CATEGORY AUSTRALASIAN DENTIST 83 LINICAL need to appreciate how the superficial and deep fat pads of the face move in relation to each other. Why? Because it will influence our dermal filler choice. If we recognise that the patient requires filler in the anterior cheek, for example, we often need to place dermal filler both superficially and in the deep fat pads too. And we will not use the same product in both. In the deep fat pad, which overlies the bone, the fat pad is fairly immobile on smiling andmovement. In this area, we need to place a rigid filler, or one with a higher G-prime In the superficial fat pads of the face, the fat pads will re-drape on smiling, showing anger and sadness. So in the superficial fat pads, we need a filler that is resilient, that bends and stretches with the face, but also retains its original shape at rest. These fillers need to have resilient or dynamic bonds that move and stretch with the patient, resembling a lower Gprime product. TECHNIQUE: Go Cannula! In the scope of this article, we have now covered anatomy, so let’s now turn our attention to technique. To deliver the cosmetic injections, we have a number of options at our disposal. However we can broadly classify two approaches, which is the use of a needle and the use of a cannula. Most practitioners that knowme, know that my preferred approach is the use of a cannula. The reason for this is improvement of safety for the patient. One of the major risks with dermal filler is the creation of a vascular occlusion, which is the result of dermal filler being accidentally injected into a vessel, causing the blood flow to slow or cease entirely. This will have devastating effects on the skin if not recognised and then rectified. I was so fortunate to have an immensely valuable mentoring session in December 2022 with Dr Lee Walker, a global leader in cosmetic injectables and global KOL for Teoxane. He again reinforced my understanding and belief in the use of the cannula technique. Consider this: When we use a needle for dermal filler, the risk of a Vascular occlusion is 1: 6410. If you use a cannula, the risk of a vascular occlusion is 1:40000. No question, you need to master the cannula. The other technique considerations are the style of deposition for the dermal filler that you are going to use. You may consider using micro-boluses, retrograde threads, fanning or tenting the filler through the tissues or any combination of the above. Consider the depth of tissue you are working in, the anatomy of the area, the product you are using, and then determine how the enhancement needs to be ‘styled’ to get the result you desire for your patient. PRODUCT. The final tier of the ATP approach. Having used many brands of dermal filler product over the years, I am so proud to use the Teoxane brand exclusively. I love that they have a product for every application, and that their dermal filler range offer both structure and resilient rheological properties that we all require as part of our armamentarium. If we revisit the example of using a stiffer (high g-prime) filler for the deep fat pads of the anterior cheek, Teoxane has the perfect product for this, being the Teosyal Ultradeep filler. This has 25mg/ml of crosslinked Hyaluronic acid, with 10% degree of modification. The really great thing about this filler, is that each syringe has 1.2ml of filler in it, which is 20% more product than other available fillers on the Australian Market. This is a huge bonus to your results for your patient. Then in the superficial tissues, we need a resilient hyaluronic acid filler, and Teoxane have the beautiful Teosyal RHA3 for this application. RHA3 has 3.6% degree of modification and 23mg/ml of HA included. Similarly, the RHA4 product can also be used in this plane. This product has a similar rheological profile, but has 1.2ml in the syringe. Again a 20% bonus for you and your patient. The perfect part of this equation, is that all the Teoxane fillers integrate very nicely in the layered structure that we place them in. We can most definitely not say this about using one brand of filler in one layer, and then using an alternate brand in another. We know in dentistry, that we cannot use one composite over a glass ionomer, for example, and get a strong or cohesive bond. It is the same in the cosmetic injectable dermal filler products. We should consider knowing a brand really well, and using compatible products together for better patient results, with a decreased risk. I must disclose that I am an Australian Key Opinion leader for Teoxane. It is a great honour to have this recognition, but I do this proudly, knowing that the Teoxane brand is globally recognised as the best. My love affair with the brand started years ago, because it is important to me that the products I use are well tested, well tolerated and the best of the bst. It matters to me, and it should matter to every injecting practitioner. Know your product and the rheological product specifications. It determines your results. The ATP approach is an all-inclusive thought and planning process for your cosmetic injections. By considering the four tiers of anatomy (vertical, horizontal, depth and movement), the techniques we are going to employ to deliver our result, and the product we are using, we give our patients predictable and safer results. The ATP approach is important so that we do not use protocol that is “paint-by-numbers” or done in a way that is not patient centric. Each patient needs to be considered as an individual and planned with the upmost of care and precision. u To learn more about the ATP approach, please visit www.dermaldistinction.com
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