1 ALMD12057W MD Codes Book V2b FA.indd 1 29/06/2017 9:56 AM 3 Contents Introducing the MD Codes™ . 4 What are the MD Codes™? . 5 Why use the MD Codes™?. 6 The MD Codes™ and the VYCROSS® Collection . 7 Treatment considerations . 8 General aseptic precautions. 9 Gender difference . 9 Injection device . 10 Injection delivery .. 11 Targeted structures . 12 Injection technique . 12 Alert areas .. 13 The MD Codes™ have been developed by Dr Mauricio de Maio and all recommendations presented in this guide are based Using the MD Codes™ . 14 on his clinical experience. The injector is responsible for The 8-point lift . 16 customising the MD Codes™ for each individual patient. The 3-point forehead reshape . 22 Please refer to Instructions for Use before injecting. The 2-point temple reshape . 28 The 3-point eyebrow reshape . 34 The 3-point lateral periorbital reshape . 40 The 3-point tear trough reshape . 46 The 5-point cheek reshape . 52 The 3-point nasolabial reshape. 58 The 8-point lip reshape . 64 The 3-point marionette lines reshape . 74 The 6-point chin reshape . 80 The 5-point jawline reshape .. 86 Danger and alert zones . 92 References and mandatories . 96 ALMD12057W MD Codes Book V2b FA.indd 2-3 29/06/2017 9:56 AM 5 What are the MD Codes™? Practical injection strategies The MD Codes™ are a series of precise sites (or subunits) within each unit that are designed to guide injection . They are based on the principle that facial units have to be rebuilt, or treated, in an architectural mode . Each injection site is represented by a combination of letters and numbers . The letters represent the anatomical unit and the numbers indicate the sequence in which the injections may potentially be delivered . The most important injection site in a particular anatomical unit is represented by the number 1 and this should usually be the starting point . Injection site number 3 is typically an alert zone, and care should be taken in these areas . Every patient will have a specific sequence and may not need all of the MD Codes™ in the anatomical unit – each patient should be assessed and treated individually . Each code is depicted with a combination of the following: Introducing the MD Codes™ Letters The anatomical unit (e .g . Ck=cheeks) Numbers The subunits of the anatomical unit (e .g . Ck1=zygomatic arch; Ck2=zygomatic eminence) The side of the face (e .g . Ck1r is the zygomatic arch on the right hand side; Ck1l is the Number location zygomatic arch on the left hand side) Superscript (Xn) refers to upper areas (e .g . Lp1=vermilion body of the upper lip) Number position Subscript (Xn) refers to lower areas (e .g . Lp1=vermilion body of the lower lip) Colours Alert areas denoted in red Shapes Technical delivery of the product ALMD12057W MD Codes Book V2b FA.indd 4-5 29/06/2017 9:56 AM 6 7 Why use the MD Codes™? The MD Codes™ and the VYCROSS® Collection A landmark in facial aesthetics Product selection The MD Codes™ are a useful tool to help patients understand their treatment motivation . The VYCROSS® Collection, manufactured by Allergan, comprises of hyaluronic acid fillers designed to meet the specific anatomical needs of different facial regions . By presenting the MD Codes™ to the patient, they will point out the areas of concern so that the injector may discuss the appropriate codes for their individual treatment plan . The MD Codes™ can help the patient to understand why the improvement The VYCROSS® Collection of hyaluronic acid fillers includes: of a target area may be achieved by treating a neighbouring or distal area . JUVÉDERM® VOLUMA® Intended to restore volume of the face, for example, in temples, midface region, The MD Codes™ are treatment patterns that guide the spotting of injection points on the patient’s face, according to their with Lidocaine chin and jaw (≤2 ml per treatment area per session)1 individual treatment needs . They represent not only specific sequences of injection points but also act as a tool to facilitate the communication between patient and doctor . Treatment of deep skin depressions, face contouring and volume restoration to JUVÉDERM® VOLIFT® In addition, the MD Codes™ can be used to aid financial planning and patient follow up . correct facial structural defects such as asymmetry, contour deformities, volume loss with Lidocaine in the lips, cheeks, chin, lower face…etc .2 Treatment of any fine lines and medium-sized skin depressions . Enhancement JUVÉDERM® VOLBELLA® and pouting of the lips to correct structural defects such as asymmetry, contour with Lidocaine The MD Codes™ are a landmark in facial aesthetics, it’s a FACT deformities, volume loss…etc .3 Finance Patients come with a specific budget Unique crosslinking technology Assessment Accurate diagnosis must be made VYCROSS® technology is a proprietary4 mix of low and high molecular weight hyaluronic acid, combined with a crosslinking Communication Clarify “Patient wants vs . Patient needs” process, which results in an efficiently and tightly crosslinked gel .5–9 This tight hyaluronic acid network results in: Technique Precise and safe injection can help achieve desired outcomes • Greater resistance to degradation, delivering long-lasting duration .5,7–9 • Minimal gel expansion due to low water uptake coupled with low hyaluronic acid concentration .5,9 This patented technology4 allows the customisation of gel hardness (G’) and cohesivity, resulting in products with optimised lift and mouldability .5–7,9 ALMD12057W MD Codes Book V2b FA.indd 6-7 29/06/2017 9:56 AM 8 9 General aseptic precautions The presence of active bacterial or viral infection should postpone treatment .1–3 Maintaining an appropriate aseptic environment will help reduce the risk of infection . Ensure the patient has removed any makeup and prepare the skin with antibacterial soap or alcohol .10 Wash your hands, wear appropriate clothing and use sterile or disposable gloves and equipment . Ensure you have everything you need before you start injecting . Gender differences Gender differences should be taken into account when individualising treatment . Treatment considerations Recommended for men Injection point for a more masculine outcome Recommended for women Injection point for a more feminine outcome ALMD12057W MD Codes Book V2b FA.indd 8-9 29/06/2017 9:56 AM 10 11 Injection device Injection delivery The choice of injection device should be based on individual experience and preference . Micro-aliquot Very small droplet of filler (0 .01–0 .05 ml per point) • May minimise risk of intravascular injury and bruising Cannula • Recommended for use in alert zone areas Aliquot Static injection of a small amount of filler (0 .1 or 0 .2 ml) • May be preferred for fine, controlled injections Needle • Ideal for bolus at the supraperiosteal level Small bolus Static injection of filler (<0 .3 ml) • Injection of JUVÉDERM® VOLUMA® with Lidocaine with the supplied 27G 1/2” sterile needle is recommended .1 Use of a cannula where mentioned is the recommendation of Dr de Maio .* Linear Antegrade or retrograde • Injection of JUVÉDERM® VOLBELLA® with Lidocaine with the supplied 30G 1/2” sterile needle is recommended . It is possible to use a 30G sterile cannula 2. • Injection of JUVÉDERM® VOLIFT® with Lidocaine with the supplied 30G 1/2” sterile needle is recommended . It is possible to use a 25G, 27G or 30G sterile cannula 3. Fanning Multiple linear injections via a single entry site creating a fan-like pattern *Use of cannula with JUVÉDERM® VOLUMA® with Lidocaine has not been validated by Allergan. ALMD12057W MD Codes Book V2b FA.indd 10-11 29/06/2017 9:56 AM 12 13 Targeted structures Alert areas 1. To minimise the risk of injury to blood vessels and nerves, standard precautionary measures should be taken in all areas Dermal Mucosa of the face . These include injecting slowly and frequently checking for signs of pain and skin colour changes . 2. Alert areas are highlighted with a caution sign, where needle aspiration is highly recommended or the use of cannulas should be considered . 3. Standard injection technique should include reflux/aspiration of the syringe plunger to check if blood is drawn into the chamber . If blood is detected, withdraw the needle, compress and choose a different site . It is important to prime Subcutaneous / fat pads Supraperiosteal before injecting . • High-risk areas where additional caution must be taken if injecting at or near these sites Injection technique Alert area • Alert areas may be highly vascular, highly innervated or adjacent to critical structures or organs 1. Aspiration is highly recommended during deep injections close to the bone . 2. Avoid scratching the periosteum during injection, it can lead to pain and bleeding . The technique and depth of the injection vary depending on the area to be treated . Do not inject • Areas to avoid injecting with dermal fillers 3. Massage gently following injection to ensure tissue integration and even distribution of the product . A more robust massage may be needed in deeper planes with a higher volume . 4. When creating structure, remember that indirect changes may happen in neighbouring or distal areas . 5. Younger patients with mild-to-moderate deficiencies may require smaller volumes than older or more complex patients . 6. Do not inject more than 2 ml of JUVÉDERM® VOLUMA® with Lidocaine per treatment area in a single session . ALMD12057W MD Codes Book V2b FA.indd 12-13 29/06/2017 9:56 AM 15 Using the MD Codes™ The treatment codes provided in this book include guidance on product, choice of injection device, technique and a suggested volume range . These recommendations are based on the clinical experience of Dr de Maio and may be adapted based on the experience of the injector and the patient’s facial features .