With one box of FREE Safer Practice endorsed Genius Ultra Filler worth £29.99 + VAT!!
Are you constantly looking at social media and wondering why you cannot create work like your competitors, or feel your current skill set is affecting your capacity to get bookings or return on training investments?
Do not feel disheartened! Our online training video ‘masterclasses’ allows you to have continued access to detailed video content to upweight your skills and become an Elite Practitioner. This video is created by our team of leading Medic and Elite Aesthetic Practitioners with years of experience in clinical practice and training.
On this Cheek Dermal Filler Masterclass, you will learn how to define and contour both the cheekbones and mid-cheek area using needle and cannula techniques. Become a master of utilising Dermal Filler to mimic a defined bone structure and replace lost volume in the mid-cheek with the skilful placement of Hyaluronic Acid. This easy to follow, online step-by-step guided video training course, will teach you how to safely create cheeks that pop to ensure your work stands out from the rest!
Add this sought-after treatment to your portfolio and add a lucrative additional revenue stream to your business today!
Included in this online training video (with voice over) is full treatment protocols, Anatomy & Physiology, Health & Safety, Dermal Filler product selection & downloadable certificate.
- The address you enter needs to be the address you would like your filler sent to, as this will be posted automatically upon purchase so cannot be changed.
- You need to be Advanced Filler trained to take this course, it is not a qualification it is a masterclass to complement your current skills. The certificate you will receive is a certificate of completion it is not an accredited course.
- Genius Filler & much more an be purchased from our online store – www.enhance-me.store
Dermal fillers are frequently used in the correction of scarring, wrinkles and other depressions in the skin. They are a form of hyaluronic acid, a substance naturally found in the body, and can be injected into the skin to improve aesthetics. They are generally made of several types of synthetic, man-made and natural substances. For anyone suffering from problems such as wrinkles, folds or depressions in the skin, dermal fillers may be the best solution to improve appearance. The procedure is quick, often taking just 30 minutes or less to complete, and many people experience no pain at all and minimum side-effects.
The use of dermal fillers dates to the early 1890s which should instil confidence in new users. This was when doctors discovered that fat taken from part of a patient’s body could provide a more youthful look when injected back into the face or arms. This is a trend which has remained popular, even in today’s medical field, as many doctors still extract fat from parts of the patient’s body and use it elsewhere for beneficial results to aesthetic and medical conditions.
So, what exactly was used in the early days? Doctors in the mid-1900s were using paraffin and silicone as filler to improve skin aesthetics. However, this form of filler had its shortcoming and there were widespread reports that these kinds of fillers were unsafe to use on human skin. Following this, scientists began to explore alternatives, and in 1980 doctors discovered a type of naturally occurring filler material in the skin of cows known as collagen. Upon further scientific tests and trials doctors established that the material would be safe for use on human beings and that this could effectively replace fat as a filler substance. This was used until the development of a human derived collagen.
Collagen became the new material to use with no risk to human safety. The American Society for Aesthetic Surgery confirmed that injections of collagen came out number thirteen as the most commonly conducted aesthetics procedure in the USA. In 2008 there were more than 58,000 reported treatments throughout the year. 49.6 per cent of these applications used bovine-derived products and 50.4 per cent human-derived collagen products. The extended use of hyaluronic acid dermal fillers which are man-made can perhaps explain a decrease in the use of human-derived collagen. These kinds of fillers (hyaluronic acid) have recently shown signs of beating collagen into almost third place.
There was a decrease in the use of collagen fillers by about 12.8 percent in 2008 when a total of 1.26 million treatments were recorded worldwide. Calcium hydroxyapatite alone currently accounts for slightly less than 123,000 treatment cases, which reflects an increase of around 3 per cent since 2007. Polymethyl methacrylate was approved by the US Food and Drug Administration and shows usage as being approximately 11,000 treatments in 2008, which is a remarkable decrease of about 10.6 percent from 2007.
Additionally, there has been a huge increase in the use of these materials in the UK. These treatments are safe and inexpensive, which goes some way to explain why many people are making the decision to undergo treatment. It is thought that people are looking for a product which is not expensive but still provides quality, reliable results.
Dates in history
1893 – German (Franz Neuber) used autogolus tissue that was harvested from the arms to correct depressed facial tissue.
1900s – After the invention of the syringe, chemical agents were used. The first injectable started being used in facial augmentation (Paraffin) (Negatives – migration and inflamed nodules)
1909 – Autogenous fats were reported to be used to correct the malar and chin area.
1934 – Researchers Karl Meyer and John Palmer found that the main function of HA and that it maintains the skin volume and hydration.
1940 – 1940s to the 1950s it emerged silicone highly refined and was being using as a dermal implant. After abuse and adverse effects the cosmetic agent was banned in 1992.
1945 – Paraffin and Silicone were being used in Japan to make women look more westernised.
1960 – Silicone was used in Nevada for unregulated breast enhancements
1970 – Various animal collagens had been researched and deemed safe to be used on humans. Collagen injections and implants were introduced in 1981 the FDA approved Zyderm.
This was the first FDA approved wrinkle filler. Zyderm and Zyplast were made of purified cow skin.
1970s – 1980s – Liposuction Emerged
1980 – Development of additional fillers started. Each one had positive attributes but ultimately failed due to immunologic cost, ease-of-use problems. Injectable collagen remained the only commercial filler option for more than 20 years.
1900s – Hyaluronic acid started to be used for joint pain, treating wound and eye surgery.
1996 – Hyaluronic Acid was used for facial tissue augmentation in Europe.
2003 – FDA approved the first hyaluronic acid dermal filler (Restylane). Easy to use, longer lasting results and does not require allergy testing.
2004 – Porcine based Collagen (pig tendons) launched in Europe in 2005.
2005 onwards – A multitude of products have since been developed for soft tissue augmentation. HA is the most frequently used in the states.
How do dermal fillers work?
The fundamental working principle of dermal fillers is that they have a ‘plumping’ effect. This simply implies that they will plump-up the area which has received the injection, levelling it with other parts of the skin and making it look plumped out, even and no longer sunken. Ultimately, different fillers may achieve this goal in slightly different ways, but the result is that the skin will look plump and firm, young and refreshed.
The treatment is successful by taking advantage of the basic roles and functions of the skin, which can also help in fully understanding the procedure. The human skin is made up of two layers, namely the epidermis and the dermis. The outermost layer is the epidermis and its main function is to serve as protection against the effects of the environment and other components. It controls water loss from tissues and cells, thus serving as a barrier to the outside environment.
The dermis layer is right below the epidermis and constitutes the skin’s structural elements, such as nerves, hair follicles and blood vessels. The growth of cells and blood vessels is enhanced through a framework provided by a network of fibres that is formed by protein.
The major component of the dermis is collagen which gives the skin its firm elasticity and strength, offering fundamental support to the skin. As one grows old the ageing process causes the upper layer (the epidermis) to gradually become thin and provides less protection to the dermis layer. In addition, collagen production in the body slows down considerably as the existing collagen becomes ineffective.
This then causes wrinkles, folds, depressions and other forms of skin abnormalities associated with old age. It is at this point that dermal fillers become necessary to reduce the consequences of the deteriorating epidermis and weakened collagen. Dermal fillers technically work as replenishment for the natural collagen which has been rendered less effective by the ageing process. They both compliment & work as replacement for collagen and, depending on the quality of the system used, impressive results can be achieved.
The general working principle is similar for all dermal fillers, but may vary slightly from one type to another. Dermal fillers are usually designed to treat one area specifically, such as the lips. Often, various dermal fillers are marketed under a similar name with each treating a different area of the body or providing a different level of treatment.
Placement of dermal filler to maximise the effect on lines is relatively simple – deep lines caused by volume loss are corrected best with deeper injections in the lower dermis. Fine creases are corrected best with a shallower injection in the mid dermis. Injections in fat may not have as much impact, and injections in the papillary dermis (very superficial) will discolour the skin.
The steps to a perfect dermal injection – for theoretical use only – advanced techniques are better demonstrated during your practical learning.
- Hold the needle correctly, wrist above, thumb on the plunger. This position enables greatest flexibility and means you don’t have stability while the needle is in the face, thus giving greater control.
- Ensure correct placement by lining up the end of the needle with the point on the skin where you want the needle to terminate. Choose your position of entry & anticipate where needle tip will reach too as an end point.
- Use the correct angle of entry- 45 degrees for deeper lines and volume loss, 30 degrees for superficial creases.
- Insert the needle at the chosen angle until around 1/3 of the need has penetrated. Then STOP.
Your needle tip should now be at the correct depth.
- Slowly change the angle until your needle is parallel with the surface of the skin. Now when you advance your depth will be maintained at the correct level.
- Advanced the needle to the desired position, then stop.
- Do a depth check. Once you are at the correct depth, check for a flashback (aspiration) by pulling back on the syringe between 3-10 seconds, depending on where you are working. If there is any blood, do not inject and repeat the process.
- If no flashback, proceed to inject as per area-specific guide.
- Withdraw and massage to be smooth, check capillary refill present.
How to do a depth check:
Too shallow: If the skin is blanched without lifting, DO NOT INJECT- you are too superficial, and filler will be visible.
Fine lines: If you lift the needle and can clearly see the shape of the needle as a defined line (which may blanch- but only on
lifting) you are in the right depth for a low viscosity filler to treat a fine line.
Deep lines: If you lift and see a rough shape of the needle but it very defined you are about right for a deeper line or
Too deep: If all you see is the skin lifting generally, you are likely deep in subcutaneous fat which is not optimal.
Anatomy – Arteries and veins
Anatomy – Why it is so very important.
Safety is paramount as always, and it is vital that you understand the underlying structures in the face before injecting. Unlike botulinum toxins, the effects of dermal filler on the structures of the face can be permanent.
The most serious side effects are caused by blocking arteries and thereby causing necrosis of any structures supplied by that vessel. In the most extreme cases, this has caused blindness (so far 32 cases worldwide). Thankfully, even with the high popularity of undertrained practitioners, these side effects remain rare. Their seriousness however makes it of vital importance that you know how to avoid and manage serious side effects.
Thankfully serious side effects are very rare, and rarer still in those who know how to avoid them.
Anatomy- Blood Vessels of the face
Muscles of the head and face:
Layers of the skin:
A needle is the traditional way of performing filler treatments. As you are aware from your foundation training it has a sharp tip and works with a high degree of accuracy.
A cannula is similar to a needle, but the tip is not sharp, it is blunt and rounded. The cannula eye lift has a few benefits:
- Cannulas can be less likely to cause bruising after filler treatment
- Cannulas may be less painful than needles
- Cannulas may require less entry points because they tend to be longer than needles
- Cannulas may be safer than needles because it is less likely to puncture a blood vessel and inject filler where it doesn’t belong
How is cannula filler done?
The cannula delicately and precisely places a biocompatible material under the skin to lift the sunken area. Or to shape the jaw line
There are multiple dermal filler brands available (Restylane, Juvéderm, Restylane, Revolax, , Belotero, Volbella, Vollure, etc.), and these consist of gels that are packaged in a syringe or a tube. At the tip of this tube is a cannula that delivers the gel in the right place.
Cannulas for the tear trough, and jaw lines improved safety and reduced risk of bruising. Here in the UK, many patients want to be able to return to their busy lives with minimal recovery time. The cannula can that much more likely than needle treatments for example tear trough treatment.
However, you don’t need to use cannulas for every filler treatment as certain situation are better suited for needle injections (e.g. shallow fine lines, acne scars, and surgical scars).
Dermal filler injections can be used in a variety of areas to add volume to the skin. A popular area being the cheeks. Sometimes the cheeks can look sunken and the face profile looks flat & lacklustre. Fillers help to regain the youthful curve of the cheeks and a strong facial contour. Skin looks tighter and more lifted.
First things first, a discussion with the client on what their desired look they want to achieve from cheek augmentation using dermal fillers. The dermal filler injections will be injected across both sides of the face while focusing on the target areas. The treatment will last about 25 minutes. Your client may experience slight swelling, redness & minor bruising afterwards but this will dissipate within a couple of days.
As with all treatments it is expected that they will experience some slight discomfort throughout the procedure. A numbing cream will be applied pre-procedure to help reduce any discomfort. Most mainstream products that are used to augment these areas contain lidocaine within the syringe, which makes the process even more tolerable. This will also help with pain after the treatment. Ice can also be used to reduce swelling.
Remember each face is unique, and therefore delivery of product should be considered in a bespoke manner. In addition, the cheek is not seen at its best in either a frontal or a profile view, it defies any exact measuring system. The influence of the cheek is best seen in a quarter or oblique profile view which is how most people see the face anyway. It is possible to isolate the most optimal area of cheek enhancement by the intersection of an oblique line drawn from the corner of the mouth to the corner of the eye and a horizontal line drawn outward from the top of the nostrils.
Consultation is key
Clients may arrive at your clinic highlighting a specific aesthetic flaw that they see. Not being experts within the field, they may misinterpret where they require treatment for example, tear trough filler or nasolabial folds, when it actually comes down to the volume loss in the cheeks.
Filling in the cheeks is often a superior alternative solution to filling in the nasolabial folds, although often it can be complimentary to work on both areas.
Identifying the root cause of the problem itself will always ensure a more favourable outcome – ensure you explain your opinions and your professional approach to your client before beginning. Always ascertain their understanding as to how you- the professional, deem it best to proceed for best post results.
As your own tissues are more mobile & pliable than any product that can be injected it is recommended In the cheek area, to inject deep-to the depth of the bone, just above the periosteum of the zygoma. This will allow the hyaluronic acid to sit below the muscle and hence the patient’s own tissues, resulting in a smooth contour. In addition smiling and laughing will recruit movement of their own muscle and dermal layers without interruption from foreign products. If the product is placed above the muscle, it can create a distortion of the facial features when the client makes an expression.
For subtle contouring as a rule of thumb, use 1ml between both cheeks or to give a cheek bone a subtle highlight. For others with greater volume loss, or who require a more contoured look will need 1ml each cheek, this will be assessed and agreed during consultation.
POINT A IS 0.1ML
POINT B IS 0.2ML
POINT C IS 0.3ML
What You Should Know about Necrosis
Necrosis is caused by a lack of blood and oxygen to the tissue. It may be triggered by chemicals, cold, trauma, radiation or chronic conditions that impair blood flow. There are many types of necrosis, as it can affect many areas of the body, including bone, skin, organs and other tissues.
One common type of necrosis is caused by damage from tissues after dermal fillers. Any time blood flow is blocked to an area, i.e. with filler or an area is so damaged that blood cannot flow to and from it, necrosis may be possible.
Injection necrosis is a rare, but important, complication associated with dermal fillers. Necrosis can be attributed to one of two factors—an interruption of vascular supply due to compression or frank obstruction of vessels by direct injection of the material into a vessel itself.
The Use of Hyaluronidase in Aesthetic Practice
There are several sources of hyaluronidase and they are generally divided into 3 subgroups (Meyer7), mammalian (obtained from the testis), hookworm/leech and microbial although recombinant human hyaluronidase is now available (Hylenex, from Halozyme Therapeutics, San Diego, California) which has a purity of 100 times higher than some currently used Bovine preparations8. There are no long-term data for this product yet but it is likely to have a lower proportion of allergic reactions.
This guidance refers to the use of Hyalase® (Wockhardt) which is readily available in the UK as a 1500 unit ampoule of powder for reconstitution and is of ovine (sheep) origin.
Off-label use of hyaluronidase
Although hyaluronidase is not licensed for the use in correcting problems with dermal filler injections and off-label promotion is not allowed by Article 87 of Directive 2001/83/EC, its use is allowed provided the patient’s best interest and autonomy are respected and forms part of the informed consent (MHRA, 2009).
What should be treated?
Vascular compromise as a result of hyaluronic acid filler injection should be treated immediately (refer to Aesthetic Complications Expert Group, Necrosis guidance). Signs of impending necrosis include pain, prolonged blanching (reticulated white or dusky appearance of the skin) and coolness of the skin. Hyaluronidase should be administered as soon as this complication occurs, there is good evidence that tissue necrosis will be prevented or be less severe the sooner the hyaluronidase is injected5.
The Tyndall effect refers to the scattering of light that may be seen in some patients after injection of hyaluronic acid resulting in a bluish hue of the skin (refer to Aesthetic Complications Expert Group, Tyndall’s effect guidance). It is often caused by injecting too superficially, placing large boluses of product in one area or using an inappropriate product for the area treated. It is most commonly seen in the sub ocular region. By degrading the hyaluronic acid using hyaluronidase, this problem can usually be corrected.
Overcorrection or misplacement of hyaluronic acid filler can be successfully treated with hyaluronidase although this is often caused by poor injection technique or poor choice of product for a particular area.
Lumps or nodules that may appear several months after the initial treatment may be amenable to hyaluronidase (refer to Aesthetic Complications Expert Group, Delayed Onset Nodules guidance). It is important to remember that hyaluronidase is used to help diffuse fluids intradermal and for hypodermoclysis so if the nodule is thought to be infective, it is important to administer antibiotics to prevent further spread of infection (refer to Aesthetic Complications Expert Group, Infection guidance).
Storage and reconstitution
It is recommended that hyaluronidase should be stored at cool temperatures (2-8oC) as this guarantees the quality of the product over a long period. If storage is at room temperature (25oC), the stability is only guaranteed for 12 months.
Hyalase® may be reconstituted with either saline or water for injection. Reconstitution with saline tends to produce less stinging so is recommended. Although local anaesthetics may be used to reconstitute the product, as the enzymatic action of hyaluronidase can be affected by pH, care should be made with diluents. Hyaluronidase is indicated to improve permeation of subcutaneous products so the injection of local anaesthetic as a diluent may lead to wider spread and increased systemic absorption. For this reason, this guidance does not advocate the addition of local anaesthetic.
Reconstitution instructions: Open a 10ml ampoule of saline and add 1ml of saline to the opened ampoule of Hyalase®, ensure the powder is fully dissolved (draw up and expel the syringe a couple of times to ensure complete mixing). Aspirate the 1ml of saline with the reconstituted Hyalase® and re-introduce it into the ampoule of saline. Agitate the ampoule to ensure the Hyalase® is mixed throughout the whole volume of saline. This now gives a concentration of 150 Units/ml. The reconstituted solution can now be drawn up in a 0.3ml or 0.5ml syringe with a 27G or 30G needle. Each 0.01ml graduation represents 1.5 Units.
At Enhance Me Academy, we pride ourselves on our knowledge, expertise and the fact that we are on the forefront of new and upcoming aesthetic treatments.
We have partnered with Lipology to offer a range of fillers, designed to improve safer practice within the services we offer. We stock filler for purchase at our academy and will help you to decide which range will meet the needs of your clientele.
Why not take a look at our range, it’s Genius!
Genius filler is designed to give a better volume effect and overall retention, boasting optimal viscoelasticity and long-lasting volume.
Thank you for choosing Enhance Me Academy!
We hope you enjoyed your online learning experience.
What can I do next?
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