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RESTYLANE
30 minute reSTORE
clinical hints
BACKGROUND
SUITABLE PATIENT
Beauty is characterised by
The most suitable patient is healthy and meets the inclusion criteria
for Restylane and Dysport and seeks restoration of volume and a
smoother facial appearance. The best candidate will have mild to
moderate volume loss and reasonably good skin elasticity.
• A youthful face
• Facial attractiveness with regards to symmetry and
harmony
• Curves in appropriate places on the face to create
interest and light reflection
• Healthy, clear skin
• Smooth lips with subtle volume, balance and symmetry • Even skin tone and texture.
Ageing is inevitable and encompasses both intrinsic and extrinsic
factors. Changes occur in the face which can be addressed to some
degree by fillers and muscle relaxers such as Dysport. Facial
contouring with NASHA™ gel can be strategically placed to
recreate anatomical harmony and restore volume loss.
AIM OF TREATMENT
NASHA™ fillers can be used to restore facial volume, which
depletes over time, creating a more youthful and enhanced
facial appearance while Dysport can be administered to restore
smoother facial appearance in the glabella region. There are many
methods used to assess the face. One of the methods is by using
Phi to determine the most appropriate relationship of various facial
structures eg. Lips – upper to lower lip ratio of 1:1.618.
INDICATIONS
There are two options within the 30 Minute Restore package
depending on the volume loss and needs of your patient.
Option 1:
2 x 1mL Restylane Perlane with lidocaine
1 x 1mL Restylane with lidocaine
50 units of Dysport
1 x Restylane Recover Cream
Option 2:
1 x 2mL SubQ with lidocaine
1 x 1mL Restylane with lidocaine
50 units of Dysport
1 x Restylane Recover Cream
A more youthful patient presents with a fuller mid face and smooth
peri-oral region. The youthful triangle becomes squared off with
ageing. Therefore the treatment focus is on elevating malar and
zygomatic regions, in conjunction with treatment of the peri-oral
and prejowl area to recreate facial harmony.
Smooth wrinkles
with Dysport® (Anti-Wrinkle treatment)
or Restylane® (Dermal Filler products)
This image shows Phi applied
to the face. It depicts the
perfect face as an oval which
is indicative of an inverted
egg shape. The harmonious
face has well proportioned
eyes, nose and mouth and
is a pleasing balanced oval.
The Golden Ratio appears
extensively in the human face
and defines our perceptions
of beauty.
Image 1
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Restore volume
with Restylane (Dermal Filler products)
to provide a more youthful appearance
Soften lines
and reduce the appearance of wrinkles and
lines with Restylane (Dermal Filler products)
Image 2
RESTYLANE
30 minute reSTORE
clinical hints
ADVANTAGES
A combination package that offers 3mLs of NASHA™ Filler for
volume restoration to create a 'wow' effect at a reasonable
investment.
An opportunity to create significant lift and smooth transition
in the mid face i.e. recreate the Ogee curve with Restylane SubQ
and Perlane.
NASHA technology allows Perlane to deliver superior lifting
capacity in a high strength, long lasting gel (David Stocks et al,
2011) A highly versatile volume filler for a range of indications.
Sub Q is an ultimate dermal filler for maximum lift and structure
in areas such as cheeks and jawline.
Image 4. Facial Aging – Coleman SR. Structural Fat Grafting. St Louis, MO:
Quality Medical Publishing 2004. Gosain AK et al. Plast Reconstr Surg 2005;
115: 1143-1152.
NLF or Marionette fold
• Different categories based on depth of depression – Mild,
Moderate, Severe or Extreme.
Image 3
PATIENT ASSESSMENT
AND CONSULTATION
Photographs prior to treatment are highly recommended
When examining the mid face it may be helpful to assess each of
the following areas to determine how much volume is required:
1. Tear Trough
2. Lid cheek junction depression
• If the patient's NLF or oral commissure is so heavy that you
would rate them as severe or exteme then they are best
to have treatment of mid face first. Multiple syringes or a
combination of treatments may be required. In some cases
surgical correction or enhancement may be a better option.
• For patients where NLF is moderate to severe – the patient
must understand that if they have a severe fold, one treatment
will improve the fold to a moderate category at best. If the fold
is in the moderate category, with a re-treatment within 6
months the next treatment may improve it to the mild category.
Group Classification Typical Age
Description
Mild
28-35
No Wrinkles
II
Moderate
35-50
Wrinkles
in Motion
Early to moderate photo aging:
early brown spots visible, keratosis
palpable but not visible, parallel
smile lines begin to appear, wears
some foundation.
III
Advanced
50-65
Wrinkles
at Rest
Advanced photo aging: obvious
discolouration, visible capillaries,
visible keratosis, wears heavier
foundation.
IV
Severe
60 & up
Only
Wrinkles
Severe photo aging: yellow/grey
skin colour, prior skin malignancies,
wrinkles throughout – no normal
skin, cannot wear makeup because
it cracks and cakes.
3. Lid cheek junction and malar fat pad depletion.
(Haideh Hirmand 2010)
Category 2 or 3 patient may require treatment of the mid face
first. Explain to the patient the rationale for requiring multi-syringe
treatment rather than single syringe.
Patients that have multiple areas may require treatment of the mid
face first and may need more volume. It is important to explain
the rationale for a multi-syringe treatment to the patient.
Richard Glogau, 1996.
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Skin Characteristics
I
Early photo aging: mild pigment
changes, no keratosis, minimal
wrinkles, minimal or no makeup.
RESTYLANE
30 minute reSTORE
Pix’l cannula can be used to create a style of face lifting technique
based on superior to inferior and lateral to medial approach.
clinical hints
TREATMENT PRINCIPLES:
• Know your anatomy and be aware that the face is well
supplied with blood vessels and nerves.
• The treatment options can be tailored to the individual
patient/client and their needs by adjusting the combination
of Restylane products.
• Cannula or Needle – both have a place depending on the
skill level of the injector and the aims of treatment.
• Asepsis is important to prevent introduction of bacteria
or contaminants.
Lateral to Medial
• Begin wider out on the lateral aspect of the face and use
either Restylane Perlane or Restylane Sub Q and fan in
towards the medial aspect of the face using products such as
Restylane or Restylane Vital (not included in the 30 minute
restore pack).
Trigeminal nerve
Supratrochlear
Supraorbital
Lacrimal
Zygomaticotemporal
Zygomaticofacial
Infra orbital
Facial
Image 5
• Suitable patients would have mild mid face volume loss, combined
with mild – moderate buccal fat pad loss and mild skin laxity.
• Commence laterally in front of tragus (beware of the facial
nerve and the parotid gland/duct) using a cannula and gentle
technique. A minimum of 3 passes of the cannula are required:
• 1st pass most lateral point to lift using Sub Q or Perlane
• 2nd pass coming more medial with Perlane or Restylane depending on the degree of buccal hollowing
• 3rd pass at the corner of the mouth using Restylane (or in
patients with finer skin consider Restylane Vital, however
this product is not part of the 30 minute restore) filling
above the lip and under the lip to replace soft tissue loss
and soften upper lip lines.
• Treating the marionette lines may add volume, so consider
the cause of the fold and reduce the weight on the area by
supporting points of prominence.
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Auriculotemporal
Buccal
Mental
Image 6. Sensory innervation of the face.
(http://www.davidson.edu/academic/psychology/ramirezsite/
neuroscience/psy324/aapatton/anatom4.jpg)
RESTYLANE
30 minute reSTORE
clinical hints
Superior to Inferior
• Commence treatment for the mid face on the upper
segment of the cheek especially if there is moderate malar
fat pad loss and/or the patient presents very flat genetically
on the zygomatic region.
• Address the areas of prominence and then the areas in between.
• Adding too much NASHA™ gel along the jawline and lower
face can add to the heaviness or squaring off of the face.
Deep plane to superficial layer
• Begin with volume filling deep in the subcutis or periosteal
layer and work up towards the dermal layers.
• Use the larger particle size NASHA™ gel fillers deep and the
smaller particle size NASHA™ gel fillers closer to the dermis.
• Layer to create a smooth surface without the need to
chase rhytids.
INJECTION TECHNIQUE
• Apply headband and remove make up.
• Determine best placement of NASHA™.
• Sterile or aseptic technique is imperative.
• Thoroughly cleanse the skin with a suitable antiseptic solution.
• If using a cannula, local anaesthetic with or without Adrenaline
may be medically prescribed for injection at the injection site to
ensure comfort, reduce bruising and allow easy entry with the
Pix’l Cannula.
Image 7. Commence treatment in midface and laterally; use cannula or
needle to deliver small threads of NASHA™ gel in a fan like fashion.
Suggested treatment areas
• Set up equipment on a sterile dressing pack to avoid
contamination of cannula and introduction of bacteria or
contaminants.
Malar and zygoma regions (SubQ or Perlane); lip and peri-oral
region (Restylane or Lip products - not included in the 30 minute
refresh pack); chin (SubQ or Perlane) for the Y lift effect.
• If using a cannula for the injection site: use a needle the same
size or slightly larger than the chosen cannula. Take care not to
insert the needle too far or to damage a blood vessel with the
introducing needle.
Other areas that can be treated include the brows (Perlane),
lateral aspect of the face (Perlane), the angle of the jaw (SubQ or
Perlane), the nose (Perlane), marionettes (Perlane).
• Carefully introduce the appropriate sized Pix’L cannula by
rotating and threading the cannula along the upper subcutaneous
or hypodermal tissue plane, or in the deep subcutis under the
muscle if you are wishing to lift the zygomaticus and malar
region. The free hand can be used to manually stretch or
support the tissues so that the cannula passes along in the
correct plane without bending or requiring undue force. It is
important to know the location of the tip of the cannula.
• Do NOT force the cannula as this may lead to potential
bending, weakening or breakage of the cannula.
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Restylane can be delivered using linear threading, fanning or Fern
Pattern (Dr Tom Van Eijk) technique. Insert the needle and inject
a small amount of NASHA gel and wait 5 – 10 seconds. Slowly
advance the needle, injecting in an ante-grade method to allow
the Lidocaine to take effect ahead of the needle.
RESTYLANE
30 minute reSTORE
Reconstitute Dysport using 2.5mLs Normal Saline for injection
as instructed in the PI. The recommended dose for glabella is
50 Dysport units which equates to 0.25mL volume.
clinical hints
BEFORE AND AFTER PHOTOS
Patient 1
Dysport is generally injected deep into the procerus and the medial
corrugator muscles and more superficially into the lateral corrugator
where it inserts into the dermis, while using a 29g, 30g or smaller
needle to minimise trauma and discomfort. Refer to Dysport PI
and glabellar treatment guide for more specific details.
Frontalis
Procerus
Corrugator supercilii
Before treatment
Depressor supercilii
7 days after
30 Minute Restore Treatment
Orbicularis oculi
Patient 2
Image 8. Recommended injection points (Illustration by Dr Lavent Efe for
IPSEN Pty Ltd)
AFTER CARE INSTRUCTIONS
• As for all Restylane treatments – Cool, Calm and Clear
• Ensure the face is clean and patient does not touch injection
sites during the immediate post treatment phase
• Avoid skin irritants during the first 24 – 48 hours post treatment.
REFERENCES
1. Hirmand, Haideh (2010) Anatomy and Nonsurgical Correction
of the Tear Trough Deformity PRS Journal 125(2): 699 - 708.
Before treatment
2. Q-Med Restylane PI.
3. Stocks, David et al. (2011) Rheological Evaluation of the Physical
Properties of Hyaluronic Acid Dermal Fillers. J Drugs Dermatol
10(9): 974 - 980.
4. Glogau R.G. (1996) Aesthetic and Anatomical Analysis of the
Aging Skin. Seminars in Cutaneous Medicine and Surgery.
15(3): 134 - 138.
5. Coleman, S. & Grover, R. (2006) The Anatomy of the Aging
Face: Volume Loss and Changes in 3-dimensional Topography.
Aesthet Surg j. 2006; Jan-Feb (1S): S4-9.
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7 days after
30 Minute Restore Treatment
Image 9
These photographs have not been re-touched and have been taken
in the exact same lighting. Each patient has had a 30 Minute
Restore treatment consisting of 3mls of Restylane dermal filler
products and 50 units of Dysport anti-wrinkle treatment.
Individual results may vary.
PBS Information 500U vial, 300U vial: Spasmodic torticollis, cerebral
palsy spasticity (equinus foot deformity), post stroke spasticity of the
upper limb, blepharospasm, hemifacial spasm: Section 100. Refer to
PBS schedule for full information. Glabellar lines: not PBS listed.
Before prescribing please refer to full Product Information, which is
available from Q-Med.
Minimum Product Information Dysport®: Clostridium botulinum type A toxin-haemagglutinin complex (300*,
500 DYSPORT UNITS/vial). Indications: spasticity of the upper limb in adults post-stroke; spasmodic torticollis
in adults; dynamic equinus foot deformity due to spasticity in cerebral palsy patients, two years of age or older;
blepharospasm in adults; hemifacial spasm in adults; moderate to severe glabellar lines in adults. Contraindications:
hypersensitivity to ingredients; myasthenia gravis or Eaton-Lambert (myasthenic) syndrome; infection at proposed
injection site. Precautions: Do not exceed recommended dosages and frequencies of administration; adverse
effects from toxin distribution to sites remote from the site of administration have been very rarely reported
(excessive muscle weakness, dysphagia, aspiration pneumonia that may be fatal): use lowest effective dose and
do not exceed recommended dose; use with caution in patients with: breathing and swallowing difficulties,
evidence of drug-induced neuromuscular weakness/motor neurone disorders, and prolonged bleeding times;
rare occurrence of antibody formation to botulinum toxin; contains small amount of human albumin so the
risk of transmission of viral infection cannot be excluded; ready availability of adrenaline injection in cases of
anaphylactic reaction; drug interactions with muscle relaxants, aminoglycoside antibiotics and other drugs – use
such drugs with caution* (see full PI); potential risk of muscle weakness or visual disturbances may temporarily impair
ability to drive or operate machinery.* Use in pregnancy only if benefit justifies risk; not recommended in lactation.*
Dysport is not therapeutically equivalent to the other botulinum type a toxin preparation available in Australia.
Extreme caution is required should it prove necessary to substitute the botulinum type a toxin of one pharmaceutical
company by another. Adverse Events: common to very common depending on indication: generalised weakness,
fatigue, ‘flu-like syndrome, pain/bruising/swelling/reddening at injection site; dysphagia; weakness of the muscle
being injected; accidental injuries/falls; dysphonia; diarrhoea; urinary incontinence; abnormal gait; ptosis; diplopia;
dry eyes, tearing; eyelid oedema; headache; facial paresis*, asthenopia*, muscle twitching* – see full PI. Dose: The
units of Dysport are not interchangeable with other preparations of botulinum type A toxin. Spasticity of upper limb
post stroke: 500-1000 units per session, distributed amongst five muscles. Spasmodic torticollis: Initially 250-500
units in divided doses; subsequent doses between 250-1000 units. Cerebral palsy spasticity: Initially 20 units/kg
bodyweight (10 units/kg for each calf); subsequent doses titrated between 10-30 units/kg bodyweight, divided
between both legs. Dose must not exceed 1000 units per session.* Blepharospasm & hemifacial spasm: Initially
40 units/eye; subsequent dose of 80 units/eye for longer duration to maximum of 120 units/eye.* Glabellar lines: 50
units divided equally among 5 injection sites. Administration: Intramuscular injection for all indications except
blepharospasm/hemifacial spasm where it is injected subcutaneously. See full PI for guidance on specific muscle
sites to be injected and frequency of administration (different for each indication) and reconstitution instructions for
300U* and 500U vials. Storage: 2°C–8°C. PBS dispensed price: 500U: $644.81; 300U: $361.52. Date of TGA
approval: 16 Dec 2010.
The full PI is available on request from Q-Med, a Galderma Division,13B Narabang Way, Belrose NSW 2085.
Phone 1800 144 944.
Restylane® is a registered trademark of Galderma Australia Pty Ltd.
Dysport® is a registered trademark of Ipsen Pty Ltd.
This material has been prepared by Galderma Australia Pty Ltd
Dysport is distributed for the treatment of moderate to severe
glabellar lines by: Galderma Australia Pty Ltd, 13B Narabang Way,
Belrose, NSW 2085, Australia.
ABN 12 003 976 930 T: 1800 144 944
Q-Med 1212-11 Dec 2012