3 June 2026

Collagen Biostimulators: Calcium Hydroxylapatite and PLLA

Name: Collagen Biostimulators: Calcium Hydroxylapatite and PLLA
Uploaded: 2026-09-02T00:00:00.000Z
Duration: 1 h 49 min 11 s
Channel: Dr. Sinan Akyürek
Description: A physician workshop on collagen biostimulators: what CaHA and PLLA do in the tissue, dilution, safe planes, session planning and complication management.

A physician workshop on collagen biostimulators: what CaHA and PLLA do in the tissue, dilution, safe planes, session planning and complication management.

This workshop was taught in Turkish. The transcript and summaries below are translated from that recording; the audio in the video is in its original language.

Loads from YouTube only when you press play.

This is the full recording of a collagen biostimulator workshop Dr. Sinan Akyürek held for physicians on 3 June 2026. The two molecules on the table are calcium hydroxylapatite (CaHA) and poly-L-lactic acid (PLLA): what each one does in the tissue, where it can go and where it cannot, how much it is diluted for which region, and how the plan is explained to the patient. The workshop was taught in Turkish; this transcript is translated into English, and the participants’ questions are left in where they were asked.

The first half is theory and case work: the microsphere structure of CaHA and how fibroblasts wrap around it, why a product that cannot be dissolved changes the way you think about complications, a patient who came back with an abscess nine months after injection, why particle-based products are kept out of the mobile central face, and PLLA’s history of reconstitution and granulomas from 1999 to today. The second half is hands-on on two models: zygoma, temple, masseter and mandibular angle, entry through the modiolus, aspiration at every point, and the millilitres actually planned for each region.

It is meant for physicians who already inject and want to follow another practitioner’s reasoning, including where he stops: the point at which collagen gain alone will not lift a descended malar fat pad, and what he tells the patient at that point. This is educational content for physicians, not medical advice; no treatment plan can be taken from a recording without an examination.

Questions? Message us on WhatsApp.

Chapters

0:01

What is calcium hydroxylapatite, and how does the body respond to it?

The workshop opens with how the Merken product family was first encountered and which two biostimulators will be covered through the day. Calcium hydroxylapatite is then described through its carrier gel, its microsphere structure and the way fibroblasts wrap around it in the tissue, explained with an oyster-and-pearl analogy. The material's origins in dentistry and orthopaedics are also covered here.
5:26

How do you manage a complication with a product that cannot be dissolved?

The osteophyte risk of applying calcium hydroxylapatite on bone, and the fact that it cannot be dissolved once it is under the skin, are underlined. If a mass effect develops, dispersing it with saline and massage is described; in the product combined with hyaluronic acid, dissolving it with hyaluronidase becomes possible. The chapter closes on the responsibility that comes with an aesthetic patient being a healthy person.
10:37

The product evolved, but patient history still decides

The evolution of calcium hydroxylapatite from sharp-edged crystals to homogeneous microspheres, and its 20-45 micrometre particle size, are explained. Examples show how an autoimmune history, Hashimoto's thyroiditis and delayed reactions change the picture after injection. The steps followed in managing oedema and infection, and how allergy testing is viewed, are also in this chapter.
15:58

An abscess nine months later: how was the case managed?

The story of a patient who came back with an abscess months after the injection is told from beginning to end: the patient disappearing, going to other clinics, and the legal side of the process. The lesson drawn is not to cut off communication with the patient and to record every step taken.
21:16

Ratio, dilution and skin type in the hybrid product

How immediate volume and collagen gain spread over months are combined in the same product is explained. In patients with heavy volume loss it is stated that this is not enough on its own and combined work is needed. Dilution ratios by region and skin thickness, and the practice of adding lidocaine, are covered.
26:20

Why does a biostimulator not go into the central face?

In mobile areas such as the under-eye, the nasolabial fold, the oral commissure, the lips and the nose, particle-based products can accumulate and form granulomas. A physician who meets a granuloma is in for a long follow-up, and steroid injections do not always give the result you want. Cannula choice and the volume given per point are also discussed here.
31:37

Does marketing set the number of sessions, or the patient?

Part of the protocols that recommend back-to-back sessions has to do with marketing; the patient's real need should be set by calculating volume. Two different approaches are compared: lift first, or definition first. How the treatment plan is explained to the patient is illustrated.
36:45

Nose and temple: the risky regions for calcium

In the nose, the narrow space between bone and basal membrane is why calcium hydroxylapatite is not preferred. At the temple, the thinness of the skin, the need for dilution and the choice of cannula gauge are covered. The second half of the chapter is given over to poly-L-lactic acid's history of reconstitution and granulomas from 1999 to today.
41:47

Why is PLLA easier in a ready-filled syringe?

The vortex mixing, foaming and sedimentation problems of classic PLLA are explained; the low cross-linked form that comes in a ready-filled syringe removes those steps. The manufacturers around the world and how the product was developed are covered. The deep-plane application seen at the biostimulator session in Monaco is introduced in this chapter.
47:15

Massage, photographs and the change the patient cannot see

The rule of massage for 5 days, 5 times a day, 5 minutes each after the procedure, and why it is needed after a deep injection, are explained. Biostimulators create a slow change, and because the patient cannot notice the difference on her own face, a photograph on day one is essential.
52:58

Where does a collagen biostimulator's limit end?

In a patient whose malar fat pad has descended or whose temple has hollowed, collagen gain will not be enough on its own, and this limit has to be told to the patient from the start. A patient consultation in which the face is explained layer by layer is illustrated. Which alternatives are discussed at the point where it is not enough is also covered.
58:16

Planning on the model: jawline or zygoma?

How treatments such as mesotherapy and the gold needle are added on top of the stimulation is discussed. The model's face is then assessed for the live application; the need for support along the jawline and the lift expected at the zygoma are described.
1:03:30

Which losses can be read on the model's face?

On the model's profile, the malar fat pad losing the support it took from the zygoma, the volume loss in the temporal region and the jowling along the jawline are shown one by one. Point selection at the temple is explained by the aim of not creating an osteophyte. The risk of intravascular occlusion is also given as a warning.
1:08:56

Brow filling, aspiration, and how is the bleeding stopped?

Point definitions in the brow region, choosing a cannula instead of a needle, and the neighbouring arteries are explained. Aspiration is done at every injection, and if bleeding starts the cannula is used to tamponade so the procedure can continue. The chapter closes with product preparation and the mixing ratio.
1:14:35

How many millilitres are planned for which region?

Separate volume plans are made for the zygoma, the masseter and the mandibular angle, aiming at three millilitres of injection in total. The share given to the temples and the use of deep and superficial planes together are explained. The question of whether a biostimulator creates scar-like tissue is also answered here.
1:19:51

Entering through the modiolus: how many points can you reach at once?

The method of reaching several points at once through a single entry port opened over the modiolus is shown. Because an artery runs in the deep plane, the cannula is kept superficial, and what is done if bleeding starts is explained. At the end of the chapter, the lifting method modified with PLLA for the second model is introduced.
1:25:18

How was the seven-point technique modified?

The point map of the method that uses PLLA's adipogenic effect in the deep tissue is drawn; a needle is preferred at some points, a cannula at others. A five-millilitre mixture is divided into seven syringes, giving 0.7 millilitres per point. In women, it is underlined that the mandibular angle should not be widened laterally, for feminisation.
1:30:35

Lip, alar base and nasolabial fold through a single entry

The injection that enters at the modiolus and goes down to the deep plane over the maxilla is shown step by step. When the work is done so as to shorten the muscle, the lip line fills out, the nasolabial line softens and the alar base opens. The move to the superficial malar fat pad is made through the same entry.
1:36:32

How much product was used in total?

The total volume applied is calculated and the effect of the share given to the temples on the midface is assessed. The reason for not adding more volume to the zygoma and the small correction made in the lower region are explained.
1:41:36

Both sides finished: closing and a product comparison

As the other side is completed, the deep plane, working on bone and the discipline of aspiration are shown again. The massage instruction to be given to the patient is repeated. The chapter closes with a comparison summarising where polycaprolactone, calcium hydroxylapatite and PLLA each stand out.

Questions & answers

How long ago was that?: They put it on the market in 2017-2018, but because they were not very active on the marketing side it never came into use as a well-known product in Turkey. For example, when we use Radiesse, calcium hydroxylapatite is held together with carboxymethylcellulose as a gel, but the life of carboxymethylcellulose under the skin is a week, ten days at most, and after that it is hydrolysed. 2:39
When you do it that way it doesn't disappear, so what happens?: It still increases collagen production, so it will give a revitalisation effect in the skin. The patient will still get some benefit from it. Because Merken's calcium hydroxylapatite is combined with hyaluronic acid, if the patient is uncomfortable with a mass effect, when we inject hyaluronidase we dissolve the hyaluronic acid inside it, so you can remove that mass effect quickly. On the complication management side, that is the advantage it has. 6:50
So, as you were saying, it isn't a nutritional, nourishing product, is it?: There you are creating a stimulation. Then, when you look at it afterwards, you do a gold needle session, and when you add something like a mesotherapy right next to it, it comes out nicer. 58:09
How many more are we doing?: Seven here, five here. 1:29:52
What did we use in total?: 0.7 times 4, 2.8 plus 3, I used about 3 millilitres of product. If I hadn't done her temples, I could actually have picked the midface up almost completely. I didn't go superficial, not subcutaneous; I did a deep plane application, on the bone. 1:36:48
Can she sleep normally?: She can. That will have no effect on this. As long as she uses a pillow it won't cause a problem, but if she sleeps on a hard surface then I would rather she lay on her back. 1:45:21

Terms in this workshop

PLA: Poly-L-lactic acid. In the recording it is described as the biostimulator that came into use with Sculptra in 1999, stimulates collagen production and is preferred for deep tissue and soft tissue support.
malar: The cheekbone region. In the recording, the malar fat pad dropping once it loses the support it took from the zygoma is shown as the first place where midface volume loss can be read.
collagen: The structure biostimulators increase in the tissue. In the recording, collagen gain is said to give tightening and some lifting, but not to cover heavy volume loss on its own.
temporal: The temple region. In the recording, volume loss here pulls the midface down, and because the skin is thin the product has to be diluted for subdermal application.
cannula: A blunt-tipped injection instrument. In the recording, working with a 22-25 gauge, 50-70 millimetre cannula is called the most reliable route for these products.
oedema: Swelling that develops in the tissue after injection. In the recording, biostimulators cause a mild irritation in the tissue and the oedema that follows will certainly be seen; it is managed with cold application and, where needed, systemic treatment.
hyaluronic acid: In the recording it appears as the component that gives immediate volume and, because it can be dissolved with hyaluronidase, leaves a way back in complication management; in the product combined with calcium hydroxylapatite it is what provides that way back.
hyaluronic acid (hyalüronik asit): In the recording it is described as the component used together with calcium hydroxylapatite and PLLA, adding immediate volume and hydration to the product.
elastin: In the recording it comes up through the collagen-elastin balance in the skin: skin high in elastin and low in collagen stretches like chewing gum when it is pulled, and responds well to collagen gain.
Liquid Facelift (Sıvı Yüz Germe): In the recording it appears as a trend that has spread on social media; the doctor explains that it does not come out of a single product but out of filler and biostimulator used together, and that collagen gain stays limited on its own.
fibroblast: In the recording, the cells that surround calcium hydroxylapatite crystals by putting out foot-like processes and start collagen production.
SMAS: In the recording, while the layers of the face are being listed, it appears as the layer above the muscles and beneath the superficial fat pad.

Full transcript

Transcribed automatically, reviewed by hand.

0:01 What is calcium hydroxylapatite, and how does the body respond to it?

0:01Thank you for watching.

0:06Thanks for watching.

0:13Welcome.

0:15Mükelle ?.

0:17Ms. Elis, doctor.

0:19Ms. Elis.

0:22I remember what you did with their content.

0:29The way you explained it, it suits your work.

0:31...

0:32but it turns out I hadn't used exactly the same setup.

0:39Cardiology, all right — why did you leave cardiology?

0:45We do it outside too; I do it outside as well.

0:47Three days of patients or so.

0:48It doesn't come to that much.

0:51Was this six months ago, how long?

0:53We got it eight months ago.

0:54So we tried to get by with the mesotherapy certificate.

0:58We are working actively at the moment.

1:00We examine in the bag-carrying setup ?.

1:03In total I saw three people.

1:04And there was the tea man.

1:06The power kept going out, too.

1:09Anyway, I had the chance to look at the manufacturing.

1:12We started using Merken's own brand, their older fillers — cross-linked, let's say.

1:19There too they had probably used something like two thousand ? or so.

1:23And 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.

1:31We did PRP; I would test this one as well.

1:34Doctor, we made this one, could you bring it — asking like that, I ended up knowing the whole product range.

1:38The last time was about two and a half months ago.

1:43They asked me: could you give a training talk, could you run a workshop for us.

1:48I didn't turn them down, but this was the earliest we could arrange it.

1:51In between, when my product ? was ready, we managed to line up the doctor colleagues.

1:58You will be the first group I teach here on behalf of a company.

2:02And as luck would have it, our air conditioning is broken.

2:05It was working before the holiday, sorry about that.

2:10But I won't drag it out too much.

2:12I mean, we are not going to explain the meaning of life here.

2:17So in total there are two biostimulators we are going to talk about here.

2:21I'll go through them very quickly.

2:24Harmonyca isn't really a new product either.

2:26Because Erdi ? has been marketing it for a year and a half, it comes across that way.

2:32Before that there was a company called Luminera that they had bought.

2:36They brought it from Israel.

2:38It was one of their products.

2:39How long ago was that?

2:46They 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.

2:55But at home, you know, there is always a measuring step around here. ?

2:59They presented it to us as if they had kept it hidden and moved on. ?

3:02Then they described it as a cure-all product.

3:05I'm not waking up to my third illness on this cure-all question. ?

3:10But with the right setups ? and when it is explained properly to the patient, it is a very good combination.

3:15It gives a seriously good revitalisation and at the same time you understand everything. ?

3:19When 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 ?.

3:47The response the body gives here: fibrocytes and fibroblasts immediately start wrapping around the calcium hydroxylapatite crystals by putting out foot-like processes.

3:58And they compare this to something.

4:01When 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.

4:14The body pushes it out, its water if not, apatite and collagen lactic. ?

4:19Here it was supported together with hyaluronic acid production.

4:22Because it also gives some increase in moisture, it adds a slight glow to the skin from that water retention.

4:30But among themselves, each one has advantages over the other.

4:34Once I have pulled it all together, I'll try to go over it as a summary.

4:40We have a colleague who is a dentist.

4:42They were actually the first to use it.

4:43Our product, we call it dil calcium ?.

4:45When you look at it, in what dentists heavily use as bone powder graft there are properties that get confused with PRP.

4:53Back then they used to call PRP stem cells.

4:57We'll mix stem cells with bone powder and build you a tooth, and so on.

5:00It 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.

5:17It is also found in large amounts in the cements they use in orthopaedics to place implants ?.

5:26 How do you manage a complication with a product that cannot be dissolved?

5:26In 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.

5:38This matters a great deal for our injections.

5:41That is why I am underlining it.

5:42Because when you inject on the bone, we are talking about a material that can cause unwanted osteophytic outgrowths on the bone.

5:51So you have to be very careful with deep injections.

5:55It 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.

6:04But in terms of safety there is this difference between them: once calcium hydroxylapatite is placed under the skin, it cannot be dissolved.

6:12With 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.

6:20Here we have no such luck.

6:22So if we are doing an injection, we have to be very careful.

6:26We did have a complication happen. ?

6:28I am speaking here about the calcium hydroxylapatite side.

6:32The 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.

6:46Otherwise you cannot get rid of the mass effect you have created.

6:50When you do it that way it doesn't disappear, so what happens?

6:52Since it still increases collagen production, it will give a revitalisation effect in the skin.

6:58The patient will still get some benefit from it.

7:00Because 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.

7:09After you do the injection you will see a volume effect.

7:14We saw the volume effect.

7:15We called the patient back 15 days later.

7:17But 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.

7:35On the complication management side, that is the advantage it has.

7:38Can I ask something?

7:39I'm very sorry, let's keep it interactive.

7:42Please, go ahead.

7:43This mixture, diffuse and to the base, I mean, how did the mixture for the borons come about? ?

7:50A one-to-one ratio.

7:51I think of it as one millilitre by volume, bringing together one millilitre of calcium hydroxylapatite and cross-linked hyaluronic acid. ?

8:01But in total the combination of these two materials does not make two millilitres.

8:45I use it for skin revitalisation as well.

8:47On the lifting side we have been using calcium hydroxylapatite for a very long time anyway.

8:53But as I said at the start, on the lifting side you have to be a bit careful.

8:57Because 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.

10:06But that doesn't mean this, the way I see it — please don't misunderstand — that is also why we asked about experience.

10:12Now, you can't just do this, can you?

10:16How you will manage it when something happens to you, keeping hold of the responsibilities, I mean ?

10:21the application skill.

10:23Because we are doing cosmetic work in the first place.

10:27The person in front of us is not a patient.

10:29So when things turn ugly they say to us: I was healthy in the first place, folks.

10:34I was healthy, doctor.

10:37 The product evolved, but patient history still decides

10:37There, under the laws in Turkey, on one side you are helping with a taxi-driver aesthetic ?.

10:43So the matter can go somewhere rather different from simple complication management.

10:48It depends on the situation of the lawyer and the prosecutor involved.

10:51So because our employment ? is at stake, while we are working in aesthetics we have to keep ourselves in the safe zone.

10:56It's like that around the world anyway; in America plastic surgeons always have the highest malpractice rates, always in their world of training them. ?

11:04We need to look at the subject in front of us a bit like this.

11:07In the end, in our field the people we deal with as patients are not patients.

11:12When you look at it, they are healthy people.

11:14That is why we always have things to deal with in relation to what we are used to.

11:26Calcium hydroxylapatite is a product that has evolved somewhat.

11:29I mean, the calcium hydroxylapatite we used 10 years ago and the calcium hydroxylapatite we use today are not the same thing.

11:36When 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.

11:50But then, over the years, ideas developed so that these too would become smoother-surfaced and more homogeneous microspheres. ?

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

12:10That is what is inside Merken as well.

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

12:19These 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. ?

12:36So oedema developing because of that is definitely on the table.

12:39And if I am using a biostimulator — because we count filler as a biostimulator too, and by that I mean filler. ?

12:46the patient's autoimmune diseases

12:51I 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 ?

13:04I mean, the one who never mentioned it to me: oh, I had fibromyalgia too, is this oedema because of that

13:14Or

13:17the 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.

13:31Things like this can happen.

13:32So you have to share these with patients as well.

13:35I mean, if you have a condition, especially an autoimmune one...

13:38Sometimes they think — oh, I have a thyroid, I'm a thyroid patient, they say.

14:07Depending 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. ?

14:16First of all, if there is hyaluronic acid involved, you start by dissolving that.

14:21and always, to suppress the oedema, a systemic Prednol antiviral ?, one tablet or two tablets depending on the severity of the reaction.

14:31I don't much like using systemic treatment.

14:33Lasix, for example, a diuretic and so on.

14:34Lasix — this is a local oedema.

14:36So going that systemic doesn't make much sense.

14:41Applying cold.

14:43After that you have to expect some harm from opportunistic pathogens. ?

14:46Sometimes I definitely add an antipyretic ?.

14:47Because there may be no infection in the picture, and three days later a superinfection is added on.

14:53Come on, because it is hematopic. ?

14:54Actually she is already in a frightened state.

14:56It could be the last compress. ?

14:57You are trying to manage that.

14:59And on top of that, when something like an abscess or a vaccine reaction develops — I'll tell you about that later on. ?

15:02And then of course, in our profession, there is burying a colleague.

15:06Burying people is a thing, a national sport.

15:09The moment she goes to another team, it starts: God knows who you went to.

15:16I am here trying to do something in good faith.

15:19Why are you putting me down?

15:20Go on then, do it and let's see the same thing.

15:22That's not there either.

15:24For example, for example, the allergy test.

15:29I don't think the allergy test has any validity at all.

15:32Now, I never get asked about this either. ?

15:34I mean, if there is an outbreak at that time, I don't do it anyway.

15:37This is the thing we are talking about in an allergy anyway, for example.

15:43One patient, a woman of Russian origin, and also the mother of a pop singer you all know very well.

15:58 An abscess nine months later: how was the case managed?

15:58We did the injection.

15:58She even had a serious asymmetry in her face.

16:00We worked asymmetrically.

16:01We parted very happy.

16:04Let me say it, of course there is a defect. ?

16:05The woman's left side is ibogenic. ?

16:07I mean, it pulled together.

16:08Everything fell into place.

16:09She was a beautiful woman to begin with.

16:12After that she was very happy.

16:13She went, she came back.

16:14In the meantime the pandemic was declared.

16:15Curfews and so on.

16:17After a while the lady turned up.

16:19An abscess this big, here.

16:20An abscess

16:23gets drained, doctor.

16:23We drained it.

16:25After that, intralesional antibiotics included, I did whatever infection management calls for.

16:34After that the hyaluronidase and the rest, wound management, wound care, everything fine.

16:38The patient disappeared.

16:40She dropped off the radar, gone. ?

16:43We call, she doesn't answer the phone and so on.

16:45And I couldn't work out what had happened.

16:47She had an elderly husband.

16:49The gentleman was her second or third husband.

16:52They had gone on holiday to Sapanca.

16:54And they stayed there for three months, apparently. ?

16:58And there, my young colleague ? at the state hospital said, come, come, I cleaned it out.

17:02A special effort came up. ?

17:04This time it was squeezed this much there. ?

17:06And the abscess carried on.

17:08Every so often the fillers I did on the other side flare up.

17:13Then a few

17:19rounds of clearing it out; after a point I worked together with my plastic surgeon colleague.

17:25The first hyperbalance... ?

17:27The first hyperbalance... ?

17:28You can't do anything.

17:30All you can do is shrink the scar.

17:31In 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. ?

17:42A foreign body reaction, and she had sent the MRI through the channel. ?

17:46And after that I was going to do the thing, you know, that much scar tissue, supraperiosteal scar formation and so on.

17:53Let'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. ?

18:01She replied about sending our MRI system with the MRI invoice. ?

18:05And she never sent the MRI itself.

18:07And she never came again.

18:09I don't know what happened.

18:12In my life it kept creating the most absurd complication. ?

18:16It came out of my place. ?

18:17And as a case, you would never expect it.

18:20Her turning up with an abscess like that nine months later is really not something that should happen.

18:25but it can happen.

18:26You have to be open to anything.

18:28Or rather, you have to be prepared for these.

18:30And while you are managing them you have to be inspiring confidence in the patient.

18:34I 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.

18:43Not: shall we do it this way, shall we do it that way.

18:46The 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.

19:01The moment you say, you can't talk to me like that, and so on, you lose the patient.

19:05After that you can't manage it.

19:06So you must never cut off communication there.

19:10All 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.

19:15Let me say these things, and we'll talk about it afterwards.

19:17At the point where you say it again, it goes a bit better.

19:20Let 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.

19:33And there the judge looks at this.

19:35Did you act actively, did you make an effort, on the side of managing the patient's complication?

19:42The 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.

19:49So there is value in our record-keeping habit ?.

19:51Unfortunately the problematic side is a bit like this.

19:53It is worth paying some attention to keeping yourself in the safe zone commercially as well.

20:01My lawyer Ali Doğan told me this. ?

20:04If you do the Dolan Forum and manage it with the complication, it gets resolved. ?

20:21Then it is called an established act, starting from 2 to 5 years. ?

20:32Without scattering the subject too much — if we go into this, we can come back out.

20:35In our country the laws in particular are very complicated.

20:39It doesn't work with the environment.

20:40I am coming particularly to this side.

20:41Because we have one more product.

20:43It is hyaluronic acid together with calcium hydroxylapatite.

20:46Because that is what the product contains.

20:48You can see the lifting with the immediate volume effect.

20:51And in the long term it is hyaluronic acid.

20:54While it comes into play — and this coming-into-play process is roughly a one-month process.

20:58we are not talking about a very hard hyaluron, that is, a heavily cross-linked, steel-like ? hyaluronic acid inside the product.

21:05I'm very sorry.

21:06There is no PLLA.

21:07Nothing at all.

21:08They did it as if we saw my heart. ?

21:10Let me correct it, because the inside of my content was made as a battery. ?

21:16 Ratio, dilution and skin type in the hybrid product

21:16The advantage is that you see that effect straight away and can show the patient what she can get.

21:21And over the following 2 months your collagen increases along with it. ?

21:26In the tissue, to put it very roughly, in plain language, it is nothing other than a product that gives tightening and thickening.

21:34I mean, in patients with a very heavy volume deficit there is no such thing as providing a very high ?.

21:40For example, when they first marketed Harmonyca in Turkey: you do one, the volume turns over, you do one, you do one, and so on. ?

21:47Volume deficit — when you apply it to patients with a lot of volume loss, especially in the fat pads, unfortunately you meet a disappointing ? result.

21:56These are clear, too.

21:57So with that type of patient you have to work a bit more in combination.

22:01Supporting 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.

22:13Along 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.

22:26There is a change of ratio in that one, depending on the region we use it in.

22:31What does he say, doctor?

22:33I mean, there is a change from 30% to 70%.

22:37Of course I use the product as it comes.

22:39If 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.

22:50Or it can be decided by the patient's skin type.

22:55Now 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. ?

23:03And then there are people with skin like mine, I mean, V-shaped

23:08when you pinch it, it comes into your hand thick and firm.

23:10Now, elevating a skin like this and elevating that paper-thin ? skin I mentioned a moment ago are not the same thing.

23:18But for example, if there is no tension, I rather prefer using it on the thin ones. ?

23:25In fact, during the examination, when you pinch it the skin comes into your hand very thin, and when you pull it, it just stretches.

23:32like elastic, sometimes it stretches out from the cheek like chewing gum.

23:35It satisfies these patients very nicely.

23:37Because of the collagen and elastin balance in the tissue: in them elastin is higher and collagen is lower.

23:43When 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 ?.

23:55Products like these are more for such patients. ?

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

24:05But for example, if it tightens the pores for the patient, in between

24:11we need an example.

24:20They usually present it at a 1:1 ratio.

24:23So 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...

24:40I don't much prefer Jetokain now, because of the substance ? in it.

24:44If there is bleeding, I wanted to see it.

24:46I mean, if three hours later the room starts swelling ? and you go looking for haematomas, that is actually more tiring.

24:53If there is any, let it be right under my hand.

24:55And then, if I have added 0.2 millilitres of Lidocaine, on top of that we can use 0.8 millilitres of saline.

25:05Or, say, you could add a mesotherapy for a bit of glow in the patient's skin, or something else, or they try DMA. ?

25:18You can get around it with that as well.

25:19For every site it has to do with any interaction. ?

25:22You won't create a problem with this.

25:28Well, you won't take advantage of its safety.

25:30That is what I am saying.

25:30There is Zikon, at the jawline and so on, definitely a level teacher. ?

25:33It won't create the inside.

25:34But on the neck the skin is thin, on the décolleté it is thin.

25:38In those places it can be diluted.

25:39At home, for example, while using the calcium group basket, a bit of a gap comes up in front. ?

25:45Cross-linked, low diameter.

25:48Skin booster,

25:53Dorotin.

25:57These days there is Jouveler's SkinWire. ?

25:59Something like that; of course SkinWire is a bit costlier than Dorotin. ?

26:05So 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 ?.

26:20 Why does a biostimulator not go into the central face?

26:20When we look, there is actually heavy volume loss, and along with that, again at the collagen point, if we get collagen

26:34gain, this is a patient where you would think you would get good results.

26:38The loss of the dermaclets and contour definition. ?

26:41If there is an ezozoma ?, you can see how far the malar region has dropped because of the volume loss in the zygomas.

26:49In 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.

26:59Under-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.

27:10In my view the colleagues who do are taking a very big risk.

27:13Because here is what happens in these areas.

27:16When 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.

27:33It can build up inside that fold, and a year later that build-up comes back to us as a granuloma.

27:38I wanted to make the point.

27:40Once you meet a granuloma, you basically have to take this patient into your household.

27:45It is a lot of work, really a lot of work.

27:47That is where steroid injections and so on come into play.

27:49And you don't always get the result you want. ?

27:52Every time you do it, when the patient comes the next time the cell ring ? is higher, and so on.

27:56Patient management becomes very difficult.

27:57So when working in the medial area, for my own part there are new-generation mesotherapy options. ?

28:03Of those, as the gentlemen said, I very much like working with ? acid.

28:08Going with the ? and using these products always makes more sense and gives nicer results.

28:13Product

28:19preparation, if we do it: as described here, I mix in a certain amount of lidocaine.

28:25It makes for a heavy injection.

28:26I 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. ?

28:36To reduce that, mixing in lidocaine at 10% to 20% always makes my hand easier.

28:43In total, a 3 millilitre syringe.

28:45Manipulating this straight from a 3 millilitre syringe feels difficult to me.

28:51So I split it in two.

28:52It also makes mixing this lidocaine easier.

28:56In 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.

29:05And I usually do this with 0.5 millilitre injections.

29:11You know this one, don't you?

29:13In the MD Codes developed by Maurício de Maio you are going to inject with a cannula anyway.

29:19And as active volume it is always 0.5 millilitres ?.

29:23And when you do an injection like that with a cannula, you get a clearly visible result.

29:30and some patients need a bit more, some respond a bit faster — you can easily observe that while you are doing the procedure.

29:45Applying it with 22 to 25 gauge, 50 to 70 millimetre cannulas is always the most reliable method for these products.

29:54But as I said, from time to time I do play with a needle as well.

29:58That is a bit of a courage question.

30:02It isn't something I always do. ?

30:04The injection version, the intervals... ?

30:06What, is he going to do one session?

30:09I first saw this on BlueSlide ?.

30:11And I can't say I apply it much like that.

30:13I think this is probably something to do with marketing.

30:17How much does the product cost?

30:19I think it is a bit like this.

30:21No shot makes you do it three times. ?

30:23A kiss, too. ?

30:24Patients at 3 millilitres, it is a whole world of a body. ?

30:27Patients need 9-10 millilitres.

30:30And if you are going to do something like that, do the first one.

30:33Waiting 3 months, with the coffee effect, one from there or so. ?

30:39If that wasn't enough, do the second one.

30:43Wait, let it settle.

30:44Let 2-3 months pass.

30:46Then you will do it.

30:47I think what they meant here is do the third one.

30:49Otherwise, what would be standard?

30:51What, 3-4 calcium?

30:53If you ask me, it is not something that should happen.

30:57Are there patients who pay for an application like that?

31:00There are, there are, there are.

31:05She is going to come every two months, but this isn't that thing — do we know the meso side?

31:25Wouldn't they be a different list?

31:27Make one.

31:28For the jawline anyway...

31:29So it isn't taken any more?

31:30At the jawline it's fine, but...

31:31I saw it, in our model.

31:32Am I asking because you compared this person directly with this?

31:36For the majority.

31:37 Does marketing set the number of sessions, or the patient?

31:37But again a

31:41distracted one — for example she is an apple, a natural apple. ?

31:45How can you use it for her?

31:47For this one, let me not use this.

31:49There is nothing else.

31:53I mean, because calcium hydroxylapatite produces a very sharp line.

31:57So basically, in deep application in particular, I would use calcium hydroxylapatite.

32:05We have one spot too many, the patient comes. ?

32:08For example, in my own practice I never do the thing.

32:11The patient comes and says I saw it on the internet, so-and-so does it, she wants some sort of glow.

32:55Some patients come, the poor woman is like a tomato.

32:58Although there is fluid, she says, I would like my face a bit thinner, a bit more layered, looking more feminine. ?

33:06And for example, I don't have a chin like this.

33:08And that is one of the enzymatic lipolysis ones. ?

33:11Six thousand litres into her chin. ?

33:15Believe me, they weren't exaggerated.

33:49I shrink it like Melahat Bey and Joe ?, then I make room for the fillers.

33:54I, on the contrary, first support the midface so that it lifts, support it with filler and gather the face up.

34:01After that I will sharpen the jawline.

34:05Both of us actually look for the anatomy first, the bone.

34:08Let's actually see the anatomical location.

34:10The same way, how much do you need.

34:12When you pull the lift, let it send your hand. ?

34:35the operations.

34:35And the orthodontic fixations are cut, an audible condition. ?

35:03There, while you are sitting with the patient over these

35:10she wants the condition too.

35:12You have to do it in the middle, where you can ?.

35:15If you cannot do that in the middle, let me

35:23say this openly, I explain it.

35:25In my view you need this.

35:27No, even if we don't do it that way it will be like this, it will be more than that.

35:29And we know how to do it.

35:33This is the treatment I am recommending to you.

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

35:44You

35:46are not in a position to like it or not.

35:56As application areas, on the face

36:00the colleague who prepared the slide has shown almost every seven. ?

36:04But if it were me, number four, six

36:09when I say six.

36:11Stay away from the middle and the lower part.

36:13And I wouldn't get too close to the stereo ? part of three.

36:17In these areas, blölyon or nodule formation, ?

36:23Merken's other ? is very good too, I use it a lot.

36:28In those places I would recommend those.

36:31Calcium hydroxylapatite into the nose region —

36:35I have come across many doctors who do it, who say they do it.

36:39I don't prefer it.

36:41And I don't much recommend it either.

36:42I mean, it is a risky region.

36:44Very risky for calcium.

36:45 Nose and temple: the risky regions for calcium

36:45Because here we are injecting on the bone a great deal.

36:48There 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. ?

37:03What would you tell the patient?

37:05I wouldn't know.

37:05At least I don't take that risk.

37:07We fill it from a new flat. ?

37:09I mean, as I said, we have to do every patient. ?

37:17Especially in the temple region, subcutaneous application meets a lot this time. ?

37:24Recently in Monaco a four-way session was held to compare biostimulators.

37:30In fact I want to share with you the thing I saw there and adapted.

37:35There was a Doctor Huygandroli ? — I don't remember the name.

37:38He particularly recommends this application a great deal.

37:41But in filler application in the temple region, and in calcium hydroxylapatite application, it is worth being a bit careful.

37:49It is one of the regions where the skin gets very thin.

37:51I mean, as we go up from the zygoma the skin thickness decreases.

37:54In subdermal applications in the forehead and temple region it is worth diluting the product a little, as my colleague said.

38:02There you may need dilutions of maybe half a millilitre to one millilitre, or even going down to one to one.

38:12Because when we are done, an appearance can be left here as if there were worms under the skin.

38:16Either you have to disperse it with very good massage, or I would recommend following this route.

38:25As for cannulas, I use 22 gauge cannulas.

38:28Or mostly it can be 23 as well.

38:31It flows comfortably through 22 or 23 too.

38:3322 gauge in particular is a bit painful because it is thick.

38:38In fact I have one 70 millimetre 22 gauge cannula, so that ears don't ring, so I don't get told off ?.

38:44In fact that one stays far away, let the man give it too. ?

38:50So moving that under the skin really takes skill, and it can hurt the patient a lot.

38:55That is why sometimes I prefer 23 more.

38:5925 can be used as well, but...

39:02And calcium-containing products can fill up and harden at the mouth of the cannula.

39:08Because it is together with hyaluronic acid, I never had that happen with Merken's calcium. ?

39:13But there is such a possibility.

39:14By the way, frankly I don't want to put myself at risk either.

39:18Is there anything you want to ask up to here?

39:20Yes,

39:23let's carry on then.

39:54In facial applications it is quite a good amount. ?

39:59I mean, what you call the liquid facelift, you know it very well from this. ?

40:08We started with PLA in '99, with Sculptra.

40:11Then in 2004 we got the FDA

40:16approval.

40:18In 2009 the indication of the FDA approval was widened.

40:23But while all this was happening there was a problem related to PLLA.

40:29When Sculptra came out it contained 150 milligrams of PLLA.

40:34It was applied with a total 5 millilitre reconstitution protocol, presented ? to doctors.

40:39And because of that they ran into an incredibly high number of granuloma ? formations, mostly granuloma formation.

40:45Then, somewhere shortly before 2009 ?, they changed those protocols.

40:52They gave a minimum 8 millilitre reconstitution protocol.

40:56They produced a protocol of 8 to 10 millilitres.

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

41:13If you add lidocaine at 10-20% you can reduce the pain of the distilled water, that is, the water for injection, and so on. ?

41:24But when you look at it, it took until 2014 for the product to start out like that and settle in.

41:30So since then it has still been going through a transition. ?

41:34And 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.

41:47 Why is PLLA easier in a ready-filled syringe?

41:47There are many manufacturers in the world working on PLA.

41:50In South Korea, almost every company you look at has a PLA of its own.

41:54I think it produces a very low mass. ?

42:00In Georgia, Aptos was producing a lot of products made of PLA.

42:04Now those were on the market too, for example.

42:06It's another brand.

42:08Sculptra is of course the original product, the one that first put it on the market.

42:13At Merken they sell other PLA products as a distributor.

42:18And they took this one as their own production, as a ready mixture. ?

42:22In fact I contributed to the development of this product as well.

42:25I mean, first the pre-mixed form ?, and before that we used the powder, the lyophilised form, reconstituting it, and so on.

42:36At the point we have reached now, with its low cross-linked form, I think it has reached the optimum level.

42:42Because in all the other forms, in my view that is the biggest problem. ?

42:47If you mix the product — with the first-generation products we start mixing 1-2 seconds ? beforehand.

42:53it goes ? into this thing, into the vortex.

42:56Then we learned that the vortex had no point ? at all.

43:00The shaking it creates is laminar flow.

43:05For it to be usable, you have to shape

43:11the inside so that a whirlpool forms.

43:14That is why you have to mix from syringe to syringe.

43:17It homogenises in turbulent flow.

43:20But once you have homogenised it, it cannot stay stable for very long.

43:24I mean, say you have prepared an 11 millilitre syringe as recommended — you can't just deliver 10 millilitres in one go.

43:30You distribute it into 1 and 2 millilitre syringes.

43:33You distributed it.

43:34And then what did you do?

43:35You looked at your moment again. ?

43:37And the sediment has started to settle.

43:40During the preparation stage it foams. ?

43:42There is a lot of foam.

43:43When I first started using it.

43:45That foam is in this vitamin shell. ?

43:48You have to draw that foam off.

43:49Then I found out later.

43:50It is of no use at all.

43:52This is something we were really getting confused about.

43:55You are supposed to use the part that looks like raki.

43:58There are a lot of details in front of it, like the taste having settled. ?

44:01That is why I think Merken's PLLA product is very successful.

44:06Because you take it and the syringe is ready.

44:09Just hand it over to the units. ?

44:12There is the amification of a five millilitre syringe. ?

44:15But after that it is very easy.

44:18What I want to share with you today is this.

44:20Until last year in Turkey we only ever saw superficial applications of PLLA.

44:25This 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. ?

44:40One presented hyaluronic acid as a biostimulator, and another presented fat injections and micrograft, nanograft fat injections.

44:52Şino presented the PLLA application, and he also did an interesting application.

44:58I modified it a bit, pulled it into a slightly safer zone.

45:01I'll describe what he did as well.

45:03And let me also show how I do it in a way that suits me better.

45:08Our model will be Ms. Çiğdem.

45:10if you are doing nanofat, exactly, there is nothing.

45:12That's all, I mean...

45:13You need someone to do it from nanofat.

45:15The lady is coming anyway.

45:18From somewhere very far away.

45:20We'll pick it up even from the smell.

45:22The publications made in the last

45:28five years are gaining ground. ?

45:31Now, we always evaluate these as biostimulators, as collagen biostimulators.

45:36But the fact that they are effective on ? has recently been included in the studies as well.

45:41Very recently, I scanned the last 5 years: there isn't enough evidence yet, more research may be needed, that's it.

45:50Dozens of studies, large groups.

45:59When we look at it, for the patients who say I don't want filler,

46:06in future they will clearly be recommending

46:11it.

46:12I mean, or in patients where we can't use it.

46:15The point where it parts from calcium hydroxylapatite is making those sharp edges you mentioned with PLLA.

46:23That is not possible.

46:24But with PLLA you can also, in the subcutaneous fat tissue, deep

46:32lipogenesis, slowly

46:37developing volume gain, and along with that you can also provide revitalisation and regeneration of the skin.

46:46in 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 ?

47:15 Massage, photographs and the change the patient cannot see

47:15provides 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

47:26And also ? the patients we described earlier, where volume loss and skin quality decline together.

47:34Now, when you see the photograph you obviously want to see what came after. ?

47:42In the slide just now it rested ? — I wonder what happened here.

47:46This photograph was taken from below.

47:49What has

47:52become of this.

47:55It isn't written here for PLA, but massage,

48:01doing massage, and doing massage after the injections, is always recommended.

48:06Classically it is recommended to massage for the 5 days after the procedure, 5 times a day, 5 minutes each time.

48:18You need to do the same for the deep injections that are part of the injection I am about to do.

48:24Because what you are doing is spreading this product inside a fat pad.

48:34In the same way, this model, this is that.

48:39I enjoyed it — is it right, is it this, is it that.

48:42We did one.

48:44The patient came.

48:45Wait 2-3 months.

48:46Well, I said I didn't get much out of this.

48:48She is bound to say that anyway.

48:50I mean

48:52I will check at 3 months.

48:55When she comes, the photograph from the first day,

49:00it actually shows that you didn't do this. ?

49:02Because

49:04because 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.

49:14The glow in her skin — well, she bought one, the creams got mixed into it. ?

49:21So keeping the consent form ? you mentioned solid for the patients,

49:28we are not in practice,

49:31I mean the details like your record, issuing an invoice and so on, which you won't remember. ?

49:36That is not my job, it is the state's job.

49:39but Taner Cizan and Tavsiye, how much they were always about me today. ?

49:46And she complains very little.

49:48Especially in Nişantaşı...

49:51In terms of talking about glow, it won't create much of a problem.

49:55With 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.

50:06Is there anything you would like to ask?

50:09Have you ever done PLA after a device treatment? ?

50:13After a device, one...

50:17If there is no trace of calcium, PLA after ?.

50:21I have no need for it at all.

50:22I mean, rather than not needing it: do the calcium hydroxylapatite.

50:29The patient didn't find it enough, she wasn't satisfied.

50:33You can't make her any more satisfied on top of that with PLLA anyway.

50:36Because the patient has stated her expectation. ?

50:43It doesn't create any problem.

50:46There is no problem.

50:47So 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.

51:00On social media right now there is a trend called the liquid facelift.

51:03Everyone is following a liquid facelift, they look at those.

51:06And 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. ?

51:16As if there were no other way.

51:18But a liquid facelift.

51:21A facelift with something liquid. ?

51:23I mean, in this one I used filler as well, for example, and I explain that to the patient.

51:27Now, lining up with the patient what you injected ? — that shouldn't be like tricking her either.

51:33Now, there is a limit to what you can do with a collagen biostimulator.

51:38As the name says, it makes collagen.

51:40But the problem is not the collagen.

51:43If 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.

51:52It won't do much good.

51:53Because the only thing calcium will give me there ? is: if it is this much, to make it this much.

51:58Or, if what you pinch stretches this far, not to let it stretch that far.

52:02To hold it here.

52:03To provide a satisfying ? lift that comes from this gathering up, from the tightening due to this collagen gain.

52:11Nothing more than that.

52:13But the patient cannot know that.

52:14Let 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. ?

52:24And then I say — the question I ask myself ? — if you insist on this product, this is all you will get.

52:33Because 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.

52:52After that: if you want, we can do these.

52:55I say, I won't send you out of here ?.

52:58 Where does a collagen biostimulator's limit end?

52:58Come, let's shake hands on that.

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

53:04If 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.

53:13But I recommended this to you; if you then say this wasn't enough for me, don't turn round and be angry with me.

53:20Now, I did calcium.

53:23If 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.

53:35and we have shared this with the patient too.

53:37And we did that at home as well. ?

53:39But 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.

53:51There you say: look, we talked about this then; come on, let's say we use PDRN on top of this to treat your pigmentation.

53:58I mean, I can't treat pigmentation with CaHA, for example.

54:02or you can say, if you want we can use an exosome, or let's turn to a device.

54:08Or: you have volume loss, come, let's work on those areas a bit with fillers.

54:12By now your trust in me has grown, don't be too afraid.

54:17If you don't like it we can dissolve it, and so on.

54:18But with persuasion methods like this you have to move the patient towards the right place.

54:23The other question: because if you leave the whole choice to the patient, you are doing nothing different from a hairdresser — and we forget that.

54:31Especially if the volume deficit after stimulators like this isn't satisfying, the filler I use afterwards is a non-cross-linked one.

54:40Otherwise, the non-cross-linked ones.

54:44For 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.

54:54We would check at 1 month, and at 2 months we supported it with fillers.

54:59There was cross-linking in it.

55:01It became cross-linked.

55:03There was a middle ground in the distant filler. ?

55:05Let's consider fat injection as an alternative.

55:07No, let them do the fat injection.

55:36Of course we did the same session.

55:40Because the depth you apply is different, and far from getting in each other's way ?, they will act synergistically.

56:26There is no such thing as never do it there.

56:30I mean, maybe he meant you don't need to do it.

56:34Because the biostimulation you have just had is already meant to increase collagen.

56:40There is no such

56:58route at all.

57:00This could be the only basis.

57:02Maybe he said that is what he was thinking.

57:04In the end, when you use protein-based products — whether peptide or collagen — your allergy risk is high.

57:12Proteins are something that stimulate immunity.

57:20Yes, exactly.

57:21He may have

57:25meant that.

57:26But I don't think that way here.

57:29While everything is already stirred up, giving something that will nourish the area gives a nicer result.

58:09So, as you were saying, it isn't a nutritional, nourishing product, is it?

58:16 Planning on the model: jawline or zygoma?

58:16There you are creating a stimulation.

58:19Then, 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.

58:29Maybe, if you have a sensitivity,

58:33in your

58:42room, for example — that lifting wasn't enough, it didn't move your lower face at all.

58:49If it were me, I would have worked that area with you.

58:52I am not surgery, doctor. ?

58:53No.

58:54For example, like this,

59:07or rather from a scientific standpoint.

59:50I did it to CW2, and from there I had gone back to CK4. ?

59:53Ahmet is the repairman.

59:59You are a wonderful model.

1:00:01Yes.

1:00:01And another thing, you lose the effect quickly, they have a chat about it. ?

1:00:07Disposable.

1:01:34Share the results with us.

1:01:37Thank you.

1:01:42Is there anyone among us who wants to leave early, who has to leave?

1:01:47Now

1:01:53Ms. Samka, the queen of our kitchen.

1:01:56Please — the lady who presents these products to you.

1:02:01Thanks to this

1:02:05series I have taken about 15 years off.

1:02:11Not at all.

1:02:13When I couldn't find a model I asked her.

1:02:16Bless her, she didn't turn me down.

1:02:18Now, if you look carefully — because she is constantly right beside me, I don't really look any more.

1:02:23She needs serious support along the jawline.

1:02:27Along with that,

1:02:30if we also do a bit of a lift at the zygoma — as I said, some generations ? need sharp support.

1:02:38In these respects I think she is a good patient for the use of calcium hydroxylapatite.

1:02:44Her skin thickness is good.

1:02:46Please, come over here as well.

1:03:03Where from? ?

1:03:06What do you think?

1:03:13At this

1:03:17point we need to work a bit more.

1:03:20Look from the side, I am looking from the side.

1:03:23When we look from the side, actually

1:03:30 Which losses can be read on the model's face?

1:03:30the exact aesthetics of our lips...

1:03:34Here the nose needs to be made smaller.

1:03:37We couldn't match the liquid ? line.

1:03:41Careful with the zygoma too.

1:03:48In fact her chin has turned a bit.

1:03:51The liquid line.

1:03:59Her chin needs nothing at all.

1:04:01Stop this and you can do the lip on its own.

1:04:04She would get a lip out of it.

1:04:05That is why the maxilla ?, the upper lip coming forward, came into it.

1:04:09in the lower lip there is a bit of a stitch. ?

1:04:18Because the maxilla is weak ?, the nasolabial lines look deeper the more you see them.

1:04:22If it is going to work, the perioral area will show.

1:04:25You have to go into ? work.

1:04:27We are asking that middle comma into three. ?

1:04:33But what can we do?

1:04:36Especially at about 45 degrees, in this lighting

1:04:42because the malar fat pad has lost the support it took from the zygoma

1:04:49when she lifts her head it looks as if it has slipped somewhere. ?

1:04:54And we have a big volume loss at the temple as well.

1:04:58If we come here, it looks as though it will be better.

1:05:00And when we look, it works like this. ?

1:05:06The lines here are clear and we have a bit of jowling.

1:05:11And after working on them together, as

1:05:17the lady described a moment ago, taking the ramus of the mandible together with its body, we get a nice ?.

1:05:26And calcium too

1:05:36At the temple, what every sensible approach recommends, if you are using calcium hydroxylapatite in this patient.

1:05:46Subdermal, with a blood product ?, it adds volume here and might do nothing else.

1:05:53And look how low the patient's eyelid is.

1:05:57Now, the orbicularis is a ?.

1:06:02It wraps around here as if it were being wiped away.

1:06:03And to keep this from dropping, along the temporal line we have the temporal retaining ligament and the zygomatic retaining ligament. ?

1:06:13Although 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.

1:06:26This has sagged, this has sagged, the retaining ligament ?, and it sags like this.

1:06:30The upper eyelid

1:06:34drooping too, and there is an immediate mechanism in the forming of the under-eye circles here.

1:06:40Then over time it gets affected here by facial movement.

1:06:44Its own loss of regime. ?

1:06:49Now, because I can't afford an osteophyte in visible places, I don't work too close in. ?

1:06:56I'll work with the pen

1:06:58and move on.

1:06:58The temporal part, below, one

1:07:01or two.

1:07:09If 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. ?

1:07:17So, doing it that way again, but be very careful, because I would like to do a second injection at the temple.

1:07:28But these,

1:07:35calcium hydroxylapatite, and

1:07:38if you have caused an intravascular occlusion, in the other

1:07:45direction we have no speed. ?

1:07:47That is why on the vascular occlusion side in particular you have to be ultra, mega careful.

1:07:54Yes, all right.

1:07:59Now

1:08:01shall we decide what to do? ?

1:08:03You could go in, but it is very difficult and it would be very heavy.

1:08:06It is very hard for the patient and very hard in terms of the limits.

1:08:09So if I pass under the muscle, that is enough.

1:08:13And because of the fillers it can't be pulled. ?

1:08:15The five-point

1:08:22one we do, the five-point one we do, the five-point one is very unsafe. ?

1:08:26We don't like people, we like the samta. ?

1:08:30Doctor,

1:08:41let's do something this evening.

1:08:43I keep looking, I keep looking.

1:08:44I keep looking, I keep looking, it doesn't feel right to me.

1:08:48My plan would be this.

1:08:56 Brow filling, aspiration, and how is the bleeding stopped?

1:08:56The temporal bone.

1:09:01The lower border

1:09:09of the frontal.

1:09:11The zygomatic eminence.

1:09:16Into the malar fat pad.

1:09:20The malar groove.

1:09:21Our chance of ? will be high.

1:09:25Into the places where there are hollows.

1:09:26And so on: to that line, to the margin, above and below, approaching for all sorts of reasons. ?

1:09:34What I am going to do is support this region.

1:09:40I lifted,

1:09:42I lifted, let's lift again,

1:09:49I changed the mandibular angle.

1:09:52Your ? comes out anyway.

1:09:54I mean, there isn't much point in playing about with the chin tip. ?

1:10:00is there anything you want to add?

1:10:02if we want to lift the brow, I will show that now

1:10:08brow 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

1:10:21I have defined them as D1, D2, D3 ? — frankly, so far I have never felt the need to inject into E2 and E3.

1:10:32But if it comes to it, I would.

1:10:33And if I do, I look to cannulas.

1:10:35Because ? increases; the trochlear artery, for E3.

1:10:41For this area a cannula is recommended as well.

1:10:43It goes in with difficulty; rather than opening a port for a cannula for 0.2 millilitres, I give it with a needle. ?

1:10:48But in this kind of area, if I am going to use a needle, I don't move the needle sideways at all. ?

1:10:54I go in.

1:10:55Now, on the way you could puncture a vessel and pass through it.

1:11:00I go in.

1:11:01I have passed through.

1:11:01I aspirated.

1:11:02I pulled back, nothing came.

1:11:04If it gets caught retrograde it creates an occlusion. ?

1:11:07So I passed through this.

1:11:09I aspirated.

1:11:10Nothing came.

1:11:10Very good.

1:11:11Hold it for ten seconds.

1:11:12Excellent.

1:11:12Every clean.

1:11:13It only delivers here.

1:11:16It bleeds on the way out anyway.

1:11:18But even if it bleeds, when I spread it outward from here with my hand, with massage, it cannot become a problem. ?

1:11:24Then, if you want support again at a second point, again

1:11:29if you do it, this is how I do it.

1:11:31But still, I am not in favour of putting too much filler at the tail of the brow ?; I think it looks very odd.

1:11:42I think it is a nice thing.

1:11:44In my view the lifting we do at the temple works out nicely.

1:11:48At that point I heard a lot about it moving once. ?

1:12:21Don't shy away from things like this.

1:12:23For example, I used to think you could inject on the bone.

1:12:28You can't do that however much you want, because there is a fat pad here.

1:12:33It is stuck to the bone.

1:12:35Even if you wanted to, you cannot separate it.

1:12:36You would have to cut it.

1:12:37The needle goes underneath it.

1:12:38We delivered it on the bone.

1:12:40At most, if you go infraperiosteal ?, you could do something like that.

1:12:44And there you have no ? anyway.

1:12:46What we are doing here is filling the fat pad here, and we are talking about quite a mobile structure. ?

1:12:53It moves, of course; that is unavoidable.

1:12:57Now let's come to our product preparation.

1:13:025 millilitres, 3

1:13:12millilitres of calcium hydroxylapatite.

1:13:15Then ? acid.

1:13:16Ms. Safka's pain threshold is high.

1:13:19So it won't create a problem.

1:13:21Oh, I couldn't bear it.

1:13:49But while turning it you have to set the channel well.

1:14:16When you pass it back and forth about 10 times you get a good result anyway.

1:14:21Now she will split it into two syringes.

1:14:25You are adding Hidrotain, aren't you?

1:14:27Probably not Hidrotain.

1:14:29Sintes.

1:14:30Sintes, exactly.

1:14:31Hidrotain —

1:14:33let's make your plans.

1:14:35 How many millilitres are planned for which region?

1:14:35Now let's also talk about how much volume I would plan for a patient like this.

1:14:45I want to lift the eyelid ? properly.

1:14:48If a total of one millilitre is going to be used, that is fine. ?

1:14:53For the zygoma, if I am going to use a product with a cannula, I planned about half a millilitre here.

1:15:00I would

1:15:06grit my teeth.

1:15:08Her masseters are very strong.

1:15:10If I enter along this line and do something like this, even half will be harmful for this patient. ?

1:15:17So I advance upwards from the mandibular angle.

1:15:23In a way similar to what Ahmet did for you.

1:15:26This is the area referred to

1:15:28as CW2 in the MD Codes.

1:15:33I mean, I think of it as injecting in a way that visually strengthens the ramus of the mandible.

1:15:38In these areas it is always the deep plane, on the bone; here I will go a bit more superficial.

1:15:43Because I also want to do a little mechanical myomodulation and weaken the muscle movement.

1:15:49Suppressing the movements of the platysma here to some extent increases the effect we will give the patient.

1:15:55So what we do subcutaneously should serve this region better in the long term. ?

1:16:02Sometimes, 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. ?

1:16:14Not for this one.

1:16:16And I would plan another half millilitre injection here so that we join up the angle of the mandible.

1:16:25A sort of arrangement we would make like this.

1:16:28So what did that come to?

1:16:29One, one and a half millilitres.

1:16:32One and a half on the other side too — a three millilitre injection would actually build up the base of the midface. ?

1:16:41But I am being a bit extravagant today.

1:16:44One millilitre each will do the temples.

1:16:47That leaves me one more millilitre.

1:16:48And this

1:16:50is the result of our decision, and it will decide from there. ?

1:16:53So in total, a three millilitre injection for this patient.

1:17:51The special bench feature, for now ?

1:17:56there is one thing left that I forgot to tell you ?.

1:18:00Now

1:18:03when I first used biostimulators, the thing that always stuck in my mind was this.

1:18:09You have played with collagen biosynthesis.

1:18:11It put fibrosis into the series. ?

1:18:13We were

1:18:21quite worried about this. ?

1:18:23It produces a tissue similar to a scar.

1:18:27But is it really

1:18:31so?

1:18:31No.

1:18:41No.

1:18:42Could it be?

1:18:43You could make skin as hard as stone.

1:18:45Would you look at it a bit tighter?

1:19:18Look, it develops that much oedema.

1:19:46My dear is right in front of me.

1:19:51 Entering through the modiolus: how many points can you reach at once?

1:19:51No, doctor, that's enough.

1:19:53Now, 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.

1:19:59And here I will choose the modiolus as the entry point.

1:20:03The modiolus — the junction here of 7 or 8 muscles. ?

1:20:10But an artery runs just beneath it, in the deep plane.

1:20:13So we keep ? very superficial.

1:20:16otherwise you would end up cutting an artery that runs from here all the way up. ?

1:20:22Then we would have a haematoma.

1:20:26Even so, I am not letting go right now.

1:20:28If there is

1:20:30any bleeding right now, I tamponade it.

1:20:38I laid it flat.

1:20:39If I still have bleeding, I tamponade it with my cannula.

1:20:45I didn't interrupt my work.

1:20:47If bleeding happens here, if you

1:20:53disperse it again, would you call it an artery anyway? ?

1:20:56I am confident about this myself, too.

1:20:58Even if I were ?, I would prefer to finish my work without letting that bleeding progress.

1:21:04Then we control that bleeding.

1:21:12I brought it up to here.

1:21:14I go in again from here.

1:21:18I was making a small fan over a short distance.

1:21:20I came back.

1:21:21Just as I am about to come out, I go in again.

1:21:36Exactly.

1:21:37You see a result straight away.

1:21:40The line always gets less. ?

1:21:43It will increase.

1:21:43In a month they will come and say, why have these started to come together.

1:21:48Because it will pull itself together.

1:21:51Exactly.

1:21:52But

1:22:01we are one way cold. ?

1:22:12Exactly.

1:22:13Both the deep and the superficial plane.

1:22:16We have been a bit extravagant.

1:22:18Normally we don't use three syringes like this on anyone.

1:22:20If you weren't here, we would be trying to finish the job with a single syringe.

1:22:25It is hard

1:22:32to find a patient this tough, too.

1:22:34You just look, a crumb. ?

1:22:38This is unbelievable.

1:22:50Get well soon.

1:23:09Thank you.

1:23:12you need to go to very hot

1:23:19places.

1:23:19Without pressing too hard with my hand, if you massage from below upwards over the next two areas, it comes out even better. ?

1:23:30Thank you very much, ?, and especially for sharing your experience.

1:23:34Not at all.

1:23:35Thank you very much.

1:23:39Sinan Akyürek medical aesthetics workshop.

1:24:17At one point there was something we called

1:24:21the 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.

1:24:46I preferred to modify it a bit, using a needle in some places and a cannula in others.

1:24:52A somewhat more reliable method.

1:24:55He 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.

1:25:05Basically he went into the midface focusing on two points.

1:25:08So that is also the reason I chose Çiğdem for this application.

1:25:13I am planning to inject a total of 1 millilitre of PLLA plus ? into this region.

1:25:18 How was the seven-point technique modified?

1:25:18Sorry, 1.5 millilitres.

1:25:20One into the deep fat pad, and the other entering like this so as to make almost a W shape here, over the whole superficial

1:25:31malar fat pad — a method built on adding volume there.

1:25:37One again, as we did a moment ago, a pistol shot into the deep plane to gather up the zygoma

1:25:50and one we will do by entering from here again to soften the nasolabial line — so what does that come to?

1:25:57one, two, three, four, one

1:26:02at 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.

1:26:25I tried it on a few of my patients.

1:26:27The long-term results are coming out quite nicely too.

1:26:31When you apply PLLA that has hyaluronic acid in it, you can already see the result immediately.

1:26:37Elif, now

1:26:40of those syringes I will want one, two, three with a needle and four with a cannula.

1:26:49Put a 27 on.

1:26:50Let's not hurt her that much.

1:26:51I don't hold that much of a grudge.

1:26:52She only forgot to do the end-of-day once, after all. ?

1:26:57She forgot to close yesterday's day, that's all.

1:26:59Now there is a total of about 5 millilitres of product in one syringe.

1:27:06A hyaluronic acid plus PLLA mixture.

1:27:08I draw this into 7 separate 0.7 millilitre syringes.

1:27:12At each of my injection points I will inject 0.7 millilitres.

1:27:19There isn't much need to add lidocaine.

1:27:21It isn't that painful an application anyway.

1:27:25Really, it isn't, honestly.

1:27:26Were you clean?

1:27:28I was clean.

1:28:00If we are ready, I'm starting.

1:28:05Would you open your mouth?

1:28:11I always aspirate.

1:28:13As I said, with these too, if you get it into a vessel you have no chance.

1:28:18That is why, a crackle,

1:28:33a single air bubble.

1:28:35That stinging, the tightness

1:28:41in your face.

1:28:42Is it all right?

1:28:43It's fine.

1:28:47Now

1:28:52was it you who asked a moment ago, doctor, how

1:28:59I 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

1:29:13right now I am on the bone, I lifted slightly, 1-2 millimetres. I aspirated, I am adding,

1:29:29it will slow down, then I add.

1:29:49Is it painful?

1:29:50A little bit, it seems.

1:29:51Shall I add some ? as well?

1:29:52How many more are we doing?

1:29:55Seven here, five here.

1:30:02It might be good if we add some.

1:30:11Then do it like this.

1:30:15When you prepare them, go back up to the five.

1:30:18The ones after this are with a cannula anyway.

1:30:35 Lip, alar base and nasolabial fold through a single entry

1:30:35I opened one entry port over the modiolus.

1:30:39From here I will address two or three points at once.

1:30:42One — I go in like this.

1:30:47I go on top of the maxilla.

1:30:52I went down to the deep plane.

1:30:54Here

1:30:57I am below the nasal cartilage.

1:31:00Well below it.

1:31:02I mean, right now I am on the maxilla.

1:31:04You are at the corner.

1:31:05I 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

1:31:27soften nicely, and by opening the alae of the nose a little I can actually help her breathe more comfortably.

1:31:35I will give 0.7 millilitres in total.

1:31:37That is a big volume load for this area.

1:31:40But after giving it

1:31:44I came out.

1:31:48What will you do with the PLLA?

1:31:49PLLA plus hyaluronic acid.

1:31:52Now I will go to the midface as well, doctor.

1:32:01Would you sit up straight?

1:32:07I wanted you to see the effect of this one on its own.

1:32:10Can you see the difference between the right and the left of the lip?

1:32:16We did the thing to the midface.

1:32:18That's what I said.

1:32:20We are not going superficial, we can see. Actually right now it is deep, exactly, that is what I did, now

1:32:45from 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 ?

1:32:56I am inside the superficial fat pad.

1:32:59From here I am already having to push my cannula into the superficial malar fat pad. ?

1:33:05It is under my hand.

1:33:08I pushed a little and got inside it.

1:33:10Now here...

1:33:20We could go deep as well, but going deep from here with a cannula would be a bit painful.

1:33:28So I will choose the needle.

1:33:39I'll take a breath.

1:34:07Yesterday's score is settled now, isn't it?

1:34:09Not yet.

1:34:11No.

1:34:13There probably isn't more than this.

1:34:25I should really do the zygoma too.

1:34:28But because the zygoma here is prominent enough, I won't go any further.

1:34:34I could have gone into the deep fat pad, but I need neither more lifting nor more volume there.

1:34:42so I won't go there either.

1:34:46There is only

1:34:48one problem I have, here.

1:34:50Normally 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.

1:35:00To correct the tissue irregularity here.

1:35:03I mean, there is constant creasing around here.

1:35:06Can you see it?

1:35:08It will be trouble for you in the future.

1:35:11I am taking a precaution with you.

1:35:12But not 0.7 — I will finish there with 0.35.

1:35:16I am not planning to load that much volume either.

1:35:20Did you see?

1:35:21Look, she just did it.

1:35:22Do it again, let me see.

1:35:23What should I do?

1:35:24I keep doing it.

1:35:27It doesn't

1:35:43hurt at all.

1:35:45Wait, try it like this then.

1:35:47Doctor, you have no pity.

1:35:49Ah, and there I was saying it doesn't hurt at all.

1:35:54No, you have no pity for this.

1:36:32 How much product was used in total?

1:36:32Is the camera here?

1:36:33Am I not taking it over here?

1:36:34Exactly.

1:36:36Would you say that again?

1:36:38Wonderful.

1:36:39So are you.

1:36:41All together.

1:36:41All of us.

1:36:42All of us.

1:36:48What did we use in total?

1:36:50Doctor, you used four.

1:36:53And a half.

1:36:55So 2.5 is left.

1:37:03Thank you.

1:37:05So in total, doing this, 4.5 mil...

1:37:08Sorry.

1:37:09Sorry — 0.7 times 4, 2.8 plus 3, I used about 3 millilitres of product.

1:37:18If I hadn't done her temples, I could actually have picked the midface up almost completely.

1:37:23And 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.

1:37:34This spot and this spot finished the job.

1:37:37That is why deep injection of PLA is very nice in this respect.

1:37:46Çiğdem 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.

1:37:54So it was good to bring that angle out a bit.

1:37:57I didn't go superficial, not subcutaneous; I did a deep plane application, on the bone.

1:38:02When it is done this way, the angling here comes out more nicely.

1:38:07A little volume in the superficial fat pad increased the projection of the cheek.

1:38:12That was enough for us.

1:38:13We didn't need much lifting anyway.

1:38:15The nasolabial ? areas were very deep.

1:38:17There she already had a fairly wide piriform fossa.

1:38:21So I filled on the bone from the deep plane.

1:38:23It will increase the fat pads in that region and at the same time the supraperiosteal fibrous tissue.

1:38:29Plus, superficially, we also gave some support to the fine wrinkles in this region.

1:38:35In addition to these, what is to be done if you look at it point by point?

1:38:401, 2, 3, two here, 4, 5, 6 and 7 — that is how we had actually planned it.

1:38:49That is how I defined the seven-point technique.

1:38:52And this is my modified version.

1:38:54Shall we do it?

1:38:55Are we ready?

1:38:56Do we believe in ourselves?

1:38:59Come on then, fingers crossed.

1:39:01I wish I believed as much as you do.

1:39:05We'll open your mouth a little.

1:39:38I hold it like this with my finger.

1:39:40Doctor, perhaps you wanted to see.

1:39:41Look, I can see the angle clearly.

1:39:44Here

1:39:46a branch of the external vena cava may be running just under your finger.

1:39:51Careful.

1:39:54Straight to the bone.

1:39:55Don't dawdle about to the left and right.

1:39:58Listen to me saying vena cava.

1:40:02External carotid.

1:40:03I mean

1:40:06I remember a femur, and there was a filler as well — is that why you go in at this angle? ?

1:40:12No.

1:40:14That's it.

1:40:27Let's hope they don't make the patient pass out.

1:40:30With this many people we would lay her down, doctor.

1:40:34Shall we try one more thing as well?

1:40:35There are this many doctors standing by.

1:40:37Even if I die.

1:40:38God forbid.

1:40:40There is a saying for that moment.

1:40:42Kill me, but make me beautiful.

1:40:44What year?

1:40:44I use that one all the time.

1:40:46They are making you beautiful anyway.

1:40:48That's good.

1:40:50That is why they are making you beautiful.

1:40:52Don't say anything.

1:40:53Şiiran, by the way, is my coordinator, but she has been my friend for 15 years.

1:40:56So I bully her every way I can.

1:40:58I show no mercy.

1:40:59Doesn't she know?

1:41:00She does the information.

1:41:00All of this is on the record.

1:41:02None of it is.

1:41:03Look, I have all of it.

1:41:05So we'll sort it out somehow.

1:41:09And of course there is a bill for all this too

1:41:21Doctor Erkut

1:41:24Right now I am sliding over the maxilla.

1:41:27I'm there.

1:41:28Look, the phone is fizzling out.

1:41:30Probably.

1:41:30I am below the canine.

1:41:33Above me, sorry.

1:41:34Just here.

1:41:36 Both sides finished: closing and a product comparison

1:41:36I am in the deep plane, on the bone, 0.7, and I aspirated too.

1:41:42Let's always aspirate, doctor.

1:41:47We deliver it right on the bone.

1:41:54When doing filler I wouldn't go in with a cannula.

1:41:58If what I had in my hand were hyaluronic acid, from here

1:42:07I would go down onto the bone with my needle.

1:42:11You really

1:42:14love that, don't you.

1:42:16Yes.

1:42:19I love it.

1:42:21Without this — I'll want one more, exactly.

1:42:25I can't have the procedure done.

1:42:35I'm there.

1:42:36Here it was the superficial structure.

1:42:37I hold it with my hand.

1:42:39Look, here I went in more easily, for example.

1:42:41Is the other side more solid, I wonder?

1:42:44Good, you have looked after this side well.

1:42:46You must have been drinking bone broth.

1:42:48Did it all go there?

1:42:49It has all gathered there.

1:42:51Interesting.

1:43:02If I needed more volume, then I would seriously need lifting as well.

1:43:09the deep plane.

1:43:10The zygomatic eminence.

1:43:12I would go in just medial to it from here with a needle and do the deep fat pad.

1:43:18Spreading it a little with massage here isn't a bad idea.

1:43:22And again, don't forget to tell the patient about the 5 days, 5 times a day, 5 minutes each of massage.

1:43:32It is classically useful for PDA. ?

1:43:34I mean, right now we are using a suspension supported with hyaluronic acid.

1:43:38Frankly I don't expect much of a problem to come up, but just in case

1:43:45as you

1:43:49can 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.

1:44:05That is how people get rich.

1:44:08Of course I can't talk while you have a needle in your hand.

1:44:12It isn't a needle, he has a cannula in his hand.

1:44:13You can talk freely.

1:44:14No, no.

1:44:14It's a needle.

1:44:16Let's talk later.

1:44:22That is my favourite part.

1:44:24I said it doesn't hurt at all here.

1:44:30That is why.

1:44:33Of course.

1:44:34Normally

1:44:38I don't spend this much time.

1:44:40Normally I don't do it with this much pleasure, actually.

1:44:42With this one I am enjoying it, as you can see.

1:44:45she 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 ?

1:45:02yes

1:45:06your husband won't recognise you at home

1:45:11now

1:45:21Can she sleep normally?

1:45:25She can.

1:45:26That will have no effect on this.

1:45:28As 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.

1:45:37But 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.

1:45:49In these biostimulators there are three products anyway.

1:45:53One is polycaprolactone, one calcium hydroxylapatite, one PLA.

1:45:57PLA is more ?; that is how I preferred it in my practice, and I also scanned the literature a bit.

1:46:05While it is preferred more for deep tissue and soft tissue support, calcium hydroxylapatite gives more successful results on the bone and definition side.

1:46:15It has to be applied deeper.

1:46:16Exactly.

1:46:20You can apply it deep, you can apply it superficially.

1:46:24It doesn't make much difference there.

1:46:25I mean, how you want to set the definition there has more to do with your hand skill.

1:46:31With polycaprolactone, on the other hand, it is for playing the longer effect.

1:46:34If she wants effects like 3 or 4 years ?, then you can use it like PLA.

1:46:41The thing is clear — you can't get definition as sharp as calcium hydroxylapatite with polycaprolactone.

1:46:49That is a well-known material too.

1:46:50Elantik ?, the threads.

1:46:52Exactly.

1:46:53It is used a lot as Elantik.

1:46:56And in the threads we use for lifting, poly-L-lactic acid and polycaprolactone are used together, in the long-acting threads.

1:47:03The life of polycaprolactone under the skin lasts about 4 years.

1:47:07The ones that halve.

1:47:09It lasts a long time.

1:47:51Thank you

1:48:03for watching.

1:48:56Thank you for watching.

1:49:05Hello, I am Doctor Sinan Akyürek; our workshop at Merken is about to begin.

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Related treatment: Merken PLA — view details →

Chapters

What is calcium hydroxylapatite, and how does the body respond to it?

How do you manage a complication with a product that cannot be dissolved?

The product evolved, but patient history still decides

An abscess nine months later: how was the case managed?

Ratio, dilution and skin type in the hybrid product

Why does a biostimulator not go into the central face?

Does marketing set the number of sessions, or the patient?

Nose and temple: the risky regions for calcium

Why is PLLA easier in a ready-filled syringe?

Massage, photographs and the change the patient cannot see

Where does a collagen biostimulator's limit end?

Planning on the model: jawline or zygoma?

Which losses can be read on the model's face?

Brow filling, aspiration, and how is the bleeding stopped?

How many millilitres are planned for which region?

Entering through the modiolus: how many points can you reach at once?

How was the seven-point technique modified?

Lip, alar base and nasolabial fold through a single entry

How much product was used in total?

Both sides finished: closing and a product comparison

Questions & answers

Terms in this workshop

Full transcript

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