Masterclass

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Complete Reflection

 

Assessment

Dr. Tapan Patel: We now have our next patient, Debbie. Debbie’s primary concern centers around her lip, so if we just concentrate on the lip indication, she tells me that as a baby she had surgery for a cleft lip. The palate was okay, but the cleft deformity was isolated to the lip only. She has had a number of surgeries, and the first couple were very successful, but in one of the surgeries it would appear that one of the stitches was made a little bit too high up, which has left her with a visible deformity. This troubles her to some degree, and she was wondering if there was anything non-surgical that could be done about it. I think one of the interesting things here is that with a patient seeking a correction of an underlying issue, we need to be very mindful that the result is less predictable. We are far less predictable now than if we were simply treating for enhancement or augmentation. The second thing about surgery is that all bets are off with the anatomy because surgery will change the tissue planes and create sheets of fibrosis and scar tissue that means that we cannot reliably know what plane the blood vessels are in. My idea here is if we focus on this area we see that it is a little recessed, so we will use a cannula to gently subcise the tissue under the mucosa and separate the planes of fibrotic tissue which are tethering this down. We will next lay in a gentle hyaluronic acid to stop the tissue reattaching, and for that we’ll use Juvederm Volbella. We will notice that we are higher up on her left side and lower on her right, so we will treat Debbie on her right to try and raise up the GK (Glogau-Klein) point on this side. Finally, we will match everything by everting the lower lip slightly and just projecting anteriorly, you can see that if I turn her towards me the lower lip has a very posterior inclination so we have this prominence due to the soft tissue under the lip, but then the actual angle of the lower lip is very posterior. Ideally, what we want to do is bring it out a little bit more gently, so we have a slightly more aesthetically pleasing resting pout. Any comments on that, gentleman? None, brilliant, let’s do it then! We have only given her a little bit of numbing with some topical anaesthetic cream, because with a patient like Debbie I want to be absolutely sure that we aren’t compromising the vasculature in any way. Accordingly, I don’t want to use a numbing block or any injected anaesthesia.


Treatment

Dr. Tapan Patel: We will begin Debbie’s treatment, and I am going to use a 25 gauge needle to make a prehole for a 27 gauge cannula. I am going to take a slightly lateral approach here, tenting the skin to make the little entry hole. Again, I want to be very superficial now, the first couple of passes that I make are all going to be what I call dry passes, so I am not going to inject any product, and I am aware of quite significant scar tissue, as we would expect. You can see that there is a little give, and now that I have seen that she has a degree of discomfort I am happy to inject small amounts of product, just not too much, so the amount I am injecting now is more to cause numbing than for any actual treatment. Our experience of treating patients with dramatic scars tells us that we do have a slightly altered pain perception as well, as we can get hyperesthesia of the nerves. I know you do a lot of scar tissue work, do you find that as well, TJ?

Dr. Tijion Esho: Yes, and what you do find, particularly when the area is trying to repair a lot of those nerve endings get buried in the scar itself so you do get hypersensitivity when going through that area of the tissue. What I think is important to understand is when you are using the cannula like this, even though you are using the cannula and not a needle, it can act like a needle if you use too much force.

Dr. Tapan Patel: Absolutely.

Dr. Tom van Eijk: It can be quite painful. As opposed to this scarring, I find that people are less sensitive in general.

Dr. Tapan Patel: There’s a completely different feel with my cannula as I go through, even a seemingly unscarred area like the red vermillion, I am aware of significant resistance and almost a gritty feeling, which we all recognise if we treat scars. I am trying to lateralise the product as much as possible. Because we are using a very soft product, it will take the path of least resistance, and that’s why we can’t just simply inject it blindly. If we do, it will just go wherever it can, and that’s going to be away from the scarred area. I am pinching here, and you can probably hear the little fibres just giving.

Dr. Tijion Esho: Would you, in her case, favour doing some external work on the scar tissue?

Dr. Tapan Patel: Absolutely, this is probably a chat fr another day, but you know I do a lot of work with scars and lasers, so I would definitely favour something like a fractional CO2 just to soften that scar tissue. As we spoke about earlier, what the cannula gives us a bit more safety and here the ability to do blind dissection, but what I want to do now is get some precision so that when I treat the other side I can put the product in a very precise location, so we will switch to a needle, and I am going to decant the product into a 0.3 ml Botox syringe.

Dr. Tijion Esho: I noticed those needles, I love those ones, from 4T Medical?

Dr. Tapan Patel: They certainly are, and I’ve got another video on how to decant the product, so anyone watching this video can just refer to that. Now what I want to do is try and match up the apex of the Cupid’s bow. You can see that we have created a little bit of height on this side, so what I want to do now is use this technique to just gently inject the product.

Dr. Tijion Esho: I think you might be tenting again, Tapan.

Dr. Tapan Patel: It definitely looks like it, doesn’t it! Now, I’ll go just slightly from inferior to superior, and the idea is just to try and restore some of the symmetry, I’m trying to drop this side and raise the other.

Dr. Tijion Esho: I think what people sometimes forget when they are trying to treat scar tissue and asymmetry is that actually sometimes you need to treat the unaffected side to counteract.

Dr. Tapan Patel: Absolutely, I’m actually going to do a proper tenting technique now, one of your procedures here, Tom, to see if I can raise this up a little bit. I’m pretty happy with that. I think the real advantage of working with colleagues is that if you see a nice technique and you see it has a clinical application, why not use it? If we just have a quick look at that now, I suspect we can probably improve the depression on this side a little bit more, but at the moment that’s looking not too bad. I’ll probably have to sit her up to have a look, and I’ve got no problem doing that because, especially with an asymmetric scar patient, even 0.01 ml can be a little bit too much, so I just want to see exactly how we’re looking, sitting all the way up now.

Dr. Tijion Esho: Obviously there’s also the effect of gravity, because the fibrotic tissue will be holding that area up higher. So what I can see now is that there is a better continuity from the medial tubercle along the body of the lip, but we’re still excessively raised at the Cupid’s peak compared to the unscarred side. Accordingly, what I need to try and do is raise this side up a little to match, and secondly I need to add a bit more product in this side to bring it out. I’m going to do a combination of these things, and I might find it easier to do by creating a philtral column on the non-scarred side because it will give me just a little bit more eversion and I might just be able to raise the lip on that side. So now what I am going to do is, in effect, create a philtral column. To do this, I am going to come from just below the GK point superficially, and the trick really is to be as superficial as possible. I am now going to pinch and I am injecting more and more product as I exit. At the same time, with the remaining product, using a needle now I am going to see if I can get a little more continuity of the scarred area. I’ll do this with a linear thread, and I’m just submucosal. At this point I am just going to give her a gentle massage before we assess her again, then take the remaining amount of product for one more little tent to try and raise this up a little bit. Unlike you, Tom, I’m going to massage here, and I think that’s down to the actual characteristics of the product, more than anything else, so I completely understand why you don’t, and I think it’s that your product range lends itself very nicely to precision and projection whereas this one tends to move a little bit more.

Dr. Tom van Eijk: I think it’s also the way you put it in, you put it in knowing that you will massage it to use that plane of loose connective tissue to spread it, whereas I want it to separate.

Dr. Tapan Patel: Absolutely. I suspect that if I can’t lower this any more then maybe what I can do is just bring it forward slightly, so give a bit more horizontal projection, which might give the appearance of lowering.

Dr. Tom van Eijk: I think that you can lower down.

Dr. Tapan Patel: By vertical projection?

Dr. Tom van Eijk: Yes, intradermal. Just make it take up space.

Dr. Tapan Patel: Oh, I see, by treating above, you mean? Let’s give it a go. The only reason I want to avoid treating above this is she has noticed herself that she is a lot fuller here above the scarring than on the other side. You can probably see that there’s a fullness that she has here that is not visible on the other side. So what I am trying to do now is work on the frame of the lip, so if I can start matching up the frame on both sides then I suspect that although she is going to have a bigger lip, I think she won’t have a problem with as long as it is more symmetrical.

Dr. Tijion Esho: Sometimes, we have to remember with these corrections, if we’re in scar tissue, that it doesn’t have to all happen in one session.

Dr. Tapan Patel: Absolutely!

Dr. Tijion Esho: So when you’ve done this now, when you go to do the next stage you’ve freed up more fibres and you’ll get more and more symmetry each time.

Dr. Tom van Eijk: I think that’s one of the great things about our job, as opposed to surgery, that you can plan certain several sections and build up, whereas with surgery you have one chance only.

Dr. Tapan Patel: I agree, and we already spoke earlier about the unpredictability of it, you don’t know. When I was treating her, I was surprised at how easily the cannula went in. Admittedly, it felt gritty but there wasn’t resistance to it. It also filled up quite nicely, and I’m aware now of a harmony across the body of the lip. The one thing that is very tented, however, is the GK point on this side because of the scarring kind of acting like a rope that is pulling up on it, and no matter how much we bring it forward, it will remain tented up. There is a limit to how high we are going to be able to go on this side, and if we go too high, we are going to effectively lower the distance at the bottom of the nose to the lip, so this area could end up a little bit too short, and again will look unaesthetic. So, completely listening to you guys and knowing that we don’t have to finish this in one go, I’m now going to move on to the lower lip to just give her a little bit of balance. So I am just going to inject the soft tissue, a little bolus here, and then do exactly the same on the other side. We are then going to finish off with one more in the lower lip to add just a little bit more volume to the bottom to balance out the rest of the lip.

Dr. Tijion Esho: So are you just leaving little boulses there?

Dr. Tapan Patel: Yes, little micro boluses because if you remember I showed you her profile and she had excess soft tissue at the bottom so that’s why I’m not doing a tenting technique, because I think that would give too much projection at the bottom border. We’ll apply some Vaseline and some massage, and that should be the end of our injecting today, and we’ll see what degree of correction we can give. There will be some swelling, and I don’t think she will bruise, but she might be a bit sore because we’ve had to have a play around with the lip, but that will settle down in a day or two. By the time I see Debbie again we should be able to see what result that’s given us so far.


Outcome

Dr. Tapan Patel: Okay Debbie, we’ll sit you up and have a look. We can see following treatment now there is by no means full resolution of the issue, but we have improved. We can now see that there is a more smooth transition from the lateral aspect of her upper lip towards the medial tubercle, the big recessed scarred step deformity that we had is less obvious now after treatment, and we have managed to balance that out now by raising the peak of the Cupid’s bow on the right side then just matching the volume projection in the lower lip. You may notice that if I turn her completely towards me we can now see that she has a more attractive projection of the lower lip, which was very posteriorly inclined before treatment but now is just sticking out, can you see that? So the profile of the lips in considerably and I am probably going to spend one more session in about a month, after this has all settled, just to see if we can continue to improve what remains an obvious but significantly reduced scarred area afterwards.

Dr. Tijion Esho: I think this is a very nice result, you’ve managed to do so much in one session, and the key is to not to try and do it all in one session. In two weeks time, when the swelling has gone down, you’re going to see a different result here again, and that tissue from freeing the fibres initially and using the filler to help space that area, it will be a lot easier to go back in there so you will get a better result that’s more comfortable for the patient.

Dr. Tom van Eijk: It’s wonderful, really great.

Dr. Tapan Patel: Thank you.