good morning I'm John Arlette and we're here today to examine a change below this patient's Ambassador she had some filler placed in this area in order to re-drape the jaw and developed a localized change which we've aspirated and shown no bacteria in it has been cultured on two occasions and it has gone down she initially had some difficulty in opening her mouth and some local discomfort that now has faded So today we're here to aspirate what's left within this small loculated area and show you ultrasound guided intervention with aspirating it after which we will put some hyaluronidase directly into the area to dissolve any remaining filler so when we just have the patient turn her head to the side a little bit we're going to localize this and I'm going to be watching on the Monitor and we can see here that we have a anechoic area at the base of the masseter right on top of the mandible you can see the fascia around the masseter we can see that this is relatively superficial and what we'll be doing is we'll go right into this so we know that the size of this area who we'll be aiming for is about 5.4 millimeters in thickness so we'll go back onto looking at this area now before I go ahead with this we can see it's well localized I'm just going to take the device off I'm going to put a little bit of local anesthetic in to make it more comfortable for our patient and lend a little bit of this a little bit of discomfort as I put the local anesthetic in now as we're doing an intervention we're moving to a sterile process the ultrasound gel we're using comes from a sterile package we're just putting a sterile cover over top of the monitor so you can see we now have a sterile sheath over top I have sterile gloves we have our sterile syringe and we're just going to pop the top off the the needle we're now going to localize the area again so we can see this under the ultrasound and I'm just going to bring the needle in here we have an example of using ultrasound guided intervention to see what has happened over time with an area of change so we had a solitary area that was initially loculated with purely materially in it this was aspirated and then the hyaluronic acid gel that was present was dissolved the area decreased in size and now we have just a firm area that does not have a loculation or Central abscess as we haven't been able to aspirate anything from this area I suspect that this is now a granuloma which causes to think about a couple of options of how this is developed and so what I'm now going to do is I'm going to inject this directly with some triamcinolone acetonide 20 milligrams per ml right into the body of the let's call it a nodule and we'll see how that then changes the course of this lesion now we're using a much thinner needle we're in our knot and you can just see the steroid go in so now we've started our second stage of treatment we've tried our intervention in terms of aspiration which we have done before we've injected it with hyaluronidase and today we've aspirated we've been unable to aspirate any material so we've injected directly into this area with triamcinolone and satanoid we've put in 0.2 ccs of 20 milligrams per mil using a 22 gauge needle so there we have it ultrasound guided intervention for an area below the masseter which develops subsequent to filler injection foreign
