Manual

MANUAL

ANATOMY PHYSIOLOGY

DERMAL FILLERS:

The skin is made up of layers. The (usually) thin outer layer is called the epidermis. Beneath the epidermis lies the dermis which is up to 20 times thicker than the epidermis. It is into the dermis, at varying levels, that dermal fillers are injected.

LIP ANATOMY

THINGS TO CONSIDER

TREATMENT STAGES:

Consultation

Medical and photographic documentation

Make-up removal

Disinfection

Anesthesia

Disinfection

Injection

Massage for proper acid distribution, also acceptable during injection

Aftercare advice and side effects

Your client’s expectations should be carefully dis cussed prior to treatment, due to the numerous options. We recommend an objective assessment around the mouth and lip area. Not all clients qualify for a perfect cupid bow or injection into the gutter column. Clients should also be warned that we build the lips up in time and we cannot always build beau tiful, emphasized lips, with a perfectly highlighted cupid’s bow in one treatment, sometimes it requires more treatments over time.

Side Effects - Should only fast a few days and are temporary, they may include the following:

• Bleeding from injection sites

Bruising and swelling

• Redness and tenderness at the site of injection

• Reactivation of cold sores or fever blisters (herpes simplex) of the lips or surrounding areas.

COMPLICATIONS:

Severe and prolonged swelling or bruising lasting one week to 10 days

Lip asymmetry (part of lips are different sizes)

Lumps and irregularities in the lips

Infection

Injection into blood vessel, causing tissue loss

Ulceration, scarring or stiffening of the lip

Allergic reaction causing redness, swelling or itching around the lips

Vascular compromise

ALWAYS ASK IF A CLIENT HAS A KNOWN MEDICAL CONDITION AS THIS LIST IS NOT EXHAUSTIVE

CONTRAINDICATIONS:

Some clients may have known medical conditions that put them at a higher risk for complications, if they decide to have an aesthetic treatment. These can be the following:

• Pregnancy and breast feeding

• Antibiotics (14days from last day of receiving)

• Epilepsy

• Diabetes Type 1

HIV & Hepatitis

Autoimmune Disease

Cancer

Active cold sore, eczema, psoriasis

Any Allergy

Alcohol

COMPLICATION VASCULAR COMPROMISE

ARTERIAL PRESENTATION

Immediate or early blanching, livedo reticularis, pain in most cases

TREATMENT STOP INJECTING

Inject hyaluronidase into affected area, massage, warm compresses, aspirin. Repeat hyaluronidase injections, massage and warm compresses Q lhr until capillary refill is normal. Continue follow up until complete recovery 72ms ASA OD x7 days

NESCROSIS/ SLOUGH

VENOUS PRESENTATION (LATE)

Presents with redness or dark discolouration, herpetic like lesions, discomfort

REATMENT

Inject hyaluronidase into the affected area, warm compresses 0 lhr until capillary fill is normal

Follow up with patient frequently, continue hyaluronidase if needed, consider hyperbaric chamber. Continue wound care, PO and typical antibiotics, PO antivirals, POprednisone, surgical debridement and hyperbaric chamber. Consider stem cell PRP to reduce scarring (fractionated laser as soon as healed). Refer to specialist for wound care +/-psychological support

TECHNIQUES

LIP TENTING AND DROPLET TECHNIQUE:

• The goal of the Lip Tenting technique is to control both shape and volume of the lip during the pro cedure, lifting the vermilion border to optimise the lip projection. The needle is inserted multi ple times injecting down from the vermilion bor der, towards the centre of the lip as the needle is withdrawn, the hyaluronic acid is injected to give volume inside the muscular part of the lip and to form pillar-like structures that project the vermilion border. It is important to do so without filling the vermilion border itself to avoid a plump aspect of the lip border.

• In the upper lip, the lip is injected approximately every 3mm, from the mouth corner towards the beginning of the philtrum. This will strengthen the lips and will enhance the shape of the phil trum by simply not touching it.

• In the lower lip, to obtain a natural result it is advisable to start injecting approximately 5mm. away from the mouth corner, all the way to the centre of the lip to define a nice contour.

• This technique will give ample opportunity to con trol the volume and shape of the lips by adjust ing the pressure on the syringe, keeping an eye on the position of the needle tip at all times. In general, young lips will need more volume in the central body of the lip, to obtain a result which is appreciated according to ‘fashion’, whereas in older patients, reconstruction of the lip contour can be more sought after. Moreover, because of the multiple injections, risks of large single vol umes of gel giving rise to palpable or even visible lumps are minimal.

TECHNIQUES

• The needle is inserted in a fashion similar to that used in linear tech nique, but immediately before the needle is withdrawn, its direction is changed and a new line is injected. This technique is best suited for lips on a more mature client, or a client who is looking for a more natural lip enhancement.

HEALTH & SAFETY IN YOUR CLINIC

for regular collection

SHARPS DISPOSAL

Proper law ensures that all needles are disposed safely. The only way to do it is using the Yellow Sharps Bins. Those are containers that once closed cannot be opened normally. All sharps bins need to be collected by a clinical waste contractor who has a license to dispose of medical waste. Doing it in another way is against the law.

THE SKIN STRUCTURE

The skin consists of two distinct layers: the epidermis and the dermis. Each layer is made of distinct tissues and performs distinct functions to support the body. A third layer of tissue under the skin, known as the hypodermis or subcutaneous layer, is not truly part of the skin itself but connects the skin loosely to the underlying muscles and bones that make up the deeper tissues of the body.

LIP ANATOMY

LIP ANATOMY

Each client is a separate case that must be individ ually analysed. Each client’s lips will be different in width, shape, volume, intensively of the red. Their texture may sometimes be similar, but it will never be the same.

The Arterial bloody supply to this area is provided by two branches of the external artery and one branch of the internal artery.

After wrapping around the lower edge of the man dibular body, the facial artery reaches the corner of the mouth, the other branch is maxillae’s artery.

The arteries that supply the lips with blood are:

- Columellar a.

- Superior labial a.

- Inferior labial a.

- Mental a. - Labiomental a. - Submental a.

Superior labial vein — a tributary of the facial vein that drains the lip.

Inferior labial vein — the vein receiving blood from the lower lip

The superior labial artery — a branch of the facial ar tery. This artery supplies the skin and muscles of the upper lip, the nasal septum and the alae (wings) of the nose.

The superior labial artery is larger than the inferior labial artery. It arises from the facial artery as the fa cial artery ascends to the maxilla and then goes along the edge of the upper lip, lying between the mucous membrane and the orbicularis oris muscle. The su perior labial artery forms anastomose with the same artery of the contralateral side and also with the in ferior labial artery.

On its course, the artery gives off an alar branch and a septal branch, which ramifies anteroinferiorly in the nasal septa.

The inferior labial artery — a branch of the facial ar tery that arises near the edge of the lower lip. This artery supplies the skin and muscles of the lower lip.

The inferior labial artery passes anteriorly beneath the depressor anguli oris muscle penetrating the or bicularis oris. It runs along the margin of the lower lip between the orbicularis oris muscle and the mucous membrane. The artery forms anastomoses with the same artery of the contralateral side and with the mental branch of the inferior alveolar artery.

HYALURONIC ACID

ets. Hyaluronic acid is crucial for health and beauty. First of all, its fundamental function is to maintain structural proteins, i.e. collagen and elastin, thus making the skin taut, supple and elastic. Secondly, HA binds water molecules, which makes it important to moisturize the skin.

HYALURONIC ACID — properties

Hyaluronic acid is responsible for moisturizing the skin and is even one of its main components. In fact, the extracellular spaces in the living epidermis are rich in hyaluronic acid. Its presence is therefore es sential to maintain skin hydration and the condition of its tissues. Together with collagen, it is considered the source of skin youth. Basically hyaluronic acid is similar to a sponge. After the age of 25, the amount of hyaluronic acid in the dermis slowly decreases, and this process intensifies around the age of 40. The skin regenerates slower, its colour is less even, it becomes dry, and the initially mimic wrinkles become stronger and deeper. As the amount of hyaluronic acid in the skin is reduced, it becomes less resistant to external factors and more sensitive.

Hyaluronic acid in cosmetology

It is the basic ingredient of moisturizing cosmetics, creams, masks, body lotions and even tonics. Crosslinked hyaluronic acid does not break down quickly

in the skin, therefore it is used in anti-aging thera py to fill wrinkles and model facial contours. Due to the fact that it is a substance that occurs naturally in the human body, its use in aesthetic medicine treat ments is so popular and relatively ‘safe’, as long as we are in good hands and the product comes from an appropriate source.

Hyaluronic acid in treatments

It is a medical device, which means that it has direct contact with the body, can be introduced into the body, but does not mean that it is a drug. Medical devices include, among others: prostheses and im plants. The main requirement of a medical device is to be patient-safe. According to the law, hyaluron ic acid must have a medical device certificate. This means that the manufacturing company must meet the standards of production conditions and product repeatability, as well as have the test results which directly show that their product is not harmful.

TYPES OF HYALURONIC ACID

• NON CROSS-LINKED

It is used in needle mesotherapy, it moisturizes, revitalizes but does not fill. It gives a short-term ef fect.

• CROSS-LINKED

There are three types of cross-linked acid: — thin (used for lips, smoker’s lines, wrinkles around the mouth)

— medium thick (lips, nasolabial folds)

— thick (volumetry - chin, jaw, cheeks)

Uncross-linked hyaluronic acid disintegrates very quickly, after about two days its half disappears in order to increase the retention time of the prepara tion, it is subjected to cross-linking, i.e. clumping of parties into larger conglomerates.

MEDIUM THICK/DENSE HA

Mostly used for lip beautification.

DIFFERENCES BETWEEN PREPARATIONS

— Cross-linking agent

— Product density

— Excipients, e.g. lidocaine

— Product flexibility

— Holding duration

PRODUCTS

We recommend You practise with different brands, so You can find the ones You most like to work with, You will see they are all different in terms of use — pressing force required, dosage etc. You should ad just Your prices according the brand of dermal filler preparation You will use. Filler’s prices range from £40 to over £100 so this may help You determine the final price of the treatment. Remember, fillers are single use, they must be disposed after use and can not be shared between clients!

FILLER MANAGEMENT

- Fillers must be stored as per manufacturers guidelines.

- No storage of fillers once syringe opened/seal broken.

- Single patient, single indication, single use of specific filler

- Safe disposal as above

Complete list for filler treatments: - dermal filler - numbing cream

- latex-free gloves - PPE - make up remover/facial wipes - sharps bin - couch roll - emergency drugs

All of the above You can purchase at the pharmacy or official dermal filler distributors in the UK. We also recommend amazon: good for gloves, sharps bin and PPE.

CONTRAINDICATIONS

Contraindications to treatments with hyaluronic acid are divided into absolute and relative.

ABSOLUTE CONTRAINDICATIONS:

- Acute or chronic skin conditions/diseases in the treated area

- Active infection or inflammation of the treated site / area (e.g. herpes)

- Skin diseases in the place of the treatment

- Allergy to any of the ingredients included in the filler

- Pregnancy or breast-feeding the filler

- Active autoimmune diseases

- Diabetes

- Epilepsy

- Granulomatous dermatitis

- Neoplastic diseases (due to possible adverse effects)

RELATIVE CONTRAINDICATIONS:

Blood coagulation disorders

Taking anticoagulants

immunosuppression (the body treats the filler as a foreign body and absorbs / metabolizes the product very quickly)

Antibiotic therapy

Tendency to form scars and keloids (ABSOLUTE, un less facial treatments have already been performed, scarring have not formed and the client demands the treatment at her own risk)

Vitiligo / psoriasis / rosacea

Mouth infection e.g. tooth decay

Client’s age under 18 years

ASPIRATION VS RUSSIAN LIPS

An injection is defined by World Health Organisation (WHO) as parenteral administration of medication through a skin puncture via a syringe, while aspira tion is defined as the pulling back of the plunger of syringe (for 5-10 seconds) prior to injecting medi cine. Aspiration is puncturing a most commonly per formed during an intramuscular (IM) or subcutane ous (SC) injection, and is meant to ensure that the needle tip is subcutaneous at the desired site, and has not accidentally punctured a blood vessel.

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure.

Performing aspiration is fixing our needle in the po sition we are about to inject, pulling back on the plunger of the syringe and ensuring no blood has pulled back into the syringe. If there is blood, this would imply that we might be in a blood vessel and hence not safe to inject. Then it’s recommended not to inject and dispose the syringe. A new product should be opened, and aspiration process repeated. If the syringe remains clean after aspiration, then it’s possible to proceed with injection.

There are 2 reasons why we rarely aspirate with Rus sian Lips. First we’re injecting closer to epidermis skin layer. Second, we’re leaving thin, linear vectors, not boluses, which means that even if it’ll hit the vein it is very unlikely to block it.

DRUG INTERACTIONS

Drugs which can cause possible reactions with by hy aluronidase: Furosemide

Benzodiazepines

Phenytoin

Dopamine

Alpha-adrenergic agonists

In case of any doubts, refer to BNF or contact the prescriber or pharmacist for advice. Several drugs act as antagonists to ibuprofen, aspi rin, diclofenac, antihistamines. If concerned confirm with pharmacist or check (British National Formu lary) before administering. At the moment there are no other medicines available in the UK that contain hyaluronidase as the active ingredient.

EMERGENCY REVERSAL PROTOCOL (DISSOLVING DERMAL FILLER USING HYALURONI DASE) Indications:

Persistently pale/appearing white skin area

Absent or slow capillary re-fill Skin pallor area distant to injection site

Extreme and increasing pain in the untreated area

HOW TO MANAGE

1. If a client has symptoms of a possible vascular occlusion, firstly refill. ask for photos showing treatment area and a video of capillary

2. Remain calm, communicate Your messages clearly and calmly.

3. You could have hrs for a reaction before

4. Optional — contact prescriber necrosis occurs. or Your Trainer for advice/support.

5. Diagnose blood supply compromise. Bring the clients if possible so you can assess in person and check the capillary refill Yourself.

6. Explain diagnosis and treatment options, ex plaining what may happen in left untreated

7. Seek client’s consent to administer hyaluroni dase

8. Prepare hyaluronidase: 1500 IU Hyalase + 2ml Saline + Syringe, green and yellow needle. With a syringe and a needle draw up 2 ml of seline. Snap the glass vial of hyaluronidase and inject 1 ml of saline into the vial to dissolve the product. Then draw the solution back to the sy ringe what we will leave You with 2 ml saline and 1500 IU Hyalase mixture. Change the needle to a smaller one and inject.

9. Allergy testing. Factors to consider whether this is necessary are client’s history of allergies and how would You manage an anaphylactic reaction in Your current environment. Take into consid eration also that tissue necrosis occurs in hours, not minutes so if the client seeked immediately for help, You may have time to do a patch test.

ALLERGY TEST ON FOREARM

Inject an intradermal bleb of the hyalase (5 units) and right next to it inject saline as control for comparison. Wait around 30 mins for results.

If both injection areas look the same, the risk of reac tion is low, proceed with hyaluronidase. If red spots or other reactions appear - seek advice from Your Trainer/pharmacist/more experienced Professional before injecting.

10. Optional: Soluble Aspirin 300 mg can be used whilst aller.gy Progress to reduce the risk of a blood clot further redosing blood supply to af fected area.

11. Inject Hyalase solution. In emergency use which ever needle you have at hand. The smaller the better for client’s comfort, the occlusion took place in the bottom lip, inject hyaluronidase all over the entire than just one area. You do not need aspirate. It can be painful so advise it. The pain is short-lived, and the client should feel a re lief almost straight away. It will be more comfort able and barrable to them to stand it.

12. Apply a warm compress and massage the area to promote the enzyme activity and dilate vessels. Keep checking capillary re-fill and repeat this cy cle 4 times (massage, warm compress and check cap-refill).

13. Inject a further -.5-1 ml hyaluronidase every 1520 minutes.

14. If You fail to retrieve blood flow within 2 hours, refer to specialist consultant to prevent further damage.

ELECTIVE REVERSAL PROTOCOLNon-emergency filler dissolving

Determine the reason for dissolving.

Non-emergency dissolving should be done only if absolutely necessary due to risk involved.

3. Remember the hyaluronidase can dissolve cli ent’s own hyaluronic acid as well as the dermal filler, so the area may not return to the original shape/size.

4. Explore and discuss other possible options.

5. Explain risks and side effects of dissolving to the

client.

6. Gain informed consent.

7. Conduct skin test (follow the same steps as in emergency protocol above)

8. Prepare hyaluronidase solution: Hyaluronidase 1500 IU + 8-10 ml Saline + Syring es

9. Inject directly into the problematic area. For example, if want to dissolve a lump, inject into lump only. Use as much of hyalase solution as the HA You’d like to dissolve. For lumps dissolv ing we advise 0.2-0.4 ml of hyalase.

10. Inject with the same depth as You would inject the filler.

11. Swelling is common straying after hyaluronidase injection.

EMERGENCY DRUGS:

It is essential for You to have these medicines before You inject any clients. These need to be stored and taken with You everywhere you go to perform the treatments (mobile client etc.).

Epi-pen (if you cannot hold of an epi-pen, o can purchase adrenaline injections (1:1000) units, or Emerade 500mcg).

Hyaluronidase 1500 units x4

TOR-BAC Bacteriostatic Sodium Chloride Am poules Solution (to mix with hyaluronidase) 5mIx4

Aspirin it is a good idea to have Lucozade bottles, or sug ary sweets/drink stocked syringes:

2ml Luer-lok Syringe x2

10mI Luer-lok Syringe x2

10ml Graduated Syringe x3 needles:

23G Blue Needles x4

27G Grey Needles x2

30G Yellow Needles x2

first aid kit is recommended

AFTERCARE ADVICES

Note just after the procedure, you can deal with a temporary swelling resulting from the injection in the lip area. Bruises may also appear after the treat ment, both immediately after and within 2-10 days. The swelling may or may not be symmetrical. It can start immediately after the procedure, but also after a few hours. You may feel lumps for a few days.

Initial Aftercare:

Avoid touching the treated area or applying with products for 24 hours following treatment. After that light makeup can be applied and the area can be gently washed with soap and water. Until the initial swelling and redness has resolved please do not expose the area to intense heat. eg sunbeds, sunbathing or extreme cold. Please do not exercise for 48 hours after your procedure as it can cause migration of filler.

If you have previous suffered facial herpes, there is a risk that injections could contribute to an other eruption.

If you are using aspirin or any similar medication, please be or bleeding at aware that this may in crease the risk of bruising the injection site. Please don’t drink alcohol 24hrs after your pro cedure.

Any injection causes an inflammatory response —This means two things

This is not your final result - It is not uncommon for the things: treatment area to remain swollen for up to two weeks. During this time the area may look very uneven, feel bumpy, bruised, dis coloured and may feel sore. Please do not panic.