Dr Askari Townshend talks about tissue stimulators
Our body undergoes major changes from birth to old age. Bone remodelling occurs and as we age, we start to resorb more bone than we lay down, so we lose bony volume.
There’s also muscle atrophy —which is important when using toxins—but in terms of revolumisation and biostimulation, it doesn’t play a huge part. However fat atrophy and the redistribution of fat is important, and these three things all contribute to volume loss. When we use hyaluronic acids (HAs) and biostimulators, volume loss is one major factor that we aim to correct. We also have issues with changes in collagen, and elastosis as we age and are exposed to the sun and toxins—I call these dermal changes.
We can address volume loss with temporary fillers, permanent fillers, implants or fat transfer. For the dermal changes there are also many treatments we can offer. Interestingly, tissue stimulators can do both of these things—they can improve volume and improve the dermal thickness. Poly-L-lactic acid Sculptra has been around for many years now; it got its CE mark in 1999 and it’s still used in the NHS now under the name of New-Fill. Another example is Polycaprolactone (PCL) under the brand name Ellansé and Radiesse also.
These types of drugs are promoting neocollagenesis—improving or rebuilding the patient’s own collagen, which is great because it means results will be long lasting. It is versatile, but it does require very good technique because you can’t dissolve away a biostimulator—you need to put it in the right place. If you don’t get the basics right, a year down the line that patient is still going to look unusual.
Hyalase is a very last resort, and I’m proud to say that unless I’m correcting other people’s mistakes I think I’ve probably only ever used it two or three times in the last ten years or so.
Using PLLA or Sculptra it can take 10-12 months to get your full results, but you should see changes within eight weeks.
With Sculptra you get type one collagen, not type three, which is the immediate, more fibrous type of collagen.
These types of biostimulators can give results that last for a long time, and we know that PLLA can give you results for over two years.
Polycaprolactone use was studied over 24 months and 40 patients in a randomised control study. Moers-Carpi et al looked at the two shorter acting Ellansé products S and M, which are a one-year and a two-year product respectively. Results showed that you will still see an improvement after a year, in the one-year product and an improvement after two years in the two-year product.
Cheeks are fundamental. They’re the centre of the face—they hang the face.
Imagine shirts or jackets are hung on those thin wire hangers from the dry cleaner—over time the hanger deforms and the cloth that is hanging over the top wrinkles. I see the same kind of analogy for the face and for the cheeks. Mid-face is like the arms of that hanger, and you need a strong mid-face structure to support the weight of the skin and the other soft tissues.
By restructuring the mid face you’re going to be able to provide lift, to give the face better support, and this is where people look in terms of that quick half a second to decide whether somebody is looking fresh, or they’re looking young or not.
Volume needs to live high, superiorly. We know that age and time is going to pull everything down, so placing volume lower down is counterintuitive because it’s going to get there anyway. I don’t have many straightforward rules but this is one of them: you can draw a line, across the nasal flares and inject the cheeks below this line, in order to increase volume. I need to have a really good reason to go above, and if you haven’t got a really good reason why, just don’t do it. You should always be above that line.
Cheeks, on the surface, might be simple, but I think they’re quite tough because it’s very easy to get them wrong and when you get them wrong your patient might not necessarily know. They may be looking a bit better than they were at the beginning, but somebody who knows what they’re looking at is going to know that something is not quite right. If you keep doing it, few years down the line they will start to get people questioning what they’ve had done.
I think its tricky treating an older patient who has reasonable volume in the mid-face, but the volume is sometimes in the wrong place. I’m not a plastic surgeon and I don’t do fat transfer so when armed with just a needle, it can be difficult to treat. If you over volumise, the results will look unusual. You need to be extremely cautious, and less is always more. You can always put more in at any time.
My first aim would be to recontour and correct the ogee curve—the curve that runs from the lateral flare all the way up the cheekbone. Often we get a break, which happens when the fat that was once sitting higher up, is now sitting lower down if pressed and makes the nasolabial fold look more prominent.
By injecting into the lateral area, we will start to correct the ogee curve. We will get a tent pole effect—in other words, when you put your tent up, as the pole increases in height it gathers the material around it. Creating an anterior projection will mean skin gathers around that, and will help relocate some of the fat that has prolapsed inferiorly.
It’s vital not to be absolutely solid with your plan at the beginning, because things are always going to change and you’ll always be surprised.
It might be that you put in a small amount of product and you get a bigger change than you had expected. It might be that you put in the amount you thought you needed, but actually you need a lot more, and you get to a stage where you think, hang on a second; I’m putting in more and more and more, but I’m not getting the change I want. If that happens please stop. Firstly, you’re wasting the patient’s money, you’re using product with no effect, but secondly, where on earth is the volume going? You may be revolumising an area that really doesn’t want it.
If you look at the proportion of the face, the thirds should be fairly equal. You also need to consider the jowls, which are very tough to treat as they are formed by fat that is relocating. We have elastosis, soft tissues that are becoming more relaxed, and so to treat this you need to repin it—this is where surgical threads can be very useful. You can’t fix jowls with injectables but you can hide them by tricking eyes and playing with shadows and contours. I try to mould the beginning of the jowls into the rest of the jaw line so they look less apparent.
If the mentalis appears as an island surrounded by a moat, the undulation casts shadows and gives the impression of the mentalis being quite separate from everything else. To correct this, you can fill in and smooth out the defect between these two areas. It doesn’t need to be completely confluent but it will create a stronger jaw line with less shadow in the area, and look much better.
Biostimulators like Ellansé, don’t go into the vermillion of the lips, stay well away from that area, and I think you need to give yourself a safety barrier as well. When I’m training I often tell people not to inject into the vermillion, and all of a sudden it turns into a competition of who can inject closest to the vermillion before actually getting into it. There are no prizes for that one. I always mark out a half centimetre or so, because you will get some spread of product.
Approaching the parotid
A lot of people get very worried about the parotid glands. The parotid lies in a deeper plane, with a thick parotid fascia over the top of it. If you’re starting to prang the parotid and inject into it without knowing about it, you need more training.
Other important vessels in the area include the transverse facial artery—which you should watch out for. It’s not a huge artery, but you know it’s going to bleed. If it does, then apply pressure, but if you are kind and gentle with your technique there shouldn’t be a huge amount to worry about here. Remember though to be very aware of the superficial temporal artery—probably your closest really important artery.
Don’t worry too much if, when you do treatments over the parotid area, they don’t look quite right in terms of being completely confluent initially. This is because it’s very near the masseter, and as the patient speaks, chews and sleeps over the next few days it will even out. It’s not an excuse for sending a patient home looking lumpy, of course. You never want to do that. Massage the area as best that you can, and don’t worry if you’ve done that and it’s not quite 100%, because it generally will even out.
Q : What is the risk of vascular compromise with collagen stimulators, and if so how do you manage it?
You are always at risk of vascular compromise. I don’t think is any different from any other product. However the difficulty with Ellansé is it’s quite a thick product, so like Radiesse, you can’t aspirate. I’m a big fan of aspiration, so unless you’re really confident and your technique is spot on, you need to consider using cannulae, because it’s much safer.
Training and using Ellansé has taught me to become much more aware of vascular compromise. Always look for blanching and look and listen for a patient that is in pain as intravascular injection can be quite painful. So if you start getting pain on injection you need to stop.
I always start with a safe injection or something that I think is safe. I say to the patient that is how it should feel, and if feels anything different in the future then please let me know. And then it’s about slow injection. If you are injecting in the wrong place then you aren’t going to dump your entire syringe or a large amount in the wrong place.
In terms of immediate complications, I’m not sure that it’s significantly greater, although of course you don’t have the reassurance of the flashback, so that’s important. In terms of later, I don’t think there are any. No one has ever described a big build up of collagen, which is then going to impinge on a vessel, I don’t think that’s possible.
Q: If you suspect necrosis how do you manage this?
With this product I inject slowly and I only ever inject aliquots of 0.2 mls, maximum, in one go in one place, so all of these things mean that if you were to have something terrible happen, your chance of it then turning into something really bad is much less.
If even despite all of that, somehow you’ve got the magic bull’s eye and you placed your 0.2ml into a particular vessel, I think then you need to start going through the protocol that everybody should have about what to do with an intravascular injection. Try to vasodilate and refer them on to a tertiary centre because they need to move fairly swiftly. Ultimately you only have a few hours before you might start to get a breakdown, and then if that does happen, it’s about how you manage the wounds. It is important to have your fundamentals perfectly tuned so that you never get to that stage.
I’ve used HAs for ten years and that is what I use mostly in my practice. The reality is if you injected a decent amount of HA into a vessel, the idea that you could then get your hyalase in there and exactly get it into the bit that you’d injected in and force it all the way up through the network is unlikely. We do know that if you inject you hyalase it can penetrate the vessels, so yes, you are going to get good effect if you try to blanket the whole area, but it certainly isn’t the panacea that some people think it is. Ultimately, never inject in a vessel. If you do, act very, very quickly.
Q: How do you use your cannula?
People always ask me which way should you use your cannula? Which direction should you go in? If you have a large fold and it’s originating at the place where you want to put your product, then, of course, why not go along the line of the fold? Because then you can withdraw and you can fill the defect as you come back. If you just have a particular place that you want to fill then if you’re comfortable and you feel that you have the skill to do it, use a needle, because it’s much more specific in terms of getting to your target. If you are using a cannula and you just want to get to a specific place, then please just use the path of least resistance. Going between A and B in a straight line is always better than wiggling around.
It always upsets me when I see somebody going through centimetres of tissue to get to a place that they could have accessed with a very simple injection very close to the area.
With a cannula it’s important to decide what you’re going to do with it. Either you put your entry point in the direction of travel; if you want to access lots of different areas with your entry point then you should put your entry point perpendicular because then it’s a bit easier to move the angle of the needle.
If you’re using a very long cannulae you need to be aware of the superficial temporal artery that’s running way back, a centimetre or so in front of the tragus. Often you can palpate it.
We all prang vessels. That is what happens when you put needles in skin. The problem is if you don’t recognise that you’ve pranged a vessel. So whatever you’re doing always be vigilant; always be watching. We have lost the old-fashioned art of just opening our eyes, plugging in some common sense and watching. That also means that when you’re injecting that you’re not covering the skin that you want to inject with your hand, because you’re not going to see if there’s any blanching or swelling. If there’s swelling that is not related to the product you’re putting in then of course there’s probably a haematoma or some bleeding that’s going on underneath the skin.
Q: Do you treat people who are anticoagulated?
If people are on aspirin or blood thinners, I think that some practitioners are perhaps a little bit over cautious about this and they exclude large numbers of patients. I don’t mind treating people who are on aspirin. Of course, if possible, I do ask them to stop it a week or ten days beforehand but I wouldn’t deny somebody an important treatment for a wedding that they had in a couple of weeks’ time, because they were on 75 mgs of aspirin.
In terms of warfarin I get a little bit more cautious, but it depends what their warfarin is for. I’ve got to be ultra cautious that if there are any issues then I’m well aware.
It’s all about your skill level, what your comfort level is, and assessing the risks appropriately. If you’re new to this and you’re not very confident, then no. Don’t treat them. Send them on to somebody who has more confidence and experience than you.
Q: What layers can you inject this product?
The way that I treat Ellansé or anything heavy like this is treat it as a heavy filler. You would not put a heavy filler in the dermis. This does not belong in the dermis, and in fact no biostimulator ever belongs in the dermis.
Many of the problems that I see are down to poor placement of product. So they should always live deep. If you have fine lines, something really fine that you want to deal with, get a thin HA because that’s what it’s for. Please use your tools correctly; have a decent toolbox, but make sure that you’re using them correctly and not trying to put a heavy product into a superficial plane, and when I say superficial plane I mean in that dermal plane. You can of course sit beneath the dermis and that is fine.
I always like to treat people in an upright position. I think that’s really important. Why? Because the tissues are going to come down with gravity; if you treat people lying down at 45 degrees, they sit up and everything comes down, and you don’t know exactly what you’ve been injecting.
Another danger area is the facial artery that is coming in just in front of the masseter. If you ask your patient to clench their teeth you feel for the masseter—the front border, the anterior border. You run your finger down and there’s a little notch on the underside of the mandibular ramus there. There’s a little wiggly worm in there and that’s your facial artery and vein. They’re going to track superior and medially to the corner of the nose and become the angular artery. So when I’m treating this area I’m well away from that, but of course there are other vessels, the inferior labial vessels, which are going to split off from that facial artery and come across.
Dr Askari Townshend has several years of injectable experience. He opened his first Aesthetic clinic in 2008, and he’s had the position of Director of Medical Services at one of the largest chains of clinics in the UK. He’s recently launched his new clinic, ASKINOLOGY —a new and different approach to offer skincare treatments. He’s also a trainer for several pharmaceutical companies.