hi everyone I'm Danny sure I'm a physician assistant and I'm going to show you ultrasound guided temple in Layer Two so the reason why I don't typically safe map the temple is because it is high risk and it's easy to get a live guided visual when I say it's high risk it's this area is its potential for causing blindness and so I always kind of start with the idea of if it's easy to get a live guided Visual and it's a high risk area then that means it's an area that I recommend doing ultrasound guided technique rather than safe mapping so we always start with the idea of where do we want to put the filler so Nikki I'm gonna have you open your mouth and this is how I kind of find what I call Temple pool this is how I find the bottom of the pool I kind of find the deepest recess and I put a little dot there to kind of use as a point of reference you can close your jaw and that is where I'm going to be focusing my bolus so this is actually a ultrasound guided bolus in the temple and I'm going to use sub Q so Layer Two you've seen layer four two is actually I think easier to get into and it's also a great layer to fill you just want to use a much more thinned out product so in order to start the process of an ultrasound guided the first thing you need to do we're going to go in the longitudinal plane with our nub and up and we're going to put it right on top of the area we just found as the middle of Temple pool so what I'm doing here is what I call checking things out in the wild so I'm kind of interested in getting my Doppler View and I want to see how things look in the wild before I do anything this is also where I plan out my attack for the temple so I always like to think about it I use the analogy as like those movies where there's a guy with a machete and he's chopping down the jungle to create a path so this is kind of like what we're doing here we've created a very narrow path of a view as to where we're going to get an in-plane injection with our cannula so in order to recreate this path we need to Mark the bottom of the probe so this is where we're gonna you know tell future visitors that this is the beginning of our jungle path okay so I go to the bottom of my probe and I've kind of created a point A to point B scenario this is my point a this was the bottom of my probe and this is the area of my middle marker where I just visualized so I want to go from point A to point B and I want to lay my bolus right in the middle of that pool which we just looked at now did we see any vessels here along this path we sort of lucked out because looking at the screen we're really not seeing vessels this is a great moment to ask yourself do you need to find the superficial temporal artery to do this injection do you need to find the Deep temporal artery to do this injection we do not because we're going to use a cannula and we are kind of plotting out our course in this very thin narrow strip I'm going to use a tongue depressor to kind of demonstrate this is the path that arcanula is going to travel about the thickness of a cannula too so we do not see those vessels in this thickness in this path okay that's okay this is not where we need to go find those vessels to do this injection so Nikki is a great a great example of locking out we don't see those vessels if we did see those vessels we would just be very cognizant of where they are and either go above or below them in layer 2 or layer 4. so Layer Two we're going to go really superficially so because we've plotted out this bottom of our probe that's where I'm going to put a little wheel of Lidocaine because that's where my cannula is going to enter just a tiny little poke Nikki just a little bit of Lidocaine and that's where we're going to enter and then after that we are going to make our cannula site now while I'm waiting for that to numb up I'm going to go back to B mode because when I'm doing ultrasound guided I really want to be in B mode I don't need all that drama of a power doppler with a cannula going into it because it'll look crazy really we just want to see that our cannula is in Layer Two which is the Sub-Q layer right beneath the skin so I'm going to make my tiny little introducer site I don't need to go crazy with it a lot of times I see people doing crazy stuff with their introducer needle I think all you need to do is make a tiny little poke and then I've got my very low G Prime product because I'm going to go superficially and then to make sure I'm Sub-Q I'm just tacking the skin down and just sliding up and it should be a very easy Glide plane it's very very easy usually doesn't hurt and now you see my point A to point B there's my point B that's the depth of my pool and now I'm going to go back with my ultrasound and I'm going to make sure that I'm in Layer Two where I envisioned and I'm exactly in Layer Two where I want to be you can see that's all Sub-Q tissue and you can see my cannula is right there at the top and we can just lay our bolus now if you want to watch it go live this is you can see the anechoic you can also see what happens on the screen which is the backtrack of the filler up the cannula I'm going to get a little bit better View and I'm just going to lay my bolus here right in that plane and a lot of times people are wondering well it doesn't spread out as much I actually think it spreads out fine now that I know I'm in that plane I can always take it off and watch it fill and that's a half of a cc of a very low G Prime product and then what I do is I just have her opener jaw again and I just spread it out and that was our first bullets now she is a little Hollow so she could actually probably use a little bit more but what I do is I usually just start with one syringe and let it get into the tissue and take a look at it before I add any more close your jaw for me and with a nice low G Prime tissue just smooshing it down with your thumb a little bit you're able to have it spread instead of using the cannula up and back um so that is ultrasound guided with a cannula
