Mr Ash Labib, Dr Alexander Rivkin and Ms Leslie Fletcher draw on their wealth of experience to offer advice on optimum delivery of cosmetic injectables
Q: Can, you give your top tips for safe and effective injections?
Ms Leslie Fletcher: I’m a firm believer in a moving needle. If I’m ever stationary, I always aspirate, and when I aspirate, I retract and I count to five. I’ve seen a flashback that came delayed a couple of times with Voluma, and I was glad I waited. There was nothing and then all of a sudden there was something. So I aspirate, hold for five seconds and then inject, if I’m bolusing. Other than that, I don’t aspirate when I’m retrograde threading.
Mr Ash Labib: I know that some people wonder whether aspiration is a good thing to do. I aspirate all the time, I inject very slowly. I check any skin changes or blanching, and I deal with it swiftly.
Dr Alexander Rivkin: I agree, my needle is always moving and I inject slowly and softly, however, I do not generally aspirate. I do not think that you can accurately say that the needle is in the same place when you are pulling back as it is when you are pushing filler through it. Especially with viscous fillers. I don’t inject boluses very much, I usually inject in vertical columns and that’s generally given me very good results.
Q: Considering cannulas versus needles, why and where do you use them?
Dr Alexander Rivkin: I don’t use a lot of cannulas, I have to admit. I mostly use a lot of needles. With my injection technique for the nose, I really focus on precision by injecting tiny bits of filler into lots of little spots on the nose. But for the rest of the face, I have a technique where I insert the needle perpendicular to the skin, and raise columns of filler by injecting as I withdraw the needle. I find that to be most efficient in terms of filler use for augmentation, and I find I’m doing multiple puncture sites and so I’m using needles mostly.
Mr Ash Labib: I use both. Though specifically I use cannulas for tear trough treatment, to build cheek hollowing and carotid area hollowing, and lately for the marionettes.
We used to use a very small amount of injection left in the syringe when treating marionette lines. It’s an area where you have to treat it very respectfully. I put on an entry point of the cannula, and I fan out and I fill the whole area, with maybe half a ml of whatever I use. I treat it with respect, and that’s the area where I use a cannula quite a lot.
Ms Leslie Fletcher: I’m more of a needle user than a cannula user, but in the tear trough area, I feel it’s much safer to use the cannula and so I do use it in the tear trough area, or any area that doesn’t need additional stimulation—so sometimes in the temples, I’ll use the cannula.
Q: Moving on to pan facial injection techniques, do you work superior, inferior, or the other way up? Lateral medial or mediolateral?
Ms Leslie Fletcher: I work superior to inferior, I feel that you can get a lift on the jaw line, once you lift up the superior lateral part of the face, it can actually pull up the jowls, and even the neck, due to the fact that it’s all one piece of fabric. I personally work lateral to medial as well, for the same rationale.
Mr Ash Labib: I work top to bottom, always. Don’t get into the trap of somebody saying to you, “I don’t like my jowl lines”, and you go and put a heavy one syringe of Voluma with that, dealing with the top part of the face. That is adding gravity and it will cause problems. Top to bottom, temple hollows, cheekbones, mid face and then lower face.
Q: Can you give your opinion on giving moulding massage post treatment?
Dr Alexander Rivkin: Sure, I generally do that. I find that the fillers we have available mould nicely, and it’s a great way to make sure that your results are as natural as possible, so I do that quite often.
Mr Ash Labib: We are in the habit of moulding and massaging and pressing on products, and trying to make it disappear, and then you end up using more products. When I do the eight-point face lift, I put certain injections in certain points, and I can see a little bit of a blip, and I want to keep it there. It’s almost like erecting a tent. Don’t keep pushing and massaging too much, because you lose the product. It will absorb water, it’s hydrophilic and in two week’s time, it will look even better. So, don’t worry about a little bit of a bumpiness, because that is desirable to lift the skin up.
Ms Leslie Fletcher: I don’t do a lot of massage. I think part of my technique is injecting in multiple vectors at multiple depths, so with massage you almost lose some of that lift, by flattening out the vectors. Having said that, I never want to send a patient out concerned, so I will tap or hold in mould, as opposed to pushing it through, just to soften the island, so that it’s not quite as aggressive for the patient, but I know within a couple of days, it will integrate into the tissue just fine.
Q: Do you subcise when you do injections? Do you open up the fourth ligaments with your cannulas, perhaps?
Mr Ash Labib: Yes, with cannulas in certain areas, you can. I think if you are to build a nasal dorsum in maybe an Asian nose, you can use Voluma. I’m very conscious of using Voluma in the tip. I think the tip is a very confined area and Voluma can be quite thick and quite compressive on vessels. This is me. I think safer to go something like Juvederm Three or maybe Juvederm Volift.
Q: How do you correct a rotated tip of the nose?
Mr Ash Labib: We inject a small amount in the dome of the tip, between the cartilages, and that will add a bit of rotation, and also by opening the angle between the nose and the lip, that will add further rotation. To correct an up tip you use your vision, it’s like sculpturing, you are actually filling a defect, either on the lateral side of the nose.
Q: How do you correct a deviated tip laterally?
Mr Ash Labib: You can compensate for the bulge on the one side by injecting slowly to compensate for that and make it look regular and symmetrical.
Dr Alexander Rivkin: Because, a deviation is due to an imbalance in terms of volume. On the one side, there is more volume than the other side, so that makes it look deviated. You add to the contralateral side, to make that side more symmetric with its opposite and it generally works out quite nicely. I like to go directly perpendicular to the skin, but I think it’s whatever you’re comfortable with. I think it’s important to actually put the material where you want it, and you know that the most lift you’re going to get is if you’re injecting the actual tip. I say this to contrast with the technique of lifting the tip by injecting the columnella. I go deep enough to get to the perichondrium and inject softly and slowly for safety.
Q: When you define the A- line, do you do that just by rotating, or do you actually inject?
Dr Alexander Rivkin: I actually inject, but very, very carefully, because that’s, as we saw on that case, that’s the point where you can really run into a lot of trouble. The blood supply to the skin in that area is not that strong, and so that’s where you can really get some vessel compression and run into problems, so yes, but I approach it gingerly.
Q: Do you do A Line dilation, do you treat that area, the flare with toxin?
Dr Alexander Rivkin: Yes.
Mr Ash Labib: Yes, I do, I just inject a very, very small amount—one unit each side, in one spot, very superficially around the alar cartilage, to stop the dilator muscle from working. I work slowly and try to avoid multiple injections, because that will create more chance of bleeding and also necrosis, if that’s something you’re trying to avoid.
Q: Have you ever used filler to narrow the alar?
Mr Ash Labib: I did that a few times, but what I want to do as well, functionally, if you have an alar collapse, when you breathe I inject the dome of the inside of the nose to support that, and that will stop that influx of the nasal alar, to help breathing. It’s a functional reason to do the fillers in that area.
Q: What products are best for longevity?
Mr Ash Labib: I think longevity is very variable, and you can’t set an exact length of time. We say up to two years, but sometimes they come after nine, 12 months and you start seeing the hump again, depends on the metabolic rate, and how quickly they break down the products. I don’t believe that there’s one product that will last longer. We all use hyaluronic acid, and the body will break it down gently over the next 12 to 18 months normally. That’s with Juvederm Three.
Dr Alexander Rivkin: With Radiesse, on average, I see nine, ten months but a minority of people come back six months later and the filler has faded significantly. One of the reasons I like Voluma, is that I get a lot more duration out of it, and that’s why I use it so much. The duration of Voluma is also variable, so I give them an average, and I tell them that everyone’s body is different.
Hyaluronidase is useful no matter what kind of filler you’re using. If you run into an ischemic situation, even if you are not using a hyaluronic acid filler, hyaluronidase just briefly dissolves the patient’s own hyaluronic acid. That gives more room in the area being injected, in case there is a compression kind of effect going on, and that buys you the time for any vasospasm to resolve and blood flow to be re-established and everything to recover.