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94 Essentials of neuromodulation
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the patients’ needs. It is recommended that every new injector take a course
on psychology to understand the patients better. Understanding the patient’s
thoughts and wishes is of equal importance to the outcome. The importance
of the assessment is essential, especially when other modalities are not
offered. The injector always needs to be rooted in morality to deliver the
best possible care, and sometimes that does mean not providing any care.
The aging process is brutal in so many ways regarding volume loss,
photodamage, static and hyperdynamic muscle movement, jowling, and
many other complaints. If the problem is photodamage, the patient should
have intensed pulse light therapy (IPL), not neuromodulation. The patient
may benefit from neuromodulation, but if it is not what they seek, it will not
make it the correct treatment for them just because it is what is offered at the
practice. Pairing neuromodulation with fillers, kybella, CoolSculpting, Profound RF skin tightening, ZO skin health prescriptive skincare are all synergistic in the outcomes. At first, novice injectors will only see the muscles.
Over time, they will begin to see the skin changes, the brown spots, the
enlarged pores, the jowling, and the ligament shifts creating volume loss
and displacement of tissues. The focus while learning to inject neuromodulation will be on the muscle and the lack of animation initially. As one progresses in their learning, a natural emersion of a greater understanding of the
facial assessment will develop. The more faces the injector sees in a consult
for neuromodulation, the more they will begin developing a greater understanding of in-depth anatomy and facial assessment. Moving beyond the
proper dose and landmark combined with the needle’s right depth will yield
the next phase in the learning curve. The individual anatomical representations of anatomy will pose the most comprehensive challenge yet. Early on
in an injector’s career, they notice the value of concomitant procedures. As
wonderful as neuromodulators are, they are limited in their ability to address
aging as a whole.
Figuring out the next treatment to bring into the practice can be overwhelming, with so many platforms influencing the decision process. Turn to
the statistics for a basis for narrowing down the options. After a thorough
review of non-surgical esthetic procedures’ statistical trends, then survey
the existing patients within the practice. If the statistical data suggested that
vaginal rejuvenation was the leading non-surgical treatment, but the existing
clients all asked for photofacial, then perhaps the national statistics should be
the jumping-off point, but the real data is the survey form the existing
patients. Existing patients are a captive audience to the injector’s marketing.
However, if the patients are not in need, they will not consume the service.
The esthetics of aging
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95
Start slow and small. Become a master in one or two treatments before offering them all and only giving marginal results. The patients within the
practice are the best people to poll to figure out the next best service.
References
Benedetti, J. (2019). Structure and function of the skin. Merck Manuals Consumer Version.
https://www.merckmanuals.com/home/skin-disorders/biology-of-the-skin/
structure-and-function-of-the-skin. (Accessed 11 August 2019).
Farkas, J. P., Pessa, J. E., Hubbard, B., & Rohrich, R. J. (2013). The science and theory
behind facial aging. Plastic and Reconstructive Surgery. Global Open, 1(1), 1–8. https://
doi.org/10.1097/gox.0b013e31828ed1da.
Grey, A. (2015). Spirituality seeking theology. The Catholic Library World, 1(1), 191.
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CHAPTER 10
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Injection preparation
Now the exciting part is moving toward learning how to prepare the products and inject the patients. Developing long-lasting relationships with the
patients will set injectors apart and excel individual injectors to the next
level. Loyal patients can have a detailed yet honest conversation about their
real opinion on their treatment. How did it make them feel, what do they
see, what does the injector see? Do not ever minimize what they feel or see;
it is their face and their experience. The job of the injector is to educate the
patient and set realistic expectations through knowledge sharing.
Pause for a minute and review which direction each muscle is moving
before neuromodulation is placed. Think of it as Neuromodulators are going
to flip the script; if the muscle goes up, then in the face of neuromodulation,
the muscle will go down.
Reconstitution
All products come in a vacuum-sealed glass bottle and are in powder form,
meaning they are lyophilized. It is advised that the instructions on each
product for reconstitution be carefully read. There is a Federal Drug Administration guideline (FDA), and then there is, frequently, a varying practical
application.
Authors Recommendations for reconstitution
(1) Attach the 27 1 1/2 gauge needle to a 3 mL syringe.
(2) Clean off the top of the medication bottle and the sterile saline or bac-
teriostatic saline bottle with alcohol.
(3) Draw up 2.5 mL of bacteriostatic saline into a 3 mL syringe with the
27 gauge needle to use Botox, Jeuveau, Xeomin. Draw up 3 mL sterile
saline or bacteriostatic saline for the use of Dysport.
(4) Insert the needle at a 45-degree angle into the medication bottle. Hold
firmly to be sure the needle will not plunge straight down to the bottom and strike the glass. Remember, the bottles are vacuum-sealed.
Therefore, the needle will be pulled in rapidly and drive straight down
Essentials of Neuromodulation Copyright © 2021 Elsevier Inc.
https://doi.org/10.1016/B978-0-323-89920-8.00030-8 All rights reserved.
97
98 Essentials of neuromodulation
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if not firmly holding onto the syringe. Once all of the saline has been
placed in the medication bottle, remove the syringe.
(5) Record the date and time of reconstitution on the side of the bottle.
Take note that the vials are indicated for single use according to the
maker’s FDA approval guidelines and further recommendations.
(6) Gently swirl the medication to mix. The exception to this rule is with
the use of Xeomin. Xeomin package instructions require the provider
to flip the bottle upside down and place it on the counter upside down
for 15 min before use.
Botox 100 unit mix with 2.5 mL of bacteriostatic saline
Xeomin 100 unit mix with 2.5 mL of bacteriostatic saline
Jeuveau 100 unit mix with 2.5 mL of bacteriostatic saline
Dysport 300 unit mix with 3 mL of bacteriostatic saline
All medication prescribing guidelines recommend reconstituting with 0.9%
preservative free saline. The Aesthetic Society (2019) found in a study that
bacteriostatic saline use caused less pain during injections and demonstrated
fewer infections.
Each product depending on how it is reconstituted will yield different
units of measure per 0.1 cc. The following Tables 10.1–10.4 will help progress the novice injector to advanced. Many injectors are given just the tables
and the thought process has been taken out of then equation. It is imperative
to be able to think independently and be able to understand the concepts of
drug reconstitution and the yielding dose (Tables 10.5 and 10.6). Below
each drug table is the formulas on how to arrive at the resulting dose depending on the reconstitution.
Table 10.1 Dilution instructions for Jeuveau
100 unit vial.
Diluent
100 unit vial
10 mL 1 unit
8 mL 1.25 units
5 mL 2.0 units
4 mL 2.5 units
a
2.5 mL 4 units
2.0 mL 5 units
1.0 mL 10 units
a
Preservative free 0.9% sodium Chloride Injection, USP
only.
a
added to
Resulting dose units
per 0.1 mL
Table 10.2 Dilution instructions for Botox Cosmetic vials (100 units and 50 units).
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a
Diluent
100 unit vial
added to
Resulting dose
units per 0.1 mL
Diluentaadded
to 50 unit vial
Resulting dose
units per 0.1 mL
10 mL 1 unit 5 mL 0.5 units
8 mL 1.25 units 3 mL 1.5 units
5 mL 2.0 units 2.5 mL 2 units
4 mL 2.5 units 2 mL 2.5 units
a
2.5 mL 4 units
a
1.25 mL 4 units
2.0 mL 5 units 1.0 mL 5 units
1.0 mL 10 units 0.5 mL 10 units
a
Preservative free 0.9% sodium Chloride Injection, USP only.
Table 10.3 Dilution instructions for Xeomin vials (50 units, 100 units, 200 units).
Diluent
added to
50 unit
vial
a
Resulting
dose units
per 0.1 mL
Diluent
added to
100 unit
vial
Resulting
dose units
per 0.1 mL
Diluent
added to
200 unit
vial
Resulting
dose units
per 0.1 mL
0.25 mL 20 units 0.25 mL – 0.25 mL –
0.5 mL 10 units 0.5 mL 20 units 0.5 mL 40 units
1 mL 5 units 1 mL 10 units 1 mL 20 units
1.25 mL 4 units 1.25 mL 8 units 1.25 mL 16 units
2 mL 2.5 units 2 mL 5 units 2 mL 10 units
2.5 mL 2 units 2.5 mL 4 units 2.5 mL 8 units
4 mL 1.25 units 4 mL 2.5 units 4 mL 5 units
5 mL 1 units 5 mL 2 units 5 mL 4 units
a
Preservative free 0.9% sodium Chloride Injection, USP only.
99Injection preparation
Table 10.4 Dilution instructions for Dysport (300 units and 500 units).
Diluent added to
500 unit vial
1 mL 50 units 0.6 mL 50 units
2 mL 25 units
2.5 mL 20 units 1.5 mL 20 units
3 mL 15 units 2.5 mL 12 units
5 mL 10 units 3.0 mL 10 units
Preservative free 0.9% sodium Chloride Injection, USP only.
Resulting dose
units per 0.1 mL
Diluent added
300 unit vial
Resulting dose
units per 0.1 mL
100 Essentials of neuromodulation
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Table 10.5 Authors suggested dosing guidelines.
Authors suggested dosing guidelines
Botox, Xeomin,
Region Muscle
Jeuveau dose Dysport dose
Glabellar Corrugator supercilii
Medial
Lateral
Depressor supercilii
Procerus
6–24
4–12
4–12
4–12
Total dose 20–60
20–60
10–30
10–30
10–30
Total dose 50–100
Crows Orbicularis oculi 12–30 30–70
Lower lids Orbicularis oris 1–6 2.5–10
Horizontal
Frontalis 6–30 5–50
forehead rhytids
Lateral brow lift Orbicularis oculi
2–14 5–25
vertical & lateral
fibers
Bunny lines Nasalis 2–85–20
Vertical lip lines Orbicularis oris
3–12 5–25
(upper and lower)
Chin Mentalis 2–10 5–20
Down turned
mouth
Horizontal neck
Depressor anguli oris
4–85–20
(DAO)
Platysma 10–20 per line 20–50 per line
lines
Platysma neck
Platysma SMAS 10–20 per band 20–50 per band
bands
Hyperhidrosis Axillae, palms, soles 50–200 N/A
Table 10.6 Authors advanced esthetic suggested dosing guidelines.
Advanced injection dosing guideline
Dose per
site Botox,
Xeomin,
Condition Muscle Injections
Jeuveau
Dose per site
Dysport
Tension
headache
Frontalis
Procerus
Corrugator
4–6 injections
1–2 injections
1–2 injections
2–2.5 units
4–5 units
4–5 units
5 units
10–12.5 units
10–12.5 units
101Injection preparation
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Temporo-
mandibular
Disorder
(TMD)
Trismus Temporalis
Masseteric
hypertrophy
Down turned
mouth
Anterior
temporalis
Masseter
Masseter
Lateral
pterygoid
Masseter 2–3 injections 10–16 units 25–40 units
Depressor
anguli oris
1 injection
anterior portion
1 injection medial
portion
Stay close to the
angle
Inject bilaterally
3 points of
injections
3–4 injections
2–3 injections
Massage muscle
with finger
1 injection on the
hyperactive side
or
if both down
turned treat
both sides
accordingly
2–8 units in
anterior
portion
4–6 units
mid
portion
4–10 units
Start low
and
increase
PRN
4–6 units
4–6 units
2 units 5 units
5–20
10–15 units
10–25 units
10–15 units
10–15 units
Gummy smile Levator labii
superioris
Bar code lip
lines
Down turn
nasal tip
Neck bands
Nefrittiti neck
lift
Orbicularus
oris
Vermillion
border of
the upper
and lower
lip
Depressor
septi nasi
Platysmal Depends on the
2 injections 2–4 units 5–10 units
2–8 injections 1 unit 2.5 units
1 injection 2 units 5 units
30 units 75 units
number of
bands
102 Essentials of neuromodulation
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Example of calculation for reconstitution of Botox
This formula can be substituted for Jeuveau and Botox but not for Dysport.
100 units of Botox divided by 2:5 salineðÞand then multiply by 0:1
¼ 4 units of Botox per 0:1mL:
100 units=2:5mLðÞ∗0:1mL¼ 4 units
or
100=2:5ðÞ∗0:1 ¼ 4
or a further example:
100 units of Botox divided by 5 saline
¼ 2 units of Botox per 0:1mL:
100 units=5MLðÞ∗0:1ML¼ 2 units
or
100=5ðÞ∗0:1 ¼ 2
ðÞ
and then multiple by 0:1
Examples of calculation for reconstitution of Xeomin
This formula can be substituted for Jeuveau and Botox but not for Dysport
100 units of Xeomin divided by 2:5 salineðÞand then multiply by 0:1
¼ 4 units of Xeomin per 0:1mL
100 units=2:5mLðÞ∗0:1mL¼ 4 units
or
100=2:5ðÞ∗0:1 ¼ 4
or a further example:
100 units of Xeomin divided by 5 salineðÞand then multiple by 0:1
¼ 2 units of Xeomin per 0:1mL
ðÞ
100 units=5ML
or
100=5ðÞ∗0:1 ¼ 2
∗0:1ML¼ 2 units
Examples of calculation for reconstitution of Jeuveau
This formula can be substituted for Botox and Xeomin but not for
Dysport
100 units of Jeuveau divided by 2:5 salineðÞand then multiply by 0:1
¼ 4 units of Jeuveau per 0:1mL
100 units=2:5mLðÞ∗0:1mL¼ 4 units
103Injection preparation
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or
100=2:5ðÞ∗0:1 ¼ 4
or a further example:
100 units of Jeuveau divided by 5 salineðÞand then multiple by 0:1
¼ 2 units of Jeuveau per 0:1mL
100 units=5MLðÞ∗0:1ML¼ 2 units
or
100=5ðÞ∗0:1 ¼ 2
Examples of calculation for reconstitution of Dysport
This formula can NOT be substituted for Botox, Jeuveau and Xeomin this is
ONLY for Dysport
300 units of Dysport divided by 3 salineðÞand then multiply by 0:1
¼ 10 units of Dysport per 0:1mL
300 units=3mLðÞ∗0:1mL¼ 10 units
or
300=3ðÞ∗0:1 ¼ 10
or a further example:
300 units of Dysport divided by 1:5 salineðÞand then multiple by 0:1
¼ 20 units of Dysport per 0:1mL
300 units=1:5MLðÞ∗0:1ML¼ 20 units
or
300=1:5ðÞ∗0:1 ¼ 20
This creates less potential spread effect as you are minimizing the volume
of saline or bacteriostatic.
Storage and handling
Unopened and not reconstituted Botox and Dysport and Jeuveau should be
stored at 36–46 °F. Xeomin does not need to be stored in a refrigerator until
after it is reconstituted. Botox Cosmetic, Jeuveau, Xeomin, and Dysport can
be mixed with bacteriostatic saline and is suitable for 6 weeks. On label,
reconstitution is with 0.9% saline.
All neuromodulators will come with a package insert and will recom-
mend to reconstitute the product with normal saline. Once reconstituted,
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