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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_19_библиотеки_им_акад_М_И_Перельмана
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Essentials of neuromodulation
Fig. 9.3 As the face ages, fat atrophy often occurs in the mid-face area and settles at or
below the jaw.
always start by looking at the patient’s skeletal structure, evaluating the fat
pads, and evaluating the skins’ overall appearance. Looking for movement
and static lines can give the injector insight into how the patient is aging.
Aging is a layered concept and often starts laterally and progresses midline.
As we begin to retire the youthful characteristics, we should be preparing to
build progressively to optimize the natural beauty of the unique features the
patient possesses. With an astute analysis and proper diagnosis, the treatment
plan for correction and restoration can be created.
The skeletal aging process can be addressed with soft gel-like hyaluronic
acid fillers. Reversible dermal fillers improve the patients’ safety profile, and
the providers, given the risk, are decreased in regards to adverse events. The
use of dermal fillers will address bone loss areas, allowing the skin to redrape
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over the re-volumized bone structure. The injector can then address skin
tone and texture with the use of chemical peels, prescriptive skincare,
and or the utilization of light-based, heat-based, or radiofrequency devices.
The last or it could be the first step in addressing the face as a whole is the use
of neuromodulators to stop the hyperdynamic expressions using neuromodulators. Morphological changes occur on every level and layer of the face;
the skin, the skeleton, soft tissue, retaining ligaments, and fat compartments.
The intrinsic and extrinsic variables are what make each patient’s presentation unique. The prescriptive plan for rejuvenation must include a proper
diagnosis and a rejuvenation plan that is obtainable with the tools the injector
has available in the office.
A patient’s restorative plan should be a stepwise approach and should
address the internal and external factors affecting aging. This plan should also
address the face with thoughtful consideration to all the layers of the face.
Create an organized and detailed plan for patients to be educated and
empowered in order to make the right decisions for themselves.
A treatment plan should be written out and provided for the patient. Find
a way to brand the prescriptive treatments so patients can be a reference
point for the patient, and if it is eye-catching and pretty, they will keep it
with them and show their friends. In Fig. 9.4 you can see the treatment cards
that DCCM™ uses at check out for the front desk staff’s convenience. The
treatment card is scanned into their record and then given to the patient as a
point of reference. It is branded so that the plan sticks out in the eye and the
minds of the patient. This will be discussed in greater detail when we move
to the assessment portion of the reading.
Throughout the aging process, 1% of dermal collagen is lost per year and
hyaluronans, especially after 50. Fillers can be curative and even preventative. Studies show that fillers have a synergistic effect in stimulating collagen
production. Maintenance is essential with upkeep and unique and specialized at-home care. Fillers and neuromodulators are not a replacement for a
facelift, but with impressive advancements in laser devices and other nonsurgical options, a facelift can be postponed. Many surgeons have found a
way to combine the facelift with other minimally invasive procedures to create an even more natural look. The current trends show that surgeries are
falling in the statistics, while non-surgical options continue to rise. Extrinsic
factors such as smoke or smoking, alcohol, nutritional intake, gut biome, and
even stress all cause brown spots, rough texture, and premature aging on all
facial levels.
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Essentials of neuromodulation
Fig. 9.4 DCCM™ prescription treatment card. (Top) cover. (Bottom) back side.
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Genetics, or otherwise known as intrinsic factors, also affects all the skin
layers and contributes to the thinning of the dermis, dryness, and elasticity
loss. Combine poor genetics with poor lifestyle choices, and a stellar recipe
for rapid and early onset aging has been developed. However, this recipie is
what creates an esthetic client. When patients seek injectors services and are
still smoking, not utilizing sunscreen, or are in tanning beds, they may not be
the best client for services. This type of client will have the most need, yet
the results most likely will not be the best due to their lifestyle choices. These
lifestyle choices can impact the outcome of esthetic treatments and or
impede longevity. At times it is best to counsel the client on lifestyle choices
before we pick up the syringe.
Aging muscles
Lying beneath the fat pads is the muscles that are repeatedly in motion
through chewing, swallowing, talking, laughing, and so many other facial
activities, causing the volume shift and or loss in the fat pads. As the fat is
lost, the muscles’ repetitive motion will directly lead to static deep lines.
Creases will begin to form at the corners of our mouth, in-between patients’
eyebrows and the corners of their eyes, to name a few.
The facial muscles do get weaker over time. The loss in muscle tone,
combined with the skin’s thinning, can make it very hard to treat a client
with just neuromodulation. As patients progress in their aging process, injectors are forced to think of it as a unit of carefully woven together subsets. As
the face ages, we also need to be mindful and often need to change the
approach to the injection plan. It is thought by many varying esthetic injectors and esthetic surgeons that the aging of muscles is not all that well understood. It has been reported that muscles lengthen with age, increase in tone,
meaning at rest. Muscles are more contracted in youth. Aging and weakening muscles are why the development of static rhytids in highly dynamic
areas increases with age.
Bones are the foundation of exterior features. Everything rests on that
gentle foundation. Typically a youthful appearance will have full high
cheekbones. Age changes the dimensions of the bones, and the position
shifts. The orbital rim will widen, creating a hallow look to the under eyes;
there is also a significant change in the brow bone’s angle, allowing the tail of
the eyebrows to drop low and create hooding skin in the lids. Bones are continuously changing from the time we are born. The height of the midface
will reduce as we age simultaneously with the angle of the anterior face.
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Essentials of neuromodulation
Fig. 9.5 Age over time.
Ultimately bone resorption changes the boney landscape, which redistributes all other structures of the face (Fig. 9.5).
Patient selection
Patient selection is crucial in esthetics. It is appreciable that there is a high
rate of body dysmorphia and unrealistic expectations in this industry. Body
dysmorphia and unrealistic expectations bring about an interesting topic for
discussion. That is, the injector gets to choose the patient as well as the
patient choosing the provider. Esthetic medicine is a talent based business
coupled with a medical or nursing license. If an injector feels a patient
may not be the right candidate for neuromodulation, the injector must
not treat them. There is a slew of reasons why a patient would not be the
right candidate. Injectors need to assess the patient not just from a physical
standpoint but also from a psychological perspective. Being sure they are of
sound mind and are reasonable with their goals and the anticipated outcome
is key to the injector’s success of the outcomes. It is far more effective to say
no to a patient than to continually chase a look that is not achievable. In the
beginning phases of an injector’s career, it is common to feel so excited to
have patients in the treatment chair looking to experiment and treat
everyone.
Nevertheless, we need to hit the breaks and genuinely assess the patient
to be sure they are appropriate candidates. Do not get so excited and
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blindsided by the opportunity or the dollar amount. Injectors must only treat
the right candidate. A significant amount of education will be necessary to
share at the patient consult. Sharing the anticipated treatment goals and realistic outcomes are all part of the process and will only aid in the patient’s
overall satisfaction with the treatment. Patient satisfaction was highlighted
previously, focusing on patients having a false sense of understanding of
the product’s intended use. Their lack of understanding, coupled with
the false sense of reality portrayed by social media platforms due to misrepresentations and filtered results, can increase patient dissatisfaction. If the
injector is quick to perform the treatment in the wrong candidate, it may
end up costing them more in the long run. It is better not to treat than
to be in the business of chasing results or having to offer refunds. Esthetic
medicine is not a get rich quick business. Esthetic medicine is medicine,
and the patient’s needs should always come first. Inject with full knowledge
of anatomy, and in-depth understanding of the mechanism of action of the
drugs being used, and a foundation of morality. Think on all levels before
beginning to inject. Look at the situation from the patient’s perspective
and develop sound treatment plans based on science, research, and integrity.
Injecting to get rich can ensure failure. The sense of integrity and morality is
transparent to the patients. Patients are savvy and will see through this mindset. This mindset can also hinder the development of meaningful relationships within the industry that will be discussed later in the reading.
Patient assessment
Before we begin to get into the art of assessment, it is a good idea to review
some terms that are more friendly to the patients’ ears. A consult is a vulnerable time for them and can lead to a feeling of worthlessness or hopelessness if
injectors do not choose positive words over negative words. Think for a
minute about the difference between these two statements.
This deep fold here on the lower face can be filled with filler, that will be
$1800.
Alternatively, another version would be:
The nasolabial fold can be softene d by redraping th e skin of the cheeks
and then adding a bit of volume directly to the affected area. This way, a
natural repositioning of the tissue wil l occur due to the placement of the
product. The total wo uld be $1800toaddressthesetwoareas.Thecostdid
not cha nge, but the presentation did. It is essential to use words th at do not
make the p atient feel bad. It is the injector’s job to create a sense of peace
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for the patient as many of them feel badly about their aging process; “I
should not have drank,” “I should not have laid in the sun,” “I should have
started earlier.” The patients are already beat ing themselves up. It is the job
of an injector to soften that blow. An injector is not just filling and freezing
better yet; they offer patients a sense of restored yout h; we are often
empowering them to look and feel their best. Many patients arrive at
the doorst ep of rejuvena tion clinics beca use they ha ve just endure d some
of their most challenging life moments, and they are ready to make a
change for the better. The first foot in the door is th eir path to making
a positive change in their lives, both physically and emotionally. If the
injector can not tap into the emotional side of the reason they are in the
treatment chair; the results will always be mediocre. Even though the
injections may be perfect, the patient also needs the confidence to recognize their beauty. The job of an injector sometimes his 90% psychological
and 10% treatment.
Create a journey for the patients and create an environmentwhere they are
relaxed,educated, and can begindevelopingtheir confidence. Empower them
to take charge and not look to the past. Better yet, show them what the future
can look like in trusting hands. Continued educationin esthetics, dermatology,
and an advanced understanding of anatomy will help empower the injector,
empowering the patient.Beinga leaderand an innovator,beingkind,and sharing knowledge are just a few keys that can help separate one injector from
another. Point and plunge injectors are not the goals that should be set to
become a success in the industry. Let us move on to those kinder, gentler terms
to share with the patient during the assessment and consultative process.
A consistent assessment with an individualized treatment
plan will yield success.
Consider sharing the following ideas with the patients:
Refill with fillers
Resurface with lasers and chemical peels
Relax with neuromodulators
Redrape with fillers or surgery
Retighten with elastin boosting treatments such as the profound device
by Candela Medical.
Consider the face like a bed. The volume loss is the mattress, and the skin is
the sheets. Once the mattress is volumized, it is essential to put fresh
unstained sheets on the new mattress. Reversing the hands of time does
not happen over night, nor does it happen on one facial plane. Be sure to
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make the patient aware of this so that then a collaborative approach to creating a treatment plan to meet their goals. When the injector and the patient
are in harmony with their understanding of one another, patient satisfaction
is increased.
Over the years, the field of esthetic medicine has moved away from assessing patients in a one-dimensional view. We now view patients at rest, in
motion, and from all sides at rest and in motion. With each new product
or device technology development, there comes a new way for injectors
to view their patient during the assessment. Another view on assessment
yields a different prescription for treatment. The advancement of technology, combined with the evolution of the assessment process, only enhances
the injector’s ability to create better and more beautiful, natural results. The
art of assessment should consist of animation, rotation, and tilting (Fig. 9.6).
Ultimately, any treatment’s success will come from the injector and the
patient viewing the facial features from all angles and in all forms of animation in all angles. It is advised that consistent photos are captured of the
patient at rest and in motion from all angles. It is common practice to have
photos from a side profile, 3/4 angle, and straight on.
(1) Animation is necessary for all esthetic treatments. Watch the patient
animate while they are talking to see them in their natural animated
state. Then, have them squint, raise their eyebrows, frown, and smile.
Be sure to take note of both upper and lower face animation changes.
Take note of asymmetries at rest and with animation. When the treatment begins, be mindful not to overcorrect the at rest asymmetry as the
correction can create a new asymmetry in animation. It is a delicate
Fig. 9.6 The art of assesment.
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balance with the treatment. Pointing out an asymmetry to the patient
should be a delicate and considerate conversation when a patient has a
stronger nasolabial fold on one side versus the other. It is best not to
point out the heaviness of the fold. Instead, discuss with the patient that
the muscle is a bit stronger on one side versus the other side, causing the
difference. Alternatively, another may approach it from another position on the face altogether. It could be helpful to note the difference in
the fullness of the patient’s cheek. The injector might say that one
cheek bone sits a bit higher than then the other side. So, if the opposite
side is volumized, the nasolabial fold can then be softened. Please note
to the patient that all patients have subtle asymmetries, and they make
each patient unique.
(2) Rotation is necessary to view from all sides of the face.
Have the patient rotate from side to side and view these positions
both in rest and animation. Take note of the severity of rhytids. Are
they moderate or severe? When the patient turns to the side, this is
an opportunity to evaluate the canthal fan; is it a full fan, upper, middle,
or a lower fan? An iPad or tablet can be helpful in the assessment process
as well as a mirror to engage the patient in the thoughts and observations as the treatment plan is being created. When they can begin to
understand the evaluation process, the multistep approach will often
be an easier transition for them. If the patient cannot understand
why the injector is doing what they are doing, they will unlikely convert from one syringe to multiple syringes or multiple modalities. We
never want to sell to the patient. We want to educate them so that they
can make informed decisions as well as informed consent.
(3) Tilting is extremely important to highlight the malar fat pad split when
the tear troughs and cheek volume are a concern. Ask the patient to put
the chin down in order to assess this portion of the face. This tilted position is also essential to notate the central laxity developing in the
patient’s face. The patient should tilt their face down, bringing the chin
to the chest, and then have them lookup. Do their eyebrows raise? The
injector can assess for ptosis in this position and focus on the levator
palpebrae superioris.
Physical assessment
Let us begin to identify key assessment features regarding neuromodulation
and those specific muscles in the treatment zone.
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Assessment of the upper face
When assessing the Glabella region, always assess at rest and in animation. It
is also wise to assess the patient naturally, observing them talking during their
consult. Capturing the standard animation is critical in successful treatment.
If the patient presents with a downward pull that forms a line at the
bridge of the nose, then a dose of neuromodulator will need to be placed
low in the procerus. Another example is if the patient presents with at rest
creases or creases with animation between the eyebrows, then the corrugator, both medially and laterally, will need to be treated.
It is imperative to note the pull of the lateral tail of the brow. If the patient
has a significant pull at the tail, and this injection is missed, they will still present with movement in this area at 2 weeks. If the opportunity to see them
back at 2 weeks is missed, the relationship an outcome could be compromised. Leaving even a little movement could shorten the life of the treatment, thus creating a dissatisfied patient.
There is an important consideration when treating only the glabella
region, which is to assess the lateral portion of the frontalis about mid
way up the forehead; this has been referred to as the Mephisto sign. To assess
this region, the injector will want to immobilize the glabella complex with
two fingers and then have the patient raise their brows. If it is noted that the
patient has an exaggerated arch in the brow during the assessment, then it
will be necessary to treat the main pull of the arch on the frontalis.
Assessment of the frontalis
First and foremost, does the patient even have a functioning frontalis muscle?
Have the patient close their eyes, gently open the eyes. If the patie nt
moves the frontalis during this gentle movement, they are not the right
candidate for forehead treatment. Given that the frontalis muscle is the
only elevator muscle for the brows, and if that is taken out by treating
the frontalis, they will feel heavy and develop hooding of the lids. They
will say they feel like they have to continually lift the brow, lift their brow
to put makeup on, or have a headache. No matter how they describe it.
They will not like it.
In a suitable candidate, one will want to asses within the treatment zone
and beyond the temporal suture lines to gain insight into the entire area.
Does the patient have a split in the midline of their forehead, or are the lines
consistent across the forehead’s entire span?
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