Help patients put their best face forward



■ Understanding the skin
The skin is the largest organ of the body. Proper knowledge of the skin’s structure helps practitioners understand how to maintain smoothness and suppleness and how dermal
fillers can work properly. There are three main layers of skin: epidermis, dermis, and subcutaneous tissue . Although they work together, each is responsible for particular functions. The top layer is the epidermis. It is the thinnest of the three layers and works as the main barrier to the body. This surface is subjected to daily exposure from the sun, weather, bacterial and viral infections, trauma, and the general stress of interacting with the environment. The epidermis contains melanin that defines skin color and sheds old keratin. It can become dry and scaly, and produce papules and macules or benign brown moles, red spots, or skin tags that patients seek to remedy whether by purchasing over-the-counter
products or consulting a healthcare practitioner for advice. The second layer is the dermis. Composed of blood vessels and nerves, it is mostly a sea of collagen, a durable protein that supports the epidermis.
Collagen gives skin a smooth, supple, and elastic feel depending on the health, age, and thickness of the layer. The term “collagen” is used loosely, as there are nearly a dozen types of collagen in the
dermal matrix, all working together to provide resilience and stability. The dermis is also the cornerstone of the cosmetic industry: manipulating the dermal layer is the key to younger-looking skin.
The final layer is the subcutaneous tissue, which stores fat. With age, however, its volume can decrease in the arms, legs, and face, while increasing in the abdomen in men, and in the thighs and buttocks in women.

■ Injection technique
Injections are generally made by five recognized methods:
straightforward 90-degree depot or bolus injections; serial punctures of multiple drops placed along the length of a wrinkle or fold; cross-hatching, which treats a frown line from opposing sides; linear threading, in which the full length of the needle is inserted and the filler injected while
pulling the needle backward so the filler is released; or fanning, which requires a single insertion while the filler is released by a pivot and swivel motion to the left and right. The NP should exercise a “treat, wait, and assess” approach to determine whether further injections are warranted.

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