SANTA BARBARA, CALIF. Resist temptation.
When the patient looks good, but the syringe in your hand still contains leftover Restylane or Juvéderm, "Put it down," advised Dr. Allan Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif.
"Don't feel that you have to use an entire syringe on these patients."
"[Don't say,] I'll find a place to put it." You don't have to put it anywhere, he said during a panel on aesthetic complications during the annual meeting of the California Society of Dermatology and Dermatologic Surgery.
Dr. Wirtzer said most of the cases he sees for correction of aesthetic filler procedures boil down to technique error. "Many times, people are injecting too much, too superficial, too soon, and sometimes, it's just a poor choice of material," he said.
Filler materials are expensive, so some physicians want to inject every drop. But overfilled cheeks, nodular lips, and bumpy chins do not lead to patients satisfied that they got their money's worth, he said.
Overtreating a patient with permanent fillers doesn't last forever. "But you can see the results of overtreatment even with Restylane or Perlane or Radiesse for months and months, and these patients are not going to be happy," he said.
Silicone fillers are not for beginners. "If you don't have years of experience with long-term fillers and short-term fillers, don't go near silicone," Dr. Wirtzer said.
Among his other tips:
▸ Inject deeply, using as few needle sticks as possible.
▸ To avoid drift with Radiesse, massage "a great deal." Around the orbicularis muscle, stay very medial so that the facial muscles used in smiling do not create forces that push the material to the outside edges of the lips.
▸ When using Restylane, avoid bulges by injecting below the orbital ridge.
▸ Minimize pain with ice and topical and local anesthetics.
▸ Invest in $3 handheld squeeze balls, which create a distraction for the patient during filler injections.
▸ If you see a blanch and realize you have an infarction in a vessel, "vigorously massage the hell out of it."
Above all, be meticulous in preprocedure discussions with patients about expected sequelae of the treatment, Dr. Wirtzer advised. "When you discuss that a person's going to get red or going to get swollen, this isn't [seen as] a complication; it's a natural event that follows the treatment."
If it is discussed only after the fact, however, it is seen by the patient as an "excuse" meant to explain away a perceived complication, he said.
Dr. Wirtzer disclosed that he serves as a consultant to Medicis Pharmaceutical Corp., maker of Restylane, and Aventis Dermatology, maker of Sculptra.
'You can see the results of overtreatment … for months and months, and these patients are not going to be happy.' DR. WIRTZER