An expert panel discusses best practices and techniques at the 2013 Vegas Cosmetic Surgery and Aesthetic Dermatology meeting.
What product do you choose for temple revolumization, what device do you use to inject, and in what plane do you inject?
Amy Taub, M.D., dermatologist, Chicago: For the temple, I inject deeply to bone and use a bolus technique. The two fillers I use on the temple are Perlane (hyaluronic acid/HA, Medicis/Valeant) and Sculptra (poly-L-lactic acid, Valeant), depending on the patient. I slowly advance the needle until I hit bone and then pull back on the needle to make sure I am not in a vessel. I inject slowly and let the material gradually fill in the hollow. Assess, mold, and, if necessary, reinject.
Michael Persky, M.D., plastic surgeon, Encino, Calif: If the patient has time I prefer Sculptra in the temple area. I inject deep, supraperiosteally, with a 25-gauge 1-1/2 inch needle. If the patient’s daughter or son is getting married in a month or two and they want an immediate, quick filling of their temple, then I like to use either Radiesse (calcium hydroxylapatite, Merz), or a mixed Juvéderm (cross-linked HA, Allergan) or Perlane with saline and lidocaine. I inject those fillers with a cannula more superficially — on top of the temporalis fascia. When I use a cannula I dilute all of the products. Val Lambrose, M.D., a plastic surgeon in Newport Beach, Calif., has done great work in this area using one part Juvéderm, one part saline and one part 1 percent lidocaine without epinephrine. He has gotten incredible results. The products seem to last long and it also makes it a lot easier to inject. Radiesse has much better flow when it is diluted with lidocaine.
Rebecca Fitzgerald, M.D., dermatologist, Los Angeles: I use a couple of things in the temple. I do the Val Lambros dilution solution technique, too, where you can do a two to one dilution with a hyaluronic acid. I use a cannula and I put it on the superficial temporalis fascia. That works very well for me right around the temporal crest. And I use a lot of Sculptra deeply underneath the temporalis fascia. I use it with a needle and I reflux before I put the Sculptra in. And I just want to share experience — in the HIV clinic, we would sometimes inject 12 or 18 people a day, and we’d do it a couple of times a week.
We were using a long needle and we were right on periosteum. We did that for years and it was not uncommon to reflux blood. It wasn’t every day that you’d reflux blood, but it wasn’t uncommon. What I speculate is that we were pushing the vessel down and pinning it, and then you would pull back blood. But I think that you can hit a vessel down there. And we know that the external and internal carotid circulation is all intermixed. And we know that there have been cases of blindness reported with injectables all over the face and that area is no exception to the rule. So you just want to do anything you can not to inject intravascularly.
Welf Prager, M.D., dermatologist, Hamburg, Germany: I used to inject Radiesse on a deep plane close to the bone but I found out that the surface — the transitions from the cheekbones to the forehead — was not as smooth as I would wish and so I changed to a subdermal injection with blunt cannulas. The product I mainly use is Belotero Balance (HA, Merz) because it has the viscosity where you can smooth it out nicely and get the transitions to the eyebrow, to the forehead, and also to the cheekbones evened out.
Derek Jones, M.D., dermatologist, Los Angeles: This is such an excellent question and I have really firm ideas on this. The temple is really easy if you do it properly. In my opinion, you want to be right down on bone. My needle is usually three quarters of an inch to an inch, minimum. I inject pretty much in bolus. I might put a few aliquots around but you’re right down on bone. If you were anywhere more superficial than that, sitting somewhere in the middle ground, there are a lot of vessels tracking in and around there — I have some interesting reports coming out on that — I think you’re asking for a problem. My problem with injecting more superficially and we’ve seen injectors at this course treating this way and some of our own panelists doing it. There are a lot of vessels there and I have had a lot of patients who come into my office who have been injected elsewhere superficially and there are contour irregularities. It’s pretty thin skin up here on the temple on a lot of individuals, especially older individuals. So it’s just like the tear trough, if you’re injecting something superficially, once everything settles down the contour may not be just perfect. I do a lot of temporal injections. I go straight down the bone and I use a fairly high G prime line product like Radiesse. I think (Juvéderm) Voluma (Allergan) will be very promising there.
Michael Kane, M.D., plastic surgeon, New York: I think temples are probably technically the easiest area of the face to inject as long as you don’t make a contour irregularity. I would inject any product there — calcium or HA. If given my first choice of what looks best, I think it’s Sculptra, but I don’t inject it deeply. I inject it superficially. When I’m injecting Sculptra I try to scrape right along the undersurface of the dermis because that’s where the fibroblasts are. And I like to try to thicken that dermis. I think you can hide some of the vessels there.
And I think the key to reducing embolic phenomena, which is what we’re talking about, is really a slow rate of injection. I’m generally not an aspirator but then I do not inject with my needle in one place. I’m constantly, constantly moving the needle and I inject at a very, very slow rate. So in the one-in-a-million chance I cannulate an arteriole, I’m out of it in a second without an appreciable amount of product being in there.
Susan Weinkle, M.D., dermatologist, Bradenton, Fla.: I personally like to inject both deep and superficial. I think one concern we need to have when we’re teaching our colleagues in terms of deep injections is the needles that come in the package with an HA often are a half-inch needle, and it is very difficult in some patients to get all the way down to that supraperiosteal plane with that short needle. I think you’re at much greater risk if you are not on the supraperiosteal plane to have an inadvertent injection of the deep temporal artery.
I recently did a cadaver dissection in Shanghai and almost fell over when I realized where the deep temporal arteries are located. It is vitally important, as we’ve all discussed on this panel, that when doing a deep injection to get down to the bone, feel the bone, and know where you are.
I reflux as well and then do a bolus injection in the deep plane. I find that some patients still need a superficial injection if they have a lot of loss. However, with those thin-skinned elderly patients that I have, there have been a few times where I have not reconstituted the product and I was not happy with the irregular contour. So live and learn. I think that’s the exciting thing about a panel like this where we can really share tips that have helped us.
I utilize a deep injecting and sometimes an icing-on-the-cake superficial injection. If injecting superficially, I would recommend reconstituting and thinning an HA or Radiesse in order to obtain a smooth, even contour.