The Aesthetic Guide May - June 2012 : Page 1

First Injection Device Launches in U.S. Market Injectables are a prominent profi t center in most, if not all aesthetic practices, as a popular and tolerable treat-ment with minimal risk, relatively low cost and high pa-tient satisfaction. New to the U.S. market, an easy-to-use assisted injection device now offers continuous fl ow for more predictable deposition of material. It can be used with any dermal fi ller, needle or cannula, and top physi-cian injectors say it makes their job easier. continued on page 3 THE Aesthetic Awards THE Aesthetic Show 2012 Review Practice Marketing with Aesthetic TV May/June 2012 Circulation 30,000 www.miinews.com P RSRT STD U.S. POSTAGE PAID PERMIT NO. 1269 LONG BEACH, CA

First Injection Device Launches In U.S. Market

Kevin A. Wilson, Contributing Editor

Injectables are a prominent profit center in most, if not all aesthetic practices, as a popular and tolerable treatment with minimal risk, relatively low cost and high patient satisfaction. New to the U.S. market, an easy-to-use assisted injection device now offers continuous flow for more predictable deposition of material. It can be used with any dermal filler, needle or cannula, and top physician injectors say it makes their job easier. Artiste Simplifies Dermal Filler Injections for More Consistent Outcomes Artiste from Nordson Micromedics, Inc. (St. Paul, Minn.), is an automated assisted injection device providing users with adjustable, continuous flow injectability, independent of viscosity.Activated and controlled via foot pedal, the system is very easy to learn and can be used with any injectable product, using a needle or cannula of virtually any length. Pressure, driven by a CO2 cartridge, can be controlled with a simple dial. Artiste users remove the plunger and connect the syringe of material using one of a variety of adaptors available, depending on the product being used. Additionally, the system’s accessory kit includes a 3 cc syringe, allowing the sterile transfer of material if needed. By eliminating the need for thumbdriven manual injection, Artiste simplifies technique, freeing users to focus on other key aspects of treatment. EDITOR’S NOTE: In the following clinical roundtable, four prominent and experienced U.S. physician injectors share their knowledge and experience with the Artiste assisted injection device. Together they bring a wealth of expertise spanning the entire scope of aesthetic injectables. Susan H. Weinkle, M.D. President American Society for Dermatologic Surgery Affiliate Clinical Professor of Dermatology University of South Florida Tampa, FL Given how physicians may feel about the art of manually injecting, what is the rationale for using Artiste? Susan H. Weinkle, M.D. – What Artiste does is level the playing field because it optimizes product flow for anyone using it properly, and it’s very easy to use. The skill aspect is still there – I’ve seen physicians who shouldn’t be injecting regardless of how smoothly the product is delivered – but by removing the flow variable we can focus on other aspects of injecting and developing the aesthetic eye. Artiste is a straightforward device. Z. Paul Lorenc, M.D., F.A.C.S. Aesthetic Plastic Surgeon Manhattan, NY Z. Paul Lorenc, M.D., F.A.C.S. – Artiste removes the possibility of thumb fatigue, which is especially important for physicians who do a lot of injections.You hold the device like a pen or paint brush. I was lead author of a soon-to-be-published multicenter study of 52 patients injected by three different, experienced injectors, each of whom reported improved dermal filler placement accuracy. We also found that it reduced the number of injections required for the same result, providing more consistent outcomes because again, placement is more exact. Yael Halaas, M.D., F.A.C.S. Cosmetic and Plastic Surgeon New York, NY Yael Halaas, M.D., F.A.C.S. – This device does not take away the artistry of injection. The surgeon is still the master, the sculptor. There is just the physical difference of where the injection pressure comes from; the device rather than the thumb. The final outcome is still heavily dependent on the aesthetic eye of the injecting physician.As a plastic surgeon I use this device to inject not only dermal fillers, but local anesthetic as well. Smooth anesthetic injection is much more comfortable for the patient. William Philip Werschler, M.D., F.A.A.D., F.A.A.C.S. Assistant Clinical Professor of Medicine/ Dermatology University of Washington School of Medicine Seattle, WA William Philip Werschler, M.D.,F. A.A.D., F.A.A.C.S. – What people may not immediately realize is that once you can more easily manage the variable of delivering continuous injection pressure, regardless of the product or needle, a whole range of things may become possible, even for less experienced injectors. You may have shied away from certain products and long cannulas, for instance, because you found them difficult to use. With Artiste you may now have access to these, which opens doors to refining your technique, broadening your armamentarium, and perhaps improving outcomes simply by being able to offer things you couldn’t before. As an experienced injector, what initially attracted you to trying the Artiste System? Dr. Halaas – I’ve had exposure to a machine for injecting local anesthetic and I saw the improved patient comfort, so I found the idea to be very attractive. Dr. Weinkle – Although I’m not a laser user, my husband is an ophthalmologist and uses pedal controls during surgery. I had also seen this concept in Europe, so I observed the advantages and was intrigued. The device comes with two pedals, one for each side so you can easily maneuver around the patient on the table. Even though I don’t usually need that, its usefulness is obvious. Dr. Lorenc – I’m always looking at new technology to enhance my practice. I want to make it better constantly and not stagnate. For my busy injectables practice a mechanical assisted injection device was an attractive concept, and I was pleased to see that Artiste worked well. Dr. Werschler – Artiste is easy to adopt because it’s very user-friendly, and you can try anything with it, but at the end of the day it doesn’t change sharp handling, create sterility issues, limit your technique choices, or force you to use certain products. In fact it’s quite the opposite. When first using Artiste, what struck you as remarkable or noteworthy? Dr. Werschler – I have been told that I am one of the most highly experienced injectors in the world, so at first I was skeptical as to whether this system would really do much for me, but I was quickly impressed and I grew to really like Artiste. The first difference for me was that it was like holding a scalpel as opposed to holding a cleaver. Instead of trying to learn finesse with gross motor skills, you can further train the fine motor skills you already possess. Its elegance and simplicity are striking. Dr. Weinkle – What stood out to me was how easy Artiste is to use.The system is nimble, yet powerful enough (and ideal) for volumization.I bank on my hands and have a thriving, high-volume injectables practice so I can use something that facilitates the process in any way. Once you get the feel of it, Artiste is quite flexible and easy to manipulate. Dr. Halaas – Artiste is really very easy-to-use. You will need to learn to adjust the injection pressure dial to account for the variable viscosities among different dermal fillers. The area you’re injecting also influences your choice of injection pressure. Physicians know this information; they just need to learn to apply it using the dial on Artiste. Dr. Lorenc – The learning curve in my experience is after a few injections you basically have it down. It’s very easy to adapt to Artiste, I don’t see much of a difficulty. It doesn’t change the ways in which we deliver the product or our injection patterns, it just makes injection easier. Also, many physicians are familiar with the concept of the foot pedal from their use of lasers or other instruments, so that doesn’t present anything novel to adapt to. What are the physician benefits in using the Artiste System? Dr. Halaas – Patient comfort is a big thing in my office and I have people come from long distances because I inject comfortably. To me, the ability to inject consistently and with less reported discomfort is part of what makes my practice successful. Artiste can only improve this. Dr. Lorenc – In our study we injected one side of each face manually and the other using Artiste, with the endpoint being optimal cosmetic result, as judged by our experienced physician injector investigators.A major benefit I saw at my site was that we used significantly less dermal filler material to obtain the same cosmetic outcome.I can’t say for sure what caused that, but I assume it’s because placement is more accurate and the flow of material is manageable and consistent. Also, since you can hold the syringe like a pen you can inject into the supraperiosteal plane and simply withdraw the needle or cannula and move to the subcutaneous or deep dermis easily. This is not so easy using the manual technique. Dr. Werschler – Although at our study site we did not note significant reductions in material, a benefit I noticed right away is that Artiste works the same regardless of the product, syringe or needle. There is a range of needles and cannulas of different lengths and gauges that we can use based more on the effect – using the best tool for the job – rather than product viscosity and how difficult it may be to inject, because Artiste makes the pressure variable easily manageable. Dr. Weinkle – Additionally, for me, it takes the pressure off of my thumb joint and reduces hand fatigue considerably.I don’t care how much experience you have, if you inject all afternoon on a regular basis your hand’s going to hurt. Women tend to have little hands, and I’ve been injecting for 30 years. This really helps. What are the patient benefits in using the Artiste System? Dr. Werschler – Patients tend to perceive the outcome in a few different ways: pain and discomfort of treatment versus the outcome, the side effects profile and the perceived quality of the result itself.My opinion is that Artiste minimizes issues related to smooth, even delivery of the product, which could positively affect perception from any of those standpoints. Further study will illuminate this but it’s fairly obvious. Dr. Lorenc – I see product being more efficiently and smoothly delivered to achieve the optimal aesthetic outcome. That’s the benefit to patients. Dr. Weinkle – Experienced patients have told me that they have less discomfort with the smoother injections by Artiste, but that’s anecdotal.We need a study to really investigate that before we make major claims, but it stands to reason given what we know about discomfort associated with injection. They certainly seem impressed by the technology. Dr. Halaas – I’m especially curious to see how Artiste affects bruising and swelling, given the results of the study. Everyone will experience some degree of bruising and swelling, but a subset of patients tend to swell to a much greater degree, so I want to see what we learn about this as we gain experience with Artiste. Please elaborate on the benefits of continuous flow and syringe positioning during injection.How does Artiste facilitate this, and what impact does it have on results? Dr. Lorenc – When injecting manually you must first reach extrusion force until you reach the yield point, where force is sufficient to move the material. This creates a small bolus of dermal filler. Then we drop to the steady and smooth delivery we’re looking for. Each time we start and stop, this occurs. With Artiste, we do not see this. The mechanical, gas-operated injection gives us smooth and uniform product placement that I do not think the human hand can match. Dr. Halaas – By taking the human element out of injection pressure and consistency of flow, we can further develop grace and elegance in the placement aspects of our technique. Dr. Weinkle – Scientific study has associated reduced bruising and trauma with a more even, continuous injection. That’s a plus for everyone. More research will be required before we go into how much we improve results over manual injection, but it’s definitely not worse. Dr. Werschler – You can massage out minor defects when injecting, and more experienced injectors have less trouble with the inevitable issue of bolus-line that defines less continuous flow. The novice or intermediate injector, however, will reap even more benefits because better tools not only make the job easier, they help you improve technique more rapidly. The high gospel of good outcomes in dermal filler injection technique is even product delivery. That’s the variable we work on repeatedly in terms of training. How might Artiste positively impact the use of different dermal filler products? Dr. Weinkle – It doesn’t really depend on dermal filler characteristics at all, and that’s the beauty of Artiste. It doesn’t matter what type of injectable you use, you simply modulate the injection pressure with the dial and you can get smooth, even, continuous flow of product every time without fail. Dr. Lorenc – The beauty of this particular system is that even if there is a syringe that doesn’t fit the cartridge, you can transfer the material to a 3 cc syringe that does fit, using the accessory kit. I’ve done this with Radiesse from Merz (San Mateo, Calif.) Because the syringe has a curved flange. Again, it’s adaptable, and not a problem because I often mix dermal fillers with lidocaine anyway. Dr. Werschler – I think the community understands that there are approved products out there, and more in development, that have not been launched simply because despite their potential benefits they’re not practical to inject for one reason or another. Artiste can change this since it takes that manual-pressure- based delivery variable out of the equation and you can use any syringe, needle or cannula. I’m excited to see what products may find a home or receive new life over the coming years because of this. Dr. Halaas – Once you’ve figured out how to properly modulate pressure with the dial, it’s easier to appreciate the way the consistencies of different dermal filler products can affect treatment positively, and give you more treatment options to consider. What other pearls of wisdom would you like to share with physicians who have or who are interested in adopting Artiste into their practice? Dr. Weinkle – Before you get too deep into this train your ancillary staff to set everything up beforehand so you don’t have to do anything but walk in and begin injecting.It’s a more efficient use of your time. Dr. Werschler – As a trainer, I rely on the old adage, “Start low and go slow.” Try it on paper with different products and pressures, and see what happens. You’ll catch on very quickly. Dr. Halaas – Start slowly and step it up as you grow more comfortable. Physicians may be used to injecting a certain way at a certain speed, but give yourself a chance to adjust. Then you’ll find your own comfort zone with different pressures depending on the product, desired injection rate and the area being injected. I have two go-to speeds, one slower for finesse work and one faster for volumization.Everyone will have their own way of doing it, and Artiste allows us that latitude. Dr. Lorenc – Enjoy how Artiste lets you concentrate on the placement of the dermal filler, refining where you place it instead of how you place it. Any final thoughts that you’d like to add? Dr. Lorenc – I’m eager to see if they further develop this technology for injecting fat in a predictable and uniform way. Dr. Halaas – It will be interesting to see how the technology develops for injecting fat. I haven’t done it but I’m curious to see that explored. Dr. Werschler – To reiterate, I think that given the direction the market is headed, Artiste will find a niche since it’s so adaptable to new products, techniques, cannulas and needles. This is an advantage, beyond the fact that you reduce injection trauma and injector fatigue as well. Dr. Weinkle – The question will be this: do the advantages seen with Artiste, which are numerous, justify the cost of the device and associated disposables? If physicians believe it is, I think this will have a serious impact in almost any practice, except maybe the lowest volume injectables practices. Nordson has done a nice job of continually evolving this product, especially with respect to developing syringe adaptors for the variety of injectables out there. The adaptor limitation is offset by the fact that you can transplant product to a generic syringe and maintain sterility. It’s in the company’s favor to pay close attention to the needs of injectors and patients as they move forward.The future of this is even more exciting; we’re injecting into more areas now, on a variety of planes, using a wider range of materials. Artiste will allow for consistent flow and precision implantation regardless of those variables. Disclosures: Both Z. Paul Lorenc, M.D.,F. A.C.S., and Yael Halaas, M.D.,F. A.C.S., are paid consultants of Nordson Micromedics. Dr. Lorenc and William Philip Werschler, M.D., F.A.A.D., F.A.A.C.S., were clinical investigators in a study funded by Nordson Micromedics. Susan H. Weinkle,M. D. has no financial disclosures.

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