Kimberly J. Butterwick, MD, is a dermatologist in private practice in San Diego. Her blog will focus on issues related to cosmetic dermatology.

BLOG: Tips from masters of aesthetics focus on neurotoxins, tumescent liposuction

I recently participated in the second annual Masters of Aesthetics Symposium in San Diego, which offered two days of practical advice with detailed how-to videos and live demonstrations.  I have reported on some of what was covered in my previous blog entry on Here are additional tips from the symposium:

Joel Cohen, MD, gave an important tip about neurotoxins to the frontalis: Don’t overtreat!  He feels this muscle is often overtreated leading to flattening, dropping of the brow or the frozen look. He educates his patients that he is trying to take the edge off the deeper wrinkles of the forehead rather than erase them and risk adverse events. His usual dose for the forehead is 4-6 units for Botox (botulinumtoxinA, Allergan) and Xeomin (incobotulinumtoxinA, Merz), and about 10 units for Dysport (abobotulinumtoxinA).

Rebecca Fitzgerald, MD, concurred.

Dr. Fitzgerald gave her usual amazing lecture and demonstration about replacing volume.  She bases her injections on observing the patient’s proportions, observing light and shadow, and analysis of anatomy, knowing which fat pad or boney change has specifically aged in a given patient. She has her patients open their mouths in order to better visualize volume loss in the temples. She likes cannulas in the deep medial fat compartment and often dilutes her hyaluronic acid with 0.5 cc of normal saline. 

Jeff Klein, MD, spoke about innovations in tumescent anesthesia with lidocaine not only for tumescent liposuction but other applications as well.  He advised that all bags of tumescent solution be labeled NOT FOR IV as there have been a few cases of inadvertent IV use.  He explained how antibiotics may possibly be added to tumescent solutions for surgical site infections in the future.

I had the opportunity to demonstrate filler techniques for the hand and lips. 

For hands, I use the 1.5 cc syringe of calcium hydroxyl apatite (recently FDA approved for the hands) and usually dilute it with 0.5 ccs of normal saline. I vary dilutions depending on the patient’s skin thickness. I prefer to use a 22 gauge 2 inch cannula and one or two injection sites and inject linear threads of product subdermally between the metacarpals up to the web space, followed by vigorous massage. Patients sit on that hand while the other hand is treated for hemostasis and smoothing. 

On the other hand, I demonstrated a different technique with a 28 gauge needle, simply tenting the loose skin and vein and injecting small boluses of product along the metacarpal spaces.

Both hands were pretreated with a topical anesthetic and prepped with Hibiclens before treatment.  I put a bleb of lidocaine before using the cannula and the patient stated that side hurt less.

Patients should ice and avoid strenuous activities with their hands for a few days to prevent swelling.  Compression gloves may be helpful for those who swell.

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