AESTHETIC FOCUS

The Linear Bolus Technique and other practical tips for the advanced use of non-traumatic cannulas in aesthetic medicine

BY JANI VAN LOGHEM

ome eight years ago, I read we focus on mastering of the cannulas in a sterilely. Then, using sterile gloves, it is about non-traumatic cannulas treatment protocol that addresses many safe to prepare your syringe, mix lido in the brochure of a French age-related anatomical changes, using and touch the cannula with your gloves. Smedical supplies company. I minimum amounts of product placed 3. Determine and mark the entrance was fascinated by the elegance of these strategically to give maximum results. places. Give a small amount (0.05- instruments, as they respect the integrity Here, I would like to share a part of the 0.1ml) of lidocaine with adrenalin of the tissues by not cutting through contents this course. at these markings for haemostasis. them. It seemed so logical that, where Within a few minutes, you will see with liposuction this is the standard, that Practical tips for controlling the blanching effect of the adrenalin with injectables a similar instrument non-traumatic cannulas on the skin. This will give you higher should reduce risks of bleeding. So I 1. Disinfect! Cannulas are long and patient comfort, as the stab needle, ordered some 27G/40mm cannulas won’t become blunt after repetitive as well as the passing of the cannula, from them. And when the cannulas use on your patient. Especially when will be painless, plus the chances finally arrived in my office, I was very placing product superficially, the of haematoma are reduced by the eager to start using them on my patients risk of infection increases, because vasoconstriction. and was already talking to them about the chances increase of the cannula 4. Lift the skin where you want to how the chances of bruising would be touching a non-disinfected area. At introduce the stab needle. By lifting considerably less. But when I did, I found high quality scientific congresses the skin, you reduce the chance of myself struggling enormously and I felt like F.A.C.E.2f@ce in Cannes, more accidentally puncturing a large blood quite clumsy with them. They seemed and more attention is focused on vessel, as large vessels are generally in a to have a will of their own and kept on complications and the term ‘biofilm’ deeper level. ending up in places that I did not intend is an often discussed subject. This is a 5. Use a stab needle that is at least the them to be. Even though I had made an low-grade infection that can remain thickness of the cannula, or thicker. opening with a needle, the skin seemed asymptomatic for some time. Especially Thicker will allow for easier passing of quite resistant to the cannula and did not with high-volume treatments like the the cannula. allow the cannula to pass. The dermis ‘Liquid Facelift’, we have to be very 6. When you’ve inserted the stab needle, seemed like a brick wall. My patients meticulous and use a surgical approach just insert the tip of the needle, so ended up bruised and traumatised to disinfection. I advise disinfecting the that you only pass the dermis and after these first attempts. Logically, my entire face, including the hair around not deeper. The deeper you advance ego got in the way, and I decided that the ears and the temples, plus the skin the needle, the higher the chance of cannulas had no place in my office, so I of the neck. When using the cannula creating a haematoma. switched back to the good old and easy close to the hair, it is advisable to place 7. Then, try to withstand the temptation to control needles. sterile wet gauzes on the hair. of repetitive puncturing of the skin. The Of course, the cannulas kept on 2. No Touch technique! I usually use more you keep on stabbing the skin, the intriguing me so I invested some time into non-sterile gloves for my injectable higher the chances of bruising. figuring them out. And as it turns out, you treatments, and therefore I never touch 8. Leave the needle inside the skin for just need to know a few tricks and after a the cannula with my glove. If you like to some time to allow any blood to small learning curve, you will love them so take the cannula between your fingers, coagulate. In the mean time, you can much that you’ll want to marry them. I would advise making a sterile field prepare your syringe for injection. In my clinic in Amsterdam, I receive on which the syringe, the cannula, the 9. If you use a needle that has exactly the many international colleagues for hands-on luer-lock connector, the sterile gauzes, same diameter as the cannula, you can training. During our ‘Liquid Facelift’ course, and all the other necessities are placed make a scraping motion when you take

pmfa news | DECEMBER/JANUARY 2016 | VOL 3 NO 2 | www.pmfanews.com AESTHETIC FOCUS

The Linear Bolus Technique Here, the Linear Bolus Technique is displayed schematically.

1. Place cannula on the periosteum. 6. Repeat these steps.

2. Advance the cannula. 3. Place a bolus of 0.05-0.1ml.

4. Retract the cannula approx. 1cm. 5. Place a second bolus.

out the needle. Scraping the dermis with 15. Keep in mind that if you use force, there resistances. the needle tip will make the opening is a chance of overshooting the SMAS 19. For the optimum use of the limited slightly bigger and thus it will be easier to and your cannula could potentially end product that we have available to our pass the dermis with the cannula. up in places you don’t want it to. So patients, the Linear Bolus Technique 10. When you can’t find the opening that protect important structures like the can be used. This technique is meant for you’ve just made, squeeze the skin until eyes by creating a physical barrier with deep deposition of product for lifting of you see a small drop of blood that marks a finger of your non-dominant hand, the soft tissues. Placing boluses on the your opening. placed on the orbital rim or the infra periostium of the zygoma in a ‘Liquid 11. For easy entrance of the cannula, spread orbital foramen, for example. Facelift’ will lift the cheeks back to the opening in the skin with thumb and 16. If you want to place the product in a their original position. If you would like index finger. That way it becomes easier superficial layer, close to the dermis, to place your limited volume in linear to hit your target with the cannula. then stretch the skin in the direction threads, you will have much less lifting 12. When you feel resistance while trying of the cannula by placing your thumb power than if you place the product in to pass the dermis, rotate the cannula behind the entry hole and your index concentrated boluses. by swiftly twisting the syringe between finger in front of it. your thumb and index finger, like rolling 17. If you push down the syringe, the a pencil between your fingers. Like the flexibility of the cannula will direct the rotating drill of a drilling machine, it will tip upward. This way, you can keep become much easier for the cannula to the cannula at the dermal-subdermal pass resistances on its way. junction. Cannulas of 27G and thinner 13. If you want to place the product at a can behave like needles because they deep level, lift up the tissue in front of are so thin. These cannulas can be Jani van Loghem, the cannula to create a path of least manoeuvred intradermally with some resistance to the deep level. effort and discomfort of the patient. Aesthetic Physician; 14. If you want to advance the cannula to Real intradermal injection is not Owner, Doctors Inc. Academy, the deep fat, or the supraperiosteal recommended while using cannulas. Amsterdam, plane, you have to pass the superficial 18. Whenever you feel any resistance The Netherlands. musculo-aponeurotic system (SMAS), at the superficial level, for example, E: [email protected] which can be quite tough. In this case, while passing the septae between Declaration of competing interests: use the rotation technique again to pass the superficial fat compartments, use None declared. through the resistance of the SMAS. the rotation technique to pass any

pmfa news | DECEMBER/JANUARY 2016 | VOL 3 NO 2 | www.pmfanews.com