moderator and host. I was just giving it a few minutes or sorry a few seconds to make sure we had most of the attendees who will be joining us today on board. I'm sure we'll see some more as the panel gets started, but in the interest of time, we'll go ahead and get started. I wanted to welcome all of you to our ASPS Global Partners webinar series. This is a phenomenal opportunity to learn from each other across the world, and I am delighted to have two outstanding guest surgeons today on behalf of the Israeli Society of Plastic and Aesthetic Surgery as well as the Turkish Society of Plastic Reconstructive and Aesthetic Surgery. We'll introduce those two folks here in a second. You obviously can see them on your Zoom joining us already. I do want to make mention that this is a dynamic conversation. This is not just a couple of monologues, so we will have an opportunity for Q&A, for questions and answers after each presentation. I would encourage you to submit those using the Q&A feature at the bottom of your Zoom. You can see that here in your screenshot. It shows you what that icon looks like. Again, if you just kind of move your mouse and you can see at the bottom of your screen, that will pop up under Q&A. So please, if you have any questions during the presentations, please type those in and I'll be sure to prioritize those and get to those first after each presentation. I also want to remind everybody that this is free for everybody and it's live version. So come one, come all. If you know anybody who wants to join at the last minute, go ahead and send the link. Again, this is free to everyone, both members and non-members. However, this is also being recorded. So for member surgeons of ASPS, you will be able to find this in the EdNet section of the ASPS website, which is plasticsurgery.org. If you are interested in becoming a member, you can email Romy Valadez. Her email address is here at the bottom of the slide. So it would encourage you either to write that down, take a screenshot or even take a photograph real quick with your cell phone. If you're live, this is great. If you're not live and you want access to this or to become a member or to find out more about becoming a member of ASPS, please email Romy. We'll go to the next slide now, please. So I'm obviously your moderator. I'm in Columbus, Ohio in the United States. I'd also like to introduce Dr. Zach Shaloh of Israel. He is an Israeli board certified plastic reconstructive anesthetic surgeon in Tel Aviv, Israel. He is the owner of a private clinic and has a special interest in rhinoplasty and facial aesthetic treatments. He is also the Israeli representative of the Young Plastic Surgeons Forum of ASPS. I also want to introduce Dr. Belur Sezgin of Turkey. She is a European board certified plastic reconstructive anesthetic surgeon based in Istanbul. She's an associate professor of plastic surgery and is full-time faculty member at the Coach University Faculty of Medicine. She has over 50 articles published in peer-reviewed journals. She's also a peer reviewer for multiple international Q1-ranked journals. She actively conducts clinical and experimental studies alongside her surgical schedule, and she is a fellow of the American College of Surgeons and is the Turkish representative of the Young Plastic Surgeons Forum of ASPS. So with that, we have two great esteemed colleagues here to present to you. We will first go with Dr. Zach Shaloh from Israel. Zach, go ahead and take it away. Hi, everyone. Just uploading my slide, my presentation. Hi, everyone. Can you see my presentation? Yep. Looks great, Zach. Looks great. Okay. Thank you. Thank you very much. Okay. So the topic I would like to discuss with you today, it's a non-surgical nose filler. It's a subject that I'm very passionate about, and I was fortunate to experience it in practice in an extensive way in the past five years. I guess I had about a few hundreds to 1,000 cases of primary and secondary patients for liquid rhinoplasty. And I'm going to share with you this experience and the knowledge that I was accumulating. I'm going to discuss with you introduction to the subject. We will go through the materials, the tools to use, some of the techniques. I'm going to show you outcomes, both of primary and secondary cases, and we're going to discuss some risks and side effects, which are also very important to this topic. So without further ado, let's go ahead. About disclaimer, I'm going to mention a few companies and brands for materials and for hyaluronic acid types. All of it is for educational purposes and a lot for financial. So what is liquid rhinoplasty? Basically, it's the injection of a dermal filler to reshape the nose in a way that's going to be more aesthetically pleasing. It gives us a temporal result, which lasts about between one to two years. It's reversible if you use hyaluronic acid, of course. It gives us a fast and immediate result with minimal downtime, usually one to three days. Usually just a few bruising and maybe some swelling, but nothing more than that. It's inexpensive in comparison to rhinoplasty, which is another advantage for the method. Now, if you look at the history of nose fillers, it's not exactly a new concept. It was performed before. It's as early as the late 19th century, where it was performed with liquid paraffin. Later on, it was in the 1960s, it was tried to be done with silicone gel. Both of the mentioned materials are permanent and they cause to the patient sometimes severe deformities. During the 2000s, a new method was introduced by micro droplet technique. This technique is still used. I'm going to mention this technique also with the use of hyaluronic acid, which gives us a great tool in this regard, but obviously not with silicone. Now we move to 2010. That's when radius and hyaluronic acid were introduced into the field of liquid rhinoplasty, and it's caused some major changes and give us a improvement and result, which can be temporary and reversible, of course. Now, so if you look at the type of patient that can fit into a few categories for liquid rhinoplasty, so some of them can be young patients, which can be prior rhinoplasty age, which can give some temporary solution before they can go on rhinoplasty. Another subgroup, which is a major subgroup, is the patient which is hesitant to undergo rhinoplasty, and that can be due to various reasons, such as fear from surgery, or due to the cost, or due to they don't want to have a massive change, just small things to change about the nose to better feel about it and to bump the self-esteem. Another subgroup is the post-rhinoplasty deformities, which from now on I'm going to refer to this group as the secondary cases of liquid rhinoplasty, and this also gives us a great tool to help this patient. Another subgroup is the elders, the ones that are past the ideal age for rhinoplasty, and if they always wanted to have some changes about the nose and they feel like they missed the train so they can jump aboard. Next one. So now I'm going to name some of the strengths of the method, so we can start to get a feeling about what we can do with liquid rhinoplasty. So one of them is obviously feeling in depressed area. Another one is lifting a droopy tip. We can smooth irregularities, which is also important for the secondary cases. We can correct under-projected tip and enhance retracted anterior nasal spine. Later on I'm going to show you pictures of all of these strengths and how we fix them. Now, this method isn't perfect. It doesn't have its draw, its cone, and these things that the method cannot do, that's something you really have to discuss with your patient. They have to understand that there is some limitation, things we cannot do, and by explaining to them what the method cannot do, you can later on have a consent patient, which is going to be a happy patient, because you're going to understand what he was getting into. So liquid rhinoplasty cannot reduce the size of the nose. It cannot alter the nostril size or position. It's not a method to correct a hanging columella, and it cannot correct a major or significant nasal deviation. So let's try to define what is the ideal patient for this procedure. Basically, there is many similarities to the ideal patient for rhinoplasty. So if you go through these things, it usually would be a young female, which have a narrow dorsum and tip. This is important because, once again, you cannot narrow the nose by the injection. The patient with a moderate-sized hump, it's easier to fix. Slightly droopy tip, it's also easy to fix. And also, the skin should be thin or normal thickness skin, because with the thicker skin, it's harder to get a good result. So now, about the materials. So what will we use? What we are going to inject? So there is two major categories of substances we can use. One of them is hyaluronic acid. This is my go-to when I do liquid rhinoplasty. And the reason is because it gives us a temporary and reversible tool. Of course, we can always dissolve it with hyaluronidase. When we choose hyaluronic acid for the nose, we're going to choose one which is cross-linked with long chain. We want the hyaluronic acid to be firm and to have the ability to elevate the tissue. And we want to stay as localized as possible. So that's a characteristic of the material that we want to use. Now, about radius, I had some experience with this material also for liquid rhinoplasty. I was using it before, but I'm not practicing with it at the moment. And the reason for that is because after injecting radius, it's causing initial temporary swelling, which means that when you are done with the procedure, the nose won't look good at the end. You need to tell, you need to advise the patient that they should wait for a few hours and one day it's going to look better. It's unsuitable for superficial injection in comparison to hyaluronic acid. And it's temporary and non-reversible. And the idea that it's not reversible, it's a problem with the type of complications that can be caused in injecting this area, which is something that we might want to avoid. The next one. Okay. So choosing the right tool. Now we're going to speak about how we inject the filler. So one option is to use a needle and the other one is to use a cannula. I like to use needles because I think it gives us a better position and it gives us the ability to inject both in pulses, in areas which are appropriate to injecting pulses, which we are going to define them later on in this presentation. And also we can use the micro droplets technique. And we can use a needle with a smaller diameter, which is give us a better precision and a less painful patient. About cannula, so if we use a cannula, so we use the retrograde injection, which is considered to be safer, though still there is the possibility of entering into a blood vessel. Usually we will use a larger diameter cannula, about 25 gauge. And another advantage for the cannula is causing less bruising. But once again, we don't have the precision and the control over the layer of injection and the site of injection. Okay, so now I would like to discuss with you about primary cases. I'm going to show you the three-point technique and we're going to do it in four steps. So the first step that I'm using in that I'm using in liquid rhinoplasty is injecting into the anterior nasal spine area. And what I achieved by that is the increase of the nasolabial angle. I'm going to show you later in the picture how it's exactly changing it. And another one is to decrease the nasal tip protrusion, which is basically the length between the filtral column, let's say, and the tip of the nose. Next one. So the next step we're going to use is to inject with another tip. This one is really important. And we're going to inject in this area between 0.1 and 0.2 mil. We don't want to over-inject this area. We don't want to push too much or to give too much stress over the tissue of the tip. Otherwise, you're going to get a patient with the red tip, which is going to last for sometimes up to a month or two months. So take it slowly with this area. We're going to inject between the middle crews of the lower cartilage. And we're going to create a new tip defining point. Sometimes we need to push this area a bit higher. So we're going to need to inject less to the radix area. I'm going to show you in this, if you watch this over here, so as higher we go over the tip, we need to inject less to the radix area. Step three, the nasal radix. This area is really important. And we're going to inject between 0.2 to 0.3 mil of filler. This is a bit of a tip of how we're doing it. So if you pinch the radix with both of your hands, just like that, you're going to get a safer injection and you're going to give your signature by creating a new radix, which is always welcome in this procedure. Now we need to insert the needle all the way to the periosteum to be in a vascular plane. And that's, that's make it safer. We're going to inject the bolus and we're going to keep correcting ourself all the time. Sometimes you can inject it like in a few portions of boluses until we're going to get the straight profile. And now for step four, we would like to connect between the dots. The meaning is that we're going to inject to the supratip region. We're going sometime to inject between the radix. And in general, we're going to fill also depressed area in the dorsal wall. But in all this area, we will use the micro droplets technique because we don't want to inject boluses in this area. Now I'm going to show you some outcomes that showing the strength of this, of this method. One example is this 27 years old female, which is a primary case. She came, she came to me with the, with the complaint of a droopy tip. And in these photos, we can see photos of, photos of, of before and one month after. And you can see a significant improvement in the, in the tip projection. And this was by using the three point technique. Another example is this 51 years old female, which, which, which is a primary case. We, what we can see basically is a moderate nasal hump, which is over here, a droopy tip and a skin is moderately thin, which is, which is once again, it's advantage for, for this method. And we can see as well, pictures before and after. This is another sample showing once again, the same, the same idea patient with the, with a bit of a droopy tip and, and the moderate dorsal hump, once again, a great result. Another example of the same. And now, now I'm going to show you, we're going to move next to the secondary cases. So in the secondary cases, this, this patient's are post rhinoplasty and they have, and they have induced deformities due to the surgery, obviously, and sometimes these patients really have problems that work with them everywhere due to the deformities, these deformities, and they really look for relief from that. I'm going to show you some, I'm going to go with you through the methods. So during the, for the secondary rhinoplasty, liquid rhinoplasty, we're going to use only micro droplet, no pulses, and that's due to the altered blood supply, which is not constant anymore, and we cannot assume that the midline is safe for injection, so we have to take, we have to take extra care with this patient. So that's why we're going to take our time, we're going to inject drop by drop, we're going to limit the volume of the filler to not more than 0.5 mil per session. One of the reasons for that is due to the scarring and skin tightness, and while injecting, we have to continuously observe for the skin for signs of vascular compromise, which sometimes can be seen in this patient, then we have to stop and we have to monitor the patients, obviously. Okay, so what can we correct? Which kind of deformities we can correct in these secondary cases? So if the patient has a thin adherent skin, it's something that we can correct in a very good way, because hyaluronic acid knows how to give us volume, it knows how to give us cover for the deformities. Another thing we can fix is a pinch tip, we can fix V deformities over the umping, visible off an open roof, sometimes we see this patient that the septum underneath is just visible, we can see irregularities of the nasal bones, and so on, and also sometimes after bioplasty, patients still have droopy tip. Okay, so in these photos, we can see a 30-year-old female, which is a secondary case, she has a thin adherent skin, pinch tip, inverted V deformities and over umping, we can see photos from the front view, we can see a good coverage of the deformities, we can see in this picture, it's visible the correction of the umping, and all in all, and all in all, she's a happy patient, and she's very grateful for this change. Another case, a 36-year-old male with a thick skin, so it's covering some of the deformities, but still we can see in this view, we can still see a droopy tip, some irregularities due to the fragmentations of cartilage and bone that is in there, like if you could feel his nose, you would feel that there is no support. Once again, showing a great result. Now, we can speak about liquid rhinoplasty without mentioning some major risks and side effects to the system, because it's arguably one of the most dangerous sites for injection in the face, maybe second only to the glabella region, but if we use some important principles, and we avoid high-pressure injection, so we can avoid some of them. So, blindness, this is the most dangerous risk that can be caused. The reason for that is due to high-pressure injection, which causes a retrograde movement of filler into the retinal artery and causing occlusion, and we can prevent this by knowing the vascular anatomy. If we look here at this photo, we can see that there is a clear path in the middle, almost clear path in the middle, but in the important region that we are injecting to, which is the radix, it's the tip, and the anterior nasal spine. If you stick to the middle in primary cases, so that's the lens that should be high vascular, always inject slowly and gradually and into the core of the depth in plan. If in any case of emergency, the symptoms for retinal artery occlusion will be ophthalmic pain and acute vision loss, in that case, you should refer the patient immediately to ophthalmologist for intraocular injection of valerone days. The next complication, which is also a serious complication, is skin necrosis. We can divide this one into two categories. One of them is arterial embolism, due to injection into an artery. In that case, we're going to see blanching, following by necrosis of the tissue that's going to develop or progress over five to seven days. Another subtype is vascular compression. This one is going to be manifested by reticular erythema, echemosis, vesicle, and postures. The second one, the vascular compression, is the more common one that we can see. In both of these cases, if we suspect, we need to start the early treatment with dissolving the hyaluronic acid with valerone days and take care of our patients, of their needs, and of course, of the wound. I'm going to give you now some tips and tricks and things that I think that helped me during the time to evolve and to get better in this procedure. One of them is to use a BD syringe with a small volume and a 31-gauge needle, which is a small needle. It's going to give you higher precision and it's going to force you and restrain you to work slowly and to use a small amount of filler. If you meet a patient that was injected before and you think that the results are not ideal, but they want to keep injecting, so try to advise them about dissolving before you're doing the procedure once again. With male patients, they get slowly, sometimes it's harder for them to adapt to changes, so it's better to do the treatment in a few sessions. Another one is many of these patients, the same like rhinoplasty, they have mycogonatia, so we should advise them about gene augmentation, which can be also performed with hyaluronic acid. And the most important one maybe is don't overfill the radix to avoid the avatar look. Take it slowly, fill the radix in at least two sessions, tell your patient that the hump, you know that the hump is going to return and you're going to refill it once again, just don't overfill it. Thank you very much. Thank you, Dr. Szilagyi. That's a fantastic presentation, very clear. I love the case examples, talked about principles, talked about implementation and even some tips and pearls. That was really a phenomenal talk. Again, for those of you who joined us late, welcome to the ASPS Global Partners webinar. For those of you that have questions about this presentation or our next one, we do have the opportunity now to ask a couple of questions, and I would ask you to please put those in the Q&A feature. So if you just move your mouse on your screen, you'll see at the bottom of the Q&A icon. If you just click on that and go ahead and register your questions, I'll be sure to get to those. Before we move on to Dr. Sezgin, we do have a couple of minutes for questions. And so while we're waiting for our audience to pose any questions that they may have, I do have a couple for you, Zach. The first slide that you had talked about the longevity of these fillers in the nose. And you talked about hyaluronic acid versus, let's say, Radiesse. Those timeframes do look different to me than the same filler in different parts of the face. Could you talk to us about, let's say, where you're using hyaluronic acid to fill a nasolabial fold versus the nose? What do you tell patients is the average longevity of a nasal injection versus, let's say, a facial injection? Yeah. There is a major difference in the longevity of hyaluronic acid between different regions in the face, for example. And it also changes between patients. So for example, for the lips region, which sometimes lasts for less time, sometimes for six months, sometimes for one year, it also varies between patients. But in the nose region, I noticed that it just stays for a long time. I don't know exactly to explain why. Maybe because there is no movement, maybe because of the way of the compartment that the hyaluronic acid sits for. It just stays for a long time. I had a series of patients that I was treating. And we called them after two years to check on them and to see maybe they want to renew their treatment. And all of them were like, said that it's still lasting. And these are heavy patients. So you gave an age range. You said that you can treat the ideal patient, but then you have some maybe indications or patient populations who would benefit from this the most. You mentioned you could treat kind of pre-ideal age patients, the younger patients, as well as the older patients. What's the youngest patient that you've treated with this technique? There was a girl that she was 14, that she definitely wanted to have rhinoplasty later on. And she was very disturbed about the shape of her nose. And she came for consultation with the parents, both of them, that was supporting the procedure. So we're doing it. But there was also a request for younger patients that I had to deny. On the other end of the spectrum, the older patient, we know from studying the morphologic changes that occur in the nose with age, that these patients tend to have droopy tips. And you mentioned that one of the ideal situations is to correct a droopy tip. Is there a limit to how much droop you can correct, especially let's say a male, older, thick-skinned patient, certainly more of a challenge? I know you gave some averages in terms of how much filler to inject in any of these places, but what about the older male with thick skin, for instance? Is there a limit to this technique? I think this technique is really, it's really a great tool for droopy tip. It sometimes keeps amazing me also about the strength of this method and what it can do. Sometimes I'm also a bit skeptical when I'm studying, when we're starting to inject, when I see a case or when I see them for a revisit, but it really has a major ability to lift a droopy tip. Of course, it comes with a price. It comes with a price of making the nose a bit wider. So when I see them for a revisit, and sometimes they want to increase the tip elevation, I'm telling them that it comes with a price. I'm going to have a wider nose. Sometimes you have to restrain them because usually also just following the treatment, it looks a bit better because it looks more defined, like a Tinkerbell tip that is like really, really defined. And later on, because it's an ionic acid, so it's smoothing and it's getting rounder. I will tell you that we've learned a lot today, including some new terminology. The avatar nose and the Tinkerbell tip are two new words that we're going to add to our dictionary after this conversation. We're going to finish with one question here from Dr. Rahman, who put it in the Q&A section, and then we'll move on. With a large number of fillers available on the market, what's your decision-making on which brand and specific product within a brand line you use? I know you said you have no financial conflicts of interest. I want to reiterate that since you mentioned that earlier on in the talk. In the last 30 seconds, can you give us maybe what's your preferred brands? Or do you want to make you uncomfortable? No, no, no. I'm very comfortable. I'm usually injecting to the nose with the Stilage XXL. I was used to work with XL, then I bumped up to XXL, and it gives great, great results. I look for the hyaluronic acid, which are more firm and give more volume and stays in place. When I was injecting, for example, with hyaluronic acid, like from Stilage with the large, that's causing the avatar look, because some of the chain are shorter and moving around, and they're causing a broad radius, which gives the avatar look. Again, thank you for an outstanding presentation. That was wonderful. For those of you that joined us late, this is free to everyone around the world live. Anybody who wants to see this on demand, this will be on ednet at plasticsurgery.org, the ASPS website for members only. For anybody interested in joining to be a member, please contact Romy Valdez, and her information is in the chat. With this, we'll move to Dr. Sezgin from Turkey. We'll go ahead and switch over from a share screen. Welcome, Dr. Sezgin, and thank you very much for joining us today. Thank you very much. I hope you can see me. I'm very, very happy and very humbled to be here today. I'm just going to go ahead and I'm just going to... Zach, you'll need to stop sharing on yours, and then we'll switch over. All right. All right, and I think I am in full screen mode. Once again, I'd like to take this opportunity to thank ASPS for allowing us to have this wonderful presentation. I'm very happy to be here, and I will be sharing my personal experiences on tailored indications for different neurotoxins. I, too, do not have any financial disclosures regarding this presentation, but I will be discussing off-label uses of neurotoxins. So just like my colleague, Dr. Shilloa, mentioned, minimally invasive procedures are definitely becoming all the trend because of their minimal downtime and the amazing results that that can provide our patients. But without a doubt, we know that botulinum toxin injections have become the most executed aesthetic procedure for the past two decades. And just looking into the normal statistics from the National Plastic Surgery Data Bank and the Aesthetic Plastic Surgery Data Bank, and even in the global data banks from ISAPS, we can see that it's definitely the highest performed procedure. And above the age of 19, worldwide, it's the most frequently performed cosmetic procedure in the world. So when we are faced with a minimally invasive procedure that is done in such a frequent way all over the world and is on such demand, it's really important to understand what we can achieve with this because it's not sort of a one-glove-fits-all kind of a thing. We actually have different products on the market that we can use. Currently, there are four different toxins in the U.S. market that are FDA approved for cosmetic procedures. For Turkey, we actually have two of them readily available in our market. So for our presentation right now, I will be mainly speaking about onotoxins and albotoxins. So the onotoxin, which is Botox produced by Allergan, is a U.S. patented one. And the albotoxin, which is the U.K. patented version produced by Dysport, produced by Ipsen, is the other form that we are using. So both have been on the market and FDA approved for a very long time. So there have been many papers, ongoing discussion and debate about which one has a higher efficacy, higher duration, better effect, longer results. But looking into all of these papers, of course, there are very good scientific papers as well, but most of them are one way or another linked with manufacturing companies. So it's not really very easy to find scientific information that is completely unbiased. But still, when we look into these papers, we see that there is a certain trend about some things that are very established regarding all of these toxins. So first of all, they're all formulated differently. They have different manufacturing processes and therefore they demonstrate unique biological characteristics. And this is why they're not interchangeable. And we also know that the onotoxin to the albotoxin has a conversion ratio, which is usually a considered to be 1 to 3 or 1 to 2.5. And this is an important one. We know that the albotoxins reconstituted in equipotent, equivolumic solutions have a broader action halo, meaning that the activity of the toxin occurs further out from the point of injection. This is also true when we dilute toxins, regardless of which toxin brand we are using. Why is this important for us? Because this broader action halo can actually allow us to sort of tailor our treatment according to the area that we want to cover. But it's also important to keep into consideration when we're thinking about potential side effects. So to generally sum it up, the onotoxin has a larger molecular weight and a smaller action halo. This gives it predictability in sensitive areas and also provides a more softer effect. Whereas the albotoxin has a smaller molecular weight and a wider action halo. This allows it to have ease in wider surface areas and also provides it with a more global action. So which one is better? Definitely, there is no superiority in regards to toxins. They're both FDA approved and both are perfectly capable to produce amazing results in the hands of expert injectors. But I like to consider them like comparing red to green apples. Both are delicious. Some may prefer one over the other. But some recipes call for a red apple, whereas other recipes call for a green apple. So it's good to know which one can be better used in which circumstance. And I'm going to try to sort of give you a general understanding of how I tend to prefer my toxins in which indications. So when I'm looking into deciding which toxin to use, I look into three things. I look at the anatomic site and its properties. I look at the patient's age and characteristics, and I look at the overall general expectations. So for the anatomic sites, I like to consider the surface area of the anatomy and also the neighboring muscles in this area. The anatomical site comes into importance when we're doing treatments for four different areas. The first treatment type is hyperhidrosis, so our treatment for over sweating. These are, of course, areas that require wide area treatments, and they do require homogeneous, widespread effects to be successful. So thinking about this, you would automatically assume, as do I, usually prefer the albotoxin because it does provide a much more homogeneous effect over this area. There's just one thing to take into consideration, especially regarding neighboring muscles. When we're doing injections in the hand, in the palmar region, we know that just underneath the skin, we have very intricate muscles, the intrinsic muscles and the thinner muscles. So in the case that the toxin would affect these muscles, you might end up having patients with weakness of their grip, which would be, of course, very disturbing. So I generally say that for main areas, most areas, I like to use the albotoxin, whether it be the forehead, the axilla. But generally, my main preference for the hands are the onotoxin. But as I mentioned, they do not have as much of a widespread effect as the albotoxin. For example, with this patient, I had done a hundred units in total, but I was unable to do two-point injections in the two little tips. And she came back after two weeks just showing that she had a little bit of sort of remnant sweating in the tips, which was still very disturbing for her. So as I mentioned, even though I had injected in these two areas, because the onotoxin does not have much of a widespread effect, it did not really have much of a benefit on those tips. And I had to go back and touch her up. The other area which I like to talk about in regards to the anatomical site is the masseter. So the masseter muscle injections have been very popular recently, both for teeth clenching, grinding, and also for jawline slimming. I want to go on vacation. I think I want to go swimming. So whatever the reason, we know that the masseter is a very strong muscle, so it's going to require a high dose. But we also know that this area has very critical neighboring muscles, including the zygomaticus muscles in the above area, and also the rhizorius muscles in the front. So because of this very critical neighboring muscle anatomy, the onotoxin is definitely my preference for this area. And of course, it's also important to be able to inject in the safety zone, because we do know that if we inject anywhere out of this, regardless of the toxin, we can still get certain problems, especially such as asymmetry of the smile or speech. So lower face asymmetry is possible in these situations. This is an example of a 35-year-old female who came because she wanted a bit of slimming in her lower face, and we were able to achieve this with 20 units of onotoxin on both sides at first month. Another patient, she came because she had some teeth clenching, some bruxism, and she was given, applied 25 units of Botox per side, and this is her at one month showing both thinning and also resolution of the clenching. And this gentleman came, he was actually referred by a dentist because he had a lot of dental issues because of the bruxism, and 30 units of Botox at the end of the first month was able to provide him with much relief for this situation. And another area that I like to think of when I'm talking about preferences and regards to anatomy is the perioral area. We also know that this area also has multiple fine delicate muscles that are neighboring and overlapping, so we need to have precise applications in this area to avoid any kind of side effects. So again, for this region, I would prefer the onotoxin. This is a lovely patient, 37 years old. She had the gummy smile deformity due to her hyperactive levator labial agnosia, and injecting into the two muscles, bellies, with just two units each gave her a much more attractive smile at the end of one month. Another patient wanting to have a more attractive perioral area, the first thing that we did was we injected the depressor anguli oris with two units, and this provided a little bit of an elevation of the corner of her mouth at the first month. She was also a smoker and had a bit of barcoding on her upper lips well, so by doing very cautious injections, I usually like to do about four points on the upper lip and just one unit each. In fact, I tell the patient it might not even have an effect at all. I just don't want to risk having asymmetry or a change in her general speech. So this was able to give her a much more smoother, much more sort of polished effect on her upper lip. And another area that we do in the perioral region is the mentalis muscle, which is sometimes overly contracted and can cause the orange peel effect. By doing injections in this area into two muscle bellies just underneath the dermis with just three units, this is her at one month looking a lot more smoother. And the final area I'd like to consider for the anatomy when choosing my toxin is the calf. So this is something I've been doing quite recently, and it's actually treatment that affects a large muscle group and it requires wide distribution of the toxin. And of course, it's a big muscle, so it's going to require a high dose. So for these reasons, I would opt to go for a abotoxin. The main thing that we do here is we try to minimize the bulging visibility of the medial and or the lateral heads of the gastrocnemius muscle. And I started doing this under ultrasound because I wanted to see, first of all, how thick the skin is, so what kind of a needle I would have to pick. And also, generally, I just wanted to see the thickness of the muscles and how it would change. And by doing 200 units of abotoxin on both sides, so a total of 400 units, we were able to achieve a thinner, more attractive look for the patient at the first month. So other than the anatomical site, the other thing that I like to take into consideration is the patient's aging characteristics. I like to group our patients into three main groups. So first time patients, the rookie patients, the young patients who are the preventative toxin patients, and then the mid to old age regular patients who are the more seasoned patient group. I also like to open a little parentheses for our male patients as well. So the rookie patient is the patient who comes in for the very first time to get toxin. They're usually very anxious and they don't know what they want. So basically, we're going to provide them with a warm up trial period. For this, I usually like to do something that's a little bit more soft and subtle. And depending on what they really like and their reaction towards this treatment, I like to plan the future according to that. So for their very first treatment, I like to prefer the anatoxin. This patient, for example, you can spot from a mile away, she can hardly hold the pose, she's giggling and laughing. This is usually the way it is with the rookie patient. And this is her after 40 minutes of Botox looking a lot more, I would say, fresh. And this 29-year-old patient, again, came to have a bit more elevation in her lateral brows, wanted to look a bit more attractive, and she was happily settled with the results after 35 units at the first month. So these patients then are later promoted into the young patient category. So these are patients who come for the prophylactic, the preventative applications. For these patients, I really have to sit down and learn their expectations because some just want a very, very subtle, very minimal effect where they want all of their mimics to sort of look like through the treatment, whereas others want a very sort of solid global airbrushed look without any lines. So it's important to talk to our patients in regards to what they really want to achieve. And I also look at the forehead width for these patients because especially if they have a skin type that's kind of oily, that's acne prone sweating, these treatments also have great benefit for diminishing and reducing the sweat and sebum production. And it definitely makes an improvement in their skin as well. So this is definitely great for them also to have a much more sort of porcelain-y kind of skin. So if they have a wider forehead, I also go towards the albotoxin to sort of be able to also affect the sweating and the sebum production as well. So I would go for either toxin. It depends on the patient. This patient we talked about with the perioral injections, this is her with her upper third injections. She wants it to look very natural. She still wants to have her mimics shine through, and we can still do this, make her look more attractive and still have her movements come out. Another patient, mainly not happy with her crow's feet, and we're able to fix these and also give her a more fresh look with 35 units. And the last group are disease and patients. So these patients are patients who have their expectations set, and they want them to be met. So they're mid to older age, and they have mid to severe wrinkles. And of course, they want to have long-term stable effects. They're actually mainly candidates for surgery sometimes. Therefore, with caution, I like to use the albotoxins for these patients as well to provide a more stable and long-term effect. For example, this patient, mid-50s, she's been coming and going for toxin treatments and other treatments as well for over 20 years, and she looks great. She just wants to look more attractive. She wants to feel more confident, and this was able to be achieved with albotoxin treatments, and this is her at the first month. Another patient, this patient is above the age of 60. She's in her mid-60s. So this is actually a risky patient to take on because as you can see, she already has quite a heavy upper eyelid and almost a bit droopy eyebrows. So we have to make sure we do not inject anywhere close to her lower frontalis because this can actually make her eyelids look even more heavy and droopy. So we need to talk to our patients and tell them that we cannot do any injections in this area regardless of the lines. I also do not inject in the lateral frontalis of these patients' group, basically to have a bit more elevation in the lateral portion, and I just tend to touch up on their second week if necessary, as I did with this patient. Another patient, similar to the one before, just younger but has very heavy skin and heavy upper eyelids. Again, good results, stable results with albotoxin in the third week. For male patients, they do have a higher muscle bulk and thicker skin, but again, it's important to know about what they really desire because some do not want anyone to know that they had anything done, whereas others are actually very happy to have a more global visible effect. So this patient, for example, 41 years old, athletic patient, didn't want anything to be noticed, just wanted to look more fresh and more rested, and this was able to be achieved with 45 units. And another patient, executive patient, he didn't want, again, anyone to know that he had anything done, but he wanted to be the best version of himself. He actually also had a blepharoplasty, by the way. I did a blepharoplasty on him and also an onotoxin injection for him. He still has his lines, but he's looking a lot more better and a lot more fresher. So the final thing that I take into consideration, which I have been mentioning before as well, is the expectations. We really have to sit down and talk to our patients because some of them just want a very subtle, soft look, whereas others really want to have a more outgoing, more, I would say, out there look in regard to their toxin treatments. So it's really about what they want and what's actually suitable for them as well. Of course, everyone is not a suitable candidate. We do know that pregnancy, lactation, and infections are out of the question for doing toxin injections. And of course, unrealistic expectations is also a very important red flag to take into consideration. And if the patient is high risk for something, again, we want to steer away from that. And the adverse effects that we can come across are usually the ones that I mentioned in my previous patients. This is, of course, another topic of another webinar. But generally speaking, when you use the right technique and you choose the right toxin for the right patient, it's not that hard to steer away from these adverse effects at all. So to sum it up, no toxin is superior to the other in terms of producing amazing effects. But when we have such a nice portfolio of toxins in our hand, it's so nice to be able to cater to each patient's needs and also provide a more customized treatment in regards to what they really want and what we can achieve for them. So I'd like to finish up with one sentence that I think is basically a motto for us. It's that it all starts with a drop of neurotoxin. Many of our patients meet us for the very first time when they want to get toxins done. And being able to provide them with a good treatment of toxins is actually great at achieving their trust and also building a good foundation for a surgeon-patient relationship for many years to come. So with that, I'd like to thank you so much for listening. And I would be happy to take any questions if you have any. Dr. Sezgin, that was a fantastic talk. Thank you so much for sharing your expertise with us and with our colleagues from around the globe. Again, this is really just a wonderful pairing of lectures that really fit nicely with each other on the use of non-surgical injectables for the betterment of aesthetic patients. So we do have time for some Q&A. We do have one question in the Q&A box. And I'll actually broaden that question because the question is about dilution or even hyperdilution in some instances. Can you give us what a typical dilution would be in your hands with either one or both of those neurotoxins? And could you also comment on whether that is with preserved or non-preserved saline? Yes. So for toxins, I usually like to do for onotoxin. I'm going to mention the names because it's going to be maybe a bit easier. As I mentioned, I do not have disclosures regarding this presentation. So for Botox, I like to generally reconstitute the toxin with about 2 cc's of saline. And this is just normal, regular saline. And for Dysport, I like to use 2.5 cc's. And do you ever mix and match toxins in the same patient? So you talked about where one toxin may be indicated more so than another for certain areas that you're trying to treat. Do you mix and match? And if you do that, what do you do with that leftover toxin? Absolutely. I do mix and match actually. For example, because it really depends on the expectations of the patient. So if a patient really wants to have a very, I would say, airbrushed effect on their face with, I would say, a more demanding toxin result, I would definitely go ahead and inject the avotoxin on their face. But regarding the masseter injections, because they come for both sometimes, I go ahead and inject the patient's masseter with the avotoxin. And thankfully, I do have a good circulation of patients on a day basis. So this is not a very big problem for me. But I would say that I definitely try to go by my own algorithm. And just because I'm going to have some leftover toxin, I don't want to end up putting my head on the pillow and saying, oh god, are they going to have an asymmetric smile in a few days? Are they going to call me and this and that? So in order to just be more safe and more, I would say, believable at believing in my treatment, I just try to go with this algorithm in the most circumstances. This is a question from the audience. Do you find that some patients are more responsive to one toxin over another? Or have you found that, especially on some of your more seasoned patients, that you have a waning effect over time? In which case do you change to a different toxin? What does that look like for you? It's interesting. I can't really describe it because there is a topic of toxin resistance that we do also talk about. But I do see sometimes when I have patients who come to me year after year and I do, for example, Botox injections on them, I see that the effect is wearing off quicker. And at this point, I like to try to change it up and use the other toxin, the other alternative. And at this point, I do see that I get a better result with these patients. So because they do have different biological properties, I think that the body is sort of kind of just shaken up and we get to sort of start over with the new toxin in regards to our treatments. And especially for the seasoned patients, I think that in general, they do benefit a lot more from the Dysport injections in comparison to the Botox treatments. Last question was just from the audience. Again, a point of clarification because we did talk about dilution, but we didn't talk about hyperdilution. For accordion lines specifically or if you have other indications, is there any comment in your hands about where you may vary from your standard dilution and go to let's say a hyperdilution? What does that look like? I do. I do. I do for some things. For example, I mentioned calf slimming. For calf slimming, when I use Dysport, I dilute twice as much. So I would dilute with four cc's of saline to get a more widespread effect because we do know that increasing the dilution of the toxin is going to give us a broader action halo. I don't do it for perioral areas or intramuscular injections, but I also hyperdilute when I do sort of a Botox mesotherapy kind of thing. So when I'm doing very, very superficial sort of skin treatment kind of treatments, if that makes sense. Because if I'm doing in the muscle, I don't want it to sort of be able to just disperse everywhere. But if I'm doing it just intradermally in the skin on the face with like needling or something, then I definitely go ahead and hyperdilute it. So very last question. Speaking of the calf slimming, I've not seen that before. Have you seen any functional consequences of this or no? Thankfully, I have not. The first patient I did, again, I was very skeptical of my own treatment. This patient was very demanding that I tried for her. She was a previous patient of mine. So with everything that we talked about, as I mentioned, to be on the safe side, I did go ahead and do lots of research. I measured her skin thickness, her muscle thickness, making sure that I was injecting in the right point. And she had no problems regarding function of her gait. And she didn't mention anything. She did say once that she had a little bit of trouble the first week wearing high heels. But then she said that that just sort of went away by itself and she was very happy later on. Well, like I said at the beginning, I mean, really fantastic talk to the both of you. Dr. Shalhoub, let's have you turn your camera on as we say good evening to everybody around the world. Thank you to the both of you for really outstanding talks. For those of you, again, that have come late, this is free for everyone live. For anybody who wants to see this again on demand, go to EdNet on the plastic surgery.org website for ASPS. And for anybody who wants to become a member, please email Romy Valadez. The email address is in your chat box because the on demand portion of this is for members only. So thank you again for the both of you taking the time to share your expertise. And I hope everybody has a good rest of their day or evening. Thank you very much.

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