There was a controversial article recently published in the Wall Street Journal about the practice of dermatology. The journalist made every dermatologist sound as if we all entered the field to simply inject Botox, avoid night call and make a lot of money. Dermatologists across the country were outraged. And rightly so. The article grossly under-represented the essence of what it means to be a dermatologist.

The field of dermatology is so much more encompassing than the journalist’s petty over-simplifications. If my patient with a diffuse, itchy unrelenting rash of 6 weeks were to speak to the WSJ, he might have a different perspective to offer. I spend 80% of my day performing medical care mixed with mandated paperwork that continues to increase year over year. And I love the variety of puzzles it offers to me as a clinician. Patients need my help, and I can give it to them. Most of them are extremely grateful for it. It is intrinsically rewarding to care for another person, and the skin is truly the one organ we can fully visualize on the macroscopic level, realizing change with therapy.

However, I do love the aesthetic practice of medicine, too. It bit me as a dermatology resident. It has more to do with a fulfillment of my artistic expression rather than monetary gain. Plus, if I look more closely at the aesthetic patient, I find that with relatively small changes made on the outside, I sometimes spark exponential changes within a person. It can be as rewarding for me as my medical dermatology patient relationships, but in a different way.

If you were bitten by the aesthetic bug, and are a new injector of filler, these teaching pearls will likely keep you and your patients safer and happier on the road to aesthetic satisfaction.

 

Pearl #1:  Start as you plan to go.

If you learn to inject with both the needle and cannula injection technique, you will never be forced to use only needles, whether they be on face or body. Cannulas are wonderful injection tools for a variety of reasons.

  • Due to the blunt nature of a cannula, there is a much less likelihood of injecting vessels or nerves leading to occlusion and resulting in tissue necrosis (the worst-case scenario for an injector). We can never say “never” or “always” in the practice of medicine, and thus it is true with cannulas—it is not a full-proof method of avoidance of this unwanted complication, but it can greatly reduce the incidence, increasing the safety for my patients.
  • Cannulas create much less bleeding, bruising, and inflammation and therefore, result in little if any down time for my patients.
  • Cannulas give the patient a very natural appearance, and typically I find myself using less product to achieve optimal outcomes.
  • Cannulas are significantly less painful than needles, and your patients will thank you for this. There is also no reason to use topical anesthetic when using the cannula technique.

There are still times when a needle injection is necessary. Precision is better with a needle, and the anatomical location may require the use of the needle. As long as you are aware of the anatomical structures and the location of your needle, remember to aspirate prior to filler injection and use no more than 0.3cc in a single bolus, proceeding when needed with a needle! But, gain a comfort with cannulas from the start. You and your patient will be glad you did.

 

Pearl #2:  Stay on Label.

I strongly encourage new providers to stay on label during the first year of practice and inject into those areas which are FDA approved for that particular filler. There is literally a smorgasbord of options for every area on face, and some on body. This should not place a burden on new providers attempting to select the correct brand or specific product appropriate to address a particular patient concern.

It is only after working consistently with various fillers for at least a year, that an injector gains the familiarity needed to know when it acceptable to use a product in an off-label area, while still maintaining patient safety.

For your free guide to FDA approved areas of filler, go to https://www.drellenturner.com/

 

Pearl #3: Facial Filling with Hyaluronic Acid Products.

To new aesthetic providers, my third and final pearl is to utilize hyaluronic acid fillers on face. While I am an advocate of bio-stimulants, and have used them for over 20 years, they are not reversible. A wise professor once taught me that none of us have ever scored 100% on every test, 100% of the time. She may not have known of Elon Musk and his ability to parallel park a rocket, so perhaps that is not exactly accurate, but the point was made. Mistakes can be made. And if they are made, we must always be able and ready to correct them. This leads to my next pearl.

Pearl #4: Always Keep Hyaluronidase on Hand.

The moment you choose to offer hyaluronic acid filler procedures for your patients, and place your first order (or receive samples from your friendly representative), remember to order hyaluronidase. An ounce of prevention is worth a pound of cure! Better to have it and not need it, than to need it and not have it.

If ever the there are lumps or bumps present post-injection, a small amount of hyaluronidase can be used to dissolve the injected product. In addition, if the patient reports severe pain, or you see white or grey discoloration of the skin, immediately inject the product as these are signs and symptoms of vascular occlusion. In another module, filler complications will be discussed in further detail.

 

If you are a healthcare provider, check out Dr. Turner’s new website DrEllenTurner.com and sign up for her e-newsletter to receive tips, tricks and updates on injections, devices and life in this incredible but, sometimes overwhelming space we call aesthetic medicine.