How to Respond to a VO Case: Hosted by Dr John Holbrook

 This is an educational webinar transcription and is designed and intended for the education of Healthcare Professionals only

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Alright, we might kick it off.

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Is not bad. It's not too big.

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And as we recorded and people end up seeing it,

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but it's good if it's, we, it might actually be small enough

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that if you guys have questions,

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you can just shut it out there.

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I will keep the chat open as well.

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Um, and I'll try and get, get to the questions.

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I don't wanna belabor the point too much or the,

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or the, the, the, the, the webinar too much.

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Um, so we'll go through some stuff.

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Hopefully it's an interesting case.

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It's really kind of one case

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and the case represents a lot of principles, uh,

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on management of these things that I've,

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uh, I've learned through the years.

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Volume's low. Is volume low for everybody

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or is it just, am I speaking too

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low? Can everyone hear me?

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Yeah, you good? Fine. I can hear you fine.

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Maybe, maybe sharing's good. Maybe it's on your end.

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Um, okay, so let's, let's kick it off.

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So we'll talk about vascular occlusions generally was

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June, 2024.

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All righty. So, and this is,

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I've recycled a couple slides from, from previous, uh,

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but any guesses as to roughly the incident in incidences,

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excuse me, the incidences of vascular occlusions.

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This is sort of within fresh 1000,

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but it actually, so I appreciate that's a figure

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that John Delaney sites, um, this is, uh,

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both within fresh, but also then, um, correlates well

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with some studies that have been done, um, more broadly.

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There's a study from some dermatologists in the US and,

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and the figure that they cite there is about one 6,000.

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That's roughly what we see as well.

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So the, I think the, the one in hundred thousand figure

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that John Delaney cites is really with any sort

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of long-term sequelae, any, um,

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necrosis or that kind of thing.

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Thankfully we have not had any occlusions with any,

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any long-term sequelae,

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but roughly, so that one in 10,000, figure one in 10,000,

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maybe a little more, slightly more common than that,

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but, you know, one in 5,000,

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one in 10,000, somewhere in there.

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Um, alright. And the safe areas to inject.

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Any, any feelings

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Safe to Inject cheeks, chins, temples, lips,

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anywhere? Yeah, there

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Is no, nothing Safe.

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Appreciate. It's a little bit of a trick question

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and it's a me on my, on my, uh, Sam, you were,

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you would've heard me at, uh,

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anatomy from injectors a little bit on my soapbox of like,

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I don't like to use, I won't use the term safe when

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injecting, uh, it's everywhere is risky.

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It's really just level of danger.

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And that's true for, uh, needles and cannulas.

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Cannulas are probably slightly less dangerous,

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but it actually depends on how you use them.

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And I've managed multiple occlusions from cannulas,

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including 22 gauge cannulas.

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So just 'cause you've got a cannula doesn't necessarily mean

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that like, like bad things can happen.

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They can happen. And, and, and so it's just good.

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It's always good to remember that I try

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and just remember

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that bad things can happen every time I pick up a syringe.

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Like this might go wrong.

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So just having that I think in the back

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of your mind is really helpful.

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Um, okay, so as I mentioned,

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there's no safe, just degrees of danger.

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Um, this I give credit to to Greg Goodman and Mike Clay.

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I dunno Mike's on this or not,

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but, um, I think a lot of it started with,

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with m and others as well.

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But just to continue to move the tip

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of your needle or your cannula.

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So we'll talk about a, principally about one case,

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but basically, um, I don't know if it's every,

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but it's virtually every really bad icl.

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Not every, almost every really bad occlusion I've managed

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has been needle to bone.

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So static needle. And if you're unlucky enough that,

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that the aperture of your needle is sitting in the lumen

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of an artery and you give a push

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and a bolus, the arteries aren't that big.

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Thumbs up. Um, the arteries aren't that big

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and it's easy to fill 'em up.

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Um, and then you find yourself in, in a bit of hurt.

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And so continuing to always move the tip.

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Um, I think it's pretty good. Taylor.

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I think your camera's on

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and you're like, uh, I can see like

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the shower just an FYI, um,

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before something embarrassing happens.

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Uh, nothing that none of us haven't seen anyway.

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Um, anyway, so just keep moving, moving the needle.

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W your needle, w your cannula, both of them.

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You'll, and, and you're less likely

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to then deliver a large bolus into an artery

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and those large boluses into an artery.

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It doesn't take a lot, uh, to then fill them up

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and you fill up trees

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and you can find yourself in some trouble as mentioned.

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So one patients, uh, patient was happy for images being used

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for teaching, but please don't show them outside

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of watching this, this all ends happily.

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And this was as are most vos really a real team effort.

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So it's good to keep that in mind.

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These are three different ones, so chin,

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but be careful when you put it in the chin.

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So we've got three different, um,

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injections of filler in the chin, uh, all

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of which then, um, uh,

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resulted in not only a, a vascular occlusion,

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vascular occlusion of the tissues in the chin,

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and then the submentum as well,

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but also that involve the tongue.

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So we'll specifically talk about the details of one,

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but it's worth noting this first one that you can see, the,

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the injection was on the left side of the chin,

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the contralateral side of the tongue that was involved

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and some of the teeth on the contralateral side as well.

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In the middle one, it was, uh, when the occlusion occurred,

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it was on the left side of the chin with a small bolus.

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And you can see the left side of the tongue there involved.

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And then the one in the, this case on the right,

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which is the case that we'll discuss a little bit midline,

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uh, injection needle to bone bolus was given.

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And then you can, there you can see the right side

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of the tongue is, um, is ischemic.

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So just

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'cause it's on, it's one of the many takeaways

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that I hope I'll review at the end is the vessels in our

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bodies, and particularly in our face, are connected, right?

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There are lots of anastomosis.

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Um, and,

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and so the chin, and we'll go through some of the anatomy.

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It seems like it's maybe a bit far from the tongue, um,

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but in fact it's not that far.

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And so, you know, that's the, obviously the, the, the,

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the devastating, uh, occlusion that everybody fears would be

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for, uh, a blindness in the eye

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and the central retinal artery.

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And, and the reason that we then, you know, none

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of the doctors will allow for filler in the nose,

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the glabella or the forehead, is

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that it would be devastating.

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And, and, and the upside, uh,

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is really just not worth the risk.

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But because these vessels are all, they're all connected.

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Um, okay, so as mentioned, needle to bone midline.

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Now for what it's worth, although, um, not wildly important,

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but this actually, this case wasn't one from,

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wasn't from one of the nurses.

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It was actually referred to me through ame.

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Um, and then like two weeks later we had two,

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um, occlusions of the chin

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that both involved the tongue on the same day.

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It was crazy. One was in Brisbane,

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one was in Melbourne, like at the same time.

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It was crazy. So, um,

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but you can see, so needle to bone, bolus midline and,

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and this is what you're then presented with, right?

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So you see the tongue right side is ischemic, that is,

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um, not pink.

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And hopefully you can appreciate there, uh,

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underneath the tongue as well that the, it's right,

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it's quite, uh, violations maybe is the right word,

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but it's a bit purple or it's got a nice pink

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color, uh, under the tongue.

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So the question is what do you do?

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You can type it in, you can answer,

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but what, like, let's say you're inject, inject a chin

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and that happens.

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What do you do? Well first,

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Let you know.

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Thank you. And the reason that that's a really important,

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uh, point is there have been a couple

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occlusions where I think, you know,

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nurse was a bit overwhelmed, some of these mics on,

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I'm getting some heavy feedback there, but,

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and just sort of like forgot everything and just,

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and didn't call and then in fact, even like,

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sent the patient home and the patient had

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to be brought back in, in one particular case

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and we had to bring the patient back in

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and it wasn't appropriately dealt with.

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And so, um, first and foremost is please call me or Katie

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or Brandon or the doctor who spoke with,

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but that's, that's thing number one to do.

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Thing number two is don't panic, actually,

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you have time even in a pretty rough case like this.

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And we'll go through it a little bit, uh,

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in terms of the timeline.

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And then thing number three is

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you grab your highlights, right?

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So I mean that's, and,

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and you guys mentioned all those things in the chat

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and that's, that's totally right.

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So don't panic, you actually have time.

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There's lots of time to, um, to manage occlusions.

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A brief point about lidocaine

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that's quite relevant in this case.

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But, um, please have 1% lidocaine.

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I appreciate that two is greater than one,

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but it doesn't necessarily mean

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that 2% lidocaine is better than 1%.

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Um, and because you can quickly, particularly with 2%,

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you can hit cardiotoxic limits on your, um, lidocaine,

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you can stop your patient's heart, which is a problem.

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And that was, uh, an issue in this case.

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We'll talk about it briefly. So, um, this shows up

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and so the, the, just a bit of the, the background

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around the case, so midline injection knee to the bone

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bolus, um, immediate onset

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of pain and discoloration, uh,

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intense pain in the pharynx.

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And, and the patient described some dysphagia,

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so really struggling to swallow 'cause of the pain.

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Described pain also, uh, right ear

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talking about sort of back of her jaw ear pain.

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And so then the injector, uh, prior to seeing me

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and they ended up, um, calling Amma

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and that's how it was then referred to me.

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Used, um, seven vials of 15 honeys of, of hilas injected in,

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in various dilutions through, um, the chin

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and the cementum and the tongue.

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The, um,

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so the patient came in, I saw the patient, um,

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the injector came along, it was great.

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And before, you know, took a good history, good examination,

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pretty exquisite amounts of pain.

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I'm, that's a good question, Sam, we'll get that.

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And, and I said, um, okay, great.

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You know, you've used dilution, how you,

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what have you used as the diluting?

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We've used 2% lidocaine.

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Okay, how much lidocaine have we used?

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Does anyone know what the cardiotoxic limits

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of lidocaine are?

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The 25 mils, 30 mils.

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So we don't talk about in

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mils, it's actually a weight-based.

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Yeah, it's,

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I think it's 3.5 milligrams without adrenaline

250
00:11:59.755 --> 00:12:01.675
and seven milligrams with adrenaline.

251
00:12:02.085 --> 00:12:03.755
Thank you Brandon. That is correct.

252
00:12:04.695 --> 00:12:08.115
Um, so 3.5 milligrams, uh, without adrenaline.

253
00:12:08.115 --> 00:12:12.075
So you essentially can double your dose, um,

254
00:12:13.695 --> 00:12:15.945
with adrenaline versus without adrenaline.

255
00:12:17.855 --> 00:12:21.915
The reason for not using, like we were at, so then, and,

256
00:12:22.055 --> 00:12:25.555
and I can't remember, but in a small individual and,

257
00:12:25.555 --> 00:12:26.635
and most of our patients are,

258
00:12:27.655 --> 00:12:29.315
or many of our patients I suppose are

259
00:12:29.315 --> 00:12:30.715
relatively small women, right?

260
00:12:30.715 --> 00:12:35.195
Like you get a, my wife is tiny, she weighs like 50 kilos.

261
00:12:35.895 --> 00:12:40.865
Um, YI could stop her heart with, it's just a few vials

262
00:12:40.865 --> 00:12:42.065
of 2% lidocaine.

263
00:12:43.245 --> 00:12:45.005
Um, right?

264
00:12:45.065 --> 00:12:47.445
So five mils at 11, um,

265
00:12:49.425 --> 00:12:51.445
10 milligrams in it at 3.5.

266
00:12:51.515 --> 00:12:53.485
It's like three vials in toast, right?

267
00:12:53.555 --> 00:12:56.645
Like, so it doesn't take a lot.

268
00:12:57.345 --> 00:12:58.765
You could double that with 1%.

269
00:12:59.265 --> 00:13:02.925
So just a bit of a like encouragement. Don't use 2%, use 1%.

270
00:13:03.265 --> 00:13:05.645
You can dilute down 2% if you haven't, but, um,

271
00:13:06.305 --> 00:13:08.125
but really one percent's better.

272
00:13:09.505 --> 00:13:13.395
So, uh,

273
00:13:14.495 --> 00:13:17.765
that's our, this is, and let's,

274
00:13:17.765 --> 00:13:19.805
before we continue about that, then what are the, you know,

275
00:13:20.735 --> 00:13:23.505
what are the signs and symptoms then of, um,

276
00:13:24.845 --> 00:13:26.105
to look for in avascular lesion?

277
00:13:27.425 --> 00:13:29.445
And we can use this as a bit of a model and,

278
00:13:29.505 --> 00:13:30.725
and I mentioned some of them,

279
00:13:30.785 --> 00:13:32.885
but just welcome to type it in and you can

280
00:13:33.315 --> 00:13:37.245
Show that pain discoloration, blanching, not blanching.

281
00:13:38.545 --> 00:13:39.725
You can have some blanching,

282
00:13:39.725 --> 00:13:41.005
but yeah, pain, pain is a good one.

283
00:13:41.105 --> 00:13:44.765
Are all occlusions painful? No, no.

284
00:13:44.825 --> 00:13:46.325
So probably about half of 'em are painless.

285
00:13:47.025 --> 00:13:51.045
Um, so, but, but pain can be a very useful sign.

286
00:13:52.185 --> 00:13:54.085
But the absence of pain doesn't necessarily mean

287
00:13:54.085 --> 00:13:55.325
it's not a vascular occlusion.

288
00:13:55.625 --> 00:14:00.205
And in fact, some occlusions, this one, um, was not,

289
00:14:00.305 --> 00:14:01.765
it didn't take so long to manage.

290
00:14:01.765 --> 00:14:04.165
Thankfully some of them take, you know, it's,

291
00:14:04.165 --> 00:14:05.965
it's a process over a week almost

292
00:14:05.965 --> 00:14:07.605
before you fully resolve that occlusion.

293
00:14:07.625 --> 00:14:09.805
And pain can be a very useful sign to help

294
00:14:10.025 --> 00:14:12.205
and identify where

295
00:14:12.745 --> 00:14:14.365
you're winning and where you're not winning.

296
00:14:14.665 --> 00:14:17.365
So pain discoloration, right?

297
00:14:17.585 --> 00:14:19.565
Um, palor changes in the color.

298
00:14:19.645 --> 00:14:22.765
I often get like this, um, reticulated pattern,

299
00:14:22.865 --> 00:14:25.245
and that's, that's just, uh, the way

300
00:14:25.715 --> 00:14:29.285
that the capillary beds are in terms of the,

301
00:14:29.285 --> 00:14:30.485
the way they sit in our skin in.

302
00:14:30.485 --> 00:14:34.565
So this particulated pattern, um, sluggish capillary refill,

303
00:14:34.935 --> 00:14:39.325
again, a normal cap refill doesn't necessarily mean

304
00:14:39.325 --> 00:14:40.725
that it's not an occlusion as well,

305
00:14:41.125 --> 00:14:44.925
although we tend to see a sluggish cre refill.

306
00:14:45.745 --> 00:14:49.205
Um, and then in, in a more sort of subacute that's acute

307
00:14:49.205 --> 00:14:51.045
and the subacute, right, you get break breakdown

308
00:14:51.085 --> 00:14:52.405
of tissues or necrosis.

309
00:14:52.405 --> 00:14:55.485
So you'll see formation of vesicles that often,

310
00:14:55.485 --> 00:14:58.445
depending on the degree of occlusion, the degree of ischemia

311
00:14:58.445 --> 00:15:00.685
to those tissues often won't see till day two

312
00:15:00.705 --> 00:15:02.965
or three post vascular occlusion.

313
00:15:03.345 --> 00:15:05.925
So you, these little pimples that form on the skin, the

314
00:15:06.725 --> 00:15:09.125
presence of those pimples doesn't necessarily mean

315
00:15:09.125 --> 00:15:10.765
that you've, in fact, it doesn't mean

316
00:15:10.765 --> 00:15:11.765
that you've lost right?

317
00:15:11.865 --> 00:15:13.285
It, but it does mean that, that

318
00:15:13.285 --> 00:15:15.525
that tissue is ischemic and you get some necrosis.

319
00:15:16.385 --> 00:15:18.445
So if you see those, um,

320
00:15:19.025 --> 00:15:20.405
it just means you need more highlights.

321
00:15:20.665 --> 00:15:23.365
Um, and you, and it's a good, it helps to localize

322
00:15:23.365 --> 00:15:25.245
that well, you know, that there's the tissue

323
00:15:25.245 --> 00:15:27.725
that's not good enough, um, blood and,

324
00:15:27.825 --> 00:15:29.005
and and enough oxygen.

325
00:15:29.025 --> 00:15:31.405
And so if we can then use that as a bit of a guide of

326
00:15:31.405 --> 00:15:33.445
where we inject, um, high,

327
00:15:36.575 --> 00:15:39.355
sorry, somebody said something.

328
00:15:39.355 --> 00:15:42.915
Maybe you're not muted. Um, maybe Deb, Deb, Deb,

329
00:15:42.995 --> 00:15:44.635
I think maybe you're not muted and maybe you said something.

330
00:15:45.375 --> 00:15:49.625
Um, uh,

331
00:15:50.165 --> 00:15:53.105
so, so increases in pain or changes in pain

332
00:15:53.105 --> 00:15:56.025
and then change in, changes in, in color, uh,

333
00:15:56.495 --> 00:15:57.865
over, over days.

334
00:15:57.865 --> 00:16:01.425
Sometimes you, it, you may not notice the, those

335
00:16:02.075 --> 00:16:03.505
color changes, but in fact,

336
00:16:03.685 --> 00:16:06.545
the following day it then really kind of presents

337
00:16:06.565 --> 00:16:08.185
as like it declares itself, right?

338
00:16:08.185 --> 00:16:10.185
This, this occlusion, these, these skin changes.

339
00:16:12.125 --> 00:16:14.825
So, so let's just briefly talk a little bit about some

340
00:16:14.825 --> 00:16:16.305
of the anatomy credit to Dr.

341
00:16:16.435 --> 00:16:19.745
Levon. If, um, I don't know if any of you know Dr.

342
00:16:19.845 --> 00:16:23.495
lvo, but he makes some awesome, um, uh,

343
00:16:23.495 --> 00:16:25.375
just some awesome medical, um, illustrations,

344
00:16:26.645 --> 00:16:27.735
some really great stuff.

345
00:16:28.035 --> 00:16:30.375
Uh, it was really helpful in our space.

346
00:16:30.995 --> 00:16:32.215
Um, and then asaps as well.

347
00:16:32.235 --> 00:16:36.015
So he, uh, uh, donated these, um, these illustrations to,

348
00:16:36.195 --> 00:16:37.495
to asaps for their use.

349
00:16:38.195 --> 00:16:42.665
Um, so if we just have a look at, at, you know, you,

350
00:16:42.765 --> 00:16:44.425
if we consider that, that case, right?

351
00:16:44.435 --> 00:16:45.465
We've, I injected the chin.

352
00:16:45.465 --> 00:16:49.385
So how do you get from the chin to the tongue

353
00:16:50.845 --> 00:16:51.865
and how do you get from the chin

354
00:16:51.865 --> 00:16:53.185
to the contralateral side of the tongue?

355
00:16:53.645 --> 00:16:56.065
And how do you get to the chin, to the teeth, right?

356
00:16:56.125 --> 00:16:57.465
So the, the teeth are supplied

357
00:16:57.465 --> 00:17:00.185
by the alveolar artery which runs inside

358
00:17:00.185 --> 00:17:01.705
of the ramus of your mandible.

359
00:17:01.705 --> 00:17:03.465
Like how, how, how do we do that?

360
00:17:04.605 --> 00:17:06.905
Um, and so just to orient, right,

361
00:17:06.905 --> 00:17:09.425
we've got the common carotid artery.

362
00:17:09.425 --> 00:17:10.745
You've got your internal carotid artery,

363
00:17:10.745 --> 00:17:15.475
your external carotid artery, um, facial artery here,

364
00:17:15.775 --> 00:17:18.155
uh, lingual artery, um, the deep lingual

365
00:17:18.155 --> 00:17:19.475
and superficial lingual artery.

366
00:17:19.475 --> 00:17:22.475
And then the, um, submental artery, you've got, uh,

367
00:17:22.475 --> 00:17:24.675
submental artery comes up, you get branches

368
00:17:24.675 --> 00:17:26.875
and those often one SMOs with your mental art,

369
00:17:26.875 --> 00:17:28.315
which comes outta the mental foramen.

370
00:17:29.345 --> 00:17:32.915
Um, and so if you get a needle,

371
00:17:32.975 --> 00:17:35.155
and as mentioned earlier, right, that aperture of

372
00:17:35.155 --> 00:17:38.675
that needle is in the vessel, you're unlucky, you, uh,

373
00:17:38.675 --> 00:17:42.125
you give it a push, you can,

374
00:17:42.305 --> 00:17:44.405
and this is, this isn't as such.

375
00:17:44.625 --> 00:17:47.485
The only way and the difficult thing is right, we'll, never,

376
00:17:47.485 --> 00:17:49.925
like, it'll be very difficult to, you couldn't,

377
00:17:49.945 --> 00:17:51.125
you couldn't do this if you tried.

378
00:17:51.465 --> 00:17:54.085
Um, so we're, we're trying to recreate things, um,

379
00:17:54.775 --> 00:17:56.325
based on going back,

380
00:17:56.385 --> 00:18:00.425
but you know, you get the flow in your face

381
00:18:00.425 --> 00:18:02.985
because there are all these anastomosis is not universally

382
00:18:02.985 --> 00:18:04.345
in one direction, right?

383
00:18:04.485 --> 00:18:07.265
And if you overcome the, a certain level of pressure,

384
00:18:07.845 --> 00:18:11.185
you can get retrograde and then flow that will go back,

385
00:18:11.245 --> 00:18:13.745
and then it will go forward once the pressure of,

386
00:18:13.925 --> 00:18:15.305
of the injection has come off.

387
00:18:15.365 --> 00:18:17.825
And so if we use this as an example, right?

388
00:18:18.605 --> 00:18:22.105
Uh, either potentially could inject directly into the

389
00:18:22.105 --> 00:18:24.745
submental artery that has then come up on the chin

390
00:18:24.965 --> 00:18:28.505
or that sub menal artery may in Eskimos, and,

391
00:18:28.645 --> 00:18:31.665
and you then get backflow down the submental artery

392
00:18:32.125 --> 00:18:35.145
and then that then flows forward into deep lingual artery

393
00:18:35.145 --> 00:18:37.225
and the, and the, uh,

394
00:18:37.255 --> 00:18:39.425
superficial lingual artery as well as an example.

395
00:18:40.165 --> 00:18:44.065
Um, right? So just that backflow and then the forward flow.

396
00:18:44.125 --> 00:18:47.505
And now you've, we've occluded, um, the tone

397
00:18:49.005 --> 00:18:51.095
similarly just to show as an example, right?

398
00:18:51.215 --> 00:18:53.695
A different, like there can be different anastomosis and so

399
00:18:53.695 --> 00:18:56.255
therefore different mechanisms where actually in this case

400
00:18:56.835 --> 00:18:58.895
it would be the deep lingual artery ISN infected,

401
00:18:59.035 --> 00:19:01.095
but actually the superficial lingual artery is.

402
00:19:01.715 --> 00:19:03.095
And, um,

403
00:19:06.025 --> 00:19:08.805
and what what isn't shown in any, in any of these, and,

404
00:19:08.825 --> 00:19:11.565
and really not illustrated well in textbooks generally is,

405
00:19:11.565 --> 00:19:13.765
but right in that example of the chin

406
00:19:13.975 --> 00:19:18.005
where we had a contralateral side of, of the, of the tongue

407
00:19:18.005 --> 00:19:20.045
that was affected, then, you know,

408
00:19:20.215 --> 00:19:24.125
there would be an anastomosis likely between, you know,

409
00:19:25.825 --> 00:19:28.445
the lingual arteries that then anastomosis,

410
00:19:28.465 --> 00:19:30.485
and then you it, it goes into the other side.

411
00:19:31.025 --> 00:19:33.085
So one of the points to be made,

412
00:19:33.085 --> 00:19:34.805
and this is, this is true certainly here,

413
00:19:34.825 --> 00:19:36.405
but it's true every ery in the face is

414
00:19:36.405 --> 00:19:37.485
there are connections everywhere.

415
00:19:37.545 --> 00:19:40.645
And so it's important when you get an occlusion

416
00:19:41.425 --> 00:19:45.605
or there's an suspected occlusion, um, that you're looking,

417
00:19:46.345 --> 00:19:50.835
um, upstream,

418
00:19:50.835 --> 00:19:54.795
downstream, uh, beyond just where the, the, the occlusion

419
00:19:54.795 --> 00:19:56.475
that you have is right.

420
00:19:56.935 --> 00:19:59.115
And that's, and in some of the, um,

421
00:20:01.725 --> 00:20:04.625
in some of the occlusions, not just in the chin, right?

422
00:20:04.625 --> 00:20:06.345
And, and, and you get into a larger vessel,

423
00:20:06.365 --> 00:20:07.505
you get into the angular artery,

424
00:20:07.525 --> 00:20:09.985
and oftentimes the angular arteries are very difficult

425
00:20:10.005 --> 00:20:11.465
to manage when they're occluded.

426
00:20:11.845 --> 00:20:14.585
And so you've gotta look upstream and downstream and,

427
00:20:14.645 --> 00:20:15.825
and, uh, yeah.

428
00:20:16.725 --> 00:20:18.145
Uh, let me see.

429
00:20:18.325 --> 00:20:21.985
So, um,

430
00:20:24.555 --> 00:20:26.465
let's talk a little bit about, let's go back

431
00:20:26.645 --> 00:20:28.385
and we'll just talk through this.

432
00:20:28.645 --> 00:20:29.665
So what do we do?

433
00:20:29.925 --> 00:20:32.025
So I, I came in there had a, a fair bit of highlights.

434
00:20:32.025 --> 00:20:34.385
And so the approach that, that I took,

435
00:20:34.485 --> 00:20:39.145
but the principles are the same, um,

436
00:20:41.945 --> 00:20:45.565
is you just keep going until you feel like you're winning.

437
00:20:45.585 --> 00:20:46.725
And we'll talk a little bit about that

438
00:20:47.465 --> 00:20:49.045
to speak directly to this tongue.

439
00:20:49.785 --> 00:20:52.365
So a you gotta make sure that the chin is okay.

440
00:20:53.105 --> 00:20:55.405
And by the time I saw the patient, the chin was mostly okay,

441
00:20:55.405 --> 00:20:56.765
we did a little bit of injecting in the chin

442
00:20:57.505 --> 00:20:59.285
and that again, you had check

443
00:20:59.285 --> 00:21:01.165
underneath the chin starting tissues.

444
00:21:01.385 --> 00:21:05.365
And then for the tongue, as, as a general rule in the body,

445
00:21:05.685 --> 00:21:07.725
arteries run medial to veins.

446
00:21:08.345 --> 00:21:12.725
And that's true for the vessels in the tongue.

447
00:21:12.825 --> 00:21:16.525
So the deep lingual artery is medial to the vein

448
00:21:16.525 --> 00:21:18.645
that then drains the tongue.

449
00:21:19.265 --> 00:21:22.565
And so essentially what we did is grab the tongue

450
00:21:23.635 --> 00:21:24.845
with very concentrated.

451
00:21:24.845 --> 00:21:28.005
So I put 1500 units in one mill of saline and poor patient.

452
00:21:28.165 --> 00:21:29.525
I was like, this is really gonna hurt.

453
00:21:29.525 --> 00:21:31.885
And I'm sorry 'cause we can't use any anymore lidocaine.

454
00:21:32.545 --> 00:21:34.685
The more concentrated, the high highlights is,

455
00:21:34.685 --> 00:21:37.525
the more it feels like you're injecting glass into somebody,

456
00:21:38.065 --> 00:21:41.045
but get some gauze, grab the tongue, pull it to the side,

457
00:21:42.255 --> 00:21:43.795
and then get a long needle

458
00:21:44.375 --> 00:21:48.315
and down at the base where the tongue meets the, um,

459
00:21:48.495 --> 00:21:51.875
the floor of the mouth, and then deep to that, uh,

460
00:21:51.875 --> 00:21:53.115
with the needle, uh,

461
00:21:53.345 --> 00:21:57.255
roughly a couple centimeters bolus of hollas.

462
00:21:57.605 --> 00:21:58.935
Then we did that a couple times.

463
00:21:59.515 --> 00:22:03.535
And then, um, after we did that, then,

464
00:22:03.535 --> 00:22:06.175
because what we don't know, right, is, is it a point

465
00:22:06.175 --> 00:22:07.695
that's in general that's occluded?

466
00:22:08.155 --> 00:22:09.575
Is it a tree that like,

467
00:22:09.575 --> 00:22:11.575
essentially multiple branches that are occluded?

468
00:22:11.915 --> 00:22:12.935
But what we do know is

469
00:22:12.935 --> 00:22:14.575
that occlusion is at least back there.

470
00:22:14.575 --> 00:22:17.895
So the patient was describing pretty intense a dysphagia

471
00:22:17.895 --> 00:22:19.175
and b pain, right?

472
00:22:19.835 --> 00:22:21.735
And then pain as mentioned to the ear.

473
00:22:23.195 --> 00:22:26.415
Now I, you know, there's a moment where you're like,

474
00:22:26.415 --> 00:22:27.975
holy moly, is this like,

475
00:22:28.915 --> 00:22:30.935
are we in massive amounts of trouble, right?

476
00:22:30.935 --> 00:22:33.695
This has gone back to the external carotid artery

477
00:22:33.695 --> 00:22:34.935
and things are really like,

478
00:22:35.035 --> 00:22:37.695
and we've we're, we really are, I have a big problem.

479
00:22:39.025 --> 00:22:42.455
After examining the patient, I was pretty confident that

480
00:22:42.455 --> 00:22:46.095
that pain was a referred pain, um, similar to

481
00:22:46.355 --> 00:22:48.175
how when you have a sore throat sometimes

482
00:22:48.205 --> 00:22:49.295
like your ear hurts.

483
00:22:49.875 --> 00:22:53.335
And that is, uh, in this case was just a referred pain.

484
00:22:53.995 --> 00:22:55.135
We could safely ignore that

485
00:22:55.275 --> 00:22:58.815
and focus on where we could see that the, um,

486
00:22:59.875 --> 00:23:01.445
tissues were ischemic.

487
00:23:01.785 --> 00:23:04.925
So deep down 1500 units times two in one mil

488
00:23:04.925 --> 00:23:07.365
of saline each time, and then the body of the tongue,

489
00:23:07.365 --> 00:23:08.525
if we pretend this is the tongue,

490
00:23:08.675 --> 00:23:10.965
because you know, again, we don't know is it a point

491
00:23:10.965 --> 00:23:12.165
that's back here deep at the tongue,

492
00:23:12.545 --> 00:23:14.365
or is it actually in fact, you know,

493
00:23:14.485 --> 00:23:16.365
a like branch through the tongue?

494
00:23:16.945 --> 00:23:20.725
We then injected retrograde, um, threads through the tongue,

495
00:23:20.905 --> 00:23:22.525
so into the tongue and then retrograde

496
00:23:22.525 --> 00:23:24.805
and another, um, so the rest of the pillar

497
00:23:24.805 --> 00:23:26.285
that way quite concentrated as well.

498
00:23:26.385 --> 00:23:28.605
Not not one mil, I think it was at three mils that I recall.

499
00:23:30.835 --> 00:23:31.055
And,

500
00:23:32.485 --> 00:23:37.045
um, and it was better.

501
00:23:37.445 --> 00:23:41.165
I actually, I don't think I put the picture of the tongue.

502
00:23:41.165 --> 00:23:43.485
Forgive me when she left the clinic, but it was better.

503
00:23:43.585 --> 00:23:46.245
It wasn't perfect and she was still in intense amounts

504
00:23:46.245 --> 00:23:48.765
of pain and it was late and it was a Saturday night

505
00:23:48.765 --> 00:23:51.205
and I was a little bit worried that she wasn't gonna make it

506
00:23:51.205 --> 00:23:53.485
through the night purely from a pain perspective

507
00:23:53.485 --> 00:23:54.925
because it was so painful.

508
00:23:55.825 --> 00:24:00.445
And so I had a chat with, um, head and neck ENT surgeon,

509
00:24:01.465 --> 00:24:05.685
and we ended up sending her to RPA just purely

510
00:24:05.865 --> 00:24:07.165
for pain management.

511
00:24:07.285 --> 00:24:08.605
I didn't have any morphine in the clinic.

512
00:24:09.185 --> 00:24:11.805
And I was like, we just, like, I'm really worried about her,

513
00:24:11.805 --> 00:24:13.525
like getting through the knife from a

514
00:24:13.525 --> 00:24:14.685
pain management perspective.

515
00:24:15.665 --> 00:24:18.085
And so they, she presented and the injector went with her

516
00:24:18.085 --> 00:24:21.565
and presented ad and they did give her some morphine.

517
00:24:23.165 --> 00:24:25.505
Um, I'll talk a bit about that in a second.

518
00:24:25.765 --> 00:24:30.655
So, uh, using that as a, uh,

519
00:24:31.035 --> 00:24:33.885
um, where is it?

520
00:24:33.885 --> 00:24:35.445
So how do you know, how do you know you're winning them

521
00:24:37.075 --> 00:24:38.615
in the, in the acute phase?

522
00:24:38.615 --> 00:24:40.495
You know, you're winning because you actually, you, you

523
00:24:41.015 --> 00:24:42.575
reestablish that blood flow, right?

524
00:24:42.635 --> 00:24:44.215
So you see those changes in color.

525
00:24:44.245 --> 00:24:45.415
It's the same, same ways

526
00:24:45.415 --> 00:24:47.375
that you recognize an occlusion, right?

527
00:24:47.375 --> 00:24:48.775
You just sort of work backwards from that.

528
00:24:49.435 --> 00:24:51.415
You reverse the sluggish capillary refill.

529
00:24:51.415 --> 00:24:53.895
Sometimes you don't get to, you know, a hundred percent of

530
00:24:53.895 --> 00:24:55.535
what it was, but you can get awfully close.

531
00:24:56.275 --> 00:25:00.535
Um, and then, and then pain again can be a very helpful pain

532
00:25:00.535 --> 00:25:03.055
or tenderness on palpation can be a very helpful sign.

533
00:25:04.995 --> 00:25:09.005
Lidocaine is helpful because you numb the patient up,

534
00:25:09.065 --> 00:25:10.565
but also means you can no longer then

535
00:25:11.355 --> 00:25:14.085
necessarily rely on pain as that, as that sign.

536
00:25:14.385 --> 00:25:17.815
Um, and then subacute again is, are you,

537
00:25:17.875 --> 00:25:19.655
are you getting those vesicles?

538
00:25:19.655 --> 00:25:22.575
If you've got those vesicles at that point,

539
00:25:22.995 --> 00:25:24.575
and then we use more hilas,

540
00:25:25.985 --> 00:25:28.275
it's very helpful not only in the case of vesicles,

541
00:25:28.275 --> 00:25:29.755
but generally in the case of an occlusion

542
00:25:29.755 --> 00:25:32.835
to have serial photos the same way that we do before and

543
00:25:32.835 --> 00:25:35.755
after photos for aesthetic purposes.

544
00:25:36.355 --> 00:25:38.315
Actually having serial photos and using them,

545
00:25:38.315 --> 00:25:40.835
putting them side by side the same way that we do before

546
00:25:40.835 --> 00:25:44.715
and afters to just be able to compare, like, this is

547
00:25:44.715 --> 00:25:47.155
before this when we started, this is what it is now.

548
00:25:47.735 --> 00:25:49.395
All that, like, it makes it very clear

549
00:25:49.395 --> 00:25:50.835
and then you're not relying on your memory

550
00:25:50.935 --> 00:25:52.955
and this is what I think, or even just clicking back

551
00:25:52.955 --> 00:25:54.675
and forth, it's there in front of you in one picture.

552
00:25:55.065 --> 00:25:56.675
This is before, this is where we're at now.

553
00:25:57.655 --> 00:26:01.315
Um, and so looking again,

554
00:26:01.315 --> 00:26:02.875
the breakdown of tissue and necrosis.

555
00:26:02.875 --> 00:26:05.275
So what you'll actually get is then resolution

556
00:26:05.335 --> 00:26:06.355
of those vesicles

557
00:26:06.415 --> 00:26:08.635
and then they'll, they'll heal all the way quite quickly.

558
00:26:08.735 --> 00:26:12.555
In fact, um, increase pain or decrease in pain and,

559
00:26:12.555 --> 00:26:13.675
and localization of that pain.

560
00:26:14.295 --> 00:26:15.715
And then the color changes as well.

561
00:26:15.715 --> 00:26:19.355
When it's, when it's on a timeframe of days, uh,

562
00:26:19.495 --> 00:26:22.595
the changes don't happen, uh, immediately.

563
00:26:22.695 --> 00:26:24.395
So if it, in like this case,

564
00:26:24.455 --> 00:26:27.195
if we can reverse it basically immediately, the the,

565
00:26:27.195 --> 00:26:28.715
the color will come back and be normal.

566
00:26:30.255 --> 00:26:35.105
Um, as a so,

567
00:26:35.205 --> 00:26:37.585
so, and I've sort of, I don't wanna blame the point,

568
00:26:37.585 --> 00:26:42.145
but you know, just 'cause the, the you, there's an occlusion

569
00:26:42.325 --> 00:26:44.925
and sometimes occlusions are complex as with this right

570
00:26:44.945 --> 00:26:48.245
to the chin, but also the tongue and some other tissues.

571
00:26:48.245 --> 00:26:50.685
You can clear one part of it, not the other, but just

572
00:26:50.805 --> 00:26:53.325
'cause you haven't cleared another part a day or two

573
00:26:53.325 --> 00:26:54.845
or three later doesn't mean it's too late.

574
00:26:54.845 --> 00:26:56.285
Definitely can continue to do it.

575
00:26:57.345 --> 00:27:01.135
Um, so just to follow up on that case.

576
00:27:01.215 --> 00:27:03.895
So that was Saturday night. I sent the patient to the ed

577
00:27:04.015 --> 00:27:05.175
'cause I was concerned about the pain.

578
00:27:05.235 --> 00:27:09.015
She went to the ED and they gave us some morphine

579
00:27:09.015 --> 00:27:11.455
and then they tossed around and basically nobody saw her

580
00:27:11.455 --> 00:27:12.495
and then they discharged her the next

581
00:27:12.495 --> 00:27:13.735
morning, um, which was fine.

582
00:27:13.735 --> 00:27:16.255
And so she then followed up, this is on Sunday, so some

583
00:27:16.255 --> 00:27:17.295
of you may or may not know Dr.

584
00:27:17.475 --> 00:27:21.575
Her Huey, who is Ed trained, he is based here in Sydney.

585
00:27:22.195 --> 00:27:25.255
Um, he then kindly agreed

586
00:27:25.395 --> 00:27:27.335
to review her the following day

587
00:27:27.335 --> 00:27:32.055
and he's, um, he her on her face

588
00:27:32.075 --> 00:27:36.975
as well just to a, see if he could find any included vessels

589
00:27:37.035 --> 00:27:39.975
and b also like a little bit of mapping of the vessels.

590
00:27:40.595 --> 00:27:44.535
And it turns out that she then had a vessel midline in her

591
00:27:44.535 --> 00:27:46.215
chin, which then branched off from

592
00:27:46.215 --> 00:27:47.295
one of the mental arteries.

593
00:27:47.675 --> 00:27:51.135
So one of the things that, uh, this case is, is timely.

594
00:27:51.135 --> 00:27:53.775
So one of the things that we looked at in this cadaver lab

595
00:27:53.775 --> 00:27:57.895
last week at an anatomy for injectors was we actually, um,

596
00:27:58.245 --> 00:28:00.695
some of the plastic surgeons that dissected the cadavers.

597
00:28:00.835 --> 00:28:04.795
So there were six cadaver heads, one third of them.

598
00:28:04.895 --> 00:28:07.235
So two of them had midline vessels in the chin.

599
00:28:08.195 --> 00:28:10.485
It's worth noting that like classically, right?

600
00:28:10.485 --> 00:28:12.005
Traditionally we've been taught like, uh,

601
00:28:12.005 --> 00:28:13.485
midline is safe in the chin, right?

602
00:28:13.485 --> 00:28:15.685
Just put your needle in there, midline giura.

603
00:28:16.755 --> 00:28:19.775
Um, but a, a full third of the cadavers had midline vessels.

604
00:28:19.955 --> 00:28:24.295
And, um, and so, and one of the things that we're now doing

605
00:28:24.295 --> 00:28:27.255
after is actually Stephania Roberts is she's gonna scan a

606
00:28:27.255 --> 00:28:28.495
whole bunch of her patients just looking

607
00:28:28.495 --> 00:28:30.815
for those midline vessels with ultrasound as well.

608
00:28:31.475 --> 00:28:35.375
Um, so this patient had midline vessel, um, but Herbert was

609
00:28:35.455 --> 00:28:36.855
otherwise pretty happy with,

610
00:28:37.355 --> 00:28:39.495
uh, how the testers were looking.

611
00:28:39.505 --> 00:28:40.535
Sorry, was that question

612
00:28:41.635 --> 00:28:42.635
Dr. John? Um, yeah.

613
00:28:42.635 --> 00:28:42.895


614
00:28:43.155 --> 00:28:44.615
Did did she have a,

615
00:28:44.735 --> 00:28:47.535
a extra forearm in accessory? Forearm in?

616
00:28:48.035 --> 00:28:50.255
So that also is a thing.

617
00:28:50.635 --> 00:28:54.975
Um, I, Herbert didn't comment on accessory foren,

618
00:28:54.975 --> 00:28:56.495
but some people will have a midline vest

619
00:28:56.495 --> 00:28:58.335
that actually pierces in the, the mandible.

620
00:28:58.375 --> 00:29:01.015
I think in her case it was, it came off, uh,

621
00:29:01.595 --> 00:29:03.295
mental artery on on one side.

622
00:29:03.395 --> 00:29:05.735
And so essentially like you get it swings medially

623
00:29:05.735 --> 00:29:07.415
and then it comes up and then mm-hmm, um,

624
00:29:08.355 --> 00:29:10.055
the swings up more superiorly.

625
00:29:11.525 --> 00:29:14.645
This is, um, interesting

626
00:29:14.745 --> 00:29:18.365
and I mean, patients love what we do for them

627
00:29:18.505 --> 00:29:19.885
and that's great and I'm grateful,

628
00:29:19.905 --> 00:29:21.965
but like, so Herbert saw her

629
00:29:22.505 --> 00:29:24.925
and he was satisfied that everything looked good

630
00:29:25.145 --> 00:29:26.365
and said, look, I actually don't

631
00:29:26.365 --> 00:29:27.405
think she needs any more leys.

632
00:29:27.705 --> 00:29:29.205
And she never needed more leys

633
00:29:29.205 --> 00:29:30.365
and she had a complete recovery

634
00:29:30.385 --> 00:29:32.925
and three days later she was asking for more filler.

635
00:29:33.005 --> 00:29:34.845
I kid you not, which is crazy.

636
00:29:35.785 --> 00:29:39.125
Um, but it's as an interesting point

637
00:29:39.125 --> 00:29:40.485
and as an interesting aside,

638
00:29:40.485 --> 00:29:42.565
and this I've seen in a couple of the tongues actually,

639
00:29:43.225 --> 00:29:45.965
so this was, I forget which day,

640
00:29:45.965 --> 00:29:50.005
but sort of maybe two days later, you can see, um,

641
00:29:50.215 --> 00:29:51.925
she's got a bit of oral thrush, right?

642
00:29:51.985 --> 00:29:53.205
So a bit of thrush on her tongue.

643
00:29:53.585 --> 00:29:56.045
So we gave her ne stat the following day, then that's

644
00:29:56.045 --> 00:29:57.045
what her tongue looked like.

645
00:29:57.585 --> 00:29:59.125
And I admit it doesn't look amazing,

646
00:29:59.385 --> 00:30:02.885
but what it does look is like it bleeds, which is great.

647
00:30:04.105 --> 00:30:07.245
Um, right? So when you're in surgery

648
00:30:07.305 --> 00:30:09.405
and you're, you're debriding dead tissue

649
00:30:09.405 --> 00:30:11.525
and you basically cut until the tissue bleeds

650
00:30:12.225 --> 00:30:13.405
and the blood is great.

651
00:30:13.405 --> 00:30:16.965
And so for us, like that's great. It's perfused.

652
00:30:17.385 --> 00:30:19.565
It looks like it's had better days.

653
00:30:19.675 --> 00:30:23.125
It's seen better days, but it's pink, it's perfused,

654
00:30:23.125 --> 00:30:25.165
and if you stick a needle in it, it bleeds.

655
00:30:25.505 --> 00:30:28.445
That's great. And her pain as well at that point, you know,

656
00:30:28.445 --> 00:30:32.805
the following day basically, um, resolved.

657
00:30:32.905 --> 00:30:35.565
And so the, some of that, I think the hiles

658
00:30:36.705 --> 00:30:39.685
the tongue looked significantly better by the time that I,

659
00:30:39.865 --> 00:30:43.575
um, seen her finished seeing Herley.

660
00:30:43.575 --> 00:30:46.015
There's some rat studies that looked at the longevity

661
00:30:46.035 --> 00:30:48.855
of hiles in tissues and rat tissues,

662
00:30:48.855 --> 00:30:50.615
but it was about probably about six hours.

663
00:30:51.395 --> 00:30:53.495
Um, and so you could assume, you know, at least

664
00:30:53.495 --> 00:30:54.855
that much time in the tongue.

665
00:30:55.195 --> 00:30:58.255
So it, during that time, I think there's enough time

666
00:30:58.315 --> 00:31:01.535
as well, uh, for the how this continue to work.

667
00:31:01.535 --> 00:31:04.015
And you get this translucent diffusion into the vessels

668
00:31:04.475 --> 00:31:07.175
and um, and, and that can then dissolve.

669
00:31:07.435 --> 00:31:09.055
So an interesting point though.

670
00:31:09.155 --> 00:31:12.895
So that's out of the four tongues I've seen 50%

671
00:31:12.895 --> 00:31:15.375
of 'em have developed thrush just from that short time.

672
00:31:15.495 --> 00:31:16.575
I think you get that insult.

673
00:31:17.085 --> 00:31:20.175
It's enough time, it's a warm, moist place

674
00:31:20.395 --> 00:31:24.075
and, uh, fungus grows.

675
00:31:25.495 --> 00:31:30.415
Um, any, any, well,

676
00:31:30.575 --> 00:31:33.375
actually let me, so here's, here's some broad points and,

677
00:31:33.515 --> 00:31:38.125
and, and this is true, like this is probably one

678
00:31:38.125 --> 00:31:39.965
of the worst, not probably definitely one

679
00:31:39.965 --> 00:31:41.965
of the worst occlusions that I've managed.

680
00:31:42.665 --> 00:31:44.525
And man, the pain was really intense.

681
00:31:44.865 --> 00:31:47.035
Um, and,

682
00:31:47.855 --> 00:31:49.915
but the principles are true for all

683
00:31:49.915 --> 00:31:53.075
of them from the smallest little, you know, uh,

684
00:31:53.435 --> 00:31:55.155
occlusion in, in the lips.

685
00:31:55.375 --> 00:31:56.515
And the lips would be the area

686
00:31:56.515 --> 00:31:58.115
that occlusions are most common in.

687
00:31:58.135 --> 00:31:59.195
And I think that's mostly

688
00:31:59.195 --> 00:32:01.195
because it's just the area that are most common

689
00:32:01.295 --> 00:32:02.395
of where we inject, right?

690
00:32:02.395 --> 00:32:03.635
We inject a lot of lips and,

691
00:32:04.095 --> 00:32:05.555
and in fact the vessels are pretty

692
00:32:05.645 --> 00:32:06.915
close to where we're injecting.

693
00:32:08.055 --> 00:32:11.315
Um, but it's a good, you know, takeaway point.

694
00:32:11.465 --> 00:32:14.595
There's no safe, you keep going until it's fixed.

695
00:32:14.625 --> 00:32:17.995
Then this case essentially, right?

696
00:32:17.995 --> 00:32:20.835
We fixed it in a day, obviously there was some follow up,

697
00:32:20.835 --> 00:32:22.595
but it didn't require any further invention.

698
00:32:22.925 --> 00:32:26.955
Inter interventions, sometimes in a really bad collision

699
00:32:27.735 --> 00:32:29.795
on more than one occasion, it's taken us a week

700
00:32:29.895 --> 00:32:30.995
to really clear things.

701
00:32:31.415 --> 00:32:33.195
And that's daily reviewing the patient

702
00:32:33.335 --> 00:32:35.035
and daily injecting hollas.

703
00:32:35.615 --> 00:32:38.955
But even still, like,

704
00:32:39.105 --> 00:32:40.805
you just keep working at it

705
00:32:40.805 --> 00:32:42.685
and working at it until you clear it.

706
00:32:43.385 --> 00:32:45.125
And so, and it's pretty,

707
00:32:46.175 --> 00:32:49.275
it can be a little disheartening when it's taken that long.

708
00:32:49.275 --> 00:32:51.595
Like, gosh, is it really like, this is hard work

709
00:32:51.615 --> 00:32:54.875
and it's miserable, it's miserable for us,

710
00:32:54.985 --> 00:32:56.395
it's miserable for the patient.

711
00:32:56.735 --> 00:32:58.275
Um, you know, it's uncomfortable,

712
00:32:58.295 --> 00:33:00.115
it hurts like heck to inject hila.

713
00:33:00.115 --> 00:33:01.995
And so to then, you know, get the patient back

714
00:33:01.995 --> 00:33:03.595
and say like, well, we gotta do it again today.

715
00:33:03.595 --> 00:33:05.635
Like, nobody likes that. It's not fun.

716
00:33:06.255 --> 00:33:10.835
But you know what, uh, between, you know, Katie

717
00:33:10.835 --> 00:33:13.955
and myself and Brandon, we see about an inclusion a week

718
00:33:14.015 --> 00:33:16.235
and we haven't had any with any sort of sort

719
00:33:16.235 --> 00:33:17.235
of long-term sequelae.

720
00:33:17.235 --> 00:33:21.915
So the good news is, you know, yeah, touch wood is that you,

721
00:33:22.015 --> 00:33:24.605
you, you, as long

722
00:33:24.605 --> 00:33:26.965
as you keep at it like you can fix these things,

723
00:33:26.965 --> 00:33:29.565
which is great, and then for me, every time

724
00:33:29.565 --> 00:33:31.965
that we manage them, um, it's

725
00:33:33.965 --> 00:33:36.165
I think a badge of honor that you get to wear, right?

726
00:33:36.185 --> 00:33:38.285
You get through it and then you're like, look, you've done

727
00:33:38.285 --> 00:33:40.005
how you survived, the patient survived.

728
00:33:40.065 --> 00:33:41.285
And it's a bit of a badge of honor.

729
00:33:41.625 --> 00:33:43.725
So that's a good question. Do I recommend aspirin?

730
00:33:43.745 --> 00:33:44.645
Let me actually, lemme come

731
00:33:44.645 --> 00:33:45.685
to the questions after this slide.

732
00:33:45.785 --> 00:33:49.455
So don't use 2% lidocaine, just use 1%.

733
00:33:49.735 --> 00:33:51.535
Vegetables are connected, especially in the face,

734
00:33:51.795 --> 00:33:53.535
so there's a lot of anastomosis in the face.

735
00:33:53.675 --> 00:33:56.215
And so it's, you gotta look upstream and downstream

736
00:33:56.215 --> 00:33:58.375
and elsewhere, anytime that you've got an occlusion

737
00:33:58.375 --> 00:34:01.535
that includes the lips, um, and anywhere really.

738
00:34:02.555 --> 00:34:04.295
And just because it's always been okay

739
00:34:04.295 --> 00:34:06.375
before doesn't mean it will be okay this time.

740
00:34:06.955 --> 00:34:09.335
So there's a trap that like, you know, there's always a risk

741
00:34:09.395 --> 00:34:11.415
to us that we can follow with that, which is like, oh,

742
00:34:11.415 --> 00:34:13.215
like I've done this a million times, it'll be fine, right?

743
00:34:13.215 --> 00:34:14.375
Like, I'm injecting the chain a

744
00:34:14.375 --> 00:34:15.535
million times, it'll be fine.

745
00:34:15.595 --> 00:34:17.415
It probably will be fine, but it might not be.

746
00:34:18.115 --> 00:34:20.455
And I think patients, it's generally as humans,

747
00:34:20.525 --> 00:34:22.615
it's difficult to assess risk

748
00:34:22.795 --> 00:34:25.055
and we're not always great at it.

749
00:34:25.275 --> 00:34:27.695
And patients in particular, like, I've had this time,

750
00:34:27.875 --> 00:34:29.575
you know, 50 times I'll be fine.

751
00:34:29.575 --> 00:34:31.815
Well, like, unfortunately, the risk remains every time.

752
00:34:31.845 --> 00:34:32.815
Like, it's like you start

753
00:34:32.815 --> 00:34:34.215
fresh, you know, every single time.

754
00:34:34.215 --> 00:34:35.615
Like it's a new roll of the dice.

755
00:34:36.395 --> 00:34:39.375
Um, and then the others please always call a doctor.

756
00:34:39.405 --> 00:34:41.215
Like we really desperately care.

757
00:34:41.495 --> 00:34:45.295
I and in fact, uh, I mean I may have heard me say this,

758
00:34:45.455 --> 00:34:47.015
I enjoy is a very strong word.

759
00:34:47.245 --> 00:34:51.335
I'll, I almost enjoy, uh, managing these occlusions, right?

760
00:34:51.335 --> 00:34:53.735
They, they're actually like, they're kind

761
00:34:53.735 --> 00:34:55.175
of really interesting and,

762
00:34:56.245 --> 00:34:58.545
and there's some serious satisfaction

763
00:34:58.545 --> 00:34:59.625
you fix it as well, right?

764
00:34:59.625 --> 00:35:01.745
In the same way that we, you get satisfaction when you,

765
00:35:01.745 --> 00:35:02.785
like, you do good work

766
00:35:02.805 --> 00:35:04.745
and you get a really beautiful cosmetic outcome.

767
00:35:05.085 --> 00:35:07.065
But that is also true when something,

768
00:35:07.365 --> 00:35:09.945
you get yourself in a tight corner and then we fix

769
00:35:09.945 --> 00:35:11.185
and we're like, oh, that's great.

770
00:35:11.445 --> 00:35:12.865
And then we can, you know,

771
00:35:12.865 --> 00:35:14.985
if the patient's brave enough a week later,

772
00:35:14.985 --> 00:35:16.425
then you can come back and, you know,

773
00:35:16.685 --> 00:35:17.705
fix things aesthetically.

774
00:35:18.445 --> 00:35:20.715
Um, but, but,

775
00:35:21.015 --> 00:35:23.395
but more than like the, you know, sick enjoyment

776
00:35:23.395 --> 00:35:25.355
of it is actually, it's like,

777
00:35:25.625 --> 00:35:28.315
it's super important from the safety perspective.

778
00:35:28.855 --> 00:35:30.435
We care deeply about that.

779
00:35:30.895 --> 00:35:33.915
Um, and I like, you know, eat, sleep, and breathe that.

780
00:35:33.935 --> 00:35:37.485
And so, you know, that's, it's, this is a team effort

781
00:35:37.985 --> 00:35:39.205
and it'll always be team effort.

782
00:35:39.305 --> 00:35:42.375
So in the panic, don't panic,

783
00:35:42.555 --> 00:35:46.135
but also call the doctor, um, tally.

784
00:35:46.155 --> 00:35:48.015
So question, when we talk

785
00:35:48.015 --> 00:35:49.215
through this case, we talk about anything.

786
00:35:49.835 --> 00:35:50.975
Do I recommend aspirin?

787
00:35:51.395 --> 00:35:55.295
Um, I don't not recommend aspirin.

788
00:35:56.155 --> 00:35:59.095
Um, there's one thing

789
00:35:59.095 --> 00:36:02.535
that fixes an occlusion and that is hilas.

790
00:36:03.795 --> 00:36:05.655
Now everything else kinda makes

791
00:36:05.655 --> 00:36:06.695
us feel good about ourselves.

792
00:36:07.155 --> 00:36:10.655
The honest truth is to, you can actually have,

793
00:36:10.755 --> 00:36:14.895
it can be further complicated by intra arterial,

794
00:36:15.395 --> 00:36:16.655
um, clots, right?

795
00:36:16.715 --> 00:36:19.095
So you can potentially, if blood's not moving, you can then,

796
00:36:20.435 --> 00:36:23.255
uh, secondary the original occlusion potentially, you know,

797
00:36:23.255 --> 00:36:25.015
have things get worse because you,

798
00:36:25.075 --> 00:36:26.655
you end up getting a, a clot there.

799
00:36:26.655 --> 00:36:28.495
And so aspirin might help a little bit with that.

800
00:36:28.515 --> 00:36:31.135
So it's not a terrible idea, it's not the most important

801
00:36:31.135 --> 00:36:34.095
thing, um, but it's certainly not gonna hurt anything.

802
00:36:34.905 --> 00:36:35.125
So,

803
00:36:37.015 --> 00:36:41.675
um, any other questions? Any question about this case?

804
00:36:42.275 --> 00:36:43.795
Question, what would you recommend?

805
00:36:43.795 --> 00:36:47.675
Like if you don't have an ultrasound, so, um, midline,

806
00:36:47.685 --> 00:36:50.755
would you recommend a cannula or

807
00:36:51.215 --> 00:36:52.215
So? So that's a

808
00:36:52.215 --> 00:36:52.875
really good question and,

809
00:36:53.055 --> 00:36:54.195
and my recommendation is,

810
00:36:54.195 --> 00:36:55.475
and I sort of started that slide briefly,

811
00:36:55.575 --> 00:36:56.795
but is to always move your needle.

812
00:36:56.855 --> 00:37:00.795
So when I bolus and I do still bolus when I see patients,

813
00:37:00.815 --> 00:37:02.515
but when I do, I and I,

814
00:37:02.515 --> 00:37:05.075
and credit to as mentioned earlier, Greg Goodman and,

815
00:37:05.075 --> 00:37:07.395
and Mike Clegg and there are others as well, that was sort

816
00:37:07.395 --> 00:37:08.795
of the, you know, that kind of came up

817
00:37:08.795 --> 00:37:10.555
with this in early advocates of it is,

818
00:37:11.055 --> 00:37:15.275
and I appreciate that Professor Koana is out there.

819
00:37:15.295 --> 00:37:16.915
He, in fact, he came to Australia

820
00:37:17.015 --> 00:37:18.355
and then he was giving everybody a hard

821
00:37:18.355 --> 00:37:19.995
time moving the needle.

822
00:37:20.215 --> 00:37:22.515
And he based this on this paper that he wrote,

823
00:37:22.515 --> 00:37:24.755
which was purely a mathematical model

824
00:37:24.815 --> 00:37:27.475
and had nothing like, didn't look at any clinical outcomes.

825
00:37:27.775 --> 00:37:31.115
So I would, I would

826
00:37:31.965 --> 00:37:34.775
happily push back on his findings in that,

827
00:37:34.885 --> 00:37:38.415
like it was a mathematical model and not clinical.

828
00:37:38.415 --> 00:37:39.655
And what do we care about? Like,

829
00:37:39.655 --> 00:37:41.215
we care about clinical endpoints, right?

830
00:37:41.245 --> 00:37:42.735
Like, I don't really care about the math,

831
00:37:42.735 --> 00:37:44.815
but I wanna notice like what's the clinical endpoint,

832
00:37:44.815 --> 00:37:48.375
because I would argue that the likelihood

833
00:37:48.375 --> 00:37:50.735
that we are always injecting in vessels is actually

834
00:37:50.735 --> 00:37:51.815
very high, right?

835
00:37:51.815 --> 00:37:54.535
Like, how many times have you done like a retrograde thread

836
00:37:55.035 --> 00:37:56.135
and then you pull your needle out

837
00:37:56.135 --> 00:37:57.135
and then somebody bleeds, right?

838
00:37:57.135 --> 00:37:58.535
Like we're injecting vessels all the time.

839
00:37:59.475 --> 00:38:02.935
Um, but we often get away with it

840
00:38:03.055 --> 00:38:04.575
'cause we move through them quickly and the volumes

841
00:38:04.575 --> 00:38:05.775
that we're injecting is actually quite small.

842
00:38:06.435 --> 00:38:08.455
So for me, when I do a bolus,

843
00:38:08.775 --> 00:38:11.375
I like am always moving the tip of my needle, right?

844
00:38:11.485 --> 00:38:13.255
Like, like I've got Parkinson's

845
00:38:13.255 --> 00:38:15.975
and I'm potentially jab my patient in the periosteum a

846
00:38:15.975 --> 00:38:17.815
hundred times and it isn't comfortable,

847
00:38:17.835 --> 00:38:19.975
but I'd rather that than end up

848
00:38:19.975 --> 00:38:22.215
with a really horrible occlusion. Um,

849
00:38:22.395 --> 00:38:25.455
And so, so the, the cannula you wouldn't recommend because

850
00:38:26.595 --> 00:38:28.575
No, not necessarily as well, like,

851
00:38:28.675 --> 00:38:31.935
but if you're gonna do a cannula, like also move, you know,

852
00:38:31.935 --> 00:38:34.135
the tip of the, the tip of your cannula, right?

853
00:38:34.285 --> 00:38:36.805
Like I think and thanks, um, Amber,

854
00:38:36.915 --> 00:38:38.085
I'll have a look at that in a minute.

855
00:38:38.305 --> 00:38:42.765
Um, one of the valuable lesson about, uh, and,

856
00:38:42.785 --> 00:38:45.365
and in fact two points to that, uh,

857
00:38:45.985 --> 00:38:48.245
if you send me something, don't send it

858
00:38:48.245 --> 00:38:49.405
to my email, I might miss it.

859
00:38:49.405 --> 00:38:50.685
Just text me. And if you,

860
00:38:50.985 --> 00:38:52.645
and if you wanna hear me back from me in like 30

861
00:38:52.645 --> 00:38:53.685
seconds, just call me.

862
00:38:54.225 --> 00:38:58.885
Um, the, as long as you're moving the, the end

863
00:38:58.885 --> 00:39:01.325
of your needle, right, the end of your cannula, like

864
00:39:01.345 --> 00:39:03.445
that's you to my mind.

865
00:39:03.595 --> 00:39:05.445
It's not a question of are you injecting a vessel,

866
00:39:05.465 --> 00:39:08.125
but are you injecting sufficient volumes

867
00:39:08.125 --> 00:39:09.525
that you're gonna find yourself in trouble?

868
00:39:09.545 --> 00:39:12.205
And so as long as you continue to move through, then I,

869
00:39:12.275 --> 00:39:15.325
than I would argue, um, you're much less likely

870
00:39:15.325 --> 00:39:19.525
to find yourself in, in really bad, like a really bad place

871
00:39:19.525 --> 00:39:20.725
with a really bad occlusion.

872
00:39:21.175 --> 00:39:22.765
Small occlusions are much easier

873
00:39:23.145 --> 00:39:25.405
to manage than really large occlusions.

874
00:39:25.505 --> 00:39:28.805
Mm-hmm. Um, often super easy, particularly lips.

875
00:39:28.805 --> 00:39:31.965
You get a little and you know, you have a small branch off

876
00:39:31.965 --> 00:39:35.205
of one of your superior or your inferior labial arteries.

877
00:39:35.545 --> 00:39:37.285
It often takes a tiny bit of Holley

878
00:39:37.285 --> 00:39:39.005
and like everything's back and it's beautiful.

879
00:39:39.005 --> 00:39:40.045
It's really easy to manage.

880
00:39:40.145 --> 00:39:44.965
Mm mm-hmm, um, uh, heat.

881
00:39:45.065 --> 00:39:48.005
So couple questions. Heat and massage, both are good ideas.

882
00:39:48.065 --> 00:39:51.165
And in fact, massage is a really good idea once you put the

883
00:39:51.305 --> 00:39:54.125
uh, uh, hilas in

884
00:39:54.125 --> 00:39:56.725
because there's a real mechanical piece

885
00:39:56.825 --> 00:40:00.485
to breaking down those cross linkages in the filler.

886
00:40:00.945 --> 00:40:03.005
So once we're, we've got the hilas in there,

887
00:40:03.005 --> 00:40:05.045
then absolutely not like rubbing the skin,

888
00:40:05.345 --> 00:40:07.725
but just massaging those tissues.

889
00:40:08.395 --> 00:40:12.285
It's really important to help break down, uh, those bonds,

890
00:40:12.495 --> 00:40:15.525
those, those, those cross linkages in the filler and,

891
00:40:15.545 --> 00:40:17.605
and then to, you know, turn into liquid.

892
00:40:17.605 --> 00:40:21.685
And yeah, so definitely heat's, uh, not a bad idea.

893
00:40:21.745 --> 00:40:22.765
And I'm, you know, and,

894
00:40:22.785 --> 00:40:25.125
and again, in fact more than anything gives a patient

895
00:40:25.125 --> 00:40:26.285
something to do, right?

896
00:40:26.285 --> 00:40:28.005
Like they can slap some heat on their face

897
00:40:28.005 --> 00:40:29.485
and they feel good and it does open

898
00:40:29.485 --> 00:40:30.685
up vessels and all of those things.

899
00:40:30.685 --> 00:40:31.725
So absolutely. Yeah.

900
00:40:32.585 --> 00:40:36.645
Um, uh, how do you manage

901
00:40:37.645 --> 00:40:40.045
a via with sculpture or with Radius?

902
00:40:40.345 --> 00:40:42.805
So I might actually let Katie speak a little bit

903
00:40:42.805 --> 00:40:46.205
to the sculpture before I do and I'll,

904
00:40:46.225 --> 00:40:48.285
and it is true for Radius as well.

905
00:40:48.985 --> 00:40:53.575
Um, there's an interesting case, um, uh,

906
00:40:54.355 --> 00:40:58.655
of a recent, I'm trying to remember who's is a doctor

907
00:40:58.755 --> 00:41:01.215
and talking to, uh, do,

908
00:41:01.295 --> 00:41:02.495
I don't know how many of you know Elsa?

909
00:41:02.955 --> 00:41:06.845
Um, Elsa is awesome. It's crazy.

910
00:41:07.505 --> 00:41:09.005
But anyway, it wasn't her case.

911
00:41:09.145 --> 00:41:12.165
Um, it was lucky for me anyway.

912
00:41:12.785 --> 00:41:16.205
Doctor had an occlusion radius, um, in the chin

913
00:41:17.065 --> 00:41:19.205
and used hilas.

914
00:41:19.695 --> 00:41:20.725
Hilas is an interesting one.

915
00:41:20.725 --> 00:41:24.165
Like it doesn't break down the bonds right in Radius

916
00:41:24.405 --> 00:41:26.885
'cause there are no bonds to be broken there as such.

917
00:41:27.025 --> 00:41:29.925
Um, but it was used long

918
00:41:29.925 --> 00:41:32.285
before we've used it, uh, in this space.

919
00:41:32.505 --> 00:41:36.085
One of its uses were was where you'd get extravasation,

920
00:41:36.135 --> 00:41:39.925
let's say you had a, a Cannula Inn, extra extravasated,

921
00:41:39.965 --> 00:41:43.235
a bunch of caustic, uh, you know, medicine.

922
00:41:44.095 --> 00:41:46.915
And then they would actually use high essentially to dilute,

923
00:41:46.975 --> 00:41:49.235
and I don't wanna say neutralize,

924
00:41:49.375 --> 00:41:51.835
but like neutralize the product.

925
00:41:52.495 --> 00:41:55.795
So I actually think there's a case to use hila, um,

926
00:41:56.295 --> 00:41:59.155
in these cases where it doesn't necessarily make sense

927
00:41:59.155 --> 00:42:01.795
to use Hila because like, well it's, you know,

928
00:42:01.795 --> 00:42:02.915
it's a hyaluronidase, right?

929
00:42:02.915 --> 00:42:04.275
It's an enzyme. It's, and it's,

930
00:42:04.275 --> 00:42:06.035
and it's breaking down the, the hila.

931
00:42:06.075 --> 00:42:07.835
I think there's some other mechanisms there

932
00:42:07.965 --> 00:42:09.195
where it can be useful.

933
00:42:09.535 --> 00:42:12.155
And so in that case of radius, radius in the chin, in

934
00:42:12.155 --> 00:42:13.675
that occlusion, they actually use holidays

935
00:42:13.675 --> 00:42:15.075
and had a full resolution.

936
00:42:15.075 --> 00:42:16.355
There's an, is it, it's actually quite an

937
00:42:16.435 --> 00:42:17.555
interesting case and a longer story.

938
00:42:17.735 --> 00:42:19.595
Um, but yeah,

939
00:42:19.775 --> 00:42:21.755
and maybe I'll, I'll, so we've had a couple occlusions

940
00:42:21.755 --> 00:42:24.795
with Sculptra and I, my Katie's lucky for Katie.

941
00:42:24.795 --> 00:42:27.315
Both of them were when I was overseas,

942
00:42:27.335 --> 00:42:29.315
and so she got to manage both of them.

943
00:42:29.655 --> 00:42:32.315
Uh, so I might let Katie maybe give

944
00:42:32.355 --> 00:42:33.395
a few pearls of wisdom there.

945
00:42:34.135 --> 00:42:36.955
So it's an un that's the joke that we have.

946
00:42:36.955 --> 00:42:39.435
As soon as John leaves, there's a, uh, sculptor video.

947
00:42:41.325 --> 00:42:43.475
First thing for is just contact one of us, one

948
00:42:43.475 --> 00:42:45.275
of the doctors, um, as soon as you can

949
00:42:45.345 --> 00:42:49.395
because, um, it takes a bit of organization

950
00:42:49.535 --> 00:42:50.595
to manage the patient.

951
00:42:51.175 --> 00:42:53.555
So what you, we can't use hilas.

952
00:42:53.555 --> 00:42:57.955
What you can do is make little blebs of, um, over the skin,

953
00:42:58.105 --> 00:42:59.315
over the overlying skin

954
00:42:59.315 --> 00:43:01.435
with some 1% lcae just around the area.

955
00:43:01.575 --> 00:43:05.515
And then you can inject saline deeper and then massage.

956
00:43:05.625 --> 00:43:06.635
That can help.

957
00:43:07.175 --> 00:43:11.555
But, um, there is some evidence that, I don't have a paper

958
00:43:11.655 --> 00:43:13.115
to prove it, but I have heard of it.

959
00:43:13.115 --> 00:43:15.115
There is some evidence that hila may help.

960
00:43:15.595 --> 00:43:18.715
I have had one patient who had a adverse reaction to hi to

961
00:43:19.275 --> 00:43:21.275
s sculptor and they did use hilas and it did improve.

962
00:43:22.055 --> 00:43:26.075
Um, but hyperbaric oxygen therapy is the,

963
00:43:27.115 --> 00:43:29.075
probably the main consideration here,

964
00:43:29.075 --> 00:43:31.795
especially if it's a large occlusion.

965
00:43:31.975 --> 00:43:34.275
Um, and it takes a bit of organization

966
00:43:34.275 --> 00:43:38.195
because there's only one in each capital city in each state

967
00:43:38.815 --> 00:43:41.795
and it, um, requires a referral.

968
00:43:42.455 --> 00:43:44.355
And some of the, um,

969
00:43:45.945 --> 00:43:48.035
hbos are now requesting plastics input

970
00:43:48.035 --> 00:43:50.075
before they actually treat the patients.

971
00:43:50.315 --> 00:43:53.795
I find, um, anyone in Victoria, Melbourne's probably the

972
00:43:54.825 --> 00:43:56.875
most accommodating and most informed.

973
00:43:57.295 --> 00:44:00.515
Um, but if, if anything happens, call us, we'll,

974
00:44:00.725 --> 00:44:01.875
we'll talk you through everything,

975
00:44:02.095 --> 00:44:04.635
but it just earlier rather than later

976
00:44:04.635 --> 00:44:06.595
because it does take a bit of organization.

977
00:44:08.335 --> 00:44:11.375
I should mention in both of those cases, the patients

978
00:44:11.395 --> 00:44:13.735
as well had full recoveries, which is good.

979
00:44:14.435 --> 00:44:17.375
Um, and there are more than one, uh, just to clarify,

980
00:44:17.425 --> 00:44:21.735
there are, there are private hyperbaric oxygen,

981
00:44:21.955 --> 00:44:23.615
oxygen chambers that you can use,

982
00:44:23.915 --> 00:44:26.335
but the big public ones are better.

983
00:44:27.475 --> 00:44:30.775
Um, and Katie can maybe they're like,

984
00:44:30.875 --> 00:44:32.845
it gets deeper into the tissues and,

985
00:44:33.145 --> 00:44:34.445
and I always had in my mind

986
00:44:34.945 --> 00:44:37.565
before this, like, you know, it was like an eye on long

987
00:44:37.565 --> 00:44:40.245
where you go sit in some tube, like out of a sci-fi movie

988
00:44:40.665 --> 00:44:43.565
and um, and then you get hyperbaric therapy.

989
00:44:43.705 --> 00:44:45.485
But actually, which I think is true for some

990
00:44:45.485 --> 00:44:48.045
of the private ones, but the big hospital ones are like just

991
00:44:48.045 --> 00:44:50.365
rooms and you sit there with the TV and watch tv,

992
00:44:50.545 --> 00:44:51.725
It, it's like an airplane,

993
00:44:51.905 --> 00:44:53.765
but, um, some of them are quite strict,

994
00:44:53.825 --> 00:44:56.725
so you can't have had your nails done within 24 hours.

995
00:44:56.825 --> 00:44:59.165
You can't have hairspray, makeup, deodorant.

996
00:44:59.475 --> 00:45:00.565
Some of them are quite strict.

997
00:45:00.585 --> 00:45:02.445
So there are a few things that you might need to do.

998
00:45:03.065 --> 00:45:05.925
Um, but also it takes about four hours per session

999
00:45:06.465 --> 00:45:10.725
and sometimes they need to, um, dive as we call it,

1000
00:45:10.905 --> 00:45:12.405
um, two, three, four times.

1001
00:45:12.785 --> 00:45:16.685
So the patient has to be prepared that it will take, um,

1002
00:45:16.795 --> 00:45:19.685
four hours and they don't get a choice when that is.

1003
00:45:19.785 --> 00:45:23.405
So the, the HBOT guys will squeeze them in when

1004
00:45:23.405 --> 00:45:24.445
they've got availability.

1005
00:45:25.145 --> 00:45:27.685
So that's the other thing to let your patients know.

1006
00:45:30.905 --> 00:45:34.035
Awesome. Thanks Katie. Any questions about that?

1007
00:45:34.215 --> 00:45:35.995
Or the case or anything else?

1008
00:45:37.095 --> 00:45:39.755
I'm just curious. Oh, sorry.

1009
00:45:40.255 --> 00:45:43.035
No, no, no, go ahead. Um, just curious,

1010
00:45:43.065 --> 00:45:46.355
with the chin treatment, was it, um, were they

1011
00:45:47.085 --> 00:45:48.435
aspirating by any chance?

1012
00:45:48.595 --> 00:45:50.395
I just wanna, I know it doesn't matter, but,

1013
00:45:50.855 --> 00:45:55.155
Uh, look, I, so here's my opinion about aspiration, um,

1014
00:45:55.765 --> 00:45:57.955
which is that you shouldn't not do it.

1015
00:45:58.155 --> 00:45:59.435
I don't wanna discourage aspiration.

1016
00:45:59.635 --> 00:46:04.475
I, uh, no, I don't think, uh, any of the chins

1017
00:46:04.475 --> 00:46:05.875
that I've managed, you know, chin

1018
00:46:05.935 --> 00:46:07.555
and tongues were aspirating

1019
00:46:08.015 --> 00:46:11.675
and I've had plenty of nurses send me, you know, pictures

1020
00:46:11.675 --> 00:46:13.795
of like, oh look, here's a positive aspirate that I had,

1021
00:46:13.855 --> 00:46:15.195
you know, in the cheek or wherever.

1022
00:46:16.295 --> 00:46:19.355
I'm not a massive fan of, fan of aspirating, purely

1023
00:46:19.355 --> 00:46:22.275
because I don't have, I don't, I don't

1024
00:46:23.095 --> 00:46:24.995
do static boluses, right?

1025
00:46:25.135 --> 00:46:28.155
So therefore for me, like it's of limited utility

1026
00:46:28.175 --> 00:46:30.355
to zero utility because my needle's not gonna

1027
00:46:30.355 --> 00:46:31.395
be in that place anyway.

1028
00:46:31.425 --> 00:46:33.795
Like, I'm gonna be moving it all over the place anyway.

1029
00:46:34.655 --> 00:46:37.365
Um, so yeah,

1030
00:46:39.805 --> 00:46:42.205
I just dunno what I feel stuck.

1031
00:46:42.445 --> 00:46:45.965
I, um, 'cause I, the last five years I've been taught,

1032
00:46:46.025 --> 00:46:47.965
you know, when I was taught how to inject,

1033
00:46:48.115 --> 00:46:52.405
I've always been still small boluses and now

1034
00:46:52.465 --> 00:46:54.045
and aspirating, and now

1035
00:46:54.395 --> 00:46:57.085
with all these new studies coming out to move the needle,

1036
00:46:57.365 --> 00:47:00.005
I just don't know if I should start moving or just staying.

1037
00:47:00.745 --> 00:47:02.045
You dry, see how you go.

1038
00:47:02.985 --> 00:47:05.725
No, I tried it once and I was like, oh, I'm too scared.

1039
00:47:05.765 --> 00:47:07.725
I don't like this. So I just stopped and went back

1040
00:47:07.825 --> 00:47:10.285
and I've, I've never had touch wood a complication,

1041
00:47:10.285 --> 00:47:11.845
which is amazing in five years,

1042
00:47:11.945 --> 00:47:13.685
but I still just think,

1043
00:47:13.805 --> 00:47:15.285
I don't know, I don't know what to do.

1044
00:47:15.505 --> 00:47:16.685
I'm just, I'm torn.

1045
00:47:17.515 --> 00:47:19.085
Well, look, I mean,

1046
00:47:19.385 --> 00:47:20.805
I'm go about, we can talk about it later.

1047
00:47:20.825 --> 00:47:22.445
The other is, you know, if, if,

1048
00:47:22.705 --> 00:47:25.525
if one insists then just consider the volume.

1049
00:47:25.885 --> 00:47:28.845
Although having said that, one of the tongues was from 0.1

1050
00:47:28.845 --> 00:47:30.805
of a mill, uh, in the chin.

1051
00:47:30.865 --> 00:47:32.725
So like, they're just, it doesn't take a lot.

1052
00:47:32.915 --> 00:47:33.925
Like, it's very small.

1053
00:47:34.585 --> 00:47:35.605
The vessels are small

1054
00:47:35.665 --> 00:47:38.365
and you know, if you're, if you get it all in there anyway.

1055
00:47:39.145 --> 00:47:43.565
Dr. With, with, with sculpt occlusion, uh, hyperbaric, uh,

1056
00:47:44.035 --> 00:47:46.085
chamber, right, if you can call it.

1057
00:47:46.085 --> 00:47:47.685
Yeah. What does it actually do?

1058
00:47:47.685 --> 00:47:50.365
Just the oxygenation of the area improves.

1059
00:47:51.725 --> 00:47:55.025
Is that the reason why they need to be, uh,

1060
00:47:55.125 --> 00:47:56.465
in hyperbaric chamber?

1061
00:47:58.155 --> 00:47:59.485
Yeah, I mean, can you wanna speak to that?

1062
00:47:59.485 --> 00:48:01.645
But yeah, it essentially gets greater oxygen

1063
00:48:01.645 --> 00:48:03.285
to the tissues, but yeah. Mm-hmm.

1064
00:48:03.395 --> 00:48:05.085
Yeah, So it increases the perfusion

1065
00:48:05.185 --> 00:48:07.885
and it also breaks, so it breaks everything down so

1066
00:48:07.885 --> 00:48:09.485
that it's smaller, it's border and slower.

1067
00:48:09.485 --> 00:48:12.525
Oh, okay. And then, so it can travel into the smaller areas,

1068
00:48:12.705 --> 00:48:16.125
but it, I think it also can help break down the material

1069
00:48:16.125 --> 00:48:17.885
depending on what's causing the occlusion.

1070
00:48:18.795 --> 00:48:23.765
Okay. Thank you. Cool.

1071
00:48:23.785 --> 00:48:27.085
And yeah, so I mean that's, um, anyway, I'm a,

1072
00:48:27.145 --> 00:48:28.445
I'm, I'm team.

1073
00:48:28.885 --> 00:48:31.245
I, I don't know that we're, I shouldn't create like team

1074
00:48:31.275 --> 00:48:36.165
Greg and team and Prof, prof, Greg Prof, Ana, uh,

1075
00:48:36.185 --> 00:48:40.165
but I, I land on Prof, Goodman's side on this one.

1076
00:48:41.145 --> 00:48:45.725
Um, any other questions?

1077
00:48:47.195 --> 00:48:49.125
It's, we've almost been an hour or so.

1078
00:48:49.525 --> 00:48:50.725
I don't think we need to take any more time,

1079
00:48:50.825 --> 00:48:54.725
but you know, as always, um, you know, reach out, um,

1080
00:48:54.985 --> 00:48:57.445
you're always welcome to, to message me, um,

1081
00:48:58.985 --> 00:49:00.525
and obviously there's WhatsApp groups

1082
00:49:00.585 --> 00:49:01.965
and et cetera, et cetera, et cetera,

1083
00:49:02.105 --> 00:49:04.485
but hopefully that is helpful.

1084
00:49:04.485 --> 00:49:08.325
Hopefully there's some principles, um, that

1085
00:49:09.315 --> 00:49:11.815
can help to, um, sort

1086
00:49:11.815 --> 00:49:13.615
of guide They're true for all occlusions.

1087
00:49:13.615 --> 00:49:16.175
And, sorry, Jessica, do I think the bruise color initially

1088
00:49:17.075 --> 00:49:18.375
did present at the time of injecting,

1089
00:49:18.375 --> 00:49:19.535
or is this more of a bruise in the

1090
00:49:19.535 --> 00:49:20.615
view on the opposing sides?

1091
00:49:20.615 --> 00:49:21.895
Unrelated. Isn't that, isn't

1092
00:49:21.895 --> 00:49:24.455
that in the first one when you say that?

1093
00:49:25.675 --> 00:49:29.875
Um, this one? Is that what you're talking about?

1094
00:49:30.735 --> 00:49:32.475
Um, if it is, that's definitely an inclusion.

1095
00:49:32.475 --> 00:49:34.155
That was, it was like a delayed presentation.

1096
00:49:34.255 --> 00:49:35.715
We didn't see that like 10 hours.

1097
00:49:35.815 --> 00:49:40.395
But, um, anyway, you guys, you'd be great.

1098
00:49:40.825 --> 00:49:42.755
Keep going. Thank you. Thank you. Thank you.

1099
00:49:42.755 --> 00:49:44.355
Have a lovely night. Go get some sleep.

1100
00:49:44.365 --> 00:49:46.435
Spend time with your children. Bye. Byebye.

1101
00:49:46.455 --> 00:49:49.915
The best number to contact me for VO is my number directly.

1102
00:49:49.915 --> 00:49:52.195
Just call me. Um, it's in the app,

1103
00:49:52.345 --> 00:49:53.395
it's in the WhatsApp groups.

1104
00:49:53.535 --> 00:49:56.595
If you don't have it, just um, find it.

1105
00:49:58.055 --> 00:49:58.795
Thanks John.

1106
00:50:12.435 --> 00:50:15.215
Thanks Dr. John. Have a good night.

1107
00:50:15.975 --> 00:50:17.515
Thanks. Yeah, you too.

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