Category Archives: dermatology

Flexible Blunt-Tipped Cannulas for Cosmetic Fillers

To start with, how about a picture of these cannulas?

blunt tip cannulas

Why the need for Cannulas in comsetic filler injections?

You might say that Juvederm, Restylane, Radiesse, Belotero, Perlane, Prevelle injections have been just fine with a plain needle.  But why increase the difficulty of the procedure?  The reason?  Less bruising?  Smoother results?  Safer?  Those are excellent reasons for having your injector / surgeon work harder.

What are cosmetic fillers?

Surgical Artistry Calvin Lee, MD Tammy Wu, MD 209-551-1888 www.SurgeryToday.com 2336 Sylvan Ave. Suite C Modesto, CA 95355 Next to Post office on Sylvan

Fillers are like they sound – they fill spaces up to replace volume that we’ve lost as we’ve aged.  Familiar fillers are Juvederm, Restylane, Perlane, and Radiesse.  There are many more brands of cosmetic injectible filler implants.  However these are some of the common ones used in my Modesto office: Surgical Artistry.  Botox isn’t a filler – Botox relaxes muscles.  Here’s a link to my page: Anatomy for Botox.  Both fillers and Botox are used for facial rejuvenation.

Why the opening on the side of a cannula?

The opening is on the side for extrusion of the filler such as Juvederm so that the tip can be made in a blunt fashion.  If the opening was at the tip, there would be sharp ends.  Thus the opening is on the side.  Is this good or bad?  It’s both.  It’s good because now the tip can be blunt.  It’s bad because we lose a bit of the precision which we were used to with the tip of a regular needle.

Why the blunt tip on the cannula?

This is the key ingredient for safety and less bruising.  Because the tip is blunt, it won’t easily go through vital structures such as arteries, veins and nerves.  It glides through fat.  In fact this blunt tip cannula idea is used in surgical liposuction.  The safety is in the prevention of cutting vital structures.  The less bruising is because there’s less internal bleeding due to the cutting of blood vessels.

Cannulas increase the difficulty of the cosmetic filler procedure

Yes, the difficulty is increased and it feels more like a complex procedure.  However, the risks diminish and many of the positive results increase – including patient satisfaction, smoother results, and less downtime.  I think this is worth the increased time and complexity – something surgeons think about all the time.

cannulas-vs-needles

Needle vs blunt-tipped micro cannula.  Safety is the #1 reason I like cannulas.

Where can cannulas be used?

For most injections where the fillers are introduced below the dermis of the skin. This is a plane where the cannula can glide.  Superficial lines – probably a difficult space for the cannula – I would most likely continue to use a needle in the superficial plane.  Examples of places for cannula use:

Why are cannulas more difficult?

  • It takes longer to do the procedure
  • There’s a need to use a pilot needle (which can still cause a bruise) to create the opening in the skin for the cannulas to slide through.
  • Cannulas are flexible and there can be physical hang ups (getting stuck), and difficulty driving the cannulas from a distance (longer needle).  And because they are flexible, sometimes they are harder to feel their presence under the skin.
  • The hole is on the side of the needle not in the front.
  • Sometimes it’s difficult to gauge the depth of the injection

What’s the main reward for using a cannula?

Patient safety.  When a blunt tipped cannula is used well by an experienced injector, there is much higher patient safety.  Using needles – one could puncture subcutaneous structures which would otherwise like to stay unpunctured.

What are other great benefits of using cannulas?

  • Patient safety (mentioned above as the #1 benefit)
  • Tip is blunt – actually might hurt less.
  • Tip is blunt – won’t injure as much under the skin such as blood vessels and nerves.
  • Less bruising – because there’s fewer injury to blood vessels and thus less internal bleeding.
  • Less swelling – for reason above.
  • Faster recovery.
  • Flexible cannula – allows for safety – the cannula moves or wiggles around some of the stiffer structures within the fatty tissue planes.
  • Longer length – thus fewer skin puncture sites.
  • There’s also the benefit of calling this instrument a cannula rather than a needle – less scary sounding.

What is my favorite cannula?

Cannulas come in many different styles and lengths.  I currently use Magic Needle and Dermasculpt cannulas.  I haven’t had the chance to try other cannulas on the market.  I believe they would be excellent.  The Magic Needle cannuals are more flexible – perhaps a little bit too flexible for my current tastes.  I know my tastes will change with time – it has before – I remain flexible myself in my choices of cannulas.  As for favorite size/length of cannulas.  I like the 27g 1.5 inch cannulas for most of my Juvederm injecting.  I use this cannula mostly for temples and cheek augmentation.

Do I think that cannulas are game changers in the world of injectable fillers?

I think so.  For the sake of patient safety and smoother appearances.  Plus with the added benefits of shorter recovery period (less bruising, less swelling).

Do I use cannulas instead of needles for everything

No.  There’s a role for each tool.

Disclaimer

These are my thoughts (Calvin Lee).  No specific medical information here.

www.SurgeryToday.com (209) 551-1888

www.SurgeryToday.com
(209) 551-1888

 

 

 

Lip Augmentation with Cannulas

First what are blunt tipped cannulas for fillers?

Surgical Artistry - Calvin Lee, MD / Tammy Wu, MD

Borrowed over from the world of liposuction and the world of Huber needles for chemotherapy.  There are four benefits of using a cannula for filler (ie. Juvederm) injections:

  1. Tip is blunt, not sharp – so it won’t easily pierce unwanted delicate structures such as nerves and blood vessels
  2. Side exit port for the opening for extrusion of filler.  This is on the side so that the tip can be blunt.  So this reason goes along with the blunt tip reason.
  3. Flexible cannula.  This allows for less injury as well, it has the potential to wiggle around obstructions which are sometimes cause by the vitals structures of nerves and vessels.
  4. Long length.  this allows for fewer puncture sites.

Why do we care about blunt tipped cannulas?

In the end the results are for safety and less bruising.  But are the effects better looking when the swelling goes down?  for the most part I think so, for broad areas such as cheek and temples.

Picture is worth a thousand words

Perhaps a picture would help describe cannulas for injectable fillers:

blunt tip cannulas

blunt tip cannulas

Lip augmentation with cannulas?

Currently, for myself as an injector in Modesto, I’m a fan of cannulas for filling the central part (body) of the lips.  But for precision, I feel that I lose a little bit of the precision needed when working on the border of the lips.  Thus I still find myself gravitating to the regular needle.  I have also used longer needles.  So for now, there’s a role for both cannulas and needles in my practice for lips.  But for the most part, I’m doing most of the lip augmentations with needles.  I like the precision that I get with a short stiff needle.  However, I understand that there is more of a risk of bruising and swelling right after the procedure.  These are just my thoughts at my current level of comfort with cannulas.  For more of what I think, visit: my thoughts on Lip Augmentation with fillers:

www.SurgeryToday.com (209) 551-1888

www.SurgeryToday.com
(209) 551-1888

My thoughts on Lip Augmentation

red lips isolated in white

Picture is not of a an actual lip augmentation patient

 

Lip Augmentation

I perform lip augmentation with fillers such as Restylane and Juvederm ultra.  I have occasionally used Juvederm Ultra plus for more dramating lip augmentation effects.  This write-up serves it’s purpose for me to put down on paper some thoughts flying around my head regarding excellent lip augmentation.   My thoughts on Cannulas for Lip Augmentation.  Much of the info here is considered off-label FDA usage.  Nothing here is meant to be personalized medical advice – just a generalized discussion here.

Does Lip Augmentation Hurt?

The procedure is done in my office in Modesto, CA.  There is no IV sedation or pill sedation or general anesthesia.  There are options of numbing cream, ice, nerve blocks, mucosal blocks, and lidocaine within the product.  Some lip augmentation patients choose all these options so that they feel pretty close to no pain.  Some patients just choose just one of these numbing options as each one does take time and patients at the office visit.

LipAugmentation3

Demonstration of Lip Augmentation with Juvederm, posted with permission from my patient.

My thoughts on  Lip Augmentation

There are several parts of the lip to consider.  First is the ratio of the upper lip tot he lower lip.  Most patients like their lower lip on the larger side.  Then there’s the part around the lip which needs to be considered.  With some extra support of the white areas around the lips – this area can use a half to whole syringe just to expand out the fine line around the lips.  Volume loss has occured here.  Take all these into consideration, then there’s the best part – augmenting the red part of the lip.

There’s three general locations to consider for injecting into the red part of the lip – my own thoughts:

  • injecting filler right at the edge of the lip to add definition
  • injecting into the belly of the lip to add forward projection and fullness
  • injecting near and at the wet-dry border of the lip to create more vertical curl of the lips.

I’ve come up with these thoughts as I’ve gained more and more experience via lips.

How many syringes of fillers needed for the lips?

considering the three locations for injecting into the lip and the white part of the lip.  One could use 2-3 syringes of Juvederm or Restylane for the project already.  However 1 syringe of Juvederm or Restylane has been the choice of many due to cost concerns and also 1 syringe does a wonderful job for many lips, and not everyone wants all aspects of the lips (definition, fullness, and curl plus the perioral lip lines) to be changed.

So quick answer: Most of the time just one syringe of filler.

There’s much more to this subject of Lip Augmentation

But this is a start.  I wrote down this information mainly for myself to help organize my thoughts on the topic of Lip Augmentation.  A personal consultation regarding lip augmentation would reveal specific personalized information which would be much more useful than this article.

I usually use temporary injected fillers for lip enhancement rather than permanent lip implants

There are many options available for lip augmentation.  I normally choose products which can be reversed and also are precise in the results which we are looking for.  Many patients consider getting lip filler placement ever 4-8 months.

Permanent lip implant options exist.  Perhaps we’ll explore those in the future.  For now, we’ve taken out several of these done by others.  I do think that there is a role in the overall lip enhancement world for these permanent products, but I’ve been personally very happy with hyaluronic acid type fillers for the lips such as Juvederm and Restylane.

What makes Lip Augmentation so difficult?

difficulty

Lip augmentation is somewhat challenging.  But as surgeons we usually like challenges and are very satisfied to get great results.

There are many different ways to achieve lip augmentation.  The three different locations for fillers and in different ratios of material allows for different effects.  The challenge here stems from having so many variables.  But we have to match these variables to:

  • Patient expectations – what is the patient’s definition of duck lips – do they want to avoid that?
  • Lip symmetry – this is a big importance between left and right sides.  Many patients are not symmetrical to begin with.
  • Lip filler product bumpiness – visible and palpable (able to feel).  We want to try to avoid this as much as possible
  • Lip bruising afterwards – this does happen and is a risk of the procedure.  I think it happens a lot more often than not.
  • Lip area tends to have more pain fibers and thus there’s the challenges and difficulties of achieving comfort for the patient.  Everyone is different when it comes to pain sensation.  But almost everyone would agree that lips are particularly more sensitive.  But we have options to include performing nerve blocks – like going to the dentist.
  • Lip lines around the lips should be addressed too.
  • The issues of infections around the lip. The lips are one the least “sterile” areas of the face to work on.  And some patients even have the challenges of cold sores.  We try to anticipate these problems and have prescriptions available at the office for Acyclovir – a drug that helps to shorten the length of active cold sores.
  • Desired ratio between upper lip and lower lip.
  • Some lips can’t take too much product all at once and a staged procedure might have to be done.  We don’t want complications of lip necrosis (dying off).
  • Another interesting challenge:  When doing fillers on the lips we have to deal with the location of the previous fillers done months ago.  Not all of it disappears and we have to be able to work with the previous filler to blend it all together and not allow the old filler to get in the way of the new filler.  For me, sometimes this is the biggest challenge, especially if the previous techniques used for lip augmentation are different from what I’m expecting.
  • This list goes on and on, but I wanted to list a few challenges which I have on my mind when going through the process of lip augmentation.

If you would like, please feel free to contact us:

Surgical Artistry
Calvin Lee, MD
Surgeon who likes to perform lip augmentation
(209) 551-1888.

Dr. Tammy Wu also does lip augmentation, and in addition she also removes permanent lip implants, lip reduction, mucosal reduction, and lip reconstructive surgeries.  But for the most part if on is interested in lip augmentation with injected fillers, Dr. Calvin Lee (me) is in charge of that part of the minimally invasive facial injections.  Lip augmentation is one of the most satisfying procedures that I have.

Derma Pen Recommendations

dermapen with logo

For our Modesto Plastic Surgery Practice, I’ve come up with these guidelines.

Derma Pen is a modality for improving:

  • Rosacea
  • Scars
  • Lax Skin
  • UV Damage
  • Stretch marks

Is the DermaPen a New Invention?

before-after-1Yes and No.  The makers of Derma Pen thinks it’s a new invention.  However, I’m an acupuncturist who does cosmetic acupuncture.  This idea of wounding the skin with a needle to cause more collagen growth is not new.  From what I know, this needling concept has been used thousands of years ago in acupuncture.  Most acupuncturists today don’t know the art of cosmetic acupuncture.  It requires additional training.  However, I (Dr. Calvin Lee) was very interested in cosmetic acupuncture because it complements our Modesto Plastic Surgery practice.

But I must say the concept of attaching 11 cosmetic acupuncture needles to the end of a machine is a new concept.  What this can do, I cannot do by hand.  I am simply not patient enough to cover as much ground as this machine can.  Finally after 5000 years, there is an improvement to acupuncture!

The Boston Channel website regarding Cosmetic Acupunture – interviews Dr. Calvin Lee (me)

Derma Pen Rivals Lasers?

Article on Automated Microneedling Rivals Energy-Based Tx

Cost of Derma Pen Procedure:

  • MD model (deeper) of the Derma Pen, not the Aesthetician Model (less deep)
  • Done by a Surgeon who is trained in aesthetic injections for the face, who is also an Acupuncturist who is also trained in Cosmetic Acupuncture (um, that’s me).
  • Includes addition of Kerotinocyte Growth Factors with no additional cost – right where the skin is most absorbent.  Yes, growth factors is another craze in the skin care industry.

$400-$500 per session.  Prices change, please call us for more info.

PRIOR TO DERMA PEN PROCEDURE:

1) Stop Tretinoin/Retin-A x 2 days before procedure
2) Avoid prologned / direct sun exposure or sun burns to the treatment area for 2 days
3) Skin should be clean and makeup free before coming for the procedure
4) We will place numbing cream containing Lidocaine 15 minutes before the procedure.

How often can the Derma Pen be done?

ANSWER: You should see an improvement in your skin after the first visit. You can have them as close as once per month. At this time we are recommending, once per month for the first 5 months, the after that possibly every third month to continue to show improvements.

How long does Derma Pen results last?

I’m going to answer this based on what I’ve seen with my Cosmetic Acupuncture practice. With Cosmetic Acupuncture, after about 10 sessions, we have seen patients keep their changes for about 2 years. I think we’ll get to that result after 4 treatments with derma pen. But the reason people keep getting treatments after 4 sessions is that improvements continue on and I think folks would be excited to see the clock turn backwards even more.

Post operative care after DERMA PEN:

1) Stay away from sun exposure x 7 days
2) Wear hat x 7 days (wear as much as you can)
3) Do not wear sun screen x 12 hours (we don’t want this to absorb into your skin)
4) Do not wear make-up x 12 hours
5) Cold sore patients may want to take medication
6) Use your serums: Phyto, B5 Gel, Vitamin C gel right away and daily afterwards to take advantage of the greater penetration after Derma Pen
7) Your skin will be dry and a bit red for the next 2-3 days after the procedure. Moisturize with Phyto, B5 Gel, and/or any other favorite moisture product of yours.

darkerskin-dermapen

Can DermaPen be used for darker skin?

Yes, Derma Pen can be used on skin of all colors.

womanlipsdermapen

 

www.SurgeryToday.com (209) 551-1888

www.SurgeryToday.com
(209) 551-1888

Marker for Botox Injections

Planning Botox injections – drawing on skin

For some patients, a precise Botox mapping is what I’d like to do as a Botox injector for best results.  However there are some challenges:

  • The marker should be easy to wipe off after the Botox injection because we might not want to agitate the location of the Botox liquid which has been injected under the skin (intradermal or intramuscular).
  • The maker should be fresh so that we have a large supply of the markers.
  • The marker should be visible on the skin and perhaps visible on the lips as well.  Although a green marker might show up better than a red marker on the lips for lip augmentation.

One solution comes from Viscot Medical.  www.viscot.com.

They make a pen alled the Dermarker (Derm-Marker) which is an EZ removal ink skin marker.  Alcohol erases it very easily without much rubbing.

I got a chance to buy a container full of these pens and I’ve tried the markings on my own skin at the Las Vegas Cosmetic Surgery Aesthetic Dermatology Conference.  I think this will work well for me and take my injection skills to the next level.

This marker could be used for areas of filler/Juvederm injection as well.  However, these markers would be a bad idea for Tummy Tuck and Breast Augmentation markings because those are larger areas and require a surgical prep which is going to erase these markers.  The same company makes a pen for these cosmetic surgeries, it’s called the XL prep resistant ink surgical marker.

We’re happy to bring these markers with us home to Modesto, CA from the Las Vegas meeting.