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    Cannula use pearls

    Experts share techniques that achieve great results

    Choosing between a needle or cannula for filler injections is largely a matter of individual preference, said live-injection experts at The Cosmetic Bootcamp (CBC) 2017. For safety and accuracy of filler placement, they chose cannulas for filling the lips, hands and periocular area.

    Lip injections with hyaluronic acid

    “When you’re dealing with a cannula, the key is to get the entrance where you want it,” says Timothy Greco, M.D., F.A.C.S. After performing a nerve block, he explains, “I usually go just a few millimeters lateral to the oral commissure,” first with a needle. He then inserts a 1.5 inch, 27-gauge cannula, tracking along the vermilion border to reach the center of the philtrum. “Then I usually place approximately 0.1 cc of Juvederm Ultra (hyaluronic acid/ HA, Allergan) along the vermilion border.” He also uses Juvederm Ultra Plus (hyaluronic acid/HA with Lidocaine, Allergan) or Restylane Silk (hyaluronic acid/HA with 0.3% Lidocaine, Galderma) for lip injections.

    Passing along the wet-dry border, Dr. Greco next inserts the cannula into the center of the central tubercle and places a similar amount of filler.

    “Then I come back and fill out the rest of the tubercle laterally. There’s absolutely no bruising or bleeding,” he says.

    To reach the philtral arch, he straightens the philtral arch with his opposite non-injecting hand and advances the cannula into it until he can inject at the base of the nose. “Remember, philtral arches shouldn’t be parallel – they should have a delicate convergence to the collumella of the nose.”

    To evert the lip edges, “I insert the cannula into the mucosa, posterior to the orbicularis oris muscle. I’m going to put a little bit there to create a buttress. That will allow the lip to roll out and create more vermilion show.”

    For the lower lip, “I do the same thing,” tracking the cannula along the vermilion border, until its tip extends slightly past the center of the lower lip, then injecting in retrograde fashion. Next, he inserts the cannula tip to the lower-lip tubercle.

    “If you take the lower lip and divide it in half, then take that half and divide it into thirds, usually that middle third is where the tubercle is. That’s also where the depressor labii inferioris inserts.”

    Injecting a small aliquot of product here shapes the lower lip, Dr. Greco says. Lastly, he injects a small amount of product behind the lower lip mucosa to slightly evert the lower lip. Both submucosal injections of the upper and lower lip are done in front of the frenulum of the lip.

    Hands with calcium hydroxylapatite

    Mary P. Lupo, M.D., says she uses Radiesse (calcium hydroxylapatite/CaHA, Merz) off-label in the hands. “I hyper-blend with an equal amount of lidocaine with epinephrine” to achieve slight vasoconstriction, she says. She is a New Orleans-based dermatologist, clinical professor of dermatology at Tulane University School of Medicine and a CBC cofounder.

    “I use a 25-gauge, 2-inch cannula,” she says. With the patient properly positioned, she lifts the hand up and injects between veins, which she has located using the AccuVein device (AccuVein Inc.). From one injection point at the central dorsal wrist, she employs a fanning technique, extending with the cannula toward the first knuckle of each finger, ultimately encompassing the entire dorsum of the hand.

    In the pivotal trial of CaHA for hands, Dr. Lupo says, investigators used three or four Radiesse syringes total per patient.1 In her practice, “I’ve never done more than two at one time — one in each hand. I don’t know if it’s because of the biostimulatory effect or another factor such as the trauma of the cannula — but I don’t find I need large volumes. It keeps the cost down” and avoids a sausage-like appearance.

    After injecting the hands, she typically massages in a topical bruise product such as Cytoactive gel (Eclipse Aesthetics).

    “Then we have the patient sit on her hand to further distribute the material and decrease any swelling,” she says.

    Periocular area with HA

    The patient treated by José Raúl Montes, M.D., requested tear trough injections, but he says her problem was really in the retro orbicularis oculi fat (ROOF) pad. He is a San Juan, Puerto Rico-based oculoplastic surgeon and associate professor, Ophthalmology Department, University of Puerto Rico School of Medicine.

    He chose a cannula to inject this area, he says, because it provides more accurate filler placement with less trauma than a needle.2 Before inserting a needle in the lateral periorbital area to make an opening for a cannula, he located and marked a vein-free zone using the AccuVein device. He also marked the patient’s orbital rim — the superior, medial and lateral canthus —and inferior orbital rim.

    “I’m going to stay in this platform to inject 0.1 cc of Volbella (HA, Allergan),” using his nondominant hand against the orbital rim for guidance, injecting right on the zygomaticus bone near the lateral corner of the eye. He placed several similar injections around the orbital rim, using his index finger as a barrier between the injection point and the eyeball, then gently massaged the filler.

    When injecting the ROOF, he recommends taking a lateral approach with the cannula.

    “Make sure that the ROOF has adequate projection, because you don’t want to flatten that whole area. You want to create some convexities and concavities, and the ROOF injection will give you that,” he says.

    Next he injected Belotero Balance (HA, Merz Aesthetics) above the orbit using a 1-inch 27-gauge cannula. Here, Dr. Montes threads the cannula without disturbing veins into the supraperiosteal area, below the orbicularis muscle.

    “The ideal site for injecting the ROOF is where the highest peak of the eyebrow turns to into the lateral eyebrow,” he says.


    References

    1. Merz Aesthetics. Radiesse injectable implant instructions for use for the dorsum of the hand. 2016. Http://radiesse.com/wp-content/uploads/EM01476-01.pdf. Accessed September 14, 2017.

    2. van Loghem JA, Humzah D, Kerscher M. Cannula versus sharp needle for placement of soft tissue fillers: an observational cadaver study. Aesthet Surg J. 2016 Dec 16. pii: sjw220. [Epub ahead of print]

    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.

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