Hyaluron Pen

Beverly Hills
 Hyaluron Pen
Beverly Hills

Hyaluron Pen
Beverly Hills

@hyaluronpenbeverlyhills

Please note: It is the student's

responsibility to do their own research into
licensing etc. as each state has different
regulations. This is a cosmetic treatment
intended for aesthetic purposes to improve
the look of skin and makes no medical
claims therefore in many countries it can be
performed by beauticians without any
special licensing.
 INDEX
Module A: Introduction………………………………………4

Module B: History of Needle Free Injections

& Hyaluronic Products……………………………………….5

Module C: Needle Free Technology……………………….7

Module D: Cosmetic Fillers…………………………………8

Module E: The Skin…………………………………………12

Module F: Wrinkles…………………………………………20

Module G: Consultation & Preparation………………….24

Module H: Contraindications……………………………..28

Module I: Adverse Effects…………………………………29

Module J: Pre-care & Aftercare………………………..….32

Module K: The Treatment………………………………….34

Module L: FAQ………………………………………………43
 INTRODUCTION
We are very excited that you decided to join us on this exciting rejuvenation
path with the Hyaluron Pen Beverly Hills. Until recently, it was unthinkable
that hyaluronic acid products could be applied without the use of a needle.
With this seminar, you will gain the necessary knowledge and experience to
use hyaluronic acid products to rejuvenate and beautify your clients.

This seminar will give you a lot of information about the techniques and
products available today. You will learn everything you need to know from
the first contact with the client to the time they leave happy and rejuvenated.

Needle-free application of hyaluronic acid products is still not well-regulated

in most countries. We recommend you complete your own due diligence to
find out what documentation is necessary before you decide to import and
work with hyaluronic acid fillers/biorevitalizing products. Should you choose
to use the Hyaluron Pen Beverly Hills and hyaluronic acid products in such a
manner that is not in accordance with the legal regulations of your country,
EKBH Beauty shall not be held liable.

4
 HISTORY
Needle-free injection systems are primarily used in the field of medicine and
pharmacy for the application of drugs and are more commonly known as Jet
Injectors, Jet Gun Injectors, Air Guns or Pneumatic Injectors.

Jet injection was discovered in the 19th century by accident. While using
high powered grease guns, a middle-aged mechanic accidentally injected
the middle finger of his right hand while testing a jet injector on a diesel
engine. He did not see a physician for 24 hours and as a result, he lost his
finger. This accident sparked the idea of using jet injection technology for
medical use.

Jet injectors are needle-free devices that drive liquid products through a
nozzle slit, creating a narrow stream under high pressure that penetrates the
skin to deliver a drug into the intradermal, subcutaneous, or intramuscular
tissue. They were designed to reduce the frequency of needle-puncture
injuries caused by healthcare providers and to overcome the improper reuse
and other drawbacks of needles and syringes in economically developing
countries. They were widely used over 50 years in mass vaccination
programs in patients suffering from smallpox, polio, and measles. They were
also used as an alternative to needle syringes for diabetics to inject insulin.
Because of all of its advantages, it was just a matter of time before this
needle-free system found applications within the cosmetics industry.

5
Dermal fillers have been around for over 40 years but have drastically
changed over the years. Throughout history, humans have experimented
with different ways to improve the aesthetics of the face to look younger.
Injectable products can be traced all the way back to the 1890s when
physicians attempted to fill out facial defects by transplanting arm fat into the
face. The first hyaluronic acid (HA) developed as a dermal filler occurred in
1989 by Balazs (Balazs and Denlinger 1989), who understood the
biocompatibility of this class of compounds. The product was not long
lasting, but it was nevertheless the start of a revolution.

6
 TECHNOLOGY
The hyaluron pen generates enough pressure to penetrate hyaluronic acid
products into human skin. It forces liquid through its specially-designed
ampoule containing a hole capable of creating an ultra fine stream of liquid
able to penetrate the skin.

What is the difference between applying hyaluronic acid products using

needles and this needle-free system?

List of advantages of the needle-free system:

• Reduced pain
• Perfect alternative for clients with a needle phobia
• Fewer punctures
• Better product placement and distribution
• Easier handling
• Elimination of the occurrence of broken needles
• Elimination of needle disposal
• Smaller puncture point size
• No tissue damage caused by a needle

7
 COSMETIC FILLERS
Dermal fillers are used to fill out wrinkles in the skin. They can also be used
to increase lip and cheek volume.

The use of injectable fillers has become one of the most requested
treatment options to re-volumize mature skin and have gained even more
popularity with the needle-free device trend.

Basically, there is no uniformly accepted classification of fillers. Cosmetic

fillers may be grouped according to their degree of degradability, as:

• Biodegradable
• Non-biodegradable (permanent)
• Fillers with biodegradable and non-biodegradable materials combined
It is vital that you familiarize yourself with all types of fillers that exist on the
market.

BIODEGRADABLE FILLERS

Biodegradable fillers are defined as having a limited lifespan, usually

ranging from 2 to several months, or even to a couple of years. They consist
of purified dermal components from human, animal or bacterial sources.

Collagens from various sources and with specific characteristics exist. Prior to
the introduction of hyaluronic acids, collagen was the most widely used filler
and was considered the gold standard with which other dermal fillers were
compared.

8
Examples: Collagen of Bovine Origin, Collagen of Porcine Origin, Collagen
of Human Origin. As collagen may, quite often, elicit hypersensitivity,
pretesting was deemed mandatory.

After bovine collagens, the emergence of different hyaluronic acid products

revolutionized the injectable filler market for three main reasons:

• No need for skin testing

• Better durability compared to other available biodegradable fillers
• The existence of products that may cancel the effects of HA Hyaluronic
acid, which belongs to the family of glycosaminoglycans, consists of
repeated disaccharide units (Glucuronic acid and Nacetylglucosamine)

The hydrophilic properties of hyaluronic acid attract water into the

extracellular matrix and therefore increase skin smoothness.

Hyaluronic acid (our own and that contained in fillers) is gradually degraded
into the human body by the enzyme Hyaluronidase, free radicals, etc. In
order to increase the durability of the various hyaluronic acid products,
stabilization is usually obtained by cross-linking mostly with 1.4- butanediol
diglycidylether (BDDE) and divinylsulfone (DVS).

Hyaluronic acids can be derived from avian (very rare) or bacterial sources;
each product has its own, specific characteristics.

HA products of bacterial origin dominate the market. Hyaluronic acid is less

allergenic than bovine collagen. Skin testing is not recommended.

Although hyaluronic acids of human and of animal origins are identical in

structure, immunological reactions in the recipient can be caused by residual
proteins from the donor (avian or bacterial antigens) or from the cross-
linking process.

9
A combination of Hyaluronic Acid with Other Products is also available on
the market (e.g. with Dextrans - increased durability, antioxidants,
anesthetics, etc.) Hyaluronic acid fillers can be further classified as biphasic
or monophasic.

Biphasic fillers contain a range of microsphere sizes, while monophasic fillers

contain homogeneous microspheres. Expert opinions are divided in terms
of whether this type of classification is justified.

Products of non cross-linked hyaluronic acid are also available on the market.
The main differences are that they have lower concentrations of hyaluronic
acid a nd last for shorter periods of time.

These products cost less than hyaluronic acid fillers. In most cases, they are
used for the biorevitalization of the skin and are a great tool when you want
to show your clients the kinds of effects they can expect with the application
of these kinds of fillers.

Poly-1-lactid acid (PLLA) (Sculptra™) is a synthetic biodegradable material. It

has a unique collagen stimulating quality. When injected into the dermis or
subdermis, it gradually stimulates collagen formation and, in this way,
restructures the facial tissue, making it a facial volumizer. Results appear
gradually over a period of a few months.

After the three initial treatments, the results are supposed to last for up to 2
years and longer.

PLLA IS KNOWN AS A BIO-STIMULATORY DERMAL FILLER, THIS MEANS IT

STIMULATES YOUR OWN SKIN TO PRODUCE NEW COLLAGEN.

Calcium hydroxylapatite (CaHa) (Radiesse™) is made from synthetically

formed calcium phosphate pearls, which means that no animals or animal
products are used.

10
It is a biostimulatory filler of CaHA spheres suspended in an aqueous gel.
When injected, they form a foundation within a matrix that allows the local
cellular infiltration of fibroblasts and growth of natural collagen fibers.

The effect of the mixture lasts, on average, for approximately 18 months.

NON-BIODEGRADEABLE FILLERS

Injectable silicone is one of the oldest non-biodegradable injectable filler

materials used. Medical-grade silicon is a clear, oily, colorless liquid.

Although the quality of the product in terms of purity has improved

significantly in the last decades, a significant number of adverse events as
granulomatous reactions, infection, ulceration, and migration have been
reported.

Polyacrylamide (Aquamid™) is composed of water and cross-linked

polyacrylamide. It is not effective on fine wrinkles.

Polyalkylimide (Bio-Alcamid™) consists of alkylimide group networks and

water. The product was available at two different viscosities. It is no longer
available on the market because of adverse effects (inflammation, migration,
hardening, etc.)

Polymethylmethacrylate (PMMA) is a permanent filler composed of PMMA

microspheres suspended in a bovine collagen gel. When a more permanent
solution to facial wrinkles is desired, PMMA is often used instead of collagen
replacement treatment or hyaluronic treatment.

Combinations

Some fillers are a combination of non-biodegradable (permanent) and

biodegradable (temporary) materials. The purpose of the biodegradable
material is to act as a carrier and to ensure an immediate effect until the non-
biodegradable filler leads to visible effects (e.g. Polymethylmethacrylate and
Collagen (Artesense™), Hydroxyethylmethacrylate and Hyaluronic Acid).
11
 SKIN
It is very important to know important facts about the skin for
performing this treatment. The skin is the largest organ composed of
three layers, each with its own important function: the epidermis, the
dermis and the hypodermis.

EPIDERMIS

The epidermis is a thin, flat layer of skin. It protects the body from toxins,
bacteria and fluid loss. It does not contain any blood vessels.
The epidermis is always comprised of a number of layers of epithelial
cells, densely packed one on top of the other, creating this compact
layer.

The epidermis consists of 5 layers according to cell maturation:

• Stratum Basale
• Stratum Spinosum
• Stratum Granulosum
• Stratum Corneum
• Stratum Lucidum Stratum Basale
The basal layer is comprised of one row of cylindrical cells which are
constantly working (proliferation) and changing (differentiation) .
Keratinocytes are produced from these cells.

Keratinocytes are the most common types of cells of the epidermis and
produce the protein keratin, which is found in skin and hair.
Keratinocytes in the basal layer are constantly dividing. 12
Melanocytes are disbursed between the basal cells and they produce
melanin, which gives hair and skin their color and they participate in
protection from the sun. By further division of the keratinocytes, melanin
transfers to the upper layers of the epidermis where it is eliminated by
desquamation in the cornified layer. Desquamation is the natural process
of regenerating the epidermis, where the outer layers of the skin are shed in
the form of tiny flakes.

Merkel cells, which are oval-shaped, mechanoreceptor s which are located in

epidermis. These cells are found very close to the nerve endings which
register the sense of touch, and are essential for light touch sensations.

Stratum Spinosum

The spinous layer (Stratum Spinosum) contains 5-10 rows of polygonal cells
which are bridged together by desmosomes and which become flatter as
they approach the granulosa layer. Keratin filaments are produced in the
cells of this layer (protein fibers).

Cells that are found in the middle of the spinous layer, the Langerhans cells,
play a significant role in the skin's immune system. They work on detecting
foreign substances and infection.

Stratum Granulosum

The granulosa layer is comprised of 2- 5 rows of flattened cells, and their

cytoplasm is full of granules in which keratin is produced. Keratin filaments
are found in the cytoplasm of these cells.

13
Stratum Corneum

The stratum corneum or 'horny layer' is comprised of approximately 25 rows

of corneocytes which are in the form of flakes. They are keratin-filled
devitalized cells (do not have the characteristics associated with live cells) .
Therefore, the most superficial layer of the body's skin is comprised of a
layer of dead cells - the horny layer.

The cells in this layer of the epidermis are hard strips of keratin and filaggrin,
a protein that binds to keratin and has a significant role in the skins function
as a barrier. The cells are bound to lipids which form the skin's protective
barrier and assist in water retention.

The cells of the lower layer of the stratum corneum (horny layer) are
connected to each other, while the outer layer is comprised of completely
flattened cells which overlap like roof tiles, giving skin its 'stretchy'
properties. These cells gradually die off and are replaced by new cells, i.e.
the process of desquamation. Desquamation is the natural process of
regenerating the epidermis, where the outer layers of the skin are shed in
the form of tiny flakes. Desquamation may be accelerated due to sunburn,
varying types of dermatitis and eczema, allergic reactions or due to certain
medications.

Stratum Lucidum

The skin on the palms of the hands and soles of the feet includes a 5th layer,
the stratum lucidum, which is found between the stratum granulosum and
the stratum corneum and is all but invisible. This layer consists of flat cells
that are densely packed and do not differ, one from the other.

14
DERMIS

The dermis is the second and thickest layer of the three major layers of skin,
located between the epidermis (top layer) and hypodermis (lowest layer).

Both the epidermis and dermis are made up of layers of cells and tissue, but
the dermis is a lot thicker than the epidermis. The dermis is made up of
fibroblast cells that produce two proteins, collagen and elastin, that give your
skin both strength and flexibility. In addition, collagen binds water to keep
the skin hydrated.

Next to fibroblast cells and the proteins collagen and elastin, the dermis
contains nerve endings, sweat glands, oil (sebaceous) glands, hair follicles
and blood vessels.

The dermis is rich with blood vessels, however, although none penetrate the
living layer of the epidermis. The site where the dermis and the epidermis
meet is called the dermal-epidermal junction (DEJ), where the network of
blood vessels obtains it s nutrients and oxygen from, and which expands
from the dermis towards the epidermis.

Little blood vessels within the dermis act as a transport system which allow
nutrients to feed the skin. The epidermis gets its nutrients from the dermis
and oxygen by means of diffusion which is the transport of substances from
the environments with higher to environments with lower concentration.

15
LAYERS OF THE DERMIS

The dermis is divided into two layers:

Stratum Papillare - the superficial, papillary layer near the surface and lies just
below the epidermis. A relatively thin layer, comprised of a wave- like border
of connective tissue.

Stratum Reticulare - the deeper, reticular layer is a deeper and thicker layer
of the dermis and lies above the hypodermis. It is comprised of this thick,
connective tissue.

These two layers differ in the variation in type and layout of connective
tissue, number of cells, as well as the way in which nerve fibers and blood
vessels are arranged.

1. Stratum Papillare

Stratum Papillare (superficial, papillary layer of the dermis) consists of loose

connective tissue, found along the epidermis. This layer provides the
epidermis with:

• Basic support
• Nutrients
• Helps to regulate the skin's temperature
In this layer, fibers are thin and fragile, arranged at right angles towards the
surface of the skin.

It is separated from epidermis via the basal membrane and in this layer it is
possible to see numerous projections (papillae) which penetrate into the
epidermis, making the basal membrane wavy-like. This arrangement of the
papillae also makes it easier for the cells of the epidermis to get the nutrients
they need for the process of diffusion.
16
The supply of nutrients and the regulation of temperature occurs due to a
broad network of blood vessels located in this layer - the blood flowing
through the dermal papilla provides nutrients and oxygen for the cells of the
epidermis, as the epidermis lacks blood vessels.

2. Stratum Reticulare

Stratum Reticulare (deeper, reticular layer) is thicker, irregular tissue, what

distinguishes it from the papillary layer, which has a loose connective tissue.
The reticular layer is located under the papillary layer and the manner in
which it is bound to the papillary layer is indistinct .

The reticular layer is comprised of fatter and rougher fibers which run
parallel with the surface of the skin. The thick, randomly joined tissue of the
reticular layer means that there is little room between the cells. This thick
network of fat collagen and elastin fibers builds irregular bundles, which run
parallel to the surface of the skin in the direction the skin is stretched, giving
the skin elasticity and mechanical stability.

Also, it supports the other components of the skin such as hair follicles,
sweat and sebaceous glands, apocrine sweat glands, as well as lymph and
blood vessels.

The main function of the reticular layer of the dermis:

• The skin's basic supporting structure

• Increases the area of the dermis
• Contains collagen and elastin HYPODERMIS

17
HYPODERMIS

The Hypodermis is the innermost and thickest layer of skin, located directly
beneath the dermis. It is also known as the subcutaneous layer or
subcutaneous tissue. This layer is composed of fat tissue which consists of fat
cells (adipocytes) and connective tissue barriers, as well as blood and lymph
vessels and nerves.

The main function of the hypodermis is energy storage, necessary for the
normal functioning of the organism. This layer is active in regulating body
temperature by trapping in heat or cold due to the blood vessels and nerve
endings that are woven throughout it .

In addition, it connects the skin with the motion structures, muscles and
bones that are situated below the skin surface. Another function of this layer
of the skin is to amortize the mechanical traumas in order to reasonably
reduce the possibility of body injury.

Where the fat is deposited and accumulates within the hypodermis depends
on hormones,as well as genetic factos. Fat distribution changes as our bodies
mature and age. Men tend to accumulate fat in different areas (neck, ar ms,
lower back and a bdomen) than do wome n (breasts, hips, thighs and
buttocks).

18
The Hypodermis and Aging:

While the hypodermis is not visible, it can have a dramatic effect on the
appearance of the skin and the way aging impacts the skin, specifically in the
area of the face and neck. With aging, the volume of facia l fat decreases and
there is less supportive tissue to support the normal elasticity of the skin. The
facial skin begins to droop and sag resulting in a look that can be interpreted
as appearing tired. The bones and muscles of the face also lose volume.

19
 WRINKLES
As we age, the amount of substances keeping the skin smooth decreases.
These include collagen, elastin and hyaluronic acid.

As the skin ages, lines appear as unevenness and cavities increase. These
irregularities of the skin are called wrinkles. Over time, the skin becomes
thinner, dry, and loses its natural elasticity and its ability to defend it self from
external factors.

Wrinkles occur in the dermis, which is made up of proteins, such as collagen

and elastin, that give the skin strength and elasticity. As we age, the process
of dermis cell multiplication slows down, collagen fibers become weaker and
irregularities appear on the surface of the skin.

At the same time, the secretion of protective oils that hydrate the skin
decreases, which dries out the skin making it more prone to wrinkles.

With time, the internal process of aging predetermined by our genomes,

along with oxidative stress caused by external factors, for example, exposure
to sun rays, affect the appearance of the skin.

An annual decrease in collagen levels of 1% and the more disorganized

distribution of dermal tissue results in the loss of the skin's firmness and the
appearance of wrinkles.

An important factor in the formation of wrinkles is hyaluronic acid - the

binding substance that surrounds the cells, giving the skin a youthful,
smooth appearance.

20
The formation of wrinkles is affected by another process that naturally
happens in our skin. This process is called glycation, which is the binding of
sugar to skin proteins. Glycation negatively affects collagen and elastin as
glycation proteins become inflexible and lose their strength and elasticity.

Glycation additionally accelerates the aging of the skin causing the

appearance of deep wrinkles and the loss of skin tone.

What Causes Wrinkles?

Different factors of lifestyle are triggers and accelerate the oxidative stress
that is the cause of the premature aging of the skin.

If the skin is exposed to the sun without protection, UV rays may contribute
to the onset of wrinkles. Prolonged and repeated exposure damages
collagen and leads to less elastic and a weaker skin structure, where wrinkles
appear more easily.

People with lighter skin have less natural resistance to the negative effects of
UV sun radiation, causing wrinkles to appear earlier than those with darker
skin tones.

Smoking is one of the main causes of skin damage caused by free radicals.
Smoking damages the skin's structure and contributes to the formation of
wrinkles by:

• Damaging the skin's microcirculation, reducing the flow of oxygen and

nutrients
• Damaging collagen and elastin, fibers that provide the skin with support
and elasticity

21
Fast-paced lifestyle and stress are also very important causes of the
premature aging of the skin. Air pollution triggers the release of free radicals
and the acceleration of oxidative stress in the skin.

Poor nutrition also plays an important role in skin aging. The regular intake of
foods rich in protein and vitamins plays a significant role in reducing skin
aging.

A lack of sleep can also affect the appearance of wrinkles. The skin needs
sleep in order to recover and regenerate.

Hormones in the skin have the role of a messenger, they stimulate the
production of various substances, such as collagen that gives sturdiness to
young skin, as well as smoothness. During menopause, hormonal activity
decreases, and the level of collagen decreases, which leads to the
appearance of wrinkles.

The face contains 25 muscles responsible for facial expressions. Everybody

uses them in their own way, which is what makes facial expressions unique.
Mimic wrinkles appear from the use of these muscles, and after the age of
20, most often on the forehead, around the eyes and on the cheeks.

Subtle fine lines are fine lines that form on the face, parallel to one another.
They form around the eyes. They usually disappear when the skin is
stretched diagonally. These fine lines are associated with the loss of elasticity
and become more pronounced with exposure to harmful sun rays.

Wrinkle Types:

There are 5 main types of wrinkles, each with their own specific
characteristics.

22
Permanent Elastic Creases

Wrinkles usually form as the result of a type of 'creasing' of the body's skin.
As we age, these types of wrinkles become more permanent. Permanent
elastic creases usually form on the cheeks, the upper lip and the base of the
neck.

Dynamic Expression Lines

When people constantly repeat the same facial expressions that crease and
crinkle the skin (such as laughing and frowning), dynamic wrinkles form,
which may eventually become permanent. Exposure to harmful sun rays
additionally accelerates the appearance of dynamic expression lines.

Gravitational Folds

As we age, the skin loses elasticity, wrinkles form and the skin begins to sag
slightly. Gravitational folds result from gravity's impact on our body and skin
over time. These wrinkles usually form in thicker skin, where creases are
more visible. A plumper face will show fewer gravitational folds than a
thinner face.

23
 CONSULTATION &
PREPARATION
A client 's perception of their needs and our impression differs much more
than we can imagine.

One important reason for this is that clients usually look at themselves in the
mirror front-facing, while observers (including cosmeticians), examine clients
mainly at an angle.

Do take the time to educate your client about the benefits of the treatment(s)
that you believe are important to them. The first consultation is very
important, as it gives the cosmetician the opportunity to get to know the kind
of client he/she will be treating.

Sometimes it is preferable not to treat a specific client (uncompromising

client) because, whatever is done, they will not be happy with the result.

It is easier if it is explained to the client that the aging process derives from
intrinsic and extrinsic reasons. Extrinsic aging results from environmental
influences such as sun exposure, smoking and climate. Intrinsic aging is
influenced mainly by genetics.

The most important information that clients must be given is that nothing can
stop the aging process but that something can always be done to smooth
the signs of aging. The sooner they start, the less invasive and expensive
treatments will be.

To ensure safe and efficient treatment, several general and technical

requirements must be met as well as few general rules respected.

24
General Requirements:

Documentation - Thorough documentation of all treatment-related data is

highly recommended. This not only is advisable for legal and billing reasons,
but will help to improve your own performance and consequently the client's
satisfaction.

The client's chart should include all necessary information. It does not matter
if the chart is paper based or electronic. The only thing that counts is that the
information in the chart is complete and accurate (client's identification data,
gender, age, the reason for the client 's visit, history of relevant concomitant
diseases (e.g., autoimmune diseases) , present relevant drug intake (e.g.
intake of acetylsalicylic acid), and previous injections of fillers)).

Photographs - It is advisable to document the status of the client before the

treatment. If possible, photographs should be standardized. Clients should
be photographed in the upright position, before administering an
anesthetic.

The consent of each client should be thoroughly documented. Clients

should date and sign a consent form for each new filler substance.

25
Technical Requirements

Chair - For most treatments, clients should be in a relaxed, horizontal

position.

Mirror - Like the client's baseline digital photography, a mirror should be

provided to ensure that client - cosmetician communication is optimal from
the start . The cosmetician should use the mirror to ensure that the client
and cosmetician are discussing exactly the same areas to be treated and the
grade of correction desired. When using the mirror, ask the client to point to
the area where he/she wants the correction. This will reduce the risk of
misinterpretation.

Small Things - Do provide good light for result evaluation. Camera

(conventional or digital) to provide photographic documentation. Gloves
(unsterile gloves are usually sufficient). A topical, local anesthetic. Material
used to place on the client's eyes.

General Rules

Listen to the client – Clients and cosmeticians are prone to the same verbal
misunderstands as everybody else. In aesthetics, the results may be
disastrous if the cosmetician misunderstands the client. It is therefore very
important to listen to the client.

Talk about money - The client should have a clear understanding of what he/
she will have to pay for the treatment (s) . Make it clear that for most clients,
one treatment will not be enough and that subsequent treatments will be
necessary to ensure a good result. It might be helpful to include the
subsequent treatments in the first cost estimation for the client.

26
Topical Anesthetics - The skin should be cleaned before applying a topical
anesthetic cream. This will allow better entry of the topical agents. Allergic
reactions to anesthetics are rare but have been known to occur. Topical
anesthetics may decrease the visibility of fine wrinkles and cause asymmetry,
and because of this, photos should be taken before applying it.

Quantity of Filler (Do Not Inject Insufficient Amounts) - Injection of an

insufficient amount of filler will leave you with an unhappy client. Make sure
that the client understands that if he/she wants an optimal result, she/he
must make the according investment.

Quantity of Filler (Do Not Inject Too Much) - Too much filler is not a good
idea either. You do not want a client with large lumps of injectable filler that
can be seen or felt for weeks or even months.

If Something Goes Wrong - for example, the client is overcorrected or the

client has an adverse reaction to the injectable filler, be accessible and
understanding. Most lawsuits arise when the cosmetician/client relationship
is dysfunctional. Also, because of this you need to have a consent form that
must be signed by client.

27
 CONTRAINDICATIONS
Contraindications for performing the treatment are the following:

• A known hypersensitivity to hyaluronic acid products or topical anesthetics

• Active infection on the site of injection (e.g. herpes simplex) or active
lesions (e.g. psoriasis)
• Suffers of Coagulopathy (bleeding disorder) and those taking
anticoagulants
• Those who consume alcohol, aspirin and non-steroidal anti-inflammatory
drugs (NSAIDs), or herbal supplements known to affect coagulation and
hemostasis within the last 24h
• A tendency towards the development of hypertrophic scars
• The presence of autoimmune diseases (even if suffered by family
members) , persons who are on autoimmune therapy
• Pregnancy and nursing mothers
• Diabetes Mellitus (uncontrolled)
• Heart diseases
• Epilepsy
• The site of the application previously treated by similar products
(permanent, semi-permanent)
• Hepatitis and HIV infections*
• PMU, Botox**
• Chemotherapy***

*The treatment can be performed with increased caution.

** The treatment can be performed one month after the mentioned
treatments.
***The treatment can be performed 3 months after the chemotherapy.

28
 ADVERSE EFFECTS
As with absolutely all beauty treatments, there are always many things that
can go wrong. Adverse effects are rare, but still possible. If your client
experiences any of the following systems due to adverse effects that persist,
direct him/her to a physician immediately.

Adverse Effects:

1. Injection Site Reaction (swelling, pain, redness, itching, ecchymosis)

Ecchymosis is the discoloration of the skin resulting from subdermal

bleeding, typically caused by bruising. Injection site reactions normally last
three (maximum 7) days and are best treated by applying a cold pack.
Ecchymosis and edema can be minimized by stopping the intake of aspirin,
NSAID, herbal supplements known to affect coagulation and hemostasis
(Ginkgo Biloba, vitamin E, Omega-3, fish oil, ginseng, kava-kava) at least one
week prior to the treatment.

2. Hypersensitivity Reaction

Hypersensitivity reactions (HR) are immune responses that are exaggerated

or inappropriate against an antigen or allergen. In this case, direct your client
to a physician immediately.

3. Infection

Injectable fillers are also associated with infections, which can result from a
breach in skin surface integrity. The infectious agents may be bacteria l, viral
or fungal. The client should not wear makeup either 24h pre or post
treatment. Skin must be disinfected prior to treatment.

29
 Reactivation of herpes simplex infection, especially when performing lip
augmentation, is not an uncommon adverse effect and should be addressed
properly. Clients with a history of recurrent herpes simplex outbreaks should
receive prophylactic antiviral therapy. Clients with active lesions of herpes
simplex infection should postpone treatment.

Clients who develop new lesions post injection need to be started on an

appropriate antiviral regimen and appropriate oral antibiotic should a
superadded bacterial infection develop.

4. Surface Irregularities and Nodules

Should any irregularities appear, advise your client to massage the treated
area with a suitable product/medication.

5. Occlusion of the Blood Vessel

Some circumstances may result in the f iller migrating into a blood vessel or
its direct proximity, applying pressure to the blood vessel.

6. Delayed adverse effects (a few weeks/months later - Biofilms, foreign body

granuloma, dyspigmentation, scarring)

30
Extremely rarely and due to unknown factors, delayed adverse effects may
ensue, in this case it is necessary to direct your client to a physician
immediately. Biofilm is a collection of bacteria surrounded by a protective
and adhesive matrix. Biofilms use the implanted filler as a surface on which
to attach and excrete their own matrix. This matrix gives them the ability to
survive, develop and resist antibiotic treatment.

Foreign body granuloma is a chronic inflammatory reaction that entraps a

foreign body, preventing its migration. This reaction occurs because of the
inability of the immune system to enzymatically degrade or phagocytose the
foreign body. Granulomatous reactions generally have a delayed onset after
filler injections, appearing as red papules, plaques or nodules with a firm
consistency, which may result from fibrosis in late stages.

31
 PRE-CARE & AFTERCARE
You will certainly come into contact with clients who will ask you how they
can prepare for the treatment. Also, before your client leaves the salon after
the treatment, you should make sure that you have provided him/her with
the proper aftercare advice.

Pre-care Advice

• Avoid blood thinning over-the-counter medications such as Aspirin,

Ibuprofen, etc. for 1 week prior. Clients should consult their physician if
they are taking Aspirin or other medication.

• Avoid supplements that affect the blood clotting process (for example,
Ginko Biloba) for 1-week pre-treatment.

• If you have previously suffered from facial cold sores, there is a risk that the
injection could contribute to another eruption of cold sores.

• Do not drink alcoholic beverages for 24 hours prior to treatment.

• Arrive at the cosmetics salon on treatment day with a 'clean face' - washed
and makeup free.

32
Aftercare Advice

Avoid scratching or picking at or around the injection site. Itching is normal

and generally disappears within a few hours to a few days. If these symptoms
last more than 3 days, please contact your physician.

To help alleviate bruising, it is recommended to use a cold pack or products

used to reduce bruising, e.g. arnica ointment. Until the swelling and redness
have subsided, avoid intense heat in the treated area (s), e.g. sunbathing,
tanning beds, saunas, hot tubs, or hot wax, hot beverages and food (in case
of the lips). Also avoid extreme cold such as skiing or other winter sports.

Avoid drinking alcohol or partaking in strenuous exercise, as it may result in

additional bruising.

Avoid laser treatments, dermo abrasive treatments and chemical peelings

until the redness and swelling disappear. Minimize movement of the treated
area (lips - no smoking for 4h, kissing for 24h).

If there is a visible bump, you need to massage the area. Depending on the
areas treated and the product used, you may feel slight 'firmness'.
These areas will soften and settle with time (usually 1 - 2 weeks).

Sunscreen and makeup can be applied 24 h after the treatment. The client
may take pain killers to reduce any pain, as necessary.

Your client should contact his/her physician immediately in the

following cases:

1. Fever and/or chills.

2. If the area appears red, hot to the touch, and extremely irritated.
3. Severe pain or increasing pain.
4. Discolored blotches in areas not injected or blanching of injected areas.

33
 THE TREATMENT
Three varying treatments may be performed using this Technique:
smoothing the appearance of nasolabial folds, marionettes and lip volume
augmentation. It is recommended to always repeat the treatment after a few
weeks, so that deposits can be made.

Nasolabial Folds

Nasolabial folds (known as laugh lines) are one of the major areas treated by
injectable fillers.

The nasolabial fold is the groove from the corner of the nose to the outer
corner of the mouth. It is present in youth and deepens with the aging
process. The thickness of the dermis of the nasolabial fold is less than 2 mm
(1.1- 1.6 depending on gender, age, genetics, etc.)

Technique:

Once the client has been prepared for treatment, the first shot should be
positioned in the lower section of the nasolabial fold. Take into account that
the client will have a physical reaction to the first shot (the noise caused by
the piston). Make sure to inform the client in advance of the noise created by
the Hyaluron Pen.

The positions of the shots are demonstrated on the image above. The image
is simply an illustrative overview, the number of shots that will be required
depends on the length and depth of the fold. It is important to follow the
positions of the shots as follows: 1 , 2l, 3l, 4 , 1R, 2R, 3R, 4R, 5l, 6l,7l, 5R, 6R,
7R, 8l, 9l, 10l, 8R, 9R, and 10R .

34
Recommended Dosage:

• Superficial (0.5 ml of the product for both sides, max. 0.03 ml per shot)
• Moderate (1 ml of the product for both sides, max. 0.03 ml per shot)
• High (1-2 ml of the product for both sides, max. 0.04 ml per shot)
After the treatment, the area injected should be massaged until no more
nodules are felt.

Warning: Injection deep into the area near the corner of the nasal can be
perilously close to the angular artery, a branch of the facial artery. Necrosis*
of the ala nasi can be seen in that case. Because of this, the last shoot (4l or
4R) should always be about 1 cm of the ala nasi (cc finger width). If severe
pain during injection is reported and a whitish discoloration develops,
contact a physician immediately.

*Necrosis - the death of most or all of the cells in an organ or tissue due to
disease, injury, or failure of the blood supply.

Don'ts

Do not inject too laterally. If you inject too laterally, the fold might become
more visible.

Do not inject too little product. If you inject just one syringe into a client who
in fact needs two or three syringes per side, the client will not be happy
because the visible changes are not as the client would have liked them to
be.

If the client has strong marionette lines as well, do not forget to treat these
lines in the same session. Otherwise the client may end up looking quite
strange.

35
NASOLABIAL FOLDS

36
Marionettes

Marionette lines are not friendly lines. They make the face appear to be sad
or more severe. These are usually associated with deep nasolabial folds. The
groove that descends vertically from the corner of the mouth toward to the
chin. In cases when just the nasolabial fold is corrected and the marionette
lines are disregarded, the overall result may be quite a strange appearance.

Technique:

The Technique and recommended dosages for marionette lines are the
same as those for the nasolabial folds. Do not forget to massage the fillers
into place after the treatment, until no more nodules are felt.

Don’ts

• Do not inject too laterally. If you inject too laterally, the fold might become
more visible.
• Do not inject too deep. You might end up with a big lump that will remain
for a long time and will remind the client of the injection each time he/she
looks into a mirror.
• Marionette lines are an important and frequently treated region.
Overcorrection should be avoided. Repeated injections may yield better
results.
• As for the nasolabial folds, do not under treat this region. Severe
marionette lines may require 1 ml of filler per side.

37
MARIONETTES

38
Lip Volume Augmentation

One of the most requested filler treatments is that of lip rejuvenation or

augmentation. The lips are very important in social interaction. A wide
spectrum of emotions is represented by the lips, from happiness to sadness
and sorrow. They also play an important role in the expression of sensuality
and sexuality.

Frontal view - the ideal upper lip: lower lip ratio is 1:1.6. The vertical height
of the upper lip should be less than that of the lower lip. Females will often
request augmentation of the upper lip alone, without considering the
balance between the upper and lower lips. Thus, it is incumbent upon the
cosmetician to educate the client regarding the ideal ratio. 'Sausage' or
'duck' lips do not merely occur from overcorrection, but also from a poor
understanding of the delicate contours of the normal lip anatomy.

It is important when filling the lips to decide what area needs to be

augmented, or, in the other words, which technique will be performed: lip
contour or lip volume contour.

The upper and lower lips are supplied respectively by the superior and
inferior labial arteries within the submucosa. Both of these are branches of
the facial artery.

39
40
Technique:

Once the client has been prepped for treatment, take into account that the
client will have a physical reaction to the first shot (the noise caused by the
piston). Make sure to inform the client in advance of the noise created by the
Hyaluron Pen.

3c 1c 9c
2c 4c
5c 3v 1v 6c
7c 5v 2v 4v 6v 8c

11v 12v
16c 9v 20c 10v 17c
14c 7v 19c 8v 15c
12c 13c
10c 18c 11c

41
It is important to follow the positions of the shots as follows:

Lip Contour:

1UL, 1UR, 2UL, 2UR, 3UL, 3UR, 4UL, 4UR, 5U,1LL, 1LR, 2LL, 2LR, 3LL, 3LR,4LL,
4LR, and 5L

Lip Volume Contour:

1UL, 1UR, 2UL, 2UR, 3UL, 3UR, 4UL, 4UR, 5U, 1LL, 1LR, 2LL, 2LR, 3LL, 3LR,4LL,
4LR, 5L, 1MUL, 1MUR, 2MUL, 2MUR, 3MUL, 3MUR, 1MLL, 1MLR, 2MLL, 2MLR,
3MLL, 3MLR, 5LM1, and 5LM2.

Recommended dosage:

1 - 2 ml for both lips, max . 0.03 - 0.04 ml per shot. In case of the lip
asymmetry, do not forget to increase the dosage where needed.

After the treatment, the area injected should be massaged into place after
injection until you feel no more nodules are felt.

Do's

When augmenting, make sure to view the client not only from the front, but
from both sides as well.

Do educate your client about "normal lip anatomy".

Don’ts

Do not treat the upper lip only, except when client insists. The lower lip
should be in harmony with the upper lip.

42
 FAQ
Are there restrictions when it comes to using the Hyaluron Pen?

When it comes to the treatment itself, it is considered non-invasive because

it does not include the use of needles. It provides way smaller effects and
risks when it comes to damaging health. Still, all users must make sure they
can do the treatment and that there are no legal restrictions in their country.
Different countries may have different rules and regulations regarding this
treatment.

Are dermal fillers semi-permanent/permanent/non-permanent?

The client 's metabolism is one of the main factors that affect the longevity of
dermal filler treatments. Since derma l fillers are made of hyaluronic acid, a
naturally occurring substance, they are metabolized by your body. For some
clients, this process will occur more quickly than in others.

What are Hyaluronic Acid fillers?

Hyaluronic acid fillers are pretty safe because the human body produces the
exact same acid, that is composed of two sugars (Glucuronic acid and
Nacetylglucosamine). The point is simple: as the human body makes the
exact same substance, it is almost impossible for an allergic reaction to
result, or complication from the substance itself. For fillers, the substance is
produced using bacteria. Everyone knows why Hyaluronic Acid exists in the
human body (joints, eyeballs, skin). Hyaluronic Acid produced by the body
itself exists in the layers of the skin and one of its main functions is to retain
water within the tissues of the skin.

43
What happens to our own Hyaluronic Acid?

Over the years, the body itself produces less Hyaluronic Acid. This results in
poor hydration of the skin and in the deepening of wrinkles. However,
Hyaluronic Acid, as a polymer and being very hydrophilic (meaning it can
form an enormous amount of connections and it binds with water molecules,
often being able to bind up to hundreds of times its own weight) is able to
hold the extracellular matrix together very strongly, however, the ability to
retain water decreases over time.

List a few contraindications?

Known allergy/hypersensitivity to the material. Active infection near the site

of injection (e.g. her pes simplex) or active lesions (e.g. psoriasis) ; A
tendency towards the development of hypertrophic scars.

Is treatment painful?

Pain is an individual thing and varies from person to person, but yes,
treatment may be painful if an anesthetic is not applied.

How long will the effect last?

3 - 12 months according to the type of fillers that has been used,

metabolism, sports activity, etc.

When can the treatment be repeated?

When the effect is reduced or within a few weeks. This depends on the
substance used.

44
What lasts longer, injection or injection-free fillers?

This depends on the type of filler, not on the technique.

What are the main differences between needle and needle free?

The main differences are: less pain, preferred by needle phobia clients,
fewer needle punctures, easier handling, no broken needles, no needle
disposal.

45
 Hyaluron Pen
Beverly Hills

Hyaluron Pen
Beverly Hills

@hyaluronpenbeverlyhills

Please note: It is the student's

responsibility to do their own research into
licensing etc. as each state has different
regulations. This is a cosmetic treatment
intended for aesthetic purposes to improve
the look of skin and makes no medical
claims therefore in many countries it can be
performed by beauticians without any
special licensing.