICP?
SICP stands for standard infection control precautions to prevent infection of the treatment area. This includes:
1. aseptic non-touch technique
2. hand hygiene
3. PPE
Injection techniques
What are the injection techniques to avoid vascular ischemia?
What is important to note with retrograde linear technique?
How do you minimise pain during injections?
Injection techniques
Injection techniques to avoid vascular ischemia:
1. knowing the anatomy of blood vessels. Inject away from supraorbital notch, infraorbital and mental foramina. Inject in deep fat compartment rather than superficial fat compartment due to blood vessels in superficial layer.
2. low volume, low pressure technique
With retrograde linear technique:
-moderate pace to avoid injecting in trajectory of blood vessels
To minimise pain:
-inject slowly
Needle size
Filler type:
What is the ideal needle size for thinner, less viscous fillers?
What is the ideal needle size for thicker, more viscous fillers?
Small vs large bore needle
What are the pros and cons?
Needle size
For thinner, less viscous fillers (low G’ and less cohesive, like Juvederm filler)-> use 30G needle (smaller)
For thicker, more viscous fillers (high G’ and more cohesive like belotero)-> use 27G needle (bigger)
Small vs large bore needle
-small needles reduce risk of tissue damage and conduits for infection whereas large bore needles have higher risk of tissue damage
-smaller needles require high extrusion force compared to large bore needles
-smaller needles have small risk of positive aspiration compared to large needles
Depth of needle
How can you tell if the needle is in the superficial fat or deep fat/periosteal layer?
-sight
-sound of injection
-palpation
-movement of the needle
At what angle should the needle be when targeting these layers:
1. skin
2. superficial fat
3. muscle
4. deep fat/supraperiosteum
At what angle should the needle be when targeting these layers:
1. skin-10-20 degrees; for subcutaneous layer-30 to 45 degrees
2. superficial fat-45 degrees
3. muscle-45 to 90 degrees
4. deep fat/supraperiosteum-close to 90 degrees
Injection techniques
Supraperiosteal bolus
-what are the indications for Supraperiosteal boluses?
-how long do you aspirate for
-what angle should the needle be? How do you know you are at the right angle?
-what kind of filler (G’, cohesivity) is normally used?
-after how many bony points, should you change the needle?
Disadvantages of supraperiosteal technique:
Supraperiosteal boluses can still cause migration of filler in other layers (skin, muscle, superficial fat etc). What are the factors that influence this?
Injection techniques
Supraperiosteal boluses
-angle at 90 degree (layer 4). You should be able to hear a scratch when hitting the bone. Gray of needle should not be seen
-Supraperiosteal boluses are often used in areas with loss of volume and projection
1. temples
2. cheeks and midface
2. mandibular angle, chin
Done with high G’ HA filler (revanesse) and calcium hydroxyapatite (radiesse)
-when injecting, aspirate for 10s first to make sure you are not in a blood vessel before injecting the bolus. Be careful during Supraperiosteal injections as it can cause subperiosteal trauma and haemorrhage. Contact with periosteum can dull the needle-> may need changing. 4 points
Disadvantages of supraperiosteal technique:
Filler can still flow backwards into other layers (retrograde flow). This depends on multiple factors:
-filler flows in path of least resistance. Layers have different densities (fat-loose, muscle-more dense)
-bore of the needle. Large bore needle will have greater likelihood of backflow
-viscoscity of product: less viscous-> more flow
-G’ and cohesivity of product: low G’ and cohesivity (less cross-links and lower conc)-> more flow
Supraperiosteal bolus
-what are the indications for Supraperiosteal boluses?
Serial puncture boluses
-what are the indications for serial puncture boluses?
-how far apart are the boluses?
what is the advantage of small boluses?
Depending on the treatment area:
-what angle should the needle be for skin treatments
-what angle should needle be for deeper areas?
Serial puncture boluses
-small boluses 2-4mm apart; depth depends on how deep you want filler to be
-indications for serial puncture technique:
1. skin boosters (10-20 degrees; intradermal)
2. thin areas like periocular region and hands due to high risk of nodules (30-45 degrees, layer 2 in hands)
3. superficial fine lines and wrinkles (again depends)
-low G’ HA filler can be used; or stimulatory fillers like calcium hydroxyapatite or HA filler
Linear technique
–what angle should the needle be? Which layer are you targeting?
-indications for linear boluses? what type of filler is commonly used?
explain the various subtypes of linear techniques. What are the benefits of these techniques and indications?
1. retrograde vs anterograde
2. cross-hatching
3. fanning technique
Linear
-angle at 35-40 degree (layer 2).
-indications for linear technique: nasolabial folds, marionette lines and vertical lip lines
-HA filler is often used
Subtypes of linear technique seen in photo:
1. retrograde technique- accurate placement of the filler in the direction of the fold/wrinkle. Often used for nasolabial folds, marionette lines and vertical lip lines
anterograde technique-injecting filler when advancing the needle. This avoids injecting into blood vessels. Often used for superficial wrinkles, lines, or folds, such as those in the forehead or around the nose and mouth.
- cross-hatching- injection in a grid pattern. Used to distribute filler more evenly in a broader area such as the cheeks. Avoids lumpiness or uneven distribution.
- fanning technique- similar to cross hatching where it helps to distribute filler more evenly but single entry point. Results in a natural even appearance without lumps. Used in lip augmentation.
Blanching technique:
-what angle should the needle be? (which layer) How do you know you are at the right angle?
-what needle should be used?
-indications for blanching?
-what type of filler is commonly used?
Blanching technique:
-needle should be 10-20 degrees aiming for skin (reticular dermis). You should be able to see the grey of the needle. Blanching of the skin should happen upon injection.
-30G needle is normally used
-indications: to smooth out superficial wrinkles around mouth (perioral), eyes (periocular) , neck and decolletage. Not to be used for volumising effect.
-type of filler: monophasic monodensified filler (juvederm) or monophasic polydensified filler (belotero).
What are the pros and cons of using needles?
What are the pros and cons of using cannulas?
In which scenarios are cannulas preferred?
Cannulas are preferred in these situations:
1. fat transfers
2. using radiesse or sculptra
3. when needed to reach different planes of the face-> mid face restoration
4. when injecting around convex areas-> cheekbones
5. areas that are more vascular due to lower risk of vascular ischemia with cannulas-> nasolabial folds, philtrum, glabella. If patient has had facial plastic surgery like rhinoplasty etc.b
Unpriming a needle
What is unpriming a needle?
Why is it important to unprime a needle?
How do you unprime a needle?
What are the factors that affect the ease of unpriming a needle?
Unpriming a needle
-removal of filler product from a needle
Why is it important to unprime a needle?
-to ensure that you do not get false negatives when pulling back on syringe
-if needle still has HA filler, filler then obscure blood even when needle is in blood vessel-> seems like negative aspirate-> dangerous because it can lead to injection in blood vessel
How do you unprime a needle?
1. removal needle cap
2. expel product until no product seen in needle tip upwards
What are the factors that affect the ease of unpriming a needle?
1. cohesivity and G’ of product-less cohesive and lower G’ products-> easier to expel
2. needle length-> shorter needle-> easier to expel
3. needle size-> bigger size like 27G-> easier to expel
What is the best technique of pulling back the syringe to ensure aspirate?
-slow and steady with maximum negative pressure
Unpriming a needle
Is negative aspiration always reliable?
What does it mean by sensitivity of an aspirate?
-what are the factors that affect sensitivity (no backflow)?
What does it mean by specificity of an aspirate?
-how may you get false positives
Unpriming a needle
Is negative aspiration always reliable?
-do not rely on negative aspirate; you might still be in a blood vessel
What does it mean by sensitivity of an aspirate?
-sensitivity refers to ability to correctly identify that needle is in a blood vessel. However this can be affected by:
1. vessel wall occlusion preventing backflow
2. high G’ and high viscous product preventing backflow
3. small needle blocked by product
4. primed needle
What does it mean by specificity of an aspirate?
-specificity refers to ability to correctly identify that needle is not in a blood vessel. However you may still get false positives (backflow of blood even though needle is not in blood vessel) if there is tissue trauma.
Cannula technique
How do you stabilise the skin during cannula entry?
Needle tenting-what does layer 2 look like when during subcutaneous injection?
What is important to note when changing trajectory of cannula?
How do you avoid nodules with a cannula?
Why are bigger cannulas (22g) preferred to smaller cannulas (30g)?
High risk areas of injection
Which parts of the face should be avoided in new practioners due to risk of embolisation to internal circulation (causing stroke) or CRO?
High risk areas of injection
Which parts of the face are high risk for central retinal artery occlusion? (CRO)
Recall the branches of the opthalmic artery
Order of injection:
What is the correct order of injection?
Top/bottom
medial/lateral
superficial/deep
Deep dermal injections
What is the needle angle for deep dermal injections?
What are the factors that affect the injection angle?
When should you use a shallower angle <45 degrees?
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Basics of Dermal Filler20
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Dermal filler (updated)9
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Complications of dermal filler20
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Pain control in injectables9
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Lip filler19
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Lip flip/botox1
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Injection techniques20
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Regulation of fillers2
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Hand filler and neck filler2
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Calcium hydroxyapatite (Radiesse) and Poly-L-Lactic acid (Sculptra)9
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Cheek filler2
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Gonial angle filler12
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Nasolabial filler3
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Tech neck4
