Welcome everyone again. My name is Melissa Alvarez. I'm the chief operating officer of empire medical training. As you may know, Dr. Cosentino normally joins me on these webinars but today he excused himself.
This is an amazing new procedure that we want to share with all of you. It is interesting how the different type of treatments that you can perform with PDO threads. This is something new for myself personally and I'm pretty interested in the new Cat Eye Lift procedure.
Our guest speaker today is Dr. TJ Tsay, he's going to share with all of us this about this new procedure that honestly sounds extremely amazing.
I want to congratulate you because I see you expanding more and more all about your different procedures and excited to hear about the new technique today. Thank you for the great introduction.
Before starting, I just wanting to explain why there's some markings on my face that we're doing that kind of a thread there. I don't have a model so I just marked some vectors and will explain the markings which is part of the procedure.
The presentation today is a potpourri of different things, we used the cat eye brow lift to get your attention but I'm going to talk about a lot of different things and try to condense a lot of different topics. I want to condense all of these topics in the next hour lecture as well as how to reopen your practice safely and then talking about the cat eye brow lift and a few other types of thread lifts. I call it show and tell, just some really cool products and procedures that I perform in my practice. Before we begin about opening the practice safely, I just wanted to take a moment about discussing, just changing our whole mindset, going into reopening the practice.
I don't know how this COVID crisis affects all of you, but of course it has and affected me as well and shut down my practice. Instead of bitching and complaining and griping about all the negative things, I think putting ourselves in a little bit of more positive mindset will help us give out positive vibes and feelings for patients and clients.
Just starting off the day, with a sense of gratitude, doing some breathing exercises and just kind of thinking about what it is that we're grateful for. I know that the restrictions with the COVID crisis affected me negatively, but I'm sure there's some way that it affected you positively - with me it's helped me to slow down. If you can immerse yourself in that. Positivity. I think that'll really bode well in terms of how you present and how you come across when we now start to reopen our practices to our patients.
The next topic is reopening the office safely. I received these pointers from a group of high level of practice owners that really have a wealth of knowledge and they are multi-million-dollar practices. We've shared our ideas on the little things that we're going to do to help reopen our practice and give our patients the perception or feeling that they're coming to a safe place. Now, maybe some of you have heard this on other webinars or in other discussion groups and some of them may be repetitive, but maybe if you will receive new thoughts and ideas from the presentation.
If you could just get one pearl out of this webinar that you could implement in your practice, then this whole webinar will be completely worth it. Number one, we're going to be screening our patients two to three days before their appointments – we will be assessing them for if they have symptoms.
Of course, if there's something symptomatic, I want them to reschedule. If they have fever, cough, shortness of breath, myalgias or something that's really specific for COVID 19 and in the early onset for COVID 19 they will be assessed. Any travel internationally or if they're presently sick just kindly ask that you reschedule for another date or that they get checked out with their primary care practice. We're going to enforce that all patients be required to wear a mask and I think this is going to be really important for reopening.
Government, cities and states have already required this from residents and it doesn't have to be an in M95 mask. If they just wear some sort of facial covering, I believe that will be suffice. Our practices acquired COVID 19 testing kits and we have the IgM and IgG antibody kits that are distributed through Henry Schein and FDA approved for the emergency use.
These tests take about 10 minutes to do, so we're going to test every single patient either in the parking lot or right when they come into the lobby. We are going to be testing every single one of our staff and if they're treating patients they should be proven negative and they're going to wear their protective equipment and coping status the testing kits on their name tag.
I think this will give the patients a little bit more security that our staff have been tested and we're going to test them every two weeks because you never know what they're going to do when they go home or grocery shop.
Let me go over the tests, the IgM antibody is for acute infection. If someone has fever, cough, shortness of breath, and they are positive for IgM then they have an acute infection and they should be sent home right away and contact their primary care doctor, but they should not be actively in your office.
If someone has a positive IgG antibody test result, they have been exposed to it. I know a lot of friends and colleagues who've said back in February I got some weird cold and I got a bad flu and maybe I got. I don't know, so the IgG antibody will tell you if you've been exposed or if you had previous infection.
When we start reopening the economy, people that are IgG positive aren't going to show they've already developed the antibodies. Theoretically you cannot get the infection again, there's some argument about that, but in my personal belief I think if you have the IgG antibody, you are somewhat protected.
We spent last week removed, redecorating the office and we took out a bunch of chairs from the lobby waiting room. We removed the magazines, flyers, brochures, beverages and snacks or anything that's going to require a patient or client to touch something and then require us to touch it in return. It's kind of nice because the lobby now looks really open and clear and there's just one chair and we're not going to have more than one person in the lobby at a given time to enforce the social distancing. We're going to use a non-touch thermometer to measure the temperature for every staff when they come in in the morning. We're going to also use it to measure the temperatures of each patient when they come in and we've ordered an acrylic sneeze guard for the front office counter. The sneeze guard will be sitting on top of the counter and it's going to go 40 inches vertically. It's going to provide a barrier for the patient and the front office staff and there will be a little opening to use the credit card machine. I think there are a lot of practices I heard are purchasing this, it's fairly inexpensive and it's not in the thousands but a few hundred dollars.
Concerning social distancing, we are limiting the number of people in our office when we reopen. It's not going to be the same as we had a really busy practice before and would see 30 patients a day, but we're not going to have that anymore soon.
For the short time being, we're going to limit patients to half the volume and we're going to have someone in charge of flow so that patients don't cross their paths. We possibly could have two patients in the office at one time, but they will never cross paths because we're going to have someone in charge of flow and we're going to be having the patients check out in the treating room versus standing in line.
We're putting air filters with a HEPA and UBC filters and for every room, including the lobby and there's going to be left running all the time as well as continue to cleaning the areas. We have also added a COVID 19 consent, this consent is available through the American Society of Plastic Surgeons. It's a really thorough consent form and you want to revise it to fit your practice or your office, but it basically tells them that the patient has chosen to do an elective procedure. The COVID 19 risk exists out there and even though we're testing them there's still a chance that they can still get infected. We haven't seen how this may play out in court or legally but I think as a practice owner it gives me more of a peace of mind.
What are some popular procedures during or after we get out of the quarantine? While everyone is going to be wearing masks, patients are going to be focusing on areas that you can see such as the periocular region, the brow, or lashes. Either they're going to be focusing on these areas or the other alternative that patients are going to be more willing to do more aggressive procedures that require a longer downtime, like PDO thread lists or CO2 lasers, micro blading, or other invasive procedures.
The highlight of this talk is the cat eye, what this stems from is people that do makeup, especially the females that do makeup and even the makeup artists. They create an effect of the lateral canthus of the eye by using the eyeliner to draw or aligned to make their lateral canthus look like it's tilted and slanting upward.
It's a very exotic look and a lot of women are already doing this with their makeup, but the cat eye brow lift can be done using PDO Barb Threads. To lift the corner of the eye or lateral canthus of the eye, PDO Threads completely changes that lateral shape to a more lifted vertical and slanted look.
As you can see in these examples, these are all Cat Eye results using a makeup effect so you can see the effect that this is going to create. This has been around for a long, long time, right? If you look at the example on your screen and into her eyes, she's got that almond shaped eye and it almost seems like she has that cat eye effect. I think certain ethnicities look well or already have some of these features and so the reason that I drew these lines are because we're going to kind of show you how to do this thread procedure without actually doing it by the vectors on my face.
The requirements of this procedure are bi-directional pre-calculated barb threads. The thread is a barbed thread as opposed to a monofilament, smooth thread. The Barb threads are the type of threads that you want to do the lifting. Bi-directional means as opposed to a unidirectional barbed thread is where the thread has the barbs that are all facing one direction - that's unidirectional. The threads that I prefer are bi-directional, the Barbs on one side is facing one way and the other side of the thread the barbs are facing the other way.
They're actually facing each other, and so when you insert these into the face, one side of the threads are lifting and then the other side of the thread where the barbs are facing down are the anchoring. Anchoring means that once you pull the barbed thread up, the lifting part is lifting, but the anchoring is preventing the lifting part from falling back down.
It is a really different concept, the pre-calculated barbs mean that the barbed thread is already attached to a blunt tip cannula because it's less traumatic, less bruising, less hematoma. The type of barbed threads that I like to use are Mint Threads. I am a speaker and trainer for them so I like the mint brand. The threads are much more grippier and the barbs are not cut into the thread and the barbs are actually molded while being one of the thickest threads on the market.
In general, you could use any bi-directional pre-formulated barbed threads, you're going to need scissors to cut the threads, Lido with epinephrine, and you're going to need 29G-38mm barbed threads.
I drew out the vectors, these two vectors here on the tail of the brow and the side of the eye here. They're pulling in an upper lateral direction and it's going to change the shape of the lateral canthus. We use a PDO, pre-calculated thread and is a bi-directional bar thread. Traditionally with a brow list people make an entry point up top and the hairline and they go down and pull it up. I have it completely different way and is a lot more effective and gives me more consistent results every single time.
I go in reverse and you can only do this because it's a bi-directional bared thread. Once you draw it in your vectors these are going to be your entry points. You're going to insert in the entry points and you can anesthetize in path of the track of the vectors going upward. The vector design is very important, if you look at these two vectors right here, these are the vectors that I use for a traditional lateral third lift.
There are two threads that I'm going to use, two threads that are traveling parallel to each other and going straight vertical. Once you anesthetize these two areas, you want to anesthetize the inherent track, then what you do is you make an entry hole and take an 18 gauge needle and make a little porthole. Basically, you are making a little stab incision with an 18G needle, be sure it's not bleeding and then those two entry holes are going to be where you place the cannula.
We enter with a cannula, it's bi-directional so if you insert in this way so you're going to have a section of the barbed thread that's going to do the lifting and then at the distal end around the temple area in your hairline. This way you're going to have an area of the thread that's doing the anchoring, meaning it's anchored up here so that the thread doesn't fall back down.
It's completely different method of doing the Brow Lift and many people do this as it gives me more consistent results and a more dramatic effect. Once you enter into the two port holes, you're going to insert the tip of the cannular into the skin at a 30 to 45 degree angle.
Once into the subcutaneous tissue, you're going to flatten it and run it parallel to your skull and push it all the way into the hairline. You want to get it as much as you can into the hairline, you don't have to go all the way back to the occiput and you don't have to even get it into the hub.
Once you place the thread in there, you're in the subcutaneous plane so it's really good. Basically, the majority of the time with the barb threads you're going to be in the subcutaneous plane.
Once you have the thread placed there, you're going to twist the cannula and put pressure and you're going to pull the cannula out. After pulling the cannula out, you're going to have a portion of the thread that's sticking out of the skin here and we're going to grab a hold of that and you're going to pull it. Notice the Brown is going to lift like you've never seen it and it is incredible. This technique gives way more of a lift than you'd ever get with any toxins or putting fillers there and finally you are going to lift the brow like so until you get the desired effect you want.
Finally, you're going to go with a scissor and basically clip it right at the entry of the skin and the barbed threads is going to be buried underneath the skin and you can repeat for the second vector. For the cat eyebrow lift, there are two vectors; one at the corner of the eyebrow and one just above the lateral canthus angled vertical and angling upward. You're going to cut both threads and then afterwards I put smooth threads that are perpendicular to the Barb threads. And I put five smooth threads per side, the smooth threads. Why do I do that? I think it adds extra reinforcement. The smooth red stimulate collagen.
When you're putting the smooth threads there, the colonies growing around the tissue is growing around the Barb threads and it helps reinforce the Barb thread effect. The smooth threads cause some skin tightening and there is a little bit of lifting though not dramatic.
By putting the smooth threads in a perpendicular direction to the barb thread you're getting a lifting perpendicular to the placement of the smooth threads. I hope that was helpful. and again, these two vectors going straight up and are the vectors that I use for the traditional lateral brow.
What is a Cadillac Brow Lift? It's the same concept where you make two entry holes right here at the base of the brow and then you make an entry point here. You place the thread here at the entry point and you push it all the way into the scalp. I've done this live in power presentations before, so you can see the way that I did it there.
Once into the skin, you lift up the barbed thread and you cut the thread and leave it there and then you put the smooth threads there - it's the same technique.
I don't have any financial relationships with any of the following, but I would like to just talk about some really cool medical devices that I've been using lately. One of them is the called the Agnes-RF from Clearskin Institute and is a really cool device. I first saw this back in I believe 2017, it was at the Aesthetic Show and they had a really small little booth. I just walked up and was just curious - it's a focus, monopolar radio frequency device using one, two, three needles.
I know a lot of people have radiofrequency devices and they think this is like their devices. It's completely different, I have a fractional radio frequency, multiple needles, called Secret. This device is considered more focused radiofrequency - basically it is a modified Bovie and it destroys the sebaceous glands. It destroys comedones and they have a 3-needle tip that goes down to four millimeters to the subcutaneous tissue for coagulation of fat. It's semi- insulated so when you insert it into the tissue the part that's insulated is totally protecting the epidermis, whereas the tip of the needle is acts like a Bovie, coagulates and burns and destroys the fat.
During the procedure there's no pain and it's absolutely incredible. There's even a 5mm single pen needle that you put it under the eye for the fat pads and you can shrink the fat pads without having to put in fillers. You've seen these cases where someone presents with a large fat pad and the only thing you can do is put some fillers in there to help cover that. Now you can combine fillers with the Agnes treatment and reduce that fat pad significantly. There's even a three-needle tip that goes down to the SMAS layer it's used for facial tightening and face lifting result, I think is better way better than Ultherapy. You've got immediate lifting, no more than one treatment is needed with the Agnes and there is a lot less swelling compared to Kybella. I definitely get way better results per session than with Kybella.
Another really cool product that I've been playing around with for the past a year and a half to two years is called Renuva. This product is an off the shelf alternative to fat transfer - it's an allograph that is an adipose matrix containing growth factors. Their company, MTF, is a nonprofit organization. They would get tissue donors and process it.
Renuva comes in a powder, you pre-mix it and you want to place it in somewhere that fat naturally exists. You want to inject renewal where there normally is fat in it and it just makes the fat grow.
The analogy is this, if you've heard of Sculptra you inject stimulate your body to produce its own collagen. It's a college and stimulating filler where Renuva is a fat stimulating filler. It's a really interesting product that, um, again, you would only use in places that you have fat.
This renewable fat filler is used for facial atrophy, facial rejuvenation, or nasal labial fold. Replace and improve their fat pads and practitioners have used it in the hands, I use a lot for people that have had liposuction which after liposuction they can sometimes get irregularities or dimpling.
There are some providers that actually have used Renuva in combining with Sculptra and calling it Nuva Sculpt. It's a renewed Sculptra combination and practices been using that for rejuvenation for both fat as well as stimulating your own collagen so that there are long lasting results. Some even say the results with the Renuva are permanent but there are no long-term studies.
That is concludes my presentation, I talked about a lot of different items and I hope you just took away one or two pearls and that this webinar was just completely worth it for you.
Aesthetic WorkshopsAnti-Aging WorkshopsPain Management Workshops
