Thank you very much for the Botox and Juvederm and Boletero review. It’s very much appreciated. And I will continue to do my best to improve and live up to those high standards written in these very kind reviews.
My first ever surgery: about 16 years ago (from 11/17/13), this (brachial basilic arterio-venous fistula) was my very first surgery I’ve ever done in my life. It was a strange way to start because the technical aspects of this surgery is high – I still consider it difficult. But I was a lowly surgical intern in Cleveland, and highly respected transplant surgeon, Dr. James Schulak, was doing the surgery. I was just retracting (Surgical Interns didn’t operate, they just held things), but during the case, Dr. Schulak was time-pressed and accidentally I got showered in the face with blood – blood dripping down my face, luckily it didn’t hit me in the eye (I love wearing glasses). He told me to get out, clean up. When I leisurely (I took my time getting all the blood off) made it back to the surgery after wiping off my face and changing. I saw that he was just waiting for me without having made any progress in the surgery. He was just sitting there without moving – bizarre. He said he had a policy: if he splashed a resident with blood, the resident gets to do the entire case. So, that’s how I did my first surgery. It took about 2 more hours, and I didn’t even know how to hold the specialized vascular instruments (given that I hadn’t even done any surgeries at all), but he guided me expertly through it, I managed to do it, and the patient had a great result. In Modesto, the operation would have taken me about 30 minutes – but we all had to start somewhere.
One stage vs. two staged surgical procedure
I sorta miss these cases (and my crazy method I personally innovated for laparoscopic peritoneal dialysis catheters). Now, with a cosmetic surgery practice, I’m focused on my Modesto Botox Patients, Veins and Acupuncture. When I used to make these brachiobasilic AV fistulas, I did them in one stage which included a pretty long incision from axilla to antecubital fossa, my theory was that I would spare the patients two trips to the operating room. There’s a theory out there that separating the operation into 2 stage approach is better in case the fistula doesn’t mature. Stage One: make the anastamosis (connection between vein and artery), and Stage Two: mobilize the basilic vein to the surface (because it is deep and not easily accessible from a dialysis standpoint). Dr. Fung of Modesto very kindly helped me improve my technique for these vascular procedures – he is the master.
2 Degrees of separation from Mr. Quinton, inventor leading up to these surgeries:
I was on a small-ship cruise a few years ago, and my family became friendly with this older couple. The woman asked what I did for work, and I told her I was an NP. She said her husband had created some medical devices – his name was Wayne Quinton. He also invented the first dialysis machine. He’s up in his 90s now and still tinkers with inventions.
To start with, how about a picture of these cannulas?
Why the need for Cannulas in comsetic filler injections?
You might say that Juvederm, Restylane, Radiesse, Belotero, Perlane, Prevelle injections have been just fine with a plain needle. But why increase the difficulty of the procedure? The reason? Less bruising? Smoother results? Safer? Those are excellent reasons for having your injector / surgeon work harder.
What are cosmetic fillers?
Fillers are like they sound – they fill spaces up to replace volume that we’ve lost as we’ve aged. Familiar fillers are Juvederm, Restylane, Perlane, and Radiesse. There are many more brands of cosmetic injectible filler implants. However these are some of the common ones used in my Modesto office: Surgical Artistry. Botox isn’t a filler – Botox relaxes muscles. Here’s a link to my page: Anatomy for Botox. Both fillers and Botox are used for facial rejuvenation.
Why the opening on the side of a cannula?
The opening is on the side for extrusion of the filler such as Juvederm so that the tip can be made in a blunt fashion. If the opening was at the tip, there would be sharp ends. Thus the opening is on the side. Is this good or bad? It’s both. It’s good because now the tip can be blunt. It’s bad because we lose a bit of the precision which we were used to with the tip of a regular needle.
Why the blunt tip on the cannula?
This is the key ingredient for safety and less bruising. Because the tip is blunt, it won’t easily go through vital structures such as arteries, veins and nerves. It glides through fat. In fact this blunt tip cannula idea is used in surgical liposuction. The safety is in the prevention of cutting vital structures. The less bruising is because there’s less internal bleeding due to the cutting of blood vessels.
Cannulas increase the difficulty of the cosmetic filler procedure
Yes, the difficulty is increased and it feels more like a complex procedure. However, the risks diminish and many of the positive results increase – including patient satisfaction, smoother results, and less downtime. I think this is worth the increased time and complexity – something surgeons think about all the time.
Needle vs blunt-tipped micro cannula. Safety is the #1 reason I like cannulas.
Where can cannulas be used?
For most injections where the fillers are introduced below the dermis of the skin. This is a plane where the cannula can glide. Superficial lines – probably a difficult space for the cannula – I would most likely continue to use a needle in the superficial plane. Examples of places for cannula use:
Pre auricular area
Lateral Eye Brow fat pad area – helps to raise the eye brows too.
There’s a need to use a pilot needle (which can still cause a bruise) to create the opening in the skin for the cannulas to slide through.
Cannulas are flexible and there can be physical hang ups (getting stuck), and difficulty driving the cannulas from a distance (longer needle). And because they are flexible, sometimes they are harder to feel their presence under the skin.
The hole is on the side of the needle not in the front.
Sometimes it’s difficult to gauge the depth of the injection
What’s the main reward for using a cannula?
Patient safety. When a blunt tipped cannula is used well by an experienced injector, there is much higher patient safety. Using needles – one could puncture subcutaneous structures which would otherwise like to stay unpunctured.
What are other great benefits of using cannulas?
Patient safety (mentioned above as the #1 benefit)
Tip is blunt – actually might hurt less.
Tip is blunt – won’t injure as much under the skin such as blood vessels and nerves.
Less bruising – because there’s fewer injury to blood vessels and thus less internal bleeding.
Less swelling – for reason above.
Flexible cannula – allows for safety – the cannula moves or wiggles around some of the stiffer structures within the fatty tissue planes.
Longer length – thus fewer skin puncture sites.
There’s also the benefit of calling this instrument a cannula rather than a needle – less scary sounding.
What is my favorite cannula?
Cannulas come in many different styles and lengths. I currently use Magic Needle and Dermasculpt cannulas. I haven’t had the chance to try other cannulas on the market. I believe they would be excellent. The Magic Needle cannuals are more flexible – perhaps a little bit too flexible for my current tastes. I know my tastes will change with time – it has before – I remain flexible myself in my choices of cannulas. As for favorite size/length of cannulas. I like the 27g 1.5 inch cannulas for most of my Juvederm injecting. I use this cannula mostly for temples and cheek augmentation.
Do I think that cannulas are game changers in the world of injectable fillers?
I think so. For the sake of patient safety and smoother appearances. Plus with the added benefits of shorter recovery period (less bruising, less swelling).
Do I use cannulas instead of needles for everything
No. There’s a role for each tool.
These are my thoughts (Calvin Lee). No specific medical information here.
I got this question today and I thought I’d try to answer this question.
How soon after vein procedure do I see results?
It’s actually not an easy question to answer because the results vary and everyone starts with a different starting point. But even after I see a patient, I still have somewhat of a hard time predicting the point where “results” are seen. First let me define results as “I’m happy to show off my legs.” or I can word the question a little differently:
How long after I START vein procedures will I be happy with the BEST reasonable results?
Reasonable results = 90% improvement from baseline.
It might be 6 months later after starting vein treatments and about 3-4 sessions of sclerotherapy (vein injections) and vein laser mixed in, and about $1500 spent. And after sclerotherapy, I don’t want patients to experience vigorous exercise for about 9 days after the procedure. Stockings after sclerotherapy is a must for those 9 days as well. But after vein procedures, the after care is easier: no stockings needed, and minimal restrictions on the exercise.
Most patients do fewer than the 3-4 to get the greatest results in 6 months. Many take their time and do 3-4 procedures over 2 years. But after each procedure, there may be about a 2-3 month recovery time depending on several factors. And after each session, I’m hoping for 30-50% improvement.
Cosmetic Vein Procedures and Medical Vein Procedures are different
I perform an ultrasound with duplex to see if there is reflux in some of the slightly deeper veins. If these veins have reflux, I consider the surface veins as a possible side effect of these veins on the inside. Most of the time, I believe that insurance covers the treatment of the refluxing veins. This is usually done via endovenous ablation with laser or radio frequency in the office/surgicenter setting or it can be done with vein stripping at a hospital setting. I have done laser ablation in my office; however, I’ve stopped taking insurances and if our ultrasound test shows that you have what I called a “medical vein issue” then I’ll make some recommendations for practitioners who take insurance, and after these veins are taken care of. We can deal with the cosmetic vein issues. However, about 30-60% of the time, I’ve seen much of the cosmetic vein problems subside after the medical vein problems have been solved or improved upon.
Sometimes teaching is a great way to learn and we just had a wonderful opportunity to teach and learn.
We were honored to have Dr. Edward Katime in our office learning about Plastic Surgery (including breast augmentation procedures), Botox, fillers (Juvederm), Veins (Sclerotherapy and Laser), and Acupuncture. We always feel that we learn a lot from having students in our office and as always, we learn a ton from our patients.
He spent 4 days with me and we are very thankful for the patients who participated in our educational process at our office in Modesto, CA. He is a UC Davis affiliated family medicine resident in his last few months of his training. He is about to become a full fledged doctor. He is also, like me, from New York City. He also loves Modesto, CA. And works at Doctors Medical Center. He had excellent questions and our patients liked him very much. I have a feeling that he is going to do very well.
I have been given the title of Assistant Professor from UC Davis and at one point I was even given a teaching award for this position as “the outstanding” community MD teacher. I really don’t do enough to deserve the award, but sometimes I wish I could do more.