Thank you for watching.
Thanks for watching.
Welcome.
Mükelle [?].
Ms. Elis, doctor.
Ms. Elis.
I remember what you did with their content.
The way you explained it, it suits your work.
...
but it turns out I hadn't used exactly the same setup.
Cardiology, all right — why did you leave cardiology?
We do it outside too; I do it outside as well.
Three days of patients or so.
It doesn't come to that much.
Was this six months ago, how long?
We got it eight months ago.
So we tried to get by with the mesotherapy certificate.
We are working actively at the moment.
We examine in the bag-carrying setup [?].
In total I saw three people.
And there was the tea man.
The power kept going out, too.
Anyway, I had the chance to look at the manufacturing.
We started using Merken's own brand, their older fillers — cross-linked, let's say.
There too they had probably used something like two thousand [?] or so.
And as they slowly developed the products: you use it well, try this one too, try this one as well, let's keep using one of them regularly.
We did PRP; I would test this one as well.
Doctor, we made this one, could you bring it — asking like that, I ended up knowing the whole product range.
The last time was about two and a half months ago.
They asked me: could you give a training talk, could you run a workshop for us.
I didn't turn them down, but this was the earliest we could arrange it.
In between, when my product [?] was ready, we managed to line up the doctor colleagues.
You will be the first group I teach here on behalf of a company.
And as luck would have it, our air conditioning is broken.
It was working before the holiday, sorry about that.
But I won't drag it out too much.
I mean, we are not going to explain the meaning of life here.
So in total there are two biostimulators we are going to talk about here.
I'll go through them very quickly.
Harmonyca isn't really a new product either.
Because Erdi [?] has been marketing it for a year and a half, it comes across that way.
Before that there was a company called Luminera that they had bought.
They brought it from Israel.
It was one of their products.
How long ago was that?
They put it on the market in 2017-2018, but because they weren't very active on the marketing side it never came into use as a well-known product in Turkey.
But at home, you know, there is always a measuring step around here. [?]
They presented it to us as if they had kept it hidden and moved on. [?]
Then they described it as a cure-all product.
I'm not waking up to my third illness on this cure-all question. [?]
But with the right setups [?] and when it is explained properly to the patient, it is a very good combination.
It gives a seriously good revitalisation and at the same time you understand everything. [?]
When we use calcium hydroxylapatite on its own it is also successful on the stimulation [?] side, but for example when we use Radiesse, which we would use conventionally [?], calcium hydroxylapatite is held together with carboxymethylcellulose as a gel; the life of carboxymethylcellulose under the skin, though, is a week, ten days at most, after that it is hydrolysed by the breakdown [?] side, and it will catch the calcium hydroxylapatite crystal [?].
The response the body gives here: fibrocytes and fibroblasts immediately start wrapping around the calcium hydroxylapatite crystals by putting out foot-like processes.
And they compare this to something.
When a grain of sand gets inside an oyster or a mussel, the animal immediately starts wrapping it in a pearl, trying to get rid of those edges that are hurting it, trying to turn it into a rounder structure.
The body pushes it out, its water if not, apatite and collagen lactic. [?]
Here it was supported together with hyaluronic acid production.
Because it also gives some increase in moisture, it adds a slight glow to the skin from that water retention.
But among themselves, each one has advantages over the other.
Once I have pulled it all together, I'll try to go over it as a summary.
We have a colleague who is a dentist.
They were actually the first to use it.
Our product, we call it dil calcium [?].
When you look at it, in what dentists heavily use as bone powder graft there are properties that get confused with PRP.
Back then they used to call PRP stem cells.
We'll mix stem cells with bone powder and build you a tooth, and so on.
It is a material dentists use a great deal to support the weakened bone tissue left inside the alveoli of the mandible after a tooth extraction.
It is also found in large amounts in the cements they use in orthopaedics to place implants [?].
In the end, because it is a mineralised material, it has the property of stimulating the response of osteoblasts in bone tissue and contributing to bone formation there.
This matters a great deal for our injections.
That is why I am underlining it.
Because when you inject on the bone, we are talking about a material that can cause unwanted osteophytic outgrowths on the bone.
So you have to be very careful with deep injections.
It is a material approved by Eftihar [?]; that is, in terms of hyaluronic acid, compared with hyaluronic acid we don't actually have a safety problem.
But in terms of safety there is this difference between them: once calcium hydroxylapatite is placed under the skin, it cannot be dissolved.
With hyaluronic acid we have our hyaluronidase, we inject it and within hours it turns to water, it disperses, it practically breaks apart — hyaluronic acid does.
Here we have no such luck.
So if we are doing an injection, we have to be very careful.
We did have a complication happen. [?]
I am speaking here about the calcium hydroxylapatite side.
The only thing that can be done is to inject saline quickly into the site where you injected, and that only within the first 2-3 months, and then with massage to spread those microspheres, those crystals, under the skin.
Otherwise you cannot get rid of the mass effect you have created.
When you do it that way it doesn't disappear, so what happens?
Since it still increases collagen production, it will give a revitalisation effect in the skin.
The patient will still get some benefit from it.
Because Merken's calcium hydroxylapatite is combined with hyaluronic acid, if the patient is uncomfortable with a mass effect — and that is an effect that shows up right away.
After you do the injection you will see a volume effect.
We saw the volume effect.
We called the patient back 15 days later.
But she said it's too much, I don't like it here, I'm uncomfortable with this part — and then, handling it as if it were a cross-linked hyaluronic acid, when we inject hyaluronidase we dissolve the hyaluronic acid inside it, so you can remove that mass effect quickly.
On the complication management side, that is the advantage it has.
Can I ask something?
I'm very sorry, let's keep it interactive.
Please, go ahead.
This mixture, diffuse and to the base, I mean, how did the mixture for the borons come about? [?]
A one-to-one ratio.
I think of it as one millilitre by volume, bringing together one millilitre of calcium hydroxylapatite and cross-linked hyaluronic acid. [?]
But in total the combination of these two materials does not make two millilitres.
I use it for skin revitalisation as well.
On the lifting side we have been using calcium hydroxylapatite for a very long time anyway.
But as I said at the start, on the lifting side you have to be a bit careful.
Because when we want lifting in a face, you have to support the retaining ligaments from the floor, from the bone level; you have to place the filler almost like a wedge and push it upwards.
But that doesn't mean this, the way I see it — please don't misunderstand — that is also why we asked about experience.
Now, you can't just do this, can you?
How you will manage it when something happens to you, keeping hold of the responsibilities, I mean [?]
the application skill.
Because we are doing cosmetic work in the first place.
The person in front of us is not a patient.
So when things turn ugly they say to us: I was healthy in the first place, folks.
I was healthy, doctor.
There, under the laws in Turkey, on one side you are helping with a taxi-driver aesthetic [?].
So the matter can go somewhere rather different from simple complication management.
It depends on the situation of the lawyer and the prosecutor involved.
So because our employment [?] is at stake, while we are working in aesthetics we have to keep ourselves in the safe zone.
It's like that around the world anyway; in America plastic surgeons always have the highest malpractice rates, always in their world of training them. [?]
We need to look at the subject in front of us a bit like this.
In the end, in our field the people we deal with as patients are not patients.
When you look at it, they are healthy people.
That is why we always have things to deal with in relation to what we are used to.
Calcium hydroxylapatite is a product that has evolved somewhat.
I mean, the calcium hydroxylapatite we used 10 years ago and the calcium hydroxylapatite we use today are not the same thing.
When it was first made, the product had this irregular, sharp-edged crystal structure; then it was worked on step by step to become microspheres, aiming at less irritation and less oedema.
But then, over the years, ideas developed so that these too would become smoother-surfaced and more homogeneous microspheres. [?]
Today almost all calcium hydroxylapatite manufacturers already use homogeneous, spherical, smooth-structured calcium hydroxylapatite crystals.
That is what is inside Merken as well.
They are giving us one of the highest technical calcium hydroxylapatites you can use in the world right now.
These microspheres are homogeneous, 20 to 45 micrometres in size, so the irritation and the oedema risk tied to it are very low, but still, if we are talking about a biostimulator, it creates a mild irritation in the tissue. [?]
So oedema developing because of that is definitely on the table.
And if I am using a biostimulator — because we count filler as a biostimulator too, and by that I mean filler. [?]
the patient's autoimmune diseases
I mean, a third of the population already has Hashimoto's thyroiditis, and if there is Hashimoto's thyroiditis you ask about it one way or another [?]
I mean, the one who never mentioned it to me: oh, I had fibromyalgia too, is this oedema because of that
Or
the injection I did on a rheumatoid arthritis patient — after nine months had passed, because she had had the Covid vaccine, she turns up in front of me with a biofilm, just like that.
Things like this can happen.
So you have to share these with patients as well.
I mean, if you have a condition, especially an autoimmune one...
Sometimes they think — oh, I have a thyroid, I'm a thyroid patient, they say.
Depending on the course, depending on the course — I mean, in those situations, if a steroid is going to be used, using a steroid is the last resort. [?]
First of all, if there is hyaluronic acid involved, you start by dissolving that.
and always, to suppress the oedema, a systemic Prednol antiviral [?], one tablet or two tablets depending on the severity of the reaction.
I don't much like using systemic treatment.
Lasix, for example, a diuretic and so on.
Lasix — this is a local oedema.
So going that systemic doesn't make much sense.
Applying cold.
After that you have to expect some harm from opportunistic pathogens. [?]
Sometimes I definitely add an antipyretic [?].
Because there may be no infection in the picture, and three days later a superinfection is added on.
Come on, because it is hematopic. [?]
Actually she is already in a frightened state.
It could be the last compress. [?]
You are trying to manage that.
And on top of that, when something like an abscess or a vaccine reaction develops — I'll tell you about that later on. [?]
And then of course, in our profession, there is burying a colleague.
Burying people is a thing, a national sport.
The moment she goes to another team, it starts: God knows who you went to.
I am here trying to do something in good faith.
Why are you putting me down?
Go on then, do it and let's see the same thing.
That's not there either.
For example, for example, the allergy test.
I don't think the allergy test has any validity at all.
Now, I never get asked about this either. [?]
I mean, if there is an outbreak at that time, I don't do it anyway.
This is the thing we are talking about in an allergy anyway, for example.
One patient, a woman of Russian origin, and also the mother of a pop singer you all know very well.
We did the injection.
She even had a serious asymmetry in her face.
We worked asymmetrically.
We parted very happy.
Let me say it, of course there is a defect. [?]
The woman's left side is ibogenic. [?]
I mean, it pulled together.
Everything fell into place.
She was a beautiful woman to begin with.
After that she was very happy.
She went, she came back.
In the meantime the pandemic was declared.
Curfews and so on.
After a while the lady turned up.
An abscess this big, here.
An abscess
gets drained, doctor.
We drained it.
After that, intralesional antibiotics included, I did whatever infection management calls for.
After that the hyaluronidase and the rest, wound management, wound care, everything fine.
The patient disappeared.
She dropped off the radar, gone. [?]
We call, she doesn't answer the phone and so on.
And I couldn't work out what had happened.
She had an elderly husband.
The gentleman was her second or third husband.
They had gone on holiday to Sapanca.
And they stayed there for three months, apparently. [?]
And there, my young colleague [?] at the state hospital said, come, come, I cleaned it out.
A special effort came up. [?]
This time it was squeezed this much there. [?]
And the abscess carried on.
Every so often the fillers I did on the other side flare up.
Then a few
rounds of clearing it out; after a point I worked together with my plastic surgeon colleague.
The first hyperbalance... [?]
You can't do anything.
All you can do is shrink the scar.
In the end, when it recurred this much, first the plastic surgery colleagues — it was so big, maybe I had broken off a good tip out there. [?]
A foreign body reaction, and she had sent the MRI through the channel. [?]
And after that I was going to do the thing, you know, that much scar tissue, supraperiosteal scar formation and so on.
Let's get those areas into a sharper state, let's do whatever it takes so we can get the woman better as soon as possible. [?]
She replied about sending our MRI system with the MRI invoice. [?]
And she never sent the MRI itself.
And she never came again.
I don't know what happened.
In my life it kept creating the most absurd complication. [?]
It came out of my place. [?]
And as a case, you would never expect it.
Her turning up with an abscess like that nine months later is really not something that should happen.
but it can happen.
You have to be open to anything.
Or rather, you have to be prepared for these.
And while you are managing them you have to be inspiring confidence in the patient.
I mean, if the patient sees your cool-headed stance, and that you are confident about the subject and calm, she falls into step with you, and you can resolve it before things grow.
Not: shall we do it this way, shall we do it that way.
The moment you run your own internal questioning out loud [?], things suddenly... Or, in my view, the most common mistake is trying to cut off communication with the patient.
The moment you say, you can't talk to me like that, and so on, you lose the patient.
After that you can't manage it.
So you must never cut off communication there.
All right, yes, you are right, I understand your anger too, but I am trying to be useful to you, I am trying to get you better.
Let me say these things, and we'll talk about it afterwards.
At the point where you say it again, it goes a bit better.
Let me play devil's advocate: if things go to a court case — I have an ongoing case right now, for example — I have no worry there at all [?], I mean, none whatsoever.
And there the judge looks at this.
Did you act actively, did you make an effort, on the side of managing the patient's complication?
The patient ran away from me, she didn't let me manage it, look, I tried this and this [?] — you have to be able to show that.
So there is value in our record-keeping habit [?].
Unfortunately the problematic side is a bit like this.
It is worth paying some attention to keeping yourself in the safe zone commercially as well.
My lawyer Ali Doğan told me this. [?]
If you do the Dolan Forum and manage it with the complication, it gets resolved. [?]
Then it is called an established act, starting from 2 to 5 years. [?]
Without scattering the subject too much — if we go into this, we can come back out.
In our country the laws in particular are very complicated.
It doesn't work with the environment.
I am coming particularly to this side.
Because we have one more product.
It is hyaluronic acid together with calcium hydroxylapatite.
Because that is what the product contains.
You can see the lifting with the immediate volume effect.
And in the long term it is hyaluronic acid.
While it comes into play — and this coming-into-play process is roughly a one-month process.
we are not talking about a very hard hyaluron, that is, a heavily cross-linked, steel-like [?] hyaluronic acid inside the product.
I'm very sorry.
There is no PLLA.
Nothing at all.
They did it as if we saw my heart. [?]
Let me correct it, because the inside of my content was made as a battery. [?]
The advantage is that you see that effect straight away and can show the patient what she can get.
And over the following 2 months your collagen increases along with it. [?]
In the tissue, to put it very roughly, in plain language, it is nothing other than a product that gives tightening and thickening.
I mean, in patients with a very heavy volume deficit there is no such thing as providing a very high [?].
For example, when they first marketed Harmonyca in Turkey: you do one, the volume turns over, you do one, you do one, and so on. [?]
Volume deficit — when you apply it to patients with a lot of volume loss, especially in the fat pads, unfortunately you meet a disappointing [?] result.
These are clear, too.
So with that type of patient you have to work a bit more in combination.
Supporting the deep tissues a bit more and then using a carotene microsal cover [?] to tighten the more superficial tissues and to increase collagen gives somewhat better results.
Along with that, in my own practice, if I want effects such as creating a sharp jawline or sharpening the zygoma, there we prefer calcium hydroxylapatite more.
There is a change of ratio in that one, depending on the region we use it in.
What does he say, doctor?
I mean, there is a change from 30% to 70%.
Of course I use the product as it comes.
If you are going to use it for revitalisation, to tighten the skin, and you are going to the neck, there it is worth diluting it a bit.
Or it can be decided by the patient's skin type.
Now when you look, some people's skin is 2 millimetres thick, and when you pinch 10 millimetres it sits there like a paper-thin covering. [?]
And then there are people with skin like mine, I mean, V-shaped
when you pinch it, it comes into your hand thick and firm.
Now, elevating a skin like this and elevating that paper-thin [?] skin I mentioned a moment ago are not the same thing.
But for example, if there is no tension, I rather prefer using it on the thin ones. [?]
In fact, during the examination, when you pinch it the skin comes into your hand very thin, and when you pull it, it just stretches.
like elastic, sometimes it stretches out from the cheek like chewing gum.
It satisfies these patients very nicely.
Because of the collagen and elastin balance in the tissue: in them elastin is higher and collagen is lower.
When you increase the collagen it gives very good results on the side of some tightening and of clearing the vertical lines that come from loose skin tissue [?].
Products like these are more for such patients. [?]
We also see a lot of benefit on the side of tightening the pores.
But for example, if it tightens the pores for the patient, in between
we need an example.
They usually present it at a 1:1 ratio.
So if you are going to do the neck, for example, you take 1 ml of the product mixture, and if you want to mix a little Lidocaine into it, at 10% to 20%, that is, into 20 litres [?] of a product, 0.1...
I don't much prefer Jetokain now, because of the substance [?] in it.
If there is bleeding, I wanted to see it.
I mean, if three hours later the room starts swelling [?] and you go looking for haematomas, that is actually more tiring.
If there is any, let it be right under my hand.
And then, if I have added 0.2 millilitres of Lidocaine, on top of that we can use 0.8 millilitres of saline.
Or, say, you could add a mesotherapy for a bit of glow in the patient's skin, or something else, or they try DMA. [?]
You can get around it with that as well.
For every site it has to do with any interaction. [?]
You won't create a problem with this.
Well, you won't take advantage of its safety.
That is what I am saying.
There is Zikon, at the jawline and so on, definitely a level teacher. [?]
It won't create the inside.
But on the neck the skin is thin, on the décolleté it is thin.
In those places it can be diluted.
At home, for example, while using the calcium group basket, a bit of a gap comes up in front. [?]
Cross-linked, low diameter.
Skin booster,
Dorotin.
These days there is Jouveler's SkinWire. [?]
Something like that; of course SkinWire is a bit costlier than Dorotin. [?]
So there too, because you can replace the patient's volume deficit, raise the skin quality and get a hydrating effect all at once, we use a nice mixture [?].
When we look, there is actually heavy volume loss, and along with that, again at the collagen point, if we get collagen
gain, this is a patient where you would think you would get good results.
The loss of the dermaclets and contour definition. [?]
If there is an ezozoma [?], you can see how far the malar region has dropped because of the volume loss in the zygomas.
In this type of patient you can get good results, but with products that work as biostimulators we should definitely not go into the middle of the face [?] — that is my advice.
Under-eye, nasolabial lines, the oral commissure and the regions in those medial areas, above the lip, the nose — personally I don't work in those regions.
In my view the colleagues who do are taking a very big risk.
Because here is what happens in these areas.
When you work in the outer two-fifths of the face you are working in a less mobile area — or rather, in an area that makes a gliding movement — and think about the products that can produce particles [?] you place here: somewhere, with facial movement, a fold forms ten thousand times over the years.
It can build up inside that fold, and a year later that build-up comes back to us as a granuloma.
I wanted to make the point.
Once you meet a granuloma, you basically have to take this patient into your household.
It is a lot of work, really a lot of work.
That is where steroid injections and so on come into play.
And you don't always get the result you want. [?]
Every time you do it, when the patient comes the next time the cell ring [?] is higher, and so on.
Patient management becomes very difficult.
So when working in the medial area, for my own part there are new-generation mesotherapy options. [?]
Of those, as the gentlemen said, I very much like working with [?] acid.
Going with the [?] and using these products always makes more sense and gives nicer results.
Product
preparation, if we do it: as described here, I mix in a certain amount of lidocaine.
It makes for a heavy injection.
I mean, in the end, when we look at a tearing material, the tension we use anyway, this tearing quality can come back to you as a heavy injection feel. [?]
To reduce that, mixing in lidocaine at 10% to 20% always makes my hand easier.
In total, a 3 millilitre syringe.
Manipulating this straight from a 3 millilitre syringe feels difficult to me.
So I split it in two.
It also makes mixing this lidocaine easier.
In one-and-a-half millilitre syringes — one and a half into one side of the face, one and a half into the other — it makes my hand very much easier.
And I usually do this with 0.5 millilitre injections.
You know this one, don't you?
In the MD Codes developed by Maurício de Maio you are going to inject with a cannula anyway.
And as active volume it is always 0.5 millilitres [?].
And when you do an injection like that with a cannula, you get a clearly visible result.
and some patients need a bit more, some respond a bit faster — you can easily observe that while you are doing the procedure.
Applying it with 22 to 25 gauge, 50 to 70 millimetre cannulas is always the most reliable method for these products.
But as I said, from time to time I do play with a needle as well.
That is a bit of a courage question.
It isn't something I always do. [?]
The injection version, the intervals... [?]
What, is he going to do one session?
I first saw this on BlueSlide [?].
And I can't say I apply it much like that.
I think this is probably something to do with marketing.
How much does the product cost?
I think it is a bit like this.
No shot makes you do it three times. [?]
A kiss, too. [?]
Patients at 3 millilitres, it is a whole world of a body. [?]
Patients need 9-10 millilitres.
And if you are going to do something like that, do the first one.
Waiting 3 months, with the coffee effect, one from there or so. [?]
If that wasn't enough, do the second one.
Wait, let it settle.
Let 2-3 months pass.
Then you will do it.
I think what they meant here is do the third one.
Otherwise, what would be standard?
What, 3-4 calcium?
If you ask me, it is not something that should happen.
Are there patients who pay for an application like that?
There are, there are, there are.
She is going to come every two months, but this isn't that thing — do we know the meso side?
Wouldn't they be a different list?
Make one.
For the jawline anyway...
So it isn't taken any more?
At the jawline it's fine, but...
I saw it, in our model.
Am I asking because you compared this person directly with this?
For the majority.
But again a
distracted one — for example she is an apple, a natural apple. [?]
How can you use it for her?
For this one, let me not use this.
There is nothing else.
I mean, because calcium hydroxylapatite produces a very sharp line.
So basically, in deep application in particular, I would use calcium hydroxylapatite.
We have one spot too many, the patient comes. [?]
For example, in my own practice I never do the thing.
The patient comes and says I saw it on the internet, so-and-so does it, she wants some sort of glow.
Some patients come, the poor woman is like a tomato.
Although there is fluid, she says, I would like my face a bit thinner, a bit more layered, looking more feminine. [?]
And for example, I don't have a chin like this.
And that is one of the enzymatic lipolysis ones. [?]
Six thousand litres into her chin. [?]
Believe me, they weren't exaggerated.
I shrink it like Melahat Bey and Joe [?], then I make room for the fillers.
I, on the contrary, first support the midface so that it lifts, support it with filler and gather the face up.
After that I will sharpen the jawline.
Both of us actually look for the anatomy first, the bone.
Let's actually see the anatomical location.
The same way, how much do you need.
When you pull the lift, let it send your hand. [?]
the operations.
And the orthodontic fixations are cut, an audible condition. [?]
There, while you are sitting with the patient over these
she wants the condition too.
You have to do it in the middle, where you can [?].
If you cannot do that in the middle, let me
say this openly, I explain it.
In my view you need this.
No, even if we don't do it that way it will be like this, it will be more than that.
And we know how to do it.
This is the treatment I am recommending to you.
I mean, say you have got a pyramid [?], you have come in, and I will choose a second-generation cephalosporin as your antibiotic.
You
are not in a position to like it or not.
As application areas, on the face
the colleague who prepared the slide has shown almost every seven. [?]
But if it were me, number four, six
when I say six.
Stay away from the middle and the lower part.
And I wouldn't get too close to the stereo [?] part of three.
In these areas, blölyon or nodule formation, [?]
Merken's other [?] is very good too, I use it a lot.
In those places I would recommend those.
Calcium hydroxylapatite into the nose region —
I have come across many doctors who do it, who say they do it.
I don't prefer it.
And I don't much recommend it either.
I mean, it is a risky region.
Very risky for calcium.
Because here we are injecting on the bone a great deal.
There is very little room; I mean, the space between the basal membrane of the dermis and the periosteum is so narrow you cannot even count it in millimetres, and these places are one single autostopic. [?]
What would you tell the patient?
I wouldn't know.
At least I don't take that risk.
We fill it from a new flat. [?]
I mean, as I said, we have to do every patient. [?]
Especially in the temple region, subcutaneous application meets a lot this time. [?]
Recently in Monaco a four-way session was held to compare biostimulators.
In fact I want to share with you the thing I saw there and adapted.
There was a Doctor Huygandroli [?] — I don't remember the name.
He particularly recommends this application a great deal.
But in filler application in the temple region, and in calcium hydroxylapatite application, it is worth being a bit careful.
It is one of the regions where the skin gets very thin.
I mean, as we go up from the zygoma the skin thickness decreases.
In subdermal applications in the forehead and temple region it is worth diluting the product a little, as my colleague said.
There you may need dilutions of maybe half a millilitre to one millilitre, or even going down to one to one.
Because when we are done, an appearance can be left here as if there were worms under the skin.
Either you have to disperse it with very good massage, or I would recommend following this route.
As for cannulas, I use 22 gauge cannulas.
Or mostly it can be 23 as well.
It flows comfortably through 22 or 23 too.
22 gauge in particular is a bit painful because it is thick.
In fact I have one 70 millimetre 22 gauge cannula, so that ears don't ring, so I don't get told off [?].
In fact that one stays far away, let the man give it too. [?]
So moving that under the skin really takes skill, and it can hurt the patient a lot.
That is why sometimes I prefer 23 more.
25 can be used as well, but...
And calcium-containing products can fill up and harden at the mouth of the cannula.
Because it is together with hyaluronic acid, I never had that happen with Merken's calcium. [?]
But there is such a possibility.
By the way, frankly I don't want to put myself at risk either.
Is there anything you want to ask up to here?
Yes,
let's carry on then.
In facial applications it is quite a good amount. [?]
I mean, what you call the liquid facelift, you know it very well from this. [?]
We started with PLA in '99, with Sculptra.
Then in 2004 we got the FDA
approval.
In 2009 the indication of the FDA approval was widened.
But while all this was happening there was a problem related to PLLA.
When Sculptra came out it contained 150 milligrams of PLLA.
It was applied with a total 5 millilitre reconstitution protocol, presented [?] to doctors.
And because of that they ran into an incredibly high number of granuloma [?] formations, mostly granuloma formation.
Then, somewhere shortly before 2009 [?], they changed those protocols.
They gave a minimum 8 millilitre reconstitution protocol.
They produced a protocol of 8 to 10 millilitres.
And they made it a condition that the product be reconstituted not with saline but with pure water, with distilled water.
If you add lidocaine at 10-20% you can reduce the pain of the distilled water, that is, the water for injection, and so on. [?]
But when you look at it, it took until 2014 for the product to start out like that and settle in.
So since then it has still been going through a transition. [?]
And with these too the product was developed in a similar way: crystals that were sharp-edged at first, then became microspheres, then the homogenisation of those.
There are many manufacturers in the world working on PLA.
In South Korea, almost every company you look at has a PLA of its own.
I think it produces a very low mass. [?]
In Georgia, Aptos was producing a lot of products made of PLA.
Now those were on the market too, for example.
It's another brand.
Sculptra is of course the original product, the one that first put it on the market.
At Merken they sell other PLA products as a distributor.
And they took this one as their own production, as a ready mixture. [?]
In fact I contributed to the development of this product as well.
I mean, first the pre-mixed form [?], and before that we used the powder, the lyophilised form, reconstituting it, and so on.
At the point we have reached now, with its low cross-linked form, I think it has reached the optimum level.
Because in all the other forms, in my view that is the biggest problem. [?]
If you mix the product — with the first-generation products we start mixing 1-2 seconds [?] beforehand.
it goes [?] into this thing, into the vortex.
Then we learned that the vortex had no point [?] at all.
The shaking it creates is laminar flow.
For it to be usable, you have to shape
the inside so that a whirlpool forms.
That is why you have to mix from syringe to syringe.
It homogenises in turbulent flow.
But once you have homogenised it, it cannot stay stable for very long.
I mean, say you have prepared an 11 millilitre syringe as recommended — you can't just deliver 10 millilitres in one go.
You distribute it into 1 and 2 millilitre syringes.
You distributed it.
And then what did you do?
You looked at your moment again. [?]
And the sediment has started to settle.
During the preparation stage it foams. [?]
There is a lot of foam.
When I first started using it.
That foam is in this vitamin shell. [?]
You have to draw that foam off.
Then I found out later.
It is of no use at all.
This is something we were really getting confused about.
You are supposed to use the part that looks like raki.
There are a lot of details in front of it, like the taste having settled. [?]
That is why I think Merken's PLLA product is very successful.
Because you take it and the syringe is ready.
Just hand it over to the units. [?]
There is the amification of a five millilitre syringe. [?]
But after that it is very easy.
What I want to share with you today is this.
Until last year in Turkey we only ever saw superficial applications of PLLA.
This April I went to Şino in Malapya, one session in Los Angeles, someone I have followed for a long time on Instagram — in this biostimulator session I mentioned there were four physicians in total. [?]
One presented hyaluronic acid as a biostimulator, and another presented fat injections and micrograft, nanograft fat injections.
Şino presented the PLLA application, and he also did an interesting application.
I modified it a bit, pulled it into a slightly safer zone.
I'll describe what he did as well.
And let me also show how I do it in a way that suits me better.
Our model will be Ms. Çiğdem.
if you are doing nanofat, exactly, there is nothing.
That's all, I mean...
You need someone to do it from nanofat.
The lady is coming anyway.
From somewhere very far away.
We'll pick it up even from the smell.
The publications made in the last
five years are gaining ground. [?]
Now, we always evaluate these as biostimulators, as collagen biostimulators.
But the fact that they are effective on [?] has recently been included in the studies as well.
Very recently, I scanned the last 5 years: there isn't enough evidence yet, more research may be needed, that's it.
Dozens of studies, large groups.
When we look at it, for the patients who say I don't want filler,
in future they will clearly be recommending
it.
I mean, or in patients where we can't use it.
The point where it parts from calcium hydroxylapatite is making those sharp edges you mentioned with PLLA.
That is not possible.
But with PLLA you can also, in the subcutaneous fat tissue, deep
lipogenesis, slowly
developing volume gain, and along with that you can also provide revitalisation and regeneration of the skin.
in the product there are 100 milligrams of DL fat and 100 milligrams of glycerol; in just over 5 millilitres there is a 20 milligram glycerol concentration, so there is no very hard filler inside it, it is the softest, and when you use it under the eye it both [?]
provides collagen stimulation and at the same time gives hydration, but as I said, I have come to like using it at a slightly deeper point
And also [?] the patients we described earlier, where volume loss and skin quality decline together.
Now, when you see the photograph you obviously want to see what came after. [?]
In the slide just now it rested [?] — I wonder what happened here.
This photograph was taken from below.
What has
become of this.
It isn't written here for PLA, but massage,
doing massage, and doing massage after the injections, is always recommended.
Classically it is recommended to massage for the 5 days after the procedure, 5 times a day, 5 minutes each time.
You need to do the same for the deep injections that are part of the injection I am about to do.
Because what you are doing is spreading this product inside a fat pad.
In the same way, this model, this is that.
I enjoyed it — is it right, is it this, is it that.
We did one.
The patient came.
Wait 2-3 months.
Well, I said I didn't get much out of this.
She is bound to say that anyway.
I mean
I will check at 3 months.
When she comes, the photograph from the first day,
it actually shows that you didn't do this. [?]
Because
because biostimulators show a change slowly over time, and because this patient looks at her own face something like 356 times [?], she will not see the difference you see.
The glow in her skin — well, she bought one, the creams got mixed into it. [?]
So keeping the consent form [?] you mentioned solid for the patients,
we are not in practice,
I mean the details like your record, issuing an invoice and so on, which you won't remember. [?]
That is not my job, it is the state's job.
but Taner Cizan and Tavsiye, how much they were always about me today. [?]
And she complains very little.
Especially in Nişantaşı...
In terms of talking about glow, it won't create much of a problem.
With the air issue, let's not get too close to the corner of the mouth; we'll deal with that right afterwards, that's all.
Is there anything you would like to ask?
Have you ever done PLA after a device treatment? [?]
After a device, one...
If there is no trace of calcium, PLA after [?].
I have no need for it at all.
I mean, rather than not needing it: do the calcium hydroxylapatite.
The patient didn't find it enough, she wasn't satisfied.
You can't make her any more satisfied on top of that with PLLA anyway.
Because the patient has stated her expectation. [?]
It doesn't create any problem.
There is no problem.
So technically there is nothing stopping you here, but in practice most of the problems we have today are this — I am closing the computer, since you asked.
On social media right now there is a trend called the liquid facelift.
Everyone is following a liquid facelift, they look at those.
And when many of our doctor colleagues say liquid facelift, at first glance — and for that reason your expectation too — we are going to use collagen as the advantage. [?]
As if there were no other way.
But a liquid facelift.
A facelift with something liquid. [?]
I mean, in this one I used filler as well, for example, and I explain that to the patient.
Now, lining up with the patient what you injected [?] — that shouldn't be like tricking her either.
Now, there is a limit to what you can do with a collagen biostimulator.
As the name says, it makes collagen.
But the problem is not the collagen.
If the malar fat pad has come down and only this much is left, or if the temple has caved in like a skeleton, I can put in as much calcium as I like.
It won't do much good.
Because the only thing calcium will give me there [?] is: if it is this much, to make it this much.
Or, if what you pinch stretches this far, not to let it stretch that far.
To hold it here.
To provide a satisfying [?] lift that comes from this gathering up, from the tightening due to this collagen gain.
Nothing more than that.
But the patient cannot know that.
Let me be clear here: many of them actually need surgery, and they say I am afraid of surgery, they may never open that subject at all. [?]
And then I say — the question I ask myself [?] — if you insist on this product, this is all you will get.
Because there are this many layers in your face; I list them for her: bone at the bottom, above it the deep fat pad, above that the muscles, SMAS, the superficial fat pad, the skin, its basal membrane. Look, we are laying this here, it is only effective here, how are you going to [?] — I explain them one by one.
After that: if you want, we can do these.
I say, I won't send you out of here [?].
Come, let's shake hands on that.
If you still don't want it, I am sorry, but this is the treatment model I am recommending to you.
If on top of this you say I don't want that, I prefer this, then if it won't harm you and will give you some benefit, I'll do it.
But I recommended this to you; if you then say this wasn't enough for me, don't turn round and be angry with me.
Now, I did calcium.
If there is no calcium in my skin [?], if you are not skimping on the product, if you use half of a 1 millilitre syringe and put the other half aside, the effect we are going to get is obvious anyway.
and we have shared this with the patient too.
And we did that at home as well. [?]
But at the point where she says, well, I wasn't satisfied with this, I want something else and so on, it isn't really possible for us to satisfy this patient on top of it with more PLLA or more calcium.
There you say: look, we talked about this then; come on, let's say we use PDRN on top of this to treat your pigmentation.
I mean, I can't treat pigmentation with CaHA, for example.
or you can say, if you want we can use an exosome, or let's turn to a device.
Or: you have volume loss, come, let's work on those areas a bit with fillers.
By now your trust in me has grown, don't be too afraid.
If you don't like it we can dissolve it, and so on.
But with persuasion methods like this you have to move the patient towards the right place.
The other question: because if you leave the whole choice to the patient, you are doing nothing different from a hairdresser — and we forget that.
Especially if the volume deficit after stimulators like this isn't satisfying, the filler I use afterwards is a non-cross-linked one.
Otherwise, the non-cross-linked ones.
For example, we say liquid facelift: you got a good collagen stimulation, the whole thing worked, the collagen thickening [?] came later, but there is volume loss in the face.
We would check at 1 month, and at 2 months we supported it with fillers.
There was cross-linking in it.
It became cross-linked.
There was a middle ground in the distant filler. [?]
Let's consider fat injection as an alternative.
No, let them do the fat injection.
Of course we did the same session.
Because the depth you apply is different, and far from getting in each other's way [?], they will act synergistically.
There is no such thing as never do it there.
I mean, maybe he meant you don't need to do it.
Because the biostimulation you have just had is already meant to increase collagen.
There is no such
route at all.
This could be the only basis.
Maybe he said that is what he was thinking.
In the end, when you use protein-based products — whether peptide or collagen — your allergy risk is high.
Proteins are something that stimulate immunity.
Yes, exactly.
He may have
meant that.
But I don't think that way here.
While everything is already stirred up, giving something that will nourish the area gives a nicer result.
So, as you were saying, it isn't a nutritional, nourishing product, is it?
There you are creating a stimulation.
Then, when you look at it afterwards, you do a gold needle session, and when you add something like a mesotherapy right next to it, it comes out nicer.
Maybe, if you have a sensitivity,
in your
room, for example — that lifting wasn't enough, it didn't move your lower face at all.
If it were me, I would have worked that area with you.
I am not surgery, doctor. [?]
No.
For example, like this,
or rather from a scientific standpoint.
I did it to CW2, and from there I had gone back to CK4. [?]
Ahmet is the repairman.
You are a wonderful model.
Yes.
And another thing, you lose the effect quickly, they have a chat about it. [?]
Disposable.
Share the results with us.
Thank you.
Is there anyone among us who wants to leave early, who has to leave?
Now
Ms. Samka, the queen of our kitchen.
Please — the lady who presents these products to you.
Thanks to this
series I have taken about 15 years off.
Not at all.
When I couldn't find a model I asked her.
Bless her, she didn't turn me down.
Now, if you look carefully — because she is constantly right beside me, I don't really look any more.
She needs serious support along the jawline.
Along with that,
if we also do a bit of a lift at the zygoma — as I said, some generations [?] need sharp support.
In these respects I think she is a good patient for the use of calcium hydroxylapatite.
Her skin thickness is good.
Please, come over here as well.
Where from? [?]
What do you think?
At this
point we need to work a bit more.
Look from the side, I am looking from the side.
When we look from the side, actually
the exact aesthetics of our lips...
Here the nose needs to be made smaller.
We couldn't match the liquid [?] line.
Careful with the zygoma too.
In fact her chin has turned a bit.
The liquid line.
Her chin needs nothing at all.
Stop this and you can do the lip on its own.
She would get a lip out of it.
That is why the maxilla [?], the upper lip coming forward, came into it.
in the lower lip there is a bit of a stitch. [?]
Because the maxilla is weak [?], the nasolabial lines look deeper the more you see them.
If it is going to work, the perioral area will show.
You have to go into [?] work.
We are asking that middle comma into three. [?]
But what can we do?
Especially at about 45 degrees, in this lighting
because the malar fat pad has lost the support it took from the zygoma
when she lifts her head it looks as if it has slipped somewhere. [?]
And we have a big volume loss at the temple as well.
If we come here, it looks as though it will be better.
And when we look, it works like this. [?]
The lines here are clear and we have a bit of jowling.
And after working on them together, as
the lady described a moment ago, taking the ramus of the mandible together with its body, we get a nice [?].
And calcium too
At the temple, what every sensible approach recommends, if you are using calcium hydroxylapatite in this patient.
Subdermal, with a blood product [?], it adds volume here and might do nothing else.
And look how low the patient's eyelid is.
Now, the orbicularis is a [?].
It wraps around here as if it were being wiped away.
And to keep this from dropping, along the temporal line we have the temporal retaining ligament and the zygomatic retaining ligament. [?]
Although these are structures that ought to hold this up like this, because of both collagen loss and even the bone underneath losing volume, it ends up sagging [?] like this.
This has sagged, this has sagged, the retaining ligament [?], and it sags like this.
The upper eyelid
drooping too, and there is an immediate mechanism in the forming of the under-eye circles here.
Then over time it gets affected here by facial movement.
Its own loss of regime. [?]
Now, because I can't afford an osteophyte in visible places, I don't work too close in. [?]
I'll work with the pen
and move on.
The temporal part, below, one
or two.
If I can create a proper osteophyte in the temporal area here, since it will support it continuously, we would take care of however many layers you want. [?]
So, doing it that way again, but be very careful, because I would like to do a second injection at the temple.
But these,
calcium hydroxylapatite, and
if you have caused an intravascular occlusion, in the other
direction we have no speed. [?]
That is why on the vascular occlusion side in particular you have to be ultra, mega careful.
Yes, all right.
Now
shall we decide what to do? [?]
You could go in, but it is very difficult and it would be very heavy.
It is very hard for the patient and very hard in terms of the limits.
So if I pass under the muscle, that is enough.
And because of the fillers it can't be pulled. [?]
The five-point
one we do, the five-point one we do, the five-point one is very unsafe. [?]
We don't like people, we like the samta. [?]
Doctor,
let's do something this evening.
I keep looking, I keep looking.
I keep looking, I keep looking, it doesn't feel right to me.
My plan would be this.
The temporal bone.
The lower border
of the frontal.
The zygomatic eminence.
Into the malar fat pad.
The malar groove.
Our chance of [?] will be high.
Into the places where there are hollows.
And so on: to that line, to the margin, above and below, approaching for all sorts of reasons. [?]
What I am going to do is support this region.
I lifted,
I lifted, let's lift again,
I changed the mandibular angle.
Your [?] comes out anyway.
I mean, there isn't much point in playing about with the chin tip. [?]
is there anything you want to add?
if we want to lift the brow, I will show that now
brow filling is something I am very fond of, and with calcium hydroxylapatite too, if what you wanted to ask is whether there is something about the energy [?], I mean, three into the brow now, and again I will go over the gown
I have defined them as D1, D2, D3 [?] — frankly, so far I have never felt the need to inject into E2 and E3.
But if it comes to it, I would.
And if I do, I look to cannulas.
Because [?] increases; the trochlear artery, for E3.
For this area a cannula is recommended as well.
It goes in with difficulty; rather than opening a port for a cannula for 0.2 millilitres, I give it with a needle. [?]
But in this kind of area, if I am going to use a needle, I don't move the needle sideways at all. [?]
I go in.
Now, on the way you could puncture a vessel and pass through it.
I go in.
I have passed through.
I aspirated.
I pulled back, nothing came.
If it gets caught retrograde it creates an occlusion. [?]
So I passed through this.
I aspirated.
Nothing came.
Very good.
Hold it for ten seconds.
Excellent.
Every clean.
It only delivers here.
It bleeds on the way out anyway.
But even if it bleeds, when I spread it outward from here with my hand, with massage, it cannot become a problem. [?]
Then, if you want support again at a second point, again
if you do it, this is how I do it.
But still, I am not in favour of putting too much filler at the tail of the brow [?]; I think it looks very odd.
I think it is a nice thing.
In my view the lifting we do at the temple works out nicely.
At that point I heard a lot about it moving once. [?]
Don't shy away from things like this.
For example, I used to think you could inject on the bone.
You can't do that however much you want, because there is a fat pad here.
It is stuck to the bone.
Even if you wanted to, you cannot separate it.
You would have to cut it.
The needle goes underneath it.
We delivered it on the bone.
At most, if you go infraperiosteal [?], you could do something like that.
And there you have no [?] anyway.
What we are doing here is filling the fat pad here, and we are talking about quite a mobile structure. [?]
It moves, of course; that is unavoidable.
Now let's come to our product preparation.
5 millilitres, 3
millilitres of calcium hydroxylapatite.
Then [?] acid.
Ms. Safka's pain threshold is high.
So it won't create a problem.
Oh, I couldn't bear it.
But while turning it you have to set the channel well.
When you pass it back and forth about 10 times you get a good result anyway.
Now she will split it into two syringes.
You are adding Hidrotain, aren't you?
Probably not Hidrotain.
Sintes.
Sintes, exactly.
Hidrotain —
let's make your plans.
Now let's also talk about how much volume I would plan for a patient like this.
I want to lift the eyelid [?] properly.
If a total of one millilitre is going to be used, that is fine. [?]
For the zygoma, if I am going to use a product with a cannula, I planned about half a millilitre here.
I would
grit my teeth.
Her masseters are very strong.
If I enter along this line and do something like this, even half will be harmful for this patient. [?]
So I advance upwards from the mandibular angle.
In a way similar to what Ahmet did for you.
This is the area referred to
as CW2 in the MD Codes.
I mean, I think of it as injecting in a way that visually strengthens the ramus of the mandible.
In these areas it is always the deep plane, on the bone; here I will go a bit more superficial.
Because I also want to do a little mechanical myomodulation and weaken the muscle movement.
Suppressing the movements of the platysma here to some extent increases the effect we will give the patient.
So what we do subcutaneously should serve this region better in the long term. [?]
Sometimes, in patients with a very weak mandibular angle, I might also consider the central area, about half a millilitre on top, but I will deal with that later. [?]
Not for this one.
And I would plan another half millilitre injection here so that we join up the angle of the mandible.
A sort of arrangement we would make like this.
So what did that come to?
One, one and a half millilitres.
One and a half on the other side too — a three millilitre injection would actually build up the base of the midface. [?]
But I am being a bit extravagant today.
One millilitre each will do the temples.
That leaves me one more millilitre.
And this
is the result of our decision, and it will decide from there. [?]
So in total, a three millilitre injection for this patient.
The special bench feature, for now [?]
there is one thing left that I forgot to tell you [?].
Now
when I first used biostimulators, the thing that always stuck in my mind was this.
You have played with collagen biosynthesis.
It put fibrosis into the series. [?]
We were
quite worried about this. [?]
It produces a tissue similar to a scar.
But is it really
so?
No.
Could it be?
You could make skin as hard as stone.
Would you look at it a bit tighter?
Look, it develops that much oedema.
My dear is right in front of me.
No, doctor, that's enough.
Now, when I do it the first time, if it is filled a bit [?], that will already make it easier for me on the side of reducing the lines.
And here I will choose the modiolus as the entry point.
The modiolus — the junction here of 7 or 8 muscles. [?]
But an artery runs just beneath it, in the deep plane.
So we keep [?] very superficial.
otherwise you would end up cutting an artery that runs from here all the way up. [?]
Then we would have a haematoma.
Even so, I am not letting go right now.
If there is
any bleeding right now, I tamponade it.
I laid it flat.
If I still have bleeding, I tamponade it with my cannula.
I didn't interrupt my work.
If bleeding happens here, if you
disperse it again, would you call it an artery anyway? [?]
I am confident about this myself, too.
Even if I were [?], I would prefer to finish my work without letting that bleeding progress.
Then we control that bleeding.
I brought it up to here.
I go in again from here.
I was making a small fan over a short distance.
I came back.
Just as I am about to come out, I go in again.
Exactly.
You see a result straight away.
The line always gets less. [?]
It will increase.
In a month they will come and say, why have these started to come together.
Because it will pull itself together.
Exactly.
But
we are one way cold. [?]
Exactly.
Both the deep and the superficial plane.
We have been a bit extravagant.
Normally we don't use three syringes like this on anyone.
If you weren't here, we would be trying to finish the job with a single syringe.
It is hard
to find a patient this tough, too.
You just look, a crumb. [?]
This is unbelievable.
Get well soon.
Thank you.
you need to go to very hot
places.
Without pressing too hard with my hand, if you massage from below upwards over the next two areas, it comes out even better. [?]
Thank you very much, [?], and especially for sharing your experience.
Not at all.
Thank you very much.
Sinan Akyürek medical aesthetics workshop.
At one point there was something we called
the Diamond Lift, a lifting method; he picked from those. Actually it is a nice method, it isn't bad, but it isn't very safe: arteries run through the points where you push the needle in, and injecting PLLA into that is not very sensible.
I preferred to modify it a bit, using a needle in some places and a cannula in others.
A somewhat more reliable method.
He built a method designed specifically to use PLLA's adipogenic effect in the deep tissues, that is, its effect of repairing the fat tissue in that area.
Basically he went into the midface focusing on two points.
So that is also the reason I chose Çiğdem for this application.
I am planning to inject a total of 1 millilitre of PLLA plus [?] into this region.
Sorry, 1.5 millilitres.
One into the deep fat pad, and the other entering like this so as to make almost a W shape here, over the whole superficial
malar fat pad — a method built on adding volume there.
One again, as we did a moment ago, a pistol shot into the deep plane to gather up the zygoma
and one we will do by entering from here again to soften the nasolabial line — so what does that come to?
one, two, three, four, one
at the mandibular angle 5, one around the mouth 6, and one on the zygomatic line: marking out 7 points he built a skin rejuvenation system, and I found it quite successful. Especially in deep plane applications its effect in patients whose malar fat pad has weakened is quite good.
I tried it on a few of my patients.
The long-term results are coming out quite nicely too.
When you apply PLLA that has hyaluronic acid in it, you can already see the result immediately.
Elif, now
of those syringes I will want one, two, three with a needle and four with a cannula.
Put a 27 on.
Let's not hurt her that much.
I don't hold that much of a grudge.
She only forgot to do the end-of-day once, after all. [?]
She forgot to close yesterday's day, that's all.
Now there is a total of about 5 millilitres of product in one syringe.
A hyaluronic acid plus PLLA mixture.
I draw this into 7 separate 0.7 millilitre syringes.
At each of my injection points I will inject 0.7 millilitres.
There isn't much need to add lidocaine.
It isn't that painful an application anyway.
Really, it isn't, honestly.
Were you clean?
I was clean.
If we are ready, I'm starting.
Would you open your mouth?
I always aspirate.
As I said, with these too, if you get it into a vessel you have no chance.
That is why, a crackle,
a single air bubble.
That stinging, the tightness
in your face.
Is it all right?
It's fine.
Now
was it you who asked a moment ago, doctor, how
I do the mandibular angle — in a woman, for feminisation, you should not do it in a way that widens it laterally; so I mark that angle with my hand, hold it, go in
right now I am on the bone, I lifted slightly, 1-2 millimetres. I aspirated, I am adding,
it will slow down, then I add.
Is it painful?
A little bit, it seems.
Shall I add some [?] as well?
How many more are we doing?
Seven here, five here.
It might be good if we add some.
Then do it like this.
When you prepare them, go back up to the five.
The ones after this are with a cannula anyway.
I opened one entry port over the modiolus.
From here I will address two or three points at once.
One — I go in like this.
I go on top of the maxilla.
I went down to the deep plane.
Here
I am below the nasal cartilage.
Well below it.
I mean, right now I am on the maxilla.
You are at the corner.
I am at the corner. My aim in doing this is: if I can use the levator labii superioris alaeque nasi in a way that shortens the muscle, then while giving her lip a fuller line I also make the nasolabial line
soften nicely, and by opening the alae of the nose a little I can actually help her breathe more comfortably.
I will give 0.7 millilitres in total.
That is a big volume load for this area.
But after giving it
I came out.
What will you do with the PLLA?
PLLA plus hyaluronic acid.
Now I will go to the midface as well, doctor.
Would you sit up straight?
I wanted you to see the effect of this one on its own.
Can you see the difference between the right and the left of the lip?
We did the thing to the midface.
That's what I said.
We are not going superficial, we can see. Actually right now it is deep, exactly, that is what I did, now
from the same entry — the reason the order got mixed up, doctor, is that when it was this close I couldn't resist, I couldn't stop myself [?]
I am inside the superficial fat pad.
From here I am already having to push my cannula into the superficial malar fat pad. [?]
It is under my hand.
I pushed a little and got inside it.
Now here...
We could go deep as well, but going deep from here with a cannula would be a bit painful.
So I will choose the needle.
I'll take a breath.
Yesterday's score is settled now, isn't it?
Not yet.
No.
There probably isn't more than this.
I should really do the zygoma too.
But because the zygoma here is prominent enough, I won't go any further.
I could have gone into the deep fat pad, but I need neither more lifting nor more volume there.
so I won't go there either.
There is only
one problem I have, here.
Normally I said let's not go this close to the mouth with either PLA or calcium hydroxylapatite, but here again I want to make a small correction in the lower half.
To correct the tissue irregularity here.
I mean, there is constant creasing around here.
Can you see it?
It will be trouble for you in the future.
I am taking a precaution with you.
But not 0.7 — I will finish there with 0.35.
I am not planning to load that much volume either.
Did you see?
Look, she just did it.
Do it again, let me see.
What should I do?
I keep doing it.
It doesn't
hurt at all.
Wait, try it like this then.
Doctor, you have no pity.
Ah, and there I was saying it doesn't hurt at all.
No, you have no pity for this.
Is the camera here?
Am I not taking it over here?
Exactly.
Would you say that again?
Wonderful.
So are you.
All together.
All of us.
What did we use in total?
Doctor, you used four.
And a half.
So 2.5 is left.
Thank you.
So in total, doing this, 4.5 mil...
Sorry.
Sorry — 0.7 times 4, 2.8 plus 3, I used about 3 millilitres of product.
If I hadn't done her temples, I could actually have picked the midface up almost completely.
And when you gather the other side with the other half of a syringe, sharing about 1 millilitre of filler half and half into her temples would have made a nice combination.
This spot and this spot finished the job.
That is why deep injection of PLA is very nice in this respect.
Çiğdem has a good jaw [?]; I mean, looking at her mandible it is good, but the definition at the back is low, and it makes the transition to the neck look weak.
So it was good to bring that angle out a bit.
I didn't go superficial, not subcutaneous; I did a deep plane application, on the bone.
When it is done this way, the angling here comes out more nicely.
A little volume in the superficial fat pad increased the projection of the cheek.
That was enough for us.
We didn't need much lifting anyway.
The nasolabial [?] areas were very deep.
There she already had a fairly wide piriform fossa.
So I filled on the bone from the deep plane.
It will increase the fat pads in that region and at the same time the supraperiosteal fibrous tissue.
Plus, superficially, we also gave some support to the fine wrinkles in this region.
In addition to these, what is to be done if you look at it point by point?
1, 2, 3, two here, 4, 5, 6 and 7 — that is how we had actually planned it.
That is how I defined the seven-point technique.
And this is my modified version.
Shall we do it?
Are we ready?
Do we believe in ourselves?
Come on then, fingers crossed.
I wish I believed as much as you do.
We'll open your mouth a little.
I hold it like this with my finger.
Doctor, perhaps you wanted to see.
Look, I can see the angle clearly.
Here
a branch of the external vena cava may be running just under your finger.
Careful.
Straight to the bone.
Don't dawdle about to the left and right.
Listen to me saying vena cava.
External carotid.
I mean
I remember a femur, and there was a filler as well — is that why you go in at this angle? [?]
No.
That's it.
Let's hope they don't make the patient pass out.
With this many people we would lay her down, doctor.
Shall we try one more thing as well?
There are this many doctors standing by.
Even if I die.
God forbid.
There is a saying for that moment.
Kill me, but make me beautiful.
What year?
I use that one all the time.
They are making you beautiful anyway.
That's good.
That is why they are making you beautiful.
Don't say anything.
Şiiran, by the way, is my coordinator, but she has been my friend for 15 years.
So I bully her every way I can.
I show no mercy.
Doesn't she know?
She does the information.
All of this is on the record.
None of it is.
Look, I have all of it.
So we'll sort it out somehow.
And of course there is a bill for all this too
Doctor Erkut
Right now I am sliding over the maxilla.
I'm there.
Look, the phone is fizzling out.
Probably.
I am below the canine.
Above me, sorry.
Just here.
I am in the deep plane, on the bone, 0.7, and I aspirated too.
Let's always aspirate, doctor.
We deliver it right on the bone.
When doing filler I wouldn't go in with a cannula.
If what I had in my hand were hyaluronic acid, from here
I would go down onto the bone with my needle.
You really
love that, don't you.
Yes.
I love it.
Without this — I'll want one more, exactly.
I can't have the procedure done.
I'm there.
Here it was the superficial structure.
I hold it with my hand.
Look, here I went in more easily, for example.
Is the other side more solid, I wonder?
Good, you have looked after this side well.
You must have been drinking bone broth.
Did it all go there?
It has all gathered there.
Interesting.
If I needed more volume, then I would seriously need lifting as well.
the deep plane.
The zygomatic eminence.
I would go in just medial to it from here with a needle and do the deep fat pad.
Spreading it a little with massage here isn't a bad idea.
And again, don't forget to tell the patient about the 5 days, 5 times a day, 5 minutes each of massage.
It is classically useful for PDA. [?]
I mean, right now we are using a suspension supported with hyaluronic acid.
Frankly I don't expect much of a problem to come up, but just in case
as you
can see, if we used a little Lidocaine in these products it would actually be much more comfortable for the patient; but if you have patients you are fond of [?], don't go to the expense — it is a few lira's worth of Lidocaine at most, but never mind, a lira is a lira.
That is how people get rich.
Of course I can't talk while you have a needle in your hand.
It isn't a needle, he has a cannula in his hand.
You can talk freely.
No, no.
It's a needle.
Let's talk later.
That is my favourite part.
I said it doesn't hurt at all here.
That is why.
Of course.
Normally
I don't spend this much time.
Normally I don't do it with this much pleasure, actually.
With this one I am enjoying it, as you can see.
she keeps stopping and starting, you keep stopping and hitting; if you had fainted he would have brought you round and carried on — normally you would have finished it while unconscious, one moment gone, one moment back, there you are [?]
yes
your husband won't recognise you at home
now
Can she sleep normally?
She can.
That will have no effect on this.
As long as she uses a pillow it won't cause a problem, but if she sleeps on a hard surface then I would rather she lay on her back.
But since I didn't work the chin tip, the zygoma and so on, it actually won't be much of a problem; I mean, we mostly gave deep tissue and soft tissue support.
In these biostimulators there are three products anyway.
One is polycaprolactone, one calcium hydroxylapatite, one PLA.
PLA is more [?]; that is how I preferred it in my practice, and I also scanned the literature a bit.
While it is preferred more for deep tissue and soft tissue support, calcium hydroxylapatite gives more successful results on the bone and definition side.
It has to be applied deeper.
Exactly.
You can apply it deep, you can apply it superficially.
It doesn't make much difference there.
I mean, how you want to set the definition there has more to do with your hand skill.
With polycaprolactone, on the other hand, it is for playing the longer effect.
If she wants effects like 3 or 4 years [?], then you can use it like PLA.
The thing is clear — you can't get definition as sharp as calcium hydroxylapatite with polycaprolactone.
That is a well-known material too.
Elantik [?], the threads.
Exactly.
It is used a lot as Elantik.
And in the threads we use for lifting, poly-L-lactic acid and polycaprolactone are used together, in the long-acting threads.
The life of polycaprolactone under the skin lasts about 4 years.
The ones that halve.
It lasts a long time.
Thank you
for watching.
Thank you for watching.
Hello, I am Doctor Sinan Akyürek; our workshop at Merken is about to begin.