WEBVTT

00:00:00.590 --> 00:00:01.550
Thank you for watching.

00:00:06.360 --> 00:00:11.760
Thanks for watching.

00:00:12.740 --> 00:00:13.500
Welcome.

00:00:15.040 --> 00:00:15.840
Mükelle [?].

00:00:16.500 --> 00:00:17.420
Ms. Elis, doctor.

00:00:18.520 --> 00:00:19.120
Ms. Elis.

00:00:21.770 --> 00:00:23.870
I remember what you did with their content.

00:00:29.050 --> 00:00:30.830
The way you explained it, it suits your work.

00:00:31.440 --> 00:00:31.640
...

00:00:31.640 --> 00:00:35.580
but it turns out I hadn't used exactly the same setup.

00:00:38.730 --> 00:00:42.790
Cardiology, all right — why did you leave cardiology?

00:00:44.710 --> 00:00:46.410
We do it outside too; I do it outside as well.

00:00:46.530 --> 00:00:47.750
Three days of patients or so.

00:00:48.270 --> 00:00:49.450
It doesn't come to that much.

00:00:51.120 --> 00:00:52.340
Was this six months ago, how long?

00:00:52.640 --> 00:00:53.900
We got it eight months ago.

00:00:53.940 --> 00:00:57.480
So we tried to get by with the mesotherapy certificate.

00:00:57.960 --> 00:00:59.420
We are working actively at the moment.

00:00:59.720 --> 00:01:00.620
We examine in the bag-carrying setup [?].

00:01:03.180 --> 00:01:04.320
In total I saw three people.

00:01:04.380 --> 00:01:05.320
And there was the tea man.

00:01:05.840 --> 00:01:07.240
The power kept going out, too.

00:01:08.540 --> 00:01:10.840
Anyway, I had the chance to look at the manufacturing.

00:01:12.230 --> 00:01:18.470
We started using Merken's own brand, their older fillers — cross-linked, let's say.

00:01:18.950 --> 00:01:22.150
There too they had probably used something like two thousand [?] or so.

00:01:23.090 --> 00:01:30.250
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.

00:01:30.770 --> 00:01:33.410
We did PRP; I would test this one as well.

00:01:33.510 --> 00:01:37.890
Doctor, we made this one, could you bring it — asking like that, I ended up knowing the whole product range.

00:01:37.890 --> 00:01:41.770
The last time was about two and a half months ago.

00:01:43.130 --> 00:01:47.930
They asked me: could you give a training talk, could you run a workshop for us.

00:01:47.970 --> 00:01:51.030
I didn't turn them down, but this was the earliest we could arrange it.

00:01:51.030 --> 00:01:56.770
In between, when my product [?] was ready, we managed to line up the doctor colleagues.

00:01:57.650 --> 00:02:00.950
You will be the first group I teach here on behalf of a company.

00:02:01.510 --> 00:02:04.190
And as luck would have it, our air conditioning is broken.

00:02:05.050 --> 00:02:07.230
It was working before the holiday, sorry about that.

00:02:09.570 --> 00:02:11.550
But I won't drag it out too much.

00:02:11.710 --> 00:02:16.550
I mean, we are not going to explain the meaning of life here.

00:02:16.670 --> 00:02:20.570
So in total there are two biostimulators we are going to talk about here.

00:02:21.210 --> 00:02:23.150
I'll go through them very quickly.

00:02:23.800 --> 00:02:25.580
Harmonyca isn't really a new product either.

00:02:25.780 --> 00:02:32.160
Because Erdi [?] has been marketing it for a year and a half, it comes across that way.

00:02:32.260 --> 00:02:36.040
Before that there was a company called Luminera that they had bought.

00:02:36.080 --> 00:02:37.080
They brought it from Israel.

00:02:38.060 --> 00:02:39.220
It was one of their products.

00:02:39.260 --> 00:02:41.080
How long ago was that?

00:02:45.900 --> 00:02:54.540
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.

00:02:54.540 --> 00:02:58.980
But at home, you know, there is always a measuring step around here. [?]

00:02:59.080 --> 00:03:02.040
They presented it to us as if they had kept it hidden and moved on. [?]

00:03:02.100 --> 00:03:04.980
Then they described it as a cure-all product.

00:03:05.140 --> 00:03:08.840
I'm not waking up to my third illness on this cure-all question. [?]

00:03:09.720 --> 00:03:14.820
But with the right setups [?] and when it is explained properly to the patient, it is a very good combination.

00:03:14.880 --> 00:03:18.820
It gives a seriously good revitalisation and at the same time you understand everything. [?]

00:03:19.220 --> 00:03:46.780
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 [?].

00:03:46.780 --> 00:03:57.820
The response the body gives here: fibrocytes and fibroblasts immediately start wrapping around the calcium hydroxylapatite crystals by putting out foot-like processes.

00:03:57.960 --> 00:04:00.240
And they compare this to something.

00:04:00.540 --> 00:04:14.020
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.

00:04:14.020 --> 00:04:17.620
The body pushes it out, its water if not, apatite and collagen lactic. [?]

00:04:18.890 --> 00:04:22.310
Here it was supported together with hyaluronic acid production.

00:04:22.490 --> 00:04:29.470
Because it also gives some increase in moisture, it adds a slight glow to the skin from that water retention.

00:04:29.770 --> 00:04:33.490
But among themselves, each one has advantages over the other.

00:04:33.650 --> 00:04:36.790
Once I have pulled it all together, I'll try to go over it as a summary.

00:04:39.620 --> 00:04:41.660
We have a colleague who is a dentist.

00:04:41.740 --> 00:04:42.940
They were actually the first to use it.

00:04:42.960 --> 00:04:44.740
Our product, we call it dil calcium [?].

00:04:44.740 --> 00:04:52.460
When you look at it, in what dentists heavily use as bone powder graft there are properties that get confused with PRP.

00:04:52.600 --> 00:04:55.020
Back then they used to call PRP stem cells.

00:04:56.560 --> 00:05:00.260
We'll mix stem cells with bone powder and build you a tooth, and so on.

00:05:00.260 --> 00:05:16.920
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.

00:05:17.080 --> 00:05:25.640
It is also found in large amounts in the cements they use in orthopaedics to place implants [?].

00:05:25.640 --> 00:05:38.080
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.

00:05:38.180 --> 00:05:40.580
This matters a great deal for our injections.

00:05:40.700 --> 00:05:41.980
That is why I am underlining it.

00:05:42.120 --> 00:05:50.560
Because when you inject on the bone, we are talking about a material that can cause unwanted osteophytic outgrowths on the bone.

00:05:50.720 --> 00:05:53.960
So you have to be very careful with deep injections.

00:05:54.680 --> 00:06:03.380
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.

00:06:03.580 --> 00:06:10.780
But in terms of safety there is this difference between them: once calcium hydroxylapatite is placed under the skin, it cannot be dissolved.

00:06:11.920 --> 00:06:20.180
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.

00:06:20.180 --> 00:06:21.900
Here we have no such luck.

00:06:21.940 --> 00:06:24.960
So if we are doing an injection, we have to be very careful.

00:06:26.000 --> 00:06:28.240
We did have a complication happen. [?]

00:06:28.360 --> 00:06:31.780
I am speaking here about the calcium hydroxylapatite side.

00:06:32.020 --> 00:06:45.660
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.

00:06:45.760 --> 00:06:49.500
Otherwise you cannot get rid of the mass effect you have created.

00:06:49.500 --> 00:06:52.000
When you do it that way it doesn't disappear, so what happens?

00:06:52.300 --> 00:06:57.720
Since it still increases collagen production, it will give a revitalisation effect in the skin.

00:06:57.800 --> 00:06:59.420
The patient will still get some benefit from it.

00:07:00.280 --> 00:07:08.840
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.

00:07:09.020 --> 00:07:13.400
After you do the injection you will see a volume effect.

00:07:13.740 --> 00:07:15.480
We saw the volume effect.

00:07:15.480 --> 00:07:17.080
We called the patient back 15 days later.

00:07:17.080 --> 00:07:34.620
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.

00:07:34.920 --> 00:07:38.120
On the complication management side, that is the advantage it has.

00:07:38.120 --> 00:07:39.180
Can I ask something?

00:07:39.260 --> 00:07:41.420
I'm very sorry, let's keep it interactive.

00:07:41.840 --> 00:07:42.780
Please, go ahead.

00:07:43.220 --> 00:07:49.520
This mixture, diffuse and to the base, I mean, how did the mixture for the borons come about? [?]

00:07:49.800 --> 00:07:51.020
A one-to-one ratio.

00:07:51.140 --> 00:08:00.040
I think of it as one millilitre by volume, bringing together one millilitre of calcium hydroxylapatite and cross-linked hyaluronic acid. [?]

00:08:01.280 --> 00:08:05.100
But in total the combination of these two materials does not make two millilitres.

00:08:44.760 --> 00:08:47.340
I use it for skin revitalisation as well.

00:08:47.480 --> 00:08:52.120
On the lifting side we have been using calcium hydroxylapatite for a very long time anyway.

00:08:52.540 --> 00:08:56.860
But as I said at the start, on the lifting side you have to be a bit careful.

00:08:56.960 --> 00:09:11.320
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.

00:10:06.050 --> 00:10:11.690
But that doesn't mean this, the way I see it — please don't misunderstand — that is also why we asked about experience.

00:10:11.770 --> 00:10:15.690
Now, you can't just do this, can you?

00:10:16.010 --> 00:10:19.710
How you will manage it when something happens to you, keeping hold of the responsibilities, I mean [?]

00:10:21.280 --> 00:10:22.760
the application skill.

00:10:22.980 --> 00:10:25.820
Because we are doing cosmetic work in the first place.

00:10:26.660 --> 00:10:28.500
The person in front of us is not a patient.

00:10:28.720 --> 00:10:34.040
So when things turn ugly they say to us: I was healthy in the first place, folks.

00:10:34.140 --> 00:10:36.180
I was healthy, doctor.

00:10:36.840 --> 00:10:42.440
There, under the laws in Turkey, on one side you are helping with a taxi-driver aesthetic [?].

00:10:42.540 --> 00:10:47.400
So the matter can go somewhere rather different from simple complication management.

00:10:47.840 --> 00:10:50.840
It depends on the situation of the lawyer and the prosecutor involved.

00:10:51.000 --> 00:10:56.360
So because our employment [?] is at stake, while we are working in aesthetics we have to keep ourselves in the safe zone.

00:10:56.360 --> 00:11:03.980
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. [?]

00:11:04.140 --> 00:11:06.420
We need to look at the subject in front of us a bit like this.

00:11:06.600 --> 00:11:10.820
In the end, in our field the people we deal with as patients are not patients.

00:11:12.100 --> 00:11:14.300
When you look at it, they are healthy people.

00:11:14.380 --> 00:11:18.620
That is why we always have things to deal with in relation to what we are used to.

00:11:25.630 --> 00:11:28.730
Calcium hydroxylapatite is a product that has evolved somewhat.

00:11:28.730 --> 00:11:35.870
I mean, the calcium hydroxylapatite we used 10 years ago and the calcium hydroxylapatite we use today are not the same thing.

00:11:36.010 --> 00:11:49.850
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.

00:11:49.850 --> 00:12:00.070
But then, over the years, ideas developed so that these too would become smoother-surfaced and more homogeneous microspheres. [?]

00:12:00.270 --> 00:12:08.710
Today almost all calcium hydroxylapatite manufacturers already use homogeneous, spherical, smooth-structured calcium hydroxylapatite crystals.

00:12:10.130 --> 00:12:11.990
That is what is inside Merken as well.

00:12:12.010 --> 00:12:18.690
They are giving us one of the highest technical calcium hydroxylapatites you can use in the world right now.

00:12:18.690 --> 00:12:35.310
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. [?]

00:12:35.510 --> 00:12:39.310
So oedema developing because of that is definitely on the table.

00:12:39.430 --> 00:12:46.330
And if I am using a biostimulator — because we count filler as a biostimulator too, and by that I mean filler. [?]

00:12:46.330 --> 00:12:49.610
the patient's autoimmune diseases

00:12:51.140 --> 00:13:02.340
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 [?]

00:13:04.390 --> 00:13:12.580
I mean, the one who never mentioned it to me: oh, I had fibromyalgia too, is this oedema because of that

00:13:13.960 --> 00:13:14.640
Or

00:13:17.010 --> 00:13:30.470
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.

00:13:30.750 --> 00:13:32.230
Things like this can happen.

00:13:32.290 --> 00:13:35.210
So you have to share these with patients as well.

00:13:35.410 --> 00:13:37.830
I mean, if you have a condition, especially an autoimmune one...

00:13:37.830 --> 00:13:41.510
Sometimes they think — oh, I have a thyroid, I'm a thyroid patient, they say.

00:14:06.630 --> 00:14:14.150
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. [?]

00:14:16.490 --> 00:14:20.690
First of all, if there is hyaluronic acid involved, you start by dissolving that.

00:14:20.690 --> 00:14:30.830
and always, to suppress the oedema, a systemic Prednol antiviral [?], one tablet or two tablets depending on the severity of the reaction.

00:14:31.090 --> 00:14:32.490
I don't much like using systemic treatment.

00:14:32.570 --> 00:14:34.150
Lasix, for example, a diuretic and so on.

00:14:34.430 --> 00:14:35.670
Lasix — this is a local oedema.

00:14:36.230 --> 00:14:39.790
So going that systemic doesn't make much sense.

00:14:41.170 --> 00:14:42.370
Applying cold.

00:14:42.650 --> 00:14:45.630
After that you have to expect some harm from opportunistic pathogens. [?]

00:14:45.630 --> 00:14:47.310
Sometimes I definitely add an antipyretic [?].

00:14:47.410 --> 00:14:52.510
Because there may be no infection in the picture, and three days later a superinfection is added on.

00:14:52.670 --> 00:14:53.650
Come on, because it is hematopic. [?]

00:14:53.810 --> 00:14:55.770
Actually she is already in a frightened state.

00:14:55.790 --> 00:14:56.630
It could be the last compress. [?]

00:14:56.950 --> 00:14:58.750
You are trying to manage that.

00:14:58.910 --> 00:15:02.090
And on top of that, when something like an abscess or a vaccine reaction develops — I'll tell you about that later on. [?]

00:15:02.250 --> 00:15:05.710
And then of course, in our profession, there is burying a colleague.

00:15:06.010 --> 00:15:09.350
Burying people is a thing, a national sport.

00:15:09.450 --> 00:15:13.370
The moment she goes to another team, it starts: God knows who you went to.

00:15:15.550 --> 00:15:18.730
I am here trying to do something in good faith.

00:15:18.810 --> 00:15:19.850
Why are you putting me down?

00:15:20.070 --> 00:15:21.570
Go on then, do it and let's see the same thing.

00:15:21.630 --> 00:15:22.070
That's not there either.

00:15:23.550 --> 00:15:27.630
For example, for example, the allergy test.

00:15:29.030 --> 00:15:31.870
I don't think the allergy test has any validity at all.

00:15:31.870 --> 00:15:33.910
Now, I never get asked about this either. [?]

00:15:34.090 --> 00:15:37.030
I mean, if there is an outbreak at that time, I don't do it anyway.

00:15:37.470 --> 00:15:42.410
This is the thing we are talking about in an allergy anyway, for example.

00:15:42.550 --> 00:15:52.150
One patient, a woman of Russian origin, and also the mother of a pop singer you all know very well.

00:15:57.590 --> 00:15:58.370
We did the injection.

00:15:58.370 --> 00:16:00.190
She even had a serious asymmetry in her face.

00:16:00.390 --> 00:16:01.350
We worked asymmetrically.

00:16:01.390 --> 00:16:02.590
We parted very happy.

00:16:03.750 --> 00:16:05.150
Let me say it, of course there is a defect. [?]

00:16:05.170 --> 00:16:06.550
The woman's left side is ibogenic. [?]

00:16:06.730 --> 00:16:08.190
I mean, it pulled together.

00:16:08.210 --> 00:16:09.070
Everything fell into place.

00:16:09.410 --> 00:16:10.870
She was a beautiful woman to begin with.

00:16:12.050 --> 00:16:13.170
After that she was very happy.

00:16:13.270 --> 00:16:13.770
She went, she came back.

00:16:13.910 --> 00:16:15.110
In the meantime the pandemic was declared.

00:16:15.190 --> 00:16:16.730
Curfews and so on.

00:16:17.130 --> 00:16:18.970
After a while the lady turned up.

00:16:19.130 --> 00:16:20.010
An abscess this big, here.

00:16:20.010 --> 00:16:20.990
An abscess

00:16:22.720 --> 00:16:23.440
gets drained, doctor.

00:16:23.460 --> 00:16:24.020
We drained it.

00:16:25.060 --> 00:16:33.080
After that, intralesional antibiotics included, I did whatever infection management calls for.

00:16:33.580 --> 00:16:38.000
After that the hyaluronidase and the rest, wound management, wound care, everything fine.

00:16:38.220 --> 00:16:39.560
The patient disappeared.

00:16:39.700 --> 00:16:41.220
She dropped off the radar, gone. [?]

00:16:42.880 --> 00:16:45.160
We call, she doesn't answer the phone and so on.

00:16:45.380 --> 00:16:46.720
And I couldn't work out what had happened.

00:16:46.760 --> 00:16:47.600
She had an elderly husband.

00:16:48.800 --> 00:16:51.160
The gentleman was her second or third husband.

00:16:51.540 --> 00:16:53.180
They had gone on holiday to Sapanca.

00:16:53.580 --> 00:16:57.800
And they stayed there for three months, apparently. [?]

00:16:58.000 --> 00:17:02.140
And there, my young colleague [?] at the state hospital said, come, come, I cleaned it out.

00:17:02.140 --> 00:17:03.960
A special effort came up. [?]

00:17:03.960 --> 00:17:05.720
This time it was squeezed this much there. [?]

00:17:06.140 --> 00:17:07.440
And the abscess carried on.

00:17:07.640 --> 00:17:10.940
Every so often the fillers I did on the other side flare up.

00:17:12.900 --> 00:17:14.800
Then a few

00:17:19.190 --> 00:17:23.830
rounds of clearing it out; after a point I worked together with my plastic surgeon colleague.

00:17:24.510 --> 00:17:25.310
The first hyperbalance... [?]

00:17:26.890 --> 00:17:28.170
The first hyperbalance... [?]

00:17:28.170 --> 00:17:29.530
You can't do anything.

00:17:29.530 --> 00:17:31.050
All you can do is shrink the scar.

00:17:31.050 --> 00:17:40.130
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. [?]

00:17:41.570 --> 00:17:44.730
A foreign body reaction, and she had sent the MRI through the channel. [?]

00:17:45.670 --> 00:17:52.930
And after that I was going to do the thing, you know, that much scar tissue, supraperiosteal scar formation and so on.

00:17:53.410 --> 00:17:59.450
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. [?]

00:18:01.050 --> 00:18:04.870
She replied about sending our MRI system with the MRI invoice. [?]

00:18:05.130 --> 00:18:06.850
And she never sent the MRI itself.

00:18:07.010 --> 00:18:08.130
And she never came again.

00:18:09.250 --> 00:18:10.390
I don't know what happened.

00:18:12.430 --> 00:18:15.430
In my life it kept creating the most absurd complication. [?]

00:18:15.550 --> 00:18:16.850
It came out of my place. [?]

00:18:17.210 --> 00:18:20.130
And as a case, you would never expect it.

00:18:20.470 --> 00:18:25.030
Her turning up with an abscess like that nine months later is really not something that should happen.

00:18:25.030 --> 00:18:25.590
but it can happen.

00:18:25.710 --> 00:18:27.390
You have to be open to anything.

00:18:27.630 --> 00:18:30.030
Or rather, you have to be prepared for these.

00:18:30.170 --> 00:18:34.110
And while you are managing them you have to be inspiring confidence in the patient.

00:18:34.210 --> 00:18:43.350
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.

00:18:43.390 --> 00:18:46.010
Not: shall we do it this way, shall we do it that way.

00:18:46.090 --> 00:19:00.350
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.

00:19:00.510 --> 00:19:04.210
The moment you say, you can't talk to me like that, and so on, you lose the patient.

00:19:04.650 --> 00:19:06.150
After that you can't manage it.

00:19:06.330 --> 00:19:09.390
So you must never cut off communication there.

00:19:09.530 --> 00:19:14.710
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.

00:19:14.790 --> 00:19:16.550
Let me say these things, and we'll talk about it afterwards.

00:19:16.590 --> 00:19:20.190
At the point where you say it again, it goes a bit better.

00:19:20.190 --> 00:19:32.310
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.

00:19:32.730 --> 00:19:34.490
And there the judge looks at this.

00:19:34.990 --> 00:19:41.010
Did you act actively, did you make an effort, on the side of managing the patient's complication?

00:19:42.090 --> 00:19:48.690
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.

00:19:48.810 --> 00:19:51.190
So there is value in our record-keeping habit [?].

00:19:51.270 --> 00:19:53.030
Unfortunately the problematic side is a bit like this.

00:19:53.110 --> 00:20:00.890
It is worth paying some attention to keeping yourself in the safe zone commercially as well.

00:20:01.070 --> 00:20:03.630
My lawyer Ali Doğan told me this. [?]

00:20:03.750 --> 00:20:08.550
If you do the Dolan Forum and manage it with the complication, it gets resolved. [?]

00:20:20.530 --> 00:20:28.230
Then it is called an established act, starting from 2 to 5 years. [?]

00:20:31.740 --> 00:20:34.620
Without scattering the subject too much — if we go into this, we can come back out.

00:20:34.940 --> 00:20:38.320
In our country the laws in particular are very complicated.

00:20:38.580 --> 00:20:39.600
It doesn't work with the environment.

00:20:39.800 --> 00:20:40.980
I am coming particularly to this side.

00:20:41.080 --> 00:20:42.500
Because we have one more product.

00:20:43.340 --> 00:20:46.440
It is hyaluronic acid together with calcium hydroxylapatite.

00:20:46.480 --> 00:20:47.540
Because that is what the product contains.

00:20:47.620 --> 00:20:51.200
You can see the lifting with the immediate volume effect.

00:20:51.200 --> 00:20:53.760
And in the long term it is hyaluronic acid.

00:20:53.840 --> 00:20:58.220
While it comes into play — and this coming-into-play process is roughly a one-month process.

00:20:58.220 --> 00:21:04.880
we are not talking about a very hard hyaluron, that is, a heavily cross-linked, steel-like [?] hyaluronic acid inside the product.

00:21:04.980 --> 00:21:05.720
I'm very sorry.

00:21:06.360 --> 00:21:07.280
There is no PLLA.

00:21:07.300 --> 00:21:07.980
Nothing at all.

00:21:07.980 --> 00:21:09.140
They did it as if we saw my heart. [?]

00:21:09.740 --> 00:21:13.600
Let me correct it, because the inside of my content was made as a battery. [?]

00:21:16.020 --> 00:21:21.020
The advantage is that you see that effect straight away and can show the patient what she can get.

00:21:21.040 --> 00:21:25.700
And over the following 2 months your collagen increases along with it. [?]

00:21:25.700 --> 00:21:33.960
In the tissue, to put it very roughly, in plain language, it is nothing other than a product that gives tightening and thickening.

00:21:34.000 --> 00:21:39.540
I mean, in patients with a very heavy volume deficit there is no such thing as providing a very high [?].

00:21:39.880 --> 00:21:47.080
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. [?]

00:21:47.080 --> 00:21:55.820
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.

00:21:55.880 --> 00:21:56.660
These are clear, too.

00:21:57.160 --> 00:22:00.520
So with that type of patient you have to work a bit more in combination.

00:22:00.600 --> 00:22:13.360
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.

00:22:13.360 --> 00:22:25.020
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.

00:22:26.160 --> 00:22:30.420
There is a change of ratio in that one, depending on the region we use it in.

00:22:31.420 --> 00:22:32.600
What does he say, doctor?

00:22:32.660 --> 00:22:36.540
I mean, there is a change from 30% to 70%.

00:22:36.540 --> 00:22:38.740
Of course I use the product as it comes.

00:22:38.820 --> 00:22:50.200
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.

00:22:50.420 --> 00:22:54.220
Or it can be decided by the patient's skin type.

00:22:54.660 --> 00:23:03.460
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. [?]

00:23:03.460 --> 00:23:06.300
And then there are people with skin like mine, I mean, V-shaped

00:23:07.740 --> 00:23:10.280
when you pinch it, it comes into your hand thick and firm.

00:23:10.480 --> 00:23:17.540
Now, elevating a skin like this and elevating that paper-thin [?] skin I mentioned a moment ago are not the same thing.

00:23:18.040 --> 00:23:23.540
But for example, if there is no tension, I rather prefer using it on the thin ones. [?]

00:23:24.840 --> 00:23:31.540
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.

00:23:31.540 --> 00:23:34.900
like elastic, sometimes it stretches out from the cheek like chewing gum.

00:23:35.120 --> 00:23:37.200
It satisfies these patients very nicely.

00:23:37.460 --> 00:23:43.080
Because of the collagen and elastin balance in the tissue: in them elastin is higher and collagen is lower.

00:23:43.240 --> 00:23:55.000
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 [?].

00:23:55.040 --> 00:23:58.180
Products like these are more for such patients. [?]

00:24:00.040 --> 00:24:04.540
We also see a lot of benefit on the side of tightening the pores.

00:24:04.580 --> 00:24:08.840
But for example, if it tightens the pores for the patient, in between

00:24:10.600 --> 00:24:11.260
we need an example.

00:24:19.870 --> 00:24:23.130
They usually present it at a 1:1 ratio.

00:24:23.330 --> 00:24:37.950
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...

00:24:40.250 --> 00:24:43.410
I don't much prefer Jetokain now, because of the substance [?] in it.

00:24:43.570 --> 00:24:45.590
If there is bleeding, I wanted to see it.

00:24:46.090 --> 00:24:52.710
I mean, if three hours later the room starts swelling [?] and you go looking for haematomas, that is actually more tiring.

00:24:52.930 --> 00:24:55.030
If there is any, let it be right under my hand.

00:24:55.290 --> 00:25:05.390
And then, if I have added 0.2 millilitres of Lidocaine, on top of that we can use 0.8 millilitres of saline.

00:25:05.390 --> 00:25:17.470
Or, say, you could add a mesotherapy for a bit of glow in the patient's skin, or something else, or they try DMA. [?]

00:25:17.730 --> 00:25:19.090
You can get around it with that as well.

00:25:19.090 --> 00:25:22.150
For every site it has to do with any interaction. [?]

00:25:22.150 --> 00:25:23.130
You won't create a problem with this.

00:25:28.330 --> 00:25:29.750
Well, you won't take advantage of its safety.

00:25:29.810 --> 00:25:30.070
That is what I am saying.

00:25:30.470 --> 00:25:33.450
There is Zikon, at the jawline and so on, definitely a level teacher. [?]

00:25:33.470 --> 00:25:33.810
It won't create the inside.

00:25:33.950 --> 00:25:37.390
But on the neck the skin is thin, on the décolleté it is thin.

00:25:38.170 --> 00:25:39.450
In those places it can be diluted.

00:25:39.450 --> 00:25:43.970
At home, for example, while using the calcium group basket, a bit of a gap comes up in front. [?]

00:25:45.440 --> 00:25:46.980
Cross-linked, low diameter.

00:25:48.340 --> 00:25:48.980
Skin booster,

00:25:52.960 --> 00:25:53.380
Dorotin.

00:25:56.580 --> 00:25:58.820
These days there is Jouveler's SkinWire. [?]

00:25:59.260 --> 00:26:03.120
Something like that; of course SkinWire is a bit costlier than Dorotin. [?]

00:26:05.000 --> 00:26:16.180
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 [?].

00:26:19.770 --> 00:26:27.510
When we look, there is actually heavy volume loss, and along with that, again at the collagen point, if we get collagen

00:26:33.810 --> 00:26:37.370
gain, this is a patient where you would think you would get good results.

00:26:37.550 --> 00:26:40.910
The loss of the dermaclets and contour definition. [?]

00:26:41.130 --> 00:26:48.530
If there is an ezozoma [?], you can see how far the malar region has dropped because of the volume loss in the zygomas.

00:26:48.630 --> 00:26:59.250
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.

00:26:59.430 --> 00:27:10.270
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.

00:27:10.270 --> 00:27:13.030
In my view the colleagues who do are taking a very big risk.

00:27:13.210 --> 00:27:15.670
Because here is what happens in these areas.

00:27:15.750 --> 00:27:32.510
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.

00:27:32.610 --> 00:27:37.790
It can build up inside that fold, and a year later that build-up comes back to us as a granuloma.

00:27:38.490 --> 00:27:39.530
I wanted to make the point.

00:27:39.690 --> 00:27:44.270
Once you meet a granuloma, you basically have to take this patient into your household.

00:27:44.670 --> 00:27:46.650
It is a lot of work, really a lot of work.

00:27:46.790 --> 00:27:49.330
That is where steroid injections and so on come into play.

00:27:49.410 --> 00:27:51.570
And you don't always get the result you want. [?]

00:27:51.610 --> 00:27:55.770
Every time you do it, when the patient comes the next time the cell ring [?] is higher, and so on.

00:27:55.970 --> 00:27:57.230
Patient management becomes very difficult.

00:27:57.350 --> 00:28:03.490
So when working in the medial area, for my own part there are new-generation mesotherapy options. [?]

00:28:03.490 --> 00:28:07.610
Of those, as the gentlemen said, I very much like working with [?] acid.

00:28:07.690 --> 00:28:12.590
Going with the [?] and using these products always makes more sense and gives nicer results.

00:28:12.770 --> 00:28:13.330
Product

00:28:18.930 --> 00:28:24.490
preparation, if we do it: as described here, I mix in a certain amount of lidocaine.

00:28:24.630 --> 00:28:25.910
It makes for a heavy injection.

00:28:26.290 --> 00:28:36.050
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. [?]

00:28:36.050 --> 00:28:43.090
To reduce that, mixing in lidocaine at 10% to 20% always makes my hand easier.

00:28:43.250 --> 00:28:45.350
In total, a 3 millilitre syringe.

00:28:45.390 --> 00:28:50.750
Manipulating this straight from a 3 millilitre syringe feels difficult to me.

00:28:50.890 --> 00:28:51.970
So I split it in two.

00:28:52.350 --> 00:28:56.030
It also makes mixing this lidocaine easier.

00:28:56.270 --> 00:29:05.190
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.

00:29:05.190 --> 00:29:10.510
And I usually do this with 0.5 millilitre injections.

00:29:10.650 --> 00:29:12.970
You know this one, don't you?

00:29:13.090 --> 00:29:18.510
In the MD Codes developed by Maurício de Maio you are going to inject with a cannula anyway.

00:29:18.570 --> 00:29:22.290
And as active volume it is always 0.5 millilitres [?].

00:29:22.710 --> 00:29:30.210
And when you do an injection like that with a cannula, you get a clearly visible result.

00:29:30.210 --> 00:29:37.510
and some patients need a bit more, some respond a bit faster — you can easily observe that while you are doing the procedure.

00:29:44.850 --> 00:29:54.210
Applying it with 22 to 25 gauge, 50 to 70 millimetre cannulas is always the most reliable method for these products.

00:29:54.290 --> 00:29:57.410
But as I said, from time to time I do play with a needle as well.

00:29:57.570 --> 00:30:02.090
That is a bit of a courage question.

00:30:02.090 --> 00:30:04.010
It isn't something I always do. [?]

00:30:04.010 --> 00:30:05.530
The injection version, the intervals... [?]

00:30:05.530 --> 00:30:08.690
What, is he going to do one session?

00:30:08.810 --> 00:30:10.990
I first saw this on BlueSlide [?].

00:30:11.010 --> 00:30:13.070
And I can't say I apply it much like that.

00:30:13.370 --> 00:30:16.570
I think this is probably something to do with marketing.

00:30:16.750 --> 00:30:18.750
How much does the product cost?

00:30:18.910 --> 00:30:20.630
I think it is a bit like this.

00:30:20.710 --> 00:30:22.430
No shot makes you do it three times. [?]

00:30:22.870 --> 00:30:23.710
A kiss, too. [?]

00:30:24.190 --> 00:30:26.590
Patients at 3 millilitres, it is a whole world of a body. [?]

00:30:26.750 --> 00:30:29.470
Patients need 9-10 millilitres.

00:30:29.710 --> 00:30:33.210
And if you are going to do something like that, do the first one.

00:30:33.390 --> 00:30:37.790
Waiting 3 months, with the coffee effect, one from there or so. [?]

00:30:38.790 --> 00:30:41.190
If that wasn't enough, do the second one.

00:30:42.890 --> 00:30:43.930
Wait, let it settle.

00:30:43.930 --> 00:30:45.570
Let 2-3 months pass.

00:30:45.690 --> 00:30:46.710
Then you will do it.

00:30:46.890 --> 00:30:48.830
I think what they meant here is do the third one.

00:30:48.990 --> 00:30:50.390
Otherwise, what would be standard?

00:30:50.510 --> 00:30:52.510
What, 3-4 calcium?

00:30:53.150 --> 00:30:55.050
If you ask me, it is not something that should happen.

00:30:57.490 --> 00:30:59.250
Are there patients who pay for an application like that?

00:31:00.430 --> 00:31:01.570
There are, there are, there are.

00:31:04.650 --> 00:31:07.930
She is going to come every two months, but this isn't that thing — do we know the meso side?

00:31:25.000 --> 00:31:26.660
Wouldn't they be a different list?

00:31:26.960 --> 00:31:27.520
Make one.

00:31:27.760 --> 00:31:28.840
For the jawline anyway...

00:31:28.840 --> 00:31:29.760
So it isn't taken any more?

00:31:30.120 --> 00:31:30.940
At the jawline it's fine, but...

00:31:30.940 --> 00:31:32.380
I saw it, in our model.

00:31:32.380 --> 00:31:35.980
Am I asking because you compared this person directly with this?

00:31:36.360 --> 00:31:37.080
For the majority.

00:31:37.260 --> 00:31:38.200
But again a

00:31:41.040 --> 00:31:44.680
distracted one — for example she is an apple, a natural apple. [?]

00:31:44.880 --> 00:31:46.700
How can you use it for her?

00:31:47.220 --> 00:31:48.860
For this one, let me not use this.

00:31:48.860 --> 00:31:49.540
There is nothing else.

00:31:52.540 --> 00:31:57.100
I mean, because calcium hydroxylapatite produces a very sharp line.

00:31:57.340 --> 00:32:04.080
So basically, in deep application in particular, I would use calcium hydroxylapatite.

00:32:05.140 --> 00:32:07.720
We have one spot too many, the patient comes. [?]

00:32:08.060 --> 00:32:11.280
For example, in my own practice I never do the thing.

00:32:11.320 --> 00:32:17.200
The patient comes and says I saw it on the internet, so-and-so does it, she wants some sort of glow.

00:32:54.560 --> 00:32:57.800
Some patients come, the poor woman is like a tomato.

00:32:58.120 --> 00:33:05.440
Although there is fluid, she says, I would like my face a bit thinner, a bit more layered, looking more feminine. [?]

00:33:05.760 --> 00:33:07.340
And for example, I don't have a chin like this.

00:33:07.500 --> 00:33:10.620
And that is one of the enzymatic lipolysis ones. [?]

00:33:10.840 --> 00:33:12.360
Six thousand litres into her chin. [?]

00:33:14.960 --> 00:33:16.240
Believe me, they weren't exaggerated.

00:33:48.560 --> 00:33:53.700
I shrink it like Melahat Bey and Joe [?], then I make room for the fillers.

00:33:53.760 --> 00:34:00.820
I, on the contrary, first support the midface so that it lifts, support it with filler and gather the face up.

00:34:00.920 --> 00:34:03.780
After that I will sharpen the jawline.

00:34:04.700 --> 00:34:07.380
Both of us actually look for the anatomy first, the bone.

00:34:07.500 --> 00:34:09.400
Let's actually see the anatomical location.

00:34:10.400 --> 00:34:12.180
The same way, how much do you need.

00:34:12.260 --> 00:34:14.060
When you pull the lift, let it send your hand. [?]

00:34:34.660 --> 00:34:35.220
the operations.

00:34:35.220 --> 00:34:39.520
And the orthodontic fixations are cut, an audible condition. [?]

00:35:03.240 --> 00:35:05.340
There, while you are sitting with the patient over these

00:35:09.660 --> 00:35:10.540
she wants the condition too.

00:35:12.000 --> 00:35:14.420
You have to do it in the middle, where you can [?].

00:35:14.680 --> 00:35:17.400
If you cannot do that in the middle, let me

00:35:23.130 --> 00:35:24.850
say this openly, I explain it.

00:35:24.910 --> 00:35:26.690
In my view you need this.

00:35:26.930 --> 00:35:29.310
No, even if we don't do it that way it will be like this, it will be more than that.

00:35:29.450 --> 00:35:30.510
And we know how to do it.

00:35:32.680 --> 00:35:34.780
This is the treatment I am recommending to you.

00:35:34.780 --> 00:35:43.840
I mean, say you have got a pyramid [?], you have come in, and I will choose a second-generation cephalosporin as your antibiotic.

00:35:43.920 --> 00:35:44.080
You

00:35:45.520 --> 00:35:46.580
are not in a position to like it or not.

00:35:55.520 --> 00:35:57.800
As application areas, on the face

00:36:00.170 --> 00:36:04.110
the colleague who prepared the slide has shown almost every seven. [?]

00:36:04.310 --> 00:36:07.710
But if it were me, number four, six

00:36:09.120 --> 00:36:09.760
when I say six.

00:36:11.280 --> 00:36:12.680
Stay away from the middle and the lower part.

00:36:12.800 --> 00:36:16.960
And I wouldn't get too close to the stereo [?] part of three.

00:36:16.960 --> 00:36:19.520
In these areas, blölyon or nodule formation, [?]

00:36:23.400 --> 00:36:27.900
Merken's other [?] is very good too, I use it a lot.

00:36:28.060 --> 00:36:29.700
In those places I would recommend those.

00:36:30.560 --> 00:36:33.620
Calcium hydroxylapatite into the nose region —

00:36:35.160 --> 00:36:38.980
I have come across many doctors who do it, who say they do it.

00:36:39.080 --> 00:36:40.320
I don't prefer it.

00:36:40.620 --> 00:36:42.000
And I don't much recommend it either.

00:36:42.100 --> 00:36:43.560
I mean, it is a risky region.

00:36:43.760 --> 00:36:45.120
Very risky for calcium.

00:36:45.280 --> 00:36:48.440
Because here we are injecting on the bone a great deal.

00:36:48.440 --> 00:37:01.660
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. [?]

00:37:03.050 --> 00:37:04.530
What would you tell the patient?

00:37:04.570 --> 00:37:05.050
I wouldn't know.

00:37:05.130 --> 00:37:06.270
At least I don't take that risk.

00:37:06.850 --> 00:37:08.590
We fill it from a new flat. [?]

00:37:09.110 --> 00:37:12.470
I mean, as I said, we have to do every patient. [?]

00:37:16.750 --> 00:37:22.890
Especially in the temple region, subcutaneous application meets a lot this time. [?]

00:37:23.680 --> 00:37:29.360
Recently in Monaco a four-way session was held to compare biostimulators.

00:37:29.500 --> 00:37:35.040
In fact I want to share with you the thing I saw there and adapted.

00:37:35.440 --> 00:37:38.040
There was a Doctor Huygandroli [?] — I don't remember the name.

00:37:38.260 --> 00:37:40.760
He particularly recommends this application a great deal.

00:37:40.860 --> 00:37:48.340
But in filler application in the temple region, and in calcium hydroxylapatite application, it is worth being a bit careful.

00:37:48.520 --> 00:37:50.840
It is one of the regions where the skin gets very thin.

00:37:50.840 --> 00:37:54.220
I mean, as we go up from the zygoma the skin thickness decreases.

00:37:54.340 --> 00:38:01.860
In subdermal applications in the forehead and temple region it is worth diluting the product a little, as my colleague said.

00:38:02.020 --> 00:38:11.860
There you may need dilutions of maybe half a millilitre to one millilitre, or even going down to one to one.

00:38:11.960 --> 00:38:16.480
Because when we are done, an appearance can be left here as if there were worms under the skin.

00:38:16.480 --> 00:38:22.540
Either you have to disperse it with very good massage, or I would recommend following this route.

00:38:25.220 --> 00:38:28.040
As for cannulas, I use 22 gauge cannulas.

00:38:28.060 --> 00:38:30.340
Or mostly it can be 23 as well.

00:38:30.780 --> 00:38:33.160
It flows comfortably through 22 or 23 too.

00:38:33.300 --> 00:38:37.420
22 gauge in particular is a bit painful because it is thick.

00:38:37.580 --> 00:38:43.940
In fact I have one 70 millimetre 22 gauge cannula, so that ears don't ring, so I don't get told off [?].

00:38:44.100 --> 00:38:46.840
In fact that one stays far away, let the man give it too. [?]

00:38:49.840 --> 00:38:55.300
So moving that under the skin really takes skill, and it can hurt the patient a lot.

00:38:55.420 --> 00:38:57.940
That is why sometimes I prefer 23 more.

00:38:58.660 --> 00:39:01.020
25 can be used as well, but...

00:39:01.800 --> 00:39:06.860
And calcium-containing products can fill up and harden at the mouth of the cannula.

00:39:07.600 --> 00:39:12.940
Because it is together with hyaluronic acid, I never had that happen with Merken's calcium. [?]

00:39:12.940 --> 00:39:14.300
But there is such a possibility.

00:39:14.400 --> 00:39:17.160
By the way, frankly I don't want to put myself at risk either.

00:39:18.060 --> 00:39:20.220
Is there anything you want to ask up to here?

00:39:20.380 --> 00:39:20.820
Yes,

00:39:22.830 --> 00:39:23.750
let's carry on then.

00:39:53.640 --> 00:39:57.740
In facial applications it is quite a good amount. [?]

00:39:58.820 --> 00:40:05.180
I mean, what you call the liquid facelift, you know it very well from this. [?]

00:40:08.440 --> 00:40:11.040
We started with PLA in '99, with Sculptra.

00:40:11.440 --> 00:40:14.560
Then in 2004 we got the FDA

00:40:16.260 --> 00:40:17.240
approval.

00:40:18.460 --> 00:40:23.080
In 2009 the indication of the FDA approval was widened.

00:40:23.080 --> 00:40:28.520
But while all this was happening there was a problem related to PLLA.

00:40:28.760 --> 00:40:33.320
When Sculptra came out it contained 150 milligrams of PLLA.

00:40:33.780 --> 00:40:38.700
It was applied with a total 5 millilitre reconstitution protocol, presented [?] to doctors.

00:40:38.920 --> 00:40:44.860
And because of that they ran into an incredibly high number of granuloma [?] formations, mostly granuloma formation.

00:40:45.080 --> 00:40:51.020
Then, somewhere shortly before 2009 [?], they changed those protocols.

00:40:51.920 --> 00:40:55.340
They gave a minimum 8 millilitre reconstitution protocol.

00:40:56.260 --> 00:40:59.700
They produced a protocol of 8 to 10 millilitres.

00:40:59.880 --> 00:41:12.040
And they made it a condition that the product be reconstituted not with saline but with pure water, with distilled water.

00:41:13.460 --> 00:41:23.580
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. [?]

00:41:23.880 --> 00:41:29.240
But when you look at it, it took until 2014 for the product to start out like that and settle in.

00:41:30.360 --> 00:41:34.480
So since then it has still been going through a transition. [?]

00:41:34.480 --> 00:41:46.420
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.

00:41:46.840 --> 00:41:50.140
There are many manufacturers in the world working on PLA.

00:41:50.220 --> 00:41:54.120
In South Korea, almost every company you look at has a PLA of its own.

00:41:54.140 --> 00:41:57.120
I think it produces a very low mass. [?]

00:41:59.960 --> 00:42:04.200
In Georgia, Aptos was producing a lot of products made of PLA.

00:42:04.320 --> 00:42:06.040
Now those were on the market too, for example.

00:42:06.220 --> 00:42:07.140
It's another brand.

00:42:08.360 --> 00:42:12.400
Sculptra is of course the original product, the one that first put it on the market.

00:42:13.040 --> 00:42:17.840
At Merken they sell other PLA products as a distributor.

00:42:17.980 --> 00:42:22.220
And they took this one as their own production, as a ready mixture. [?]

00:42:22.300 --> 00:42:24.900
In fact I contributed to the development of this product as well.

00:42:24.900 --> 00:42:35.160
I mean, first the pre-mixed form [?], and before that we used the powder, the lyophilised form, reconstituting it, and so on.

00:42:35.560 --> 00:42:42.180
At the point we have reached now, with its low cross-linked form, I think it has reached the optimum level.

00:42:42.260 --> 00:42:46.140
Because in all the other forms, in my view that is the biggest problem. [?]

00:42:46.680 --> 00:42:52.880
If you mix the product — with the first-generation products we start mixing 1-2 seconds [?] beforehand.

00:42:52.880 --> 00:42:55.800
it goes [?] into this thing, into the vortex.

00:42:55.900 --> 00:43:00.320
Then we learned that the vortex had no point [?] at all.

00:43:00.380 --> 00:43:02.560
The shaking it creates is laminar flow.

00:43:05.060 --> 00:43:07.660
For it to be usable, you have to shape

00:43:10.700 --> 00:43:13.820
the inside so that a whirlpool forms.

00:43:13.940 --> 00:43:16.380
That is why you have to mix from syringe to syringe.

00:43:16.500 --> 00:43:19.920
It homogenises in turbulent flow.

00:43:20.180 --> 00:43:23.820
But once you have homogenised it, it cannot stay stable for very long.

00:43:23.980 --> 00:43:29.820
I mean, say you have prepared an 11 millilitre syringe as recommended — you can't just deliver 10 millilitres in one go.

00:43:29.900 --> 00:43:32.840
You distribute it into 1 and 2 millilitre syringes.

00:43:33.400 --> 00:43:33.960
You distributed it.

00:43:34.080 --> 00:43:35.200
And then what did you do?

00:43:35.380 --> 00:43:36.440
You looked at your moment again. [?]

00:43:36.500 --> 00:43:38.300
And the sediment has started to settle.

00:43:39.640 --> 00:43:42.260
During the preparation stage it foams. [?]

00:43:42.320 --> 00:43:43.020
There is a lot of foam.

00:43:43.360 --> 00:43:44.860
When I first started using it.

00:43:44.900 --> 00:43:47.020
That foam is in this vitamin shell. [?]

00:43:47.700 --> 00:43:48.860
You have to draw that foam off.

00:43:49.140 --> 00:43:50.420
Then I found out later.

00:43:50.480 --> 00:43:51.800
It is of no use at all.

00:43:51.800 --> 00:43:54.500
This is something we were really getting confused about.

00:43:54.920 --> 00:43:58.100
You are supposed to use the part that looks like raki.

00:43:58.240 --> 00:44:00.900
There are a lot of details in front of it, like the taste having settled. [?]

00:44:01.000 --> 00:44:05.660
That is why I think Merken's PLLA product is very successful.

00:44:05.800 --> 00:44:07.740
Because you take it and the syringe is ready.

00:44:08.780 --> 00:44:11.000
Just hand it over to the units. [?]

00:44:12.360 --> 00:44:15.160
There is the amification of a five millilitre syringe. [?]

00:44:15.320 --> 00:44:16.980
But after that it is very easy.

00:44:17.700 --> 00:44:20.020
What I want to share with you today is this.

00:44:20.020 --> 00:44:24.720
Until last year in Turkey we only ever saw superficial applications of PLLA.

00:44:24.760 --> 00:44:39.520
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. [?]

00:44:39.760 --> 00:44:51.200
One presented hyaluronic acid as a biostimulator, and another presented fat injections and micrograft, nanograft fat injections.

00:44:51.640 --> 00:44:58.160
Şino presented the PLLA application, and he also did an interesting application.

00:44:58.200 --> 00:45:00.940
I modified it a bit, pulled it into a slightly safer zone.

00:45:01.000 --> 00:45:02.880
I'll describe what he did as well.

00:45:02.960 --> 00:45:07.920
And let me also show how I do it in a way that suits me better.

00:45:07.920 --> 00:45:09.540
Our model will be Ms. Çiğdem.

00:45:09.660 --> 00:45:11.600
if you are doing nanofat, exactly, there is nothing.

00:45:11.860 --> 00:45:12.860
That's all, I mean...

00:45:12.860 --> 00:45:14.980
You need someone to do it from nanofat.

00:45:15.120 --> 00:45:16.900
The lady is coming anyway.

00:45:17.780 --> 00:45:19.560
From somewhere very far away.

00:45:20.180 --> 00:45:21.360
We'll pick it up even from the smell.

00:45:22.140 --> 00:45:22.820
The publications made in the last

00:45:28.420 --> 00:45:31.180
five years are gaining ground. [?]

00:45:31.340 --> 00:45:35.800
Now, we always evaluate these as biostimulators, as collagen biostimulators.

00:45:35.900 --> 00:45:41.220
But the fact that they are effective on [?] has recently been included in the studies as well.

00:45:41.220 --> 00:45:49.220
Very recently, I scanned the last 5 years: there isn't enough evidence yet, more research may be needed, that's it.

00:45:49.600 --> 00:45:52.520
Dozens of studies, large groups.

00:45:59.100 --> 00:46:02.240
When we look at it, for the patients who say I don't want filler,

00:46:06.240 --> 00:46:09.440
in future they will clearly be recommending

00:46:10.820 --> 00:46:11.460
it.

00:46:11.700 --> 00:46:13.780
I mean, or in patients where we can't use it.

00:46:14.960 --> 00:46:22.520
The point where it parts from calcium hydroxylapatite is making those sharp edges you mentioned with PLLA.

00:46:22.640 --> 00:46:23.440
That is not possible.

00:46:23.580 --> 00:46:28.100
But with PLLA you can also, in the subcutaneous fat tissue, deep

00:46:31.880 --> 00:46:33.900
lipogenesis, slowly

00:46:36.710 --> 00:46:44.930
developing volume gain, and along with that you can also provide revitalisation and regeneration of the skin.

00:46:46.070 --> 00:47:04.630
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 [?]

00:47:14.740 --> 00:47:24.180
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

00:47:26.390 --> 00:47:33.950
And also [?] the patients we described earlier, where volume loss and skin quality decline together.

00:47:34.150 --> 00:47:40.090
Now, when you see the photograph you obviously want to see what came after. [?]

00:47:41.710 --> 00:47:43.830
In the slide just now it rested [?] — I wonder what happened here.

00:47:45.700 --> 00:47:46.820
This photograph was taken from below.

00:47:48.850 --> 00:47:50.970
What has

00:47:52.310 --> 00:47:52.950
become of this.

00:47:54.520 --> 00:47:58.800
It isn't written here for PLA, but massage,

00:48:00.910 --> 00:48:05.330
doing massage, and doing massage after the injections, is always recommended.

00:48:05.510 --> 00:48:14.050
Classically it is recommended to massage for the 5 days after the procedure, 5 times a day, 5 minutes each time.

00:48:17.630 --> 00:48:23.910
You need to do the same for the deep injections that are part of the injection I am about to do.

00:48:23.970 --> 00:48:28.290
Because what you are doing is spreading this product inside a fat pad.

00:48:33.960 --> 00:48:37.820
In the same way, this model, this is that.

00:48:39.280 --> 00:48:41.560
I enjoyed it — is it right, is it this, is it that.

00:48:42.480 --> 00:48:43.800
We did one.

00:48:43.980 --> 00:48:44.820
The patient came.

00:48:45.080 --> 00:48:45.840
Wait 2-3 months.

00:48:46.040 --> 00:48:48.260
Well, I said I didn't get much out of this.

00:48:48.400 --> 00:48:49.440
She is bound to say that anyway.

00:48:49.700 --> 00:48:49.940
I mean

00:48:51.660 --> 00:48:52.820
I will check at 3 months.

00:48:54.760 --> 00:48:56.760
When she comes, the photograph from the first day,

00:49:00.280 --> 00:49:01.660
it actually shows that you didn't do this. [?]

00:49:01.840 --> 00:49:02.240
Because

00:49:03.620 --> 00:49:14.260
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.

00:49:14.460 --> 00:49:18.580
The glow in her skin — well, she bought one, the creams got mixed into it. [?]

00:49:20.930 --> 00:49:25.450
So keeping the consent form [?] you mentioned solid for the patients,

00:49:28.220 --> 00:49:28.920
we are not in practice,

00:49:30.650 --> 00:49:36.110
I mean the details like your record, issuing an invoice and so on, which you won't remember. [?]

00:49:36.230 --> 00:49:38.830
That is not my job, it is the state's job.

00:49:38.830 --> 00:49:44.550
but Taner Cizan and Tavsiye, how much they were always about me today. [?]

00:49:45.950 --> 00:49:47.130
And she complains very little.

00:49:48.010 --> 00:49:49.930
Especially in Nişantaşı...

00:49:51.150 --> 00:49:54.850
In terms of talking about glow, it won't create much of a problem.

00:49:55.070 --> 00:50:00.710
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.

00:50:06.370 --> 00:50:08.230
Is there anything you would like to ask?

00:50:09.250 --> 00:50:11.610
Have you ever done PLA after a device treatment? [?]

00:50:13.190 --> 00:50:16.510
After a device, one...

00:50:17.270 --> 00:50:19.410
If there is no trace of calcium, PLA after [?].

00:50:20.550 --> 00:50:22.130
I have no need for it at all.

00:50:22.130 --> 00:50:29.410
I mean, rather than not needing it: do the calcium hydroxylapatite.

00:50:29.490 --> 00:50:32.190
The patient didn't find it enough, she wasn't satisfied.

00:50:32.710 --> 00:50:36.250
You can't make her any more satisfied on top of that with PLLA anyway.

00:50:36.430 --> 00:50:38.290
Because the patient has stated her expectation. [?]

00:50:42.930 --> 00:50:44.530
It doesn't create any problem.

00:50:45.790 --> 00:50:46.710
There is no problem.

00:50:47.210 --> 00:50:56.970
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.

00:50:59.670 --> 00:51:02.870
On social media right now there is a trend called the liquid facelift.

00:51:03.050 --> 00:51:05.850
Everyone is following a liquid facelift, they look at those.

00:51:06.390 --> 00:51:16.330
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. [?]

00:51:16.330 --> 00:51:17.450
As if there were no other way.

00:51:18.330 --> 00:51:19.810
But a liquid facelift.

00:51:20.770 --> 00:51:22.990
A facelift with something liquid. [?]

00:51:23.250 --> 00:51:26.750
I mean, in this one I used filler as well, for example, and I explain that to the patient.

00:51:26.970 --> 00:51:31.690
Now, lining up with the patient what you injected [?] — that shouldn't be like tricking her either.

00:51:32.590 --> 00:51:37.350
Now, there is a limit to what you can do with a collagen biostimulator.

00:51:37.590 --> 00:51:39.550
As the name says, it makes collagen.

00:51:39.710 --> 00:51:42.150
But the problem is not the collagen.

00:51:42.770 --> 00:51:51.690
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.

00:51:51.830 --> 00:51:52.910
It won't do much good.

00:51:53.050 --> 00:51:57.970
Because the only thing calcium will give me there [?] is: if it is this much, to make it this much.

00:51:58.330 --> 00:52:01.750
Or, if what you pinch stretches this far, not to let it stretch that far.

00:52:01.750 --> 00:52:02.890
To hold it here.

00:52:03.010 --> 00:52:10.470
To provide a satisfying [?] lift that comes from this gathering up, from the tightening due to this collagen gain.

00:52:10.990 --> 00:52:12.330
Nothing more than that.

00:52:12.530 --> 00:52:13.790
But the patient cannot know that.

00:52:14.010 --> 00:52:23.570
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. [?]

00:52:24.070 --> 00:52:32.290
And then I say — the question I ask myself [?] — if you insist on this product, this is all you will get.

00:52:33.010 --> 00:52:51.590
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.

00:52:51.950 --> 00:52:54.930
After that: if you want, we can do these.

00:52:54.950 --> 00:52:57.830
I say, I won't send you out of here [?].

00:52:58.070 --> 00:52:59.410
Come, let's shake hands on that.

00:52:59.650 --> 00:53:03.810
If you still don't want it, I am sorry, but this is the treatment model I am recommending to you.

00:53:03.810 --> 00:53:13.170
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.

00:53:13.270 --> 00:53:17.570
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.

00:53:20.220 --> 00:53:22.220
Now, I did calcium.

00:53:23.120 --> 00:53:34.720
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.

00:53:34.720 --> 00:53:36.360
and we have shared this with the patient too.

00:53:37.220 --> 00:53:38.740
And we did that at home as well. [?]

00:53:38.900 --> 00:53:50.340
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.

00:53:51.320 --> 00:53:58.380
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.

00:53:58.440 --> 00:54:01.780
I mean, I can't treat pigmentation with CaHA, for example.

00:54:01.780 --> 00:54:07.500
or you can say, if you want we can use an exosome, or let's turn to a device.

00:54:07.600 --> 00:54:12.080
Or: you have volume loss, come, let's work on those areas a bit with fillers.

00:54:12.180 --> 00:54:15.920
By now your trust in me has grown, don't be too afraid.

00:54:16.540 --> 00:54:18.200
If you don't like it we can dissolve it, and so on.

00:54:18.480 --> 00:54:22.840
But with persuasion methods like this you have to move the patient towards the right place.

00:54:23.020 --> 00:54:29.920
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.

00:54:31.300 --> 00:54:40.180
Especially if the volume deficit after stimulators like this isn't satisfying, the filler I use afterwards is a non-cross-linked one.

00:54:40.400 --> 00:54:43.720
Otherwise, the non-cross-linked ones.

00:54:44.040 --> 00:54:54.220
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.

00:54:54.220 --> 00:54:58.280
We would check at 1 month, and at 2 months we supported it with fillers.

00:54:58.500 --> 00:54:59.300
There was cross-linking in it.

00:55:00.780 --> 00:55:01.700
It became cross-linked.

00:55:02.940 --> 00:55:04.860
There was a middle ground in the distant filler. [?]

00:55:04.860 --> 00:55:06.720
Let's consider fat injection as an alternative.

00:55:07.000 --> 00:55:08.700
No, let them do the fat injection.

00:55:36.020 --> 00:55:37.700
Of course we did the same session.

00:55:39.710 --> 00:55:49.650
Because the depth you apply is different, and far from getting in each other's way [?], they will act synergistically.

00:56:26.460 --> 00:56:29.460
There is no such thing as never do it there.

00:56:29.700 --> 00:56:33.500
I mean, maybe he meant you don't need to do it.

00:56:33.560 --> 00:56:39.340
Because the biostimulation you have just had is already meant to increase collagen.

00:56:39.660 --> 00:56:41.460
There is no such

00:56:58.010 --> 00:56:58.470
route at all.

00:57:00.360 --> 00:57:02.340
This could be the only basis.

00:57:02.380 --> 00:57:04.120
Maybe he said that is what he was thinking.

00:57:04.180 --> 00:57:11.500
In the end, when you use protein-based products — whether peptide or collagen — your allergy risk is high.

00:57:12.100 --> 00:57:17.140
Proteins are something that stimulate immunity.

00:57:19.920 --> 00:57:20.780
Yes, exactly.

00:57:21.080 --> 00:57:21.840
He may have

00:57:24.910 --> 00:57:25.850
meant that.

00:57:26.230 --> 00:57:28.430
But I don't think that way here.

00:57:28.610 --> 00:57:34.230
While everything is already stirred up, giving something that will nourish the area gives a nicer result.

00:58:08.500 --> 00:58:13.740
So, as you were saying, it isn't a nutritional, nourishing product, is it?

00:58:16.100 --> 00:58:18.480
There you are creating a stimulation.

00:58:18.680 --> 00:58:27.420
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.

00:58:28.700 --> 00:58:31.640
Maybe, if you have a sensitivity,

00:58:33.140 --> 00:58:34.060
in your

00:58:41.900 --> 00:58:48.040
room, for example — that lifting wasn't enough, it didn't move your lower face at all.

00:58:49.280 --> 00:58:51.660
If it were me, I would have worked that area with you.

00:58:51.780 --> 00:58:53.040
I am not surgery, doctor. [?]

00:58:53.240 --> 00:58:53.660
No.

00:58:53.980 --> 00:58:55.120
For example, like this,

00:59:07.250 --> 00:59:09.370
or rather from a scientific standpoint.

00:59:49.890 --> 00:59:52.910
I did it to CW2, and from there I had gone back to CK4. [?]

00:59:53.030 --> 00:59:54.190
Ahmet is the repairman.

00:59:59.340 --> 01:00:00.400
You are a wonderful model.

01:00:00.940 --> 01:00:01.320
Yes.

01:00:01.320 --> 01:00:04.980
And another thing, you lose the effect quickly, they have a chat about it. [?]

01:00:07.400 --> 01:00:08.060
Disposable.

01:01:34.400 --> 01:01:35.900
Share the results with us.

01:01:36.980 --> 01:01:38.080
Thank you.

01:01:42.090 --> 01:01:46.330
Is there anyone among us who wants to leave early, who has to leave?

01:01:46.590 --> 01:01:47.090
Now

01:01:52.980 --> 01:01:55.480
Ms. Samka, the queen of our kitchen.

01:01:55.640 --> 01:02:01.340
Please — the lady who presents these products to you.

01:02:01.340 --> 01:02:01.880
Thanks to this

01:02:05.330 --> 01:02:09.790
series I have taken about 15 years off.

01:02:10.790 --> 01:02:11.650
Not at all.

01:02:12.610 --> 01:02:15.690
When I couldn't find a model I asked her.

01:02:15.730 --> 01:02:16.830
Bless her, she didn't turn me down.

01:02:17.610 --> 01:02:22.370
Now, if you look carefully — because she is constantly right beside me, I don't really look any more.

01:02:23.410 --> 01:02:27.170
She needs serious support along the jawline.

01:02:27.390 --> 01:02:28.570
Along with that,

01:02:30.190 --> 01:02:37.490
if we also do a bit of a lift at the zygoma — as I said, some generations [?] need sharp support.

01:02:38.270 --> 01:02:43.670
In these respects I think she is a good patient for the use of calcium hydroxylapatite.

01:02:43.850 --> 01:02:45.470
Her skin thickness is good.

01:02:45.610 --> 01:02:46.790
Please, come over here as well.

01:03:03.450 --> 01:03:04.950
Where from? [?]

01:03:06.030 --> 01:03:07.730
What do you think?

01:03:12.550 --> 01:03:13.510
At this

01:03:16.610 --> 01:03:19.710
point we need to work a bit more.

01:03:20.230 --> 01:03:22.370
Look from the side, I am looking from the side.

01:03:22.810 --> 01:03:26.590
When we look from the side, actually

01:03:30.210 --> 01:03:33.530
the exact aesthetics of our lips...

01:03:33.530 --> 01:03:35.450
Here the nose needs to be made smaller.

01:03:37.310 --> 01:03:39.170
We couldn't match the liquid [?] line.

01:03:41.230 --> 01:03:42.510
Careful with the zygoma too.

01:03:47.530 --> 01:03:50.910
In fact her chin has turned a bit.

01:03:51.130 --> 01:03:51.770
The liquid line.

01:03:58.950 --> 01:03:59.910
Her chin needs nothing at all.

01:04:00.890 --> 01:04:03.450
Stop this and you can do the lip on its own.

01:04:04.010 --> 01:04:05.230
She would get a lip out of it.

01:04:05.350 --> 01:04:09.490
That is why the maxilla [?], the upper lip coming forward, came into it.

01:04:09.490 --> 01:04:12.050
in the lower lip there is a bit of a stitch. [?]

01:04:17.950 --> 01:04:21.290
Because the maxilla is weak [?], the nasolabial lines look deeper the more you see them.

01:04:21.790 --> 01:04:24.550
If it is going to work, the perioral area will show.

01:04:24.630 --> 01:04:26.490
You have to go into [?] work.

01:04:27.100 --> 01:04:29.230
We are asking that middle comma into three. [?]

01:04:32.790 --> 01:04:33.710
But what can we do?

01:04:36.330 --> 01:04:40.290
Especially at about 45 degrees, in this lighting

01:04:41.930 --> 01:04:45.050
because the malar fat pad has lost the support it took from the zygoma

01:04:49.440 --> 01:04:52.360
when she lifts her head it looks as if it has slipped somewhere. [?]

01:04:54.210 --> 01:04:56.270
And we have a big volume loss at the temple as well.

01:04:58.010 --> 01:05:00.130
If we come here, it looks as though it will be better.

01:05:00.490 --> 01:05:05.390
And when we look, it works like this. [?]

01:05:05.710 --> 01:05:09.910
The lines here are clear and we have a bit of jowling.

01:05:11.090 --> 01:05:13.470
And after working on them together, as

01:05:16.870 --> 01:05:26.070
the lady described a moment ago, taking the ramus of the mandible together with its body, we get a nice [?].

01:05:26.470 --> 01:05:27.930
And calcium too

01:05:36.230 --> 01:05:44.410
At the temple, what every sensible approach recommends, if you are using calcium hydroxylapatite in this patient.

01:05:45.890 --> 01:05:49.930
Subdermal, with a blood product [?], it adds volume here and might do nothing else.

01:05:53.170 --> 01:05:56.730
And look how low the patient's eyelid is.

01:05:57.390 --> 01:06:01.470
Now, the orbicularis is a [?].

01:06:01.530 --> 01:06:03.130
It wraps around here as if it were being wiped away.

01:06:03.130 --> 01:06:12.930
And to keep this from dropping, along the temporal line we have the temporal retaining ligament and the zygomatic retaining ligament. [?]

01:06:13.150 --> 01:06:24.850
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.

01:06:25.790 --> 01:06:30.330
This has sagged, this has sagged, the retaining ligament [?], and it sags like this.

01:06:30.330 --> 01:06:31.610
The upper eyelid

01:06:33.910 --> 01:06:39.510
drooping too, and there is an immediate mechanism in the forming of the under-eye circles here.

01:06:39.790 --> 01:06:43.930
Then over time it gets affected here by facial movement.

01:06:44.010 --> 01:06:44.950
Its own loss of regime. [?]

01:06:49.000 --> 01:06:55.520
Now, because I can't afford an osteophyte in visible places, I don't work too close in. [?]

01:06:55.580 --> 01:06:56.440
I'll work with the pen

01:06:58.010 --> 01:06:58.370
and move on.

01:06:58.430 --> 01:06:59.730
The temporal part, below, one

01:07:01.420 --> 01:07:01.860
or two.

01:07:08.730 --> 01:07:17.250
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. [?]

01:07:17.410 --> 01:07:25.730
So, doing it that way again, but be very careful, because I would like to do a second injection at the temple.

01:07:27.840 --> 01:07:28.460
But these,

01:07:34.900 --> 01:07:36.220
calcium hydroxylapatite, and

01:07:38.130 --> 01:07:40.850
if you have caused an intravascular occlusion, in the other

01:07:44.820 --> 01:07:45.720
direction we have no speed. [?]

01:07:46.500 --> 01:07:54.260
That is why on the vascular occlusion side in particular you have to be ultra, mega careful.

01:07:54.260 --> 01:07:54.480
Yes, all right.

01:07:59.240 --> 01:07:59.840
Now

01:08:01.250 --> 01:08:03.230
shall we decide what to do? [?]

01:08:03.290 --> 01:08:05.670
You could go in, but it is very difficult and it would be very heavy.

01:08:06.270 --> 01:08:09.330
It is very hard for the patient and very hard in terms of the limits.

01:08:09.470 --> 01:08:12.030
So if I pass under the muscle, that is enough.

01:08:12.610 --> 01:08:14.210
And because of the fillers it can't be pulled. [?]

01:08:14.710 --> 01:08:15.310
The five-point

01:08:22.120 --> 01:08:26.160
one we do, the five-point one we do, the five-point one is very unsafe. [?]

01:08:26.340 --> 01:08:29.260
We don't like people, we like the samta. [?]

01:08:29.540 --> 01:08:30.080
Doctor,

01:08:40.960 --> 01:08:42.200
let's do something this evening.

01:08:42.980 --> 01:08:44.100
I keep looking, I keep looking.

01:08:44.100 --> 01:08:46.860
I keep looking, I keep looking, it doesn't feel right to me.

01:08:48.200 --> 01:08:50.420
My plan would be this.

01:08:55.570 --> 01:08:56.870
The temporal bone.

01:09:01.090 --> 01:09:02.190
The lower border

01:09:09.030 --> 01:09:09.650
of the frontal.

01:09:10.950 --> 01:09:12.230
The zygomatic eminence.

01:09:16.470 --> 01:09:17.950
Into the malar fat pad.

01:09:19.610 --> 01:09:20.890
The malar groove.

01:09:21.210 --> 01:09:23.890
Our chance of [?] will be high.

01:09:24.610 --> 01:09:26.190
Into the places where there are hollows.

01:09:26.190 --> 01:09:34.170
And so on: to that line, to the margin, above and below, approaching for all sorts of reasons. [?]

01:09:34.230 --> 01:09:39.590
What I am going to do is support this region.

01:09:39.670 --> 01:09:40.030
I lifted,

01:09:42.040 --> 01:09:46.500
I lifted, let's lift again,

01:09:48.820 --> 01:09:51.400
I changed the mandibular angle.

01:09:51.540 --> 01:09:53.620
Your [?] comes out anyway.

01:09:54.140 --> 01:09:57.960
I mean, there isn't much point in playing about with the chin tip. [?]

01:09:59.880 --> 01:10:01.800
is there anything you want to add?

01:10:01.800 --> 01:10:06.260
if we want to lift the brow, I will show that now

01:10:08.050 --> 01:10:19.330
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

01:10:20.710 --> 01:10:31.690
I have defined them as D1, D2, D3 [?] — frankly, so far I have never felt the need to inject into E2 and E3.

01:10:31.910 --> 01:10:32.930
But if it comes to it, I would.

01:10:33.250 --> 01:10:35.230
And if I do, I look to cannulas.

01:10:35.450 --> 01:10:39.810
Because [?] increases; the trochlear artery, for E3.

01:10:41.090 --> 01:10:43.170
For this area a cannula is recommended as well.

01:10:43.450 --> 01:10:47.570
It goes in with difficulty; rather than opening a port for a cannula for 0.2 millilitres, I give it with a needle. [?]

01:10:48.190 --> 01:10:53.590
But in this kind of area, if I am going to use a needle, I don't move the needle sideways at all. [?]

01:10:53.590 --> 01:10:54.770
I go in.

01:10:55.330 --> 01:10:58.550
Now, on the way you could puncture a vessel and pass through it.

01:10:59.970 --> 01:11:00.650
I go in.

01:11:00.730 --> 01:11:01.210
I have passed through.

01:11:01.310 --> 01:11:02.350
I aspirated.

01:11:02.470 --> 01:11:03.550
I pulled back, nothing came.

01:11:03.870 --> 01:11:06.690
If it gets caught retrograde it creates an occlusion. [?]

01:11:06.990 --> 01:11:08.950
So I passed through this.

01:11:08.970 --> 01:11:09.750
I aspirated.

01:11:09.750 --> 01:11:10.150
Nothing came.

01:11:10.290 --> 01:11:10.750
Very good.

01:11:10.930 --> 01:11:11.750
Hold it for ten seconds.

01:11:11.970 --> 01:11:12.270
Excellent.

01:11:12.450 --> 01:11:13.030
Every clean.

01:11:13.170 --> 01:11:14.450
It only delivers here.

01:11:15.770 --> 01:11:17.310
It bleeds on the way out anyway.

01:11:18.290 --> 01:11:23.250
But even if it bleeds, when I spread it outward from here with my hand, with massage, it cannot become a problem. [?]

01:11:23.510 --> 01:11:26.590
Then, if you want support again at a second point, again

01:11:28.960 --> 01:11:30.220
if you do it, this is how I do it.

01:11:30.500 --> 01:11:37.200
But still, I am not in favour of putting too much filler at the tail of the brow [?]; I think it looks very odd.

01:11:42.230 --> 01:11:43.570
I think it is a nice thing.

01:11:44.090 --> 01:11:48.210
In my view the lifting we do at the temple works out nicely.

01:11:48.210 --> 01:11:50.910
At that point I heard a lot about it moving once. [?]

01:12:20.810 --> 01:12:22.130
Don't shy away from things like this.

01:12:23.270 --> 01:12:27.250
For example, I used to think you could inject on the bone.

01:12:27.990 --> 01:12:33.250
You can't do that however much you want, because there is a fat pad here.

01:12:33.410 --> 01:12:34.670
It is stuck to the bone.

01:12:34.810 --> 01:12:35.790
Even if you wanted to, you cannot separate it.

01:12:35.810 --> 01:12:36.570
You would have to cut it.

01:12:37.010 --> 01:12:38.410
The needle goes underneath it.

01:12:38.470 --> 01:12:39.310
We delivered it on the bone.

01:12:39.690 --> 01:12:44.130
At most, if you go infraperiosteal [?], you could do something like that.

01:12:44.150 --> 01:12:45.690
And there you have no [?] anyway.

01:12:45.690 --> 01:12:53.170
What we are doing here is filling the fat pad here, and we are talking about quite a mobile structure. [?]

01:12:53.230 --> 01:12:55.190
It moves, of course; that is unavoidable.

01:12:57.350 --> 01:13:00.030
Now let's come to our product preparation.

01:13:02.300 --> 01:13:03.860
5 millilitres, 3

01:13:12.440 --> 01:13:14.480
millilitres of calcium hydroxylapatite.

01:13:14.540 --> 01:13:15.700
Then [?] acid.

01:13:16.300 --> 01:13:18.840
Ms. Safka's pain threshold is high.

01:13:18.840 --> 01:13:20.500
So it won't create a problem.

01:13:20.540 --> 01:13:21.080
Oh, I couldn't bear it.

01:13:49.360 --> 01:13:52.160
But while turning it you have to set the channel well.

01:14:15.570 --> 01:14:20.710
When you pass it back and forth about 10 times you get a good result anyway.

01:14:20.990 --> 01:14:23.090
Now she will split it into two syringes.

01:14:25.090 --> 01:14:26.530
You are adding Hidrotain, aren't you?

01:14:27.230 --> 01:14:28.530
Probably not Hidrotain.

01:14:28.750 --> 01:14:29.210
Sintes.

01:14:29.670 --> 01:14:30.470
Sintes, exactly.

01:14:30.670 --> 01:14:31.210
Hidrotain —

01:14:32.550 --> 01:14:34.390
let's make your plans.

01:14:34.550 --> 01:14:39.430
Now let's also talk about how much volume I would plan for a patient like this.

01:14:45.090 --> 01:14:48.010
I want to lift the eyelid [?] properly.

01:14:48.190 --> 01:14:52.190
If a total of one millilitre is going to be used, that is fine. [?]

01:14:52.770 --> 01:14:59.870
For the zygoma, if I am going to use a product with a cannula, I planned about half a millilitre here.

01:15:00.090 --> 01:15:00.490
I would

01:15:05.840 --> 01:15:06.640
grit my teeth.

01:15:08.210 --> 01:15:09.670
Her masseters are very strong.

01:15:09.930 --> 01:15:16.970
If I enter along this line and do something like this, even half will be harmful for this patient. [?]

01:15:16.970 --> 01:15:23.270
So I advance upwards from the mandibular angle.

01:15:23.290 --> 01:15:25.850
In a way similar to what Ahmet did for you.

01:15:26.230 --> 01:15:27.710
This is the area referred to

01:15:27.770 --> 01:15:32.650
as CW2 in the MD Codes.

01:15:32.750 --> 01:15:37.230
I mean, I think of it as injecting in a way that visually strengthens the ramus of the mandible.

01:15:37.530 --> 01:15:43.390
In these areas it is always the deep plane, on the bone; here I will go a bit more superficial.

01:15:43.390 --> 01:15:48.330
Because I also want to do a little mechanical myomodulation and weaken the muscle movement.

01:15:48.590 --> 01:15:55.330
Suppressing the movements of the platysma here to some extent increases the effect we will give the patient.

01:15:55.430 --> 01:16:00.590
So what we do subcutaneously should serve this region better in the long term. [?]

01:16:01.650 --> 01:16:13.730
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. [?]

01:16:14.130 --> 01:16:15.190
Not for this one.

01:16:16.030 --> 01:16:24.830
And I would plan another half millilitre injection here so that we join up the angle of the mandible.

01:16:24.890 --> 01:16:28.050
A sort of arrangement we would make like this.

01:16:28.150 --> 01:16:29.050
So what did that come to?

01:16:29.270 --> 01:16:32.370
One, one and a half millilitres.

01:16:32.370 --> 01:16:40.490
One and a half on the other side too — a three millilitre injection would actually build up the base of the midface. [?]

01:16:40.590 --> 01:16:43.490
But I am being a bit extravagant today.

01:16:43.670 --> 01:16:46.450
One millilitre each will do the temples.

01:16:46.590 --> 01:16:48.230
That leaves me one more millilitre.

01:16:48.410 --> 01:16:48.770
And this

01:16:50.270 --> 01:16:53.070
is the result of our decision, and it will decide from there. [?]

01:16:53.190 --> 01:16:58.290
So in total, a three millilitre injection for this patient.

01:17:50.700 --> 01:17:52.700
The special bench feature, for now [?]

01:17:56.350 --> 01:18:00.090
there is one thing left that I forgot to tell you [?].

01:18:00.150 --> 01:18:00.530
Now

01:18:02.800 --> 01:18:08.400
when I first used biostimulators, the thing that always stuck in my mind was this.

01:18:08.580 --> 01:18:10.460
You have played with collagen biosynthesis.

01:18:11.280 --> 01:18:12.640
It put fibrosis into the series. [?]

01:18:12.760 --> 01:18:12.900
We were

01:18:20.580 --> 01:18:21.280
quite worried about this. [?]

01:18:22.690 --> 01:18:24.190
It produces a tissue similar to a scar.

01:18:26.540 --> 01:18:27.380
But is it really

01:18:30.740 --> 01:18:31.040
so?

01:18:31.220 --> 01:18:31.760
No.

01:18:41.250 --> 01:18:41.670
No.

01:18:42.110 --> 01:18:42.770
Could it be?

01:18:42.870 --> 01:18:44.690
You could make skin as hard as stone.

01:18:44.830 --> 01:18:46.070
Would you look at it a bit tighter?

01:19:17.650 --> 01:19:19.250
Look, it develops that much oedema.

01:19:46.070 --> 01:19:47.210
My dear is right in front of me.

01:19:50.730 --> 01:19:52.570
No, doctor, that's enough.

01:19:52.770 --> 01:19:59.150
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.

01:19:59.310 --> 01:20:02.390
And here I will choose the modiolus as the entry point.

01:20:03.070 --> 01:20:09.550
The modiolus — the junction here of 7 or 8 muscles. [?]

01:20:09.630 --> 01:20:12.670
But an artery runs just beneath it, in the deep plane.

01:20:12.750 --> 01:20:15.830
So we keep [?] very superficial.

01:20:15.830 --> 01:20:21.230
otherwise you would end up cutting an artery that runs from here all the way up. [?]

01:20:21.590 --> 01:20:23.570
Then we would have a haematoma.

01:20:25.510 --> 01:20:27.210
Even so, I am not letting go right now.

01:20:27.610 --> 01:20:28.310
If there is

01:20:30.140 --> 01:20:32.070
any bleeding right now, I tamponade it.

01:20:38.420 --> 01:20:39.120
I laid it flat.

01:20:39.340 --> 01:20:42.200
If I still have bleeding, I tamponade it with my cannula.

01:20:44.970 --> 01:20:45.870
I didn't interrupt my work.

01:20:47.050 --> 01:20:50.330
If bleeding happens here, if you

01:20:53.050 --> 01:20:56.070
disperse it again, would you call it an artery anyway? [?]

01:20:56.150 --> 01:20:57.750
I am confident about this myself, too.

01:20:57.750 --> 01:21:03.810
Even if I were [?], I would prefer to finish my work without letting that bleeding progress.

01:21:04.070 --> 01:21:05.750
Then we control that bleeding.

01:21:11.660 --> 01:21:12.960
I brought it up to here.

01:21:13.640 --> 01:21:15.280
I go in again from here.

01:21:17.780 --> 01:21:19.920
I was making a small fan over a short distance.

01:21:20.420 --> 01:21:21.100
I came back.

01:21:21.460 --> 01:21:23.640
Just as I am about to come out, I go in again.

01:21:36.030 --> 01:21:36.610
Exactly.

01:21:37.010 --> 01:21:39.090
You see a result straight away.

01:21:39.910 --> 01:21:41.990
The line always gets less. [?]

01:21:42.810 --> 01:21:43.490
It will increase.

01:21:43.490 --> 01:21:46.950
In a month they will come and say, why have these started to come together.

01:21:47.770 --> 01:21:49.770
Because it will pull itself together.

01:21:50.790 --> 01:21:51.450
Exactly.

01:21:51.910 --> 01:21:52.270
But

01:22:00.520 --> 01:22:01.260
we are one way cold. [?]

01:22:11.960 --> 01:22:12.620
Exactly.

01:22:13.080 --> 01:22:14.900
Both the deep and the superficial plane.

01:22:16.060 --> 01:22:17.740
We have been a bit extravagant.

01:22:17.800 --> 01:22:20.160
Normally we don't use three syringes like this on anyone.

01:22:20.220 --> 01:22:24.300
If you weren't here, we would be trying to finish the job with a single syringe.

01:22:24.600 --> 01:22:24.940
It is hard

01:22:32.270 --> 01:22:33.890
to find a patient this tough, too.

01:22:34.310 --> 01:22:36.770
You just look, a crumb. [?]

01:22:38.170 --> 01:22:39.310
This is unbelievable.

01:22:49.590 --> 01:22:51.270
Get well soon.

01:23:09.250 --> 01:23:12.050
Thank you.

01:23:12.090 --> 01:23:14.110
you need to go to very hot

01:23:19.100 --> 01:23:19.160
places.

01:23:19.160 --> 01:23:27.640
Without pressing too hard with my hand, if you massage from below upwards over the next two areas, it comes out even better. [?]

01:23:30.120 --> 01:23:33.980
Thank you very much, [?], and especially for sharing your experience.

01:23:33.980 --> 01:23:34.700
Not at all.

01:23:34.740 --> 01:23:35.640
Thank you very much.

01:23:38.780 --> 01:23:41.170
Sinan Akyürek medical aesthetics workshop.

01:24:17.360 --> 01:24:19.660
At one point there was something we called

01:24:20.910 --> 01:24:45.730
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.

01:24:45.730 --> 01:24:51.570
I preferred to modify it a bit, using a needle in some places and a cannula in others.

01:24:51.570 --> 01:24:53.310
A somewhat more reliable method.

01:24:55.010 --> 01:25:04.350
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.

01:25:04.590 --> 01:25:08.270
Basically he went into the midface focusing on two points.

01:25:08.270 --> 01:25:12.190
So that is also the reason I chose Çiğdem for this application.

01:25:12.670 --> 01:25:18.150
I am planning to inject a total of 1 millilitre of PLLA plus [?] into this region.

01:25:18.190 --> 01:25:19.350
Sorry, 1.5 millilitres.

01:25:19.510 --> 01:25:29.210
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

01:25:30.770 --> 01:25:36.550
malar fat pad — a method built on adding volume there.

01:25:36.550 --> 01:25:48.570
One again, as we did a moment ago, a pistol shot into the deep plane to gather up the zygoma

01:25:50.010 --> 01:25:56.830
and one we will do by entering from here again to soften the nasolabial line — so what does that come to?

01:25:56.830 --> 01:26:00.110
one, two, three, four, one

01:26:01.650 --> 01:26:24.970
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.

01:26:25.090 --> 01:26:26.510
I tried it on a few of my patients.

01:26:26.510 --> 01:26:28.750
The long-term results are coming out quite nicely too.

01:26:30.570 --> 01:26:35.870
When you apply PLLA that has hyaluronic acid in it, you can already see the result immediately.

01:26:37.450 --> 01:26:38.510
Elif, now

01:26:40.250 --> 01:26:46.750
of those syringes I will want one, two, three with a needle and four with a cannula.

01:26:48.630 --> 01:26:49.790
Put a 27 on.

01:26:49.930 --> 01:26:50.890
Let's not hurt her that much.

01:26:51.030 --> 01:26:52.230
I don't hold that much of a grudge.

01:26:52.330 --> 01:26:54.230
She only forgot to do the end-of-day once, after all. [?]

01:26:56.600 --> 01:26:58.600
She forgot to close yesterday's day, that's all.

01:26:59.220 --> 01:27:05.380
Now there is a total of about 5 millilitres of product in one syringe.

01:27:05.500 --> 01:27:07.760
A hyaluronic acid plus PLLA mixture.

01:27:08.390 --> 01:27:12.140
I draw this into 7 separate 0.7 millilitre syringes.

01:27:12.260 --> 01:27:16.600
At each of my injection points I will inject 0.7 millilitres.

01:27:18.820 --> 01:27:21.160
There isn't much need to add lidocaine.

01:27:21.220 --> 01:27:23.380
It isn't that painful an application anyway.

01:27:25.040 --> 01:27:26.200
Really, it isn't, honestly.

01:27:26.440 --> 01:27:27.440
Were you clean?

01:27:27.780 --> 01:27:28.560
I was clean.

01:27:59.500 --> 01:28:00.740
If we are ready, I'm starting.

01:28:04.750 --> 01:28:05.630
Would you open your mouth?

01:28:11.300 --> 01:28:12.720
I always aspirate.

01:28:13.140 --> 01:28:18.320
As I said, with these too, if you get it into a vessel you have no chance.

01:28:18.480 --> 01:28:20.840
That is why, a crackle,

01:28:33.410 --> 01:28:35.010
a single air bubble.

01:28:35.130 --> 01:28:37.830
That stinging, the tightness

01:28:40.910 --> 01:28:41.410
in your face.

01:28:42.190 --> 01:28:42.710
Is it all right?

01:28:43.170 --> 01:28:43.750
It's fine.

01:28:46.680 --> 01:28:47.680
Now

01:28:52.190 --> 01:28:57.230
was it you who asked a moment ago, doctor, how

01:28:59.250 --> 01:29:11.330
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

01:29:13.180 --> 01:29:21.240
right now I am on the bone, I lifted slightly, 1-2 millimetres. I aspirated, I am adding,

01:29:28.920 --> 01:29:30.920
it will slow down, then I add.

01:29:48.530 --> 01:29:49.170
Is it painful?

01:29:49.770 --> 01:29:50.590
A little bit, it seems.

01:29:50.590 --> 01:29:51.470
Shall I add some [?] as well?

01:29:52.290 --> 01:29:53.610
How many more are we doing?

01:29:55.010 --> 01:29:57.130
Seven here, five here.

01:30:02.030 --> 01:30:02.930
It might be good if we add some.

01:30:10.690 --> 01:30:12.170
Then do it like this.

01:30:14.790 --> 01:30:16.350
When you prepare them, go back up to the five.

01:30:17.930 --> 01:30:19.650
The ones after this are with a cannula anyway.

01:30:34.810 --> 01:30:38.290
I opened one entry port over the modiolus.

01:30:38.530 --> 01:30:41.450
From here I will address two or three points at once.

01:30:41.750 --> 01:30:45.090
One — I go in like this.

01:30:47.290 --> 01:30:50.990
I go on top of the maxilla.

01:30:51.770 --> 01:30:53.490
I went down to the deep plane.

01:30:53.830 --> 01:30:54.670
Here

01:30:56.690 --> 01:30:59.270
I am below the nasal cartilage.

01:30:59.510 --> 01:31:00.830
Well below it.

01:31:01.590 --> 01:31:03.970
I mean, right now I am on the maxilla.

01:31:04.070 --> 01:31:04.770
You are at the corner.

01:31:04.770 --> 01:31:25.310
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

01:31:26.790 --> 01:31:33.950
soften nicely, and by opening the alae of the nose a little I can actually help her breathe more comfortably.

01:31:34.530 --> 01:31:36.530
I will give 0.7 millilitres in total.

01:31:36.570 --> 01:31:37.890
That is a big volume load for this area.

01:31:39.630 --> 01:31:41.210
But after giving it

01:31:44.020 --> 01:31:44.580
I came out.

01:31:47.910 --> 01:31:49.330
What will you do with the PLLA?

01:31:49.470 --> 01:31:51.130
PLLA plus hyaluronic acid.

01:31:52.330 --> 01:31:54.190
Now I will go to the midface as well, doctor.

01:32:01.270 --> 01:32:02.090
Would you sit up straight?

01:32:07.270 --> 01:32:09.890
I wanted you to see the effect of this one on its own.

01:32:10.130 --> 01:32:12.730
Can you see the difference between the right and the left of the lip?

01:32:15.830 --> 01:32:17.530
We did the thing to the midface.

01:32:17.690 --> 01:32:19.490
That's what I said.

01:32:19.850 --> 01:32:35.430
We are not going superficial, we can see. Actually right now it is deep, exactly, that is what I did, now

01:32:44.640 --> 01:32:53.720
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 [?]

01:32:56.360 --> 01:32:58.320
I am inside the superficial fat pad.

01:32:58.720 --> 01:33:05.140
From here I am already having to push my cannula into the superficial malar fat pad. [?]

01:33:05.380 --> 01:33:06.280
It is under my hand.

01:33:07.540 --> 01:33:09.280
I pushed a little and got inside it.

01:33:10.050 --> 01:33:11.160
Now here...

01:33:19.620 --> 01:33:27.600
We could go deep as well, but going deep from here with a cannula would be a bit painful.

01:33:28.220 --> 01:33:30.460
So I will choose the needle.

01:33:39.470 --> 01:33:40.130
I'll take a breath.

01:34:07.250 --> 01:34:08.990
Yesterday's score is settled now, isn't it?

01:34:09.270 --> 01:34:10.090
Not yet.

01:34:10.550 --> 01:34:11.270
No.

01:34:12.910 --> 01:34:15.230
There probably isn't more than this.

01:34:24.840 --> 01:34:26.720
I should really do the zygoma too.

01:34:27.760 --> 01:34:32.880
But because the zygoma here is prominent enough, I won't go any further.

01:34:33.680 --> 01:34:42.420
I could have gone into the deep fat pad, but I need neither more lifting nor more volume there.

01:34:42.420 --> 01:34:44.080
so I won't go there either.

01:34:45.700 --> 01:34:46.280
There is only

01:34:48.060 --> 01:34:49.520
one problem I have, here.

01:34:50.260 --> 01:35:00.100
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.

01:35:00.180 --> 01:35:03.000
To correct the tissue irregularity here.

01:35:03.140 --> 01:35:05.980
I mean, there is constant creasing around here.

01:35:06.020 --> 01:35:06.620
Can you see it?

01:35:07.980 --> 01:35:09.460
It will be trouble for you in the future.

01:35:10.900 --> 01:35:12.260
I am taking a precaution with you.

01:35:12.420 --> 01:35:16.200
But not 0.7 — I will finish there with 0.35.

01:35:16.220 --> 01:35:17.800
I am not planning to load that much volume either.

01:35:20.260 --> 01:35:21.000
Did you see?

01:35:21.120 --> 01:35:22.240
Look, she just did it.

01:35:22.240 --> 01:35:22.840
Do it again, let me see.

01:35:23.280 --> 01:35:23.760
What should I do?

01:35:24.000 --> 01:35:24.700
I keep doing it.

01:35:26.520 --> 01:35:27.160
It doesn't

01:35:43.290 --> 01:35:43.870
hurt at all.

01:35:45.150 --> 01:35:47.130
Wait, try it like this then.

01:35:47.170 --> 01:35:48.970
Doctor, you have no pity.

01:35:49.410 --> 01:35:53.350
Ah, and there I was saying it doesn't hurt at all.

01:35:53.690 --> 01:35:55.810
No, you have no pity for this.

01:36:32.370 --> 01:36:33.450
Is the camera here?

01:36:33.490 --> 01:36:33.850
Am I not taking it over here?

01:36:34.430 --> 01:36:34.790
Exactly.

01:36:35.790 --> 01:36:36.870
Would you say that again?

01:36:37.990 --> 01:36:38.710
Wonderful.

01:36:38.850 --> 01:36:40.490
So are you.

01:36:40.650 --> 01:36:41.230
All together.

01:36:41.490 --> 01:36:41.730
All of us.

01:36:42.070 --> 01:36:42.630
All of us.

01:36:48.370 --> 01:36:49.750
What did we use in total?

01:36:50.210 --> 01:36:52.790
Doctor, you used four.

01:36:52.850 --> 01:36:53.690
And a half.

01:36:54.890 --> 01:36:56.630
So 2.5 is left.

01:37:02.890 --> 01:37:04.010
Thank you.

01:37:04.870 --> 01:37:08.430
So in total, doing this, 4.5 mil...

01:37:08.430 --> 01:37:08.810
Sorry.

01:37:08.810 --> 01:37:17.170
Sorry — 0.7 times 4, 2.8 plus 3, I used about 3 millilitres of product.

01:37:17.590 --> 01:37:22.990
If I hadn't done her temples, I could actually have picked the midface up almost completely.

01:37:23.050 --> 01:37:33.630
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.

01:37:34.150 --> 01:37:36.770
This spot and this spot finished the job.

01:37:36.770 --> 01:37:40.410
That is why deep injection of PLA is very nice in this respect.

01:37:45.970 --> 01:37:54.390
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.

01:37:54.450 --> 01:37:56.890
So it was good to bring that angle out a bit.

01:37:57.470 --> 01:38:02.030
I didn't go superficial, not subcutaneous; I did a deep plane application, on the bone.

01:38:02.030 --> 01:38:05.550
When it is done this way, the angling here comes out more nicely.

01:38:07.250 --> 01:38:11.590
A little volume in the superficial fat pad increased the projection of the cheek.

01:38:11.590 --> 01:38:13.010
That was enough for us.

01:38:13.030 --> 01:38:15.210
We didn't need much lifting anyway.

01:38:15.410 --> 01:38:17.030
The nasolabial [?] areas were very deep.

01:38:17.190 --> 01:38:20.650
There she already had a fairly wide piriform fossa.

01:38:20.910 --> 01:38:23.390
So I filled on the bone from the deep plane.

01:38:23.450 --> 01:38:29.170
It will increase the fat pads in that region and at the same time the supraperiosteal fibrous tissue.

01:38:29.350 --> 01:38:34.830
Plus, superficially, we also gave some support to the fine wrinkles in this region.

01:38:35.490 --> 01:38:39.750
In addition to these, what is to be done if you look at it point by point?

01:38:39.750 --> 01:38:48.250
1, 2, 3, two here, 4, 5, 6 and 7 — that is how we had actually planned it.

01:38:48.570 --> 01:38:50.890
That is how I defined the seven-point technique.

01:38:52.010 --> 01:38:53.730
And this is my modified version.

01:38:54.010 --> 01:38:54.850
Shall we do it?

01:38:55.110 --> 01:38:56.050
Are we ready?

01:38:56.470 --> 01:38:57.830
Do we believe in ourselves?

01:38:58.950 --> 01:39:00.410
Come on then, fingers crossed.

01:39:00.510 --> 01:39:02.530
I wish I believed as much as you do.

01:39:04.530 --> 01:39:05.950
We'll open your mouth a little.

01:39:37.930 --> 01:39:39.570
I hold it like this with my finger.

01:39:39.730 --> 01:39:41.170
Doctor, perhaps you wanted to see.

01:39:41.230 --> 01:39:43.630
Look, I can see the angle clearly.

01:39:43.890 --> 01:39:44.530
Here

01:39:45.770 --> 01:39:50.470
a branch of the external vena cava may be running just under your finger.

01:39:50.630 --> 01:39:51.310
Careful.

01:39:53.560 --> 01:39:54.600
Straight to the bone.

01:39:54.600 --> 01:39:56.740
Don't dawdle about to the left and right.

01:39:58.220 --> 01:39:59.880
Listen to me saying vena cava.

01:40:01.660 --> 01:40:02.920
External carotid.

01:40:03.120 --> 01:40:03.800
I mean

01:40:06.450 --> 01:40:11.890
I remember a femur, and there was a filler as well — is that why you go in at this angle? [?]

01:40:11.930 --> 01:40:12.570
No.

01:40:14.110 --> 01:40:14.950
That's it.

01:40:26.840 --> 01:40:28.480
Let's hope they don't make the patient pass out.

01:40:29.660 --> 01:40:31.500
With this many people we would lay her down, doctor.

01:40:33.840 --> 01:40:35.420
Shall we try one more thing as well?

01:40:35.420 --> 01:40:36.600
There are this many doctors standing by.

01:40:37.080 --> 01:40:37.760
Even if I die.

01:40:37.920 --> 01:40:39.140
God forbid.

01:40:39.620 --> 01:40:41.360
There is a saying for that moment.

01:40:41.600 --> 01:40:43.480
Kill me, but make me beautiful.

01:40:43.660 --> 01:40:44.300
What year?

01:40:44.420 --> 01:40:46.040
I use that one all the time.

01:40:46.040 --> 01:40:47.440
They are making you beautiful anyway.

01:40:47.880 --> 01:40:48.400
That's good.

01:40:49.660 --> 01:40:51.060
That is why they are making you beautiful.

01:40:51.680 --> 01:40:52.960
Don't say anything.

01:40:52.980 --> 01:40:55.860
Şiiran, by the way, is my coordinator, but she has been my friend for 15 years.

01:40:55.860 --> 01:40:57.600
So I bully her every way I can.

01:40:57.960 --> 01:40:59.000
I show no mercy.

01:40:59.000 --> 01:40:59.440
Doesn't she know?

01:40:59.500 --> 01:41:00.040
She does the information.

01:41:00.220 --> 01:41:01.620
All of this is on the record.

01:41:01.620 --> 01:41:02.600
None of it is.

01:41:02.700 --> 01:41:03.600
Look, I have all of it.

01:41:04.640 --> 01:41:06.620
So we'll sort it out somehow.

01:41:09.020 --> 01:41:11.260
And of course there is a bill for all this too

01:41:21.320 --> 01:41:22.240
Doctor Erkut

01:41:24.100 --> 01:41:26.000
Right now I am sliding over the maxilla.

01:41:27.020 --> 01:41:27.640
I'm there.

01:41:27.640 --> 01:41:29.020
Look, the phone is fizzling out.

01:41:29.640 --> 01:41:29.900
Probably.

01:41:30.340 --> 01:41:32.820
I am below the canine.

01:41:32.980 --> 01:41:33.800
Above me, sorry.

01:41:34.420 --> 01:41:35.040
Just here.

01:41:36.200 --> 01:41:41.700
I am in the deep plane, on the bone, 0.7, and I aspirated too.

01:41:42.200 --> 01:41:44.180
Let's always aspirate, doctor.

01:41:47.300 --> 01:41:49.720
We deliver it right on the bone.

01:41:54.000 --> 01:41:56.860
When doing filler I wouldn't go in with a cannula.

01:41:57.860 --> 01:42:02.340
If what I had in my hand were hyaluronic acid, from here

01:42:07.070 --> 01:42:09.410
I would go down onto the bone with my needle.

01:42:11.080 --> 01:42:11.920
You really

01:42:13.970 --> 01:42:15.830
love that, don't you.

01:42:16.230 --> 01:42:17.070
Yes.

01:42:18.610 --> 01:42:19.750
I love it.

01:42:21.270 --> 01:42:24.550
Without this — I'll want one more, exactly.

01:42:24.590 --> 01:42:25.730
I can't have the procedure done.

01:42:34.510 --> 01:42:35.250
I'm there.

01:42:35.770 --> 01:42:37.210
Here it was the superficial structure.

01:42:37.230 --> 01:42:38.990
I hold it with my hand.

01:42:39.210 --> 01:42:40.890
Look, here I went in more easily, for example.

01:42:41.050 --> 01:42:42.670
Is the other side more solid, I wonder?

01:42:43.870 --> 01:42:45.770
Good, you have looked after this side well.

01:42:45.810 --> 01:42:46.990
You must have been drinking bone broth.

01:42:47.550 --> 01:42:48.910
Did it all go there?

01:42:49.150 --> 01:42:50.270
It has all gathered there.

01:42:51.270 --> 01:42:51.830
Interesting.

01:43:02.170 --> 01:43:08.630
If I needed more volume, then I would seriously need lifting as well.

01:43:08.630 --> 01:43:09.250
the deep plane.

01:43:10.450 --> 01:43:11.930
The zygomatic eminence.

01:43:11.930 --> 01:43:17.130
I would go in just medial to it from here with a needle and do the deep fat pad.

01:43:18.250 --> 01:43:21.390
Spreading it a little with massage here isn't a bad idea.

01:43:22.270 --> 01:43:31.410
And again, don't forget to tell the patient about the 5 days, 5 times a day, 5 minutes each of massage.

01:43:31.530 --> 01:43:33.790
It is classically useful for PDA. [?]

01:43:33.870 --> 01:43:37.670
I mean, right now we are using a suspension supported with hyaluronic acid.

01:43:37.750 --> 01:43:42.430
Frankly I don't expect much of a problem to come up, but just in case

01:43:44.930 --> 01:43:47.430
as you

01:43:49.030 --> 01:44:05.410
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.

01:44:05.470 --> 01:44:06.850
That is how people get rich.

01:44:08.310 --> 01:44:11.350
Of course I can't talk while you have a needle in your hand.

01:44:11.770 --> 01:44:12.850
It isn't a needle, he has a cannula in his hand.

01:44:12.930 --> 01:44:13.810
You can talk freely.

01:44:14.010 --> 01:44:14.290
No, no.

01:44:14.450 --> 01:44:15.050
It's a needle.

01:44:15.870 --> 01:44:17.210
Let's talk later.

01:44:22.140 --> 01:44:23.510
That is my favourite part.

01:44:23.650 --> 01:44:24.850
I said it doesn't hurt at all here.

01:44:30.320 --> 01:44:30.620
That is why.

01:44:32.980 --> 01:44:33.680
Of course.

01:44:33.680 --> 01:44:34.380
Normally

01:44:38.470 --> 01:44:39.530
I don't spend this much time.

01:44:39.570 --> 01:44:41.350
Normally I don't do it with this much pleasure, actually.

01:44:41.710 --> 01:44:45.250
With this one I am enjoying it, as you can see.

01:44:45.250 --> 01:44:58.450
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 [?]

01:45:02.360 --> 01:45:02.580
yes

01:45:05.680 --> 01:45:07.860
your husband won't recognise you at home

01:45:11.240 --> 01:45:12.360
now

01:45:21.200 --> 01:45:22.180
Can she sleep normally?

01:45:24.800 --> 01:45:25.320
She can.

01:45:25.540 --> 01:45:28.120
That will have no effect on this.

01:45:28.180 --> 01:45:36.500
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.

01:45:36.840 --> 01:45:48.460
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.

01:45:48.960 --> 01:45:52.440
In these biostimulators there are three products anyway.

01:45:52.520 --> 01:45:56.940
One is polycaprolactone, one calcium hydroxylapatite, one PLA.

01:45:57.200 --> 01:46:04.740
PLA is more [?]; that is how I preferred it in my practice, and I also scanned the literature a bit.

01:46:05.300 --> 01:46:14.660
While it is preferred more for deep tissue and soft tissue support, calcium hydroxylapatite gives more successful results on the bone and definition side.

01:46:14.680 --> 01:46:16.120
It has to be applied deeper.

01:46:16.460 --> 01:46:17.100
Exactly.

01:46:20.460 --> 01:46:23.440
You can apply it deep, you can apply it superficially.

01:46:23.540 --> 01:46:24.760
It doesn't make much difference there.

01:46:25.260 --> 01:46:29.960
I mean, how you want to set the definition there has more to do with your hand skill.

01:46:30.860 --> 01:46:33.760
With polycaprolactone, on the other hand, it is for playing the longer effect.

01:46:33.820 --> 01:46:39.680
If she wants effects like 3 or 4 years [?], then you can use it like PLA.

01:46:40.620 --> 01:46:48.780
The thing is clear — you can't get definition as sharp as calcium hydroxylapatite with polycaprolactone.

01:46:48.880 --> 01:46:50.040
That is a well-known material too.

01:46:50.060 --> 01:46:51.580
Elantik [?], the threads.

01:46:52.230 --> 01:46:52.620
Exactly.

01:46:53.460 --> 01:46:55.440
It is used a lot as Elantik.

01:46:55.520 --> 01:47:02.100
And in the threads we use for lifting, poly-L-lactic acid and polycaprolactone are used together, in the long-acting threads.

01:47:03.140 --> 01:47:06.240
The life of polycaprolactone under the skin lasts about 4 years.

01:47:06.750 --> 01:47:07.760
The ones that halve.

01:47:09.240 --> 01:47:10.260
It lasts a long time.

01:47:50.610 --> 01:47:52.410
Thank you

01:48:03.420 --> 01:48:05.460
for watching.

01:48:55.650 --> 01:48:59.790
Thank you for watching.

01:49:04.890 --> 01:49:09.650
Hello, I am Doctor Sinan Akyürek; our workshop at Merken is about to begin.