Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_19_библиотеки_им_акад_М_И_Перельмана
.pdf
104 Essentials of neuromodulation
https://t.me/medicina_free
it is recommended that the product be utilized within 6–24 h. It is necessary
to read the package insert frequently on each product to keep current on best
practice. However, it is common practice to reconstitute the neuromodulator products with bacteriostatic saline. When the product is reconstituted
with bacteriostatic saline, the shelf life will increase from 24 h (with normal
saline) to 6 weeks (with bacteriostatic saline). However, once the injector
has strayed from the on-label guidelines, it is no longer on the FDA
approved use of the product.
Novice areas and advanced areas for neuromodulation
Commonly treated areas
Lateral Canthal lines
Frontalis Muscle
Glabellar region
Procerus
Orbicularis Oculi
Advanced areas
Vertical Rhytids above the lips
Bunny Lines
DOA
Mentalis (Peau d’ orange)
Lower orbicularis oculi
Platysmal Bands
Masseter
Depressor Supercili
Novice (N) areas and advanced areas (A)
(N) Forhead wrinkles—Frontalis muscle to treat the transverse rhytids
on the forehead
(N) Frown Lines—Glabeller Complex Injections
(N) Eyebrow Shaping—Lateral and Medial Arch
(N) Crows Feet—Lateral Canthal Rhytids
(A) Bunny lines
(A) Gummy Smile—Gingival display
(A) Nasal tip ptosis
Injection preparation
https://t.me/medicina_free
105
(A) Marionette lines
(A) Depressor Anguli Oris Injection
(A) Neck bands—Platsymal bands
(A) Dimpled Chin: Hypertrophic Mentalis Injections
(A) Hyperhidrosis: Axillae
(A) Dental Application
References
The Aesthetic Society. (2019). Aesthetic plastic surgery national databank. https://www.surgery.
org/sites/default/files/Aesthetic-Society_Stats2019Book_FINAL.pdf. (Accessed May
2020).
Further reading
Allergan. (2020). Botox cosmetic history. https://www.botoxcosmetic.com/what-is-botox-
cosmetic/botox-cosmetic-history. (Accessed March 2020).
Dysport. (2020). For health care professionals. https://www.dysportusa.com/healthcare-
professionals#importantsafetyinformation. (Accessed March 2020).
Jeuveau. (2020). Ready for a modern-made tox?. https://jeuveau.evolus.com. (Accessed July
2020).
Xeomin. (2020). A uniquely purified choice for frown lines. https://www.xeominaesthetic.com/
professionals/. (Accessed March 2020).
This page intentionally left blank
https://t.me/medicina_free
CHAPTER 11
https://t.me/medicina_free
Neuromodulation injection
technique procedural steps
1. Treatment area
2. Indications with area defined
3. Emotions expressed with animation
4. Muscles in the treatment area
5. Muscles to be treated in the targeted zone
6. Special consideration
7. Complimentary locations to increase the efficacy
8. Treatment goals
9. Documentation
10. Equipment
11. Assessment
12. Pre-procedure steps
13. Technique
14. Results
15. Duration
16. Follow up
17. Complications
Areas for injection
1. Glabellar complex
2. Frontalis
3. Eyebrow shaping—lateral and medial arch
4. Crows feet-lateral canthal rhytids
5. Bunny lines
6. Gummy smile-gingival display
7. Smokers lines
8. Nasal tip ptosis
9. Marionette lines
10. Depressor Anguli Oris Injection
11. Neckbands—Platsymal bands
Essentials of Neuromodulation Copyright © 2021 Elsevier Inc.
https://doi.org/10.1016/B978-0-323-89920-8.00011-4 All rights reserved.
107
108
https://t.me/medicina_free
Essentials of neuromodulation
12. Dimpled chin: hypertrophic mentalis injections
13. Hyperhidrosis: Axillae
14. Dental application
Fig. 11.1 Elevator and depressor muscle diagram. Neuromodulation will cause the
opposite effect once placed in the muscle. Depressors become elevated and
elevators become depressed.
Neuromodulation for frown lines—Glabellar complex
injections
Static and dynamic frown lines occur due to the active use of the complex
depressor muscles, which consist of the procerus and the medial and lateral
109Neuromodulation injection technique procedural steps
https://t.me/medicina_free
corrugators. This was the most commonly treated area for neuromodulation, but with the recent additional FDA approval Botox, has acquired
for additional areas such as the forehead lines and the crows feet, these statistics will be rapidly changing (Fig. 11.1).
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of moderate to severe glabellar lines associated with corrugator and procerus muscle activity in adult patients.
1. Frown lines
2. Medial eyebrow elevation
Emotion
Disapproving, angry, squint due to bright lights, irritation, disdain, disgruntled, frustrated, concentration.
Muscles in treatment area
Proceurus
Corrugator
Frontalis
Depressor Supercilli
Orbicularis oculli
Levator palbebrae
Muscles to be treated in the targeted zone
Procerus
Corrugator medial and lateral portions
Depressor Supercilli
Lateral tail of the orbicularis oculi
Special considerations
If the patient has a deep-set crease across the bridge of the nose, the injector
will want to inject a bit lower at the procerus insertion point on the nasal
bridge. Alternatively, provide two injection points into the procures to help
remedy the horizontal crease. It is common to find patients that use their
frontalis muscle to frown. If this is the case, it is advised that the injector educate the patient on the need for concomitant treatment of the frontalis.
110 Essentials of neuromodulation
https://t.me/medicina_free
Complimentary locations to increase efficacy
Frontalis
Lateral canthal lines
Treatment goals
Inhibit the procerus and corrugators’ activation to minimize the patient’s
ability to frown or furrow. Preventing muscle activity in this area will help
to prevent deep-set at rest rhytids from developing. This treatment can be
both preventative and restorative.
Dosing
Women 12–30 units Botox, Jeuveau, and Xeomin
Women 30–70 units Dsyport
Men 24–40 units Botox, Jeuveau and Xeomin
Men 50–70 units Dsyport
Documentation
Medical history including allergies
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
Treatment area and specific dose per injection point
How the patient tolerated
Treatment plan
Equipment
Medication
Botox
Jeuveau
Xeomin
Dysport
Bacteriostatic saline or preservative-free saline
3 mL luer lock syringe
27 Gauge luer lock 1 1/2 in. needle
2 2 non-woven gauze
111Neuromodulation injection technique procedural steps
https://t.me/medicina_free
Alcohol
Ice
Bottle opener
Marking pencil
BD insulin Syringe 31 gauge ultra thin
Non-sterile gloves
Hemostat, if needed, to assist in the removal of tight needles from luer lock
or removing the metal portion of the bottle of neuromodulator.
Assessment
The patient should be assessed in animation and at rest. They should further
be assessed from all angles. Even if only the glabellar complex is being treated, the forehead should still be assessed at rest and with animation. It is
essential to understand the relationship between the brows and the treatment
area. It is also necessary to have the patient smile as well to assess how the
smile can interfere with the lateral tail of the eyebrow, which is most often
a part of the treatment zone for the glabellar complex.
Pre-procedure steps
1. Consultation
2. Have patient sign consent and pre and post-procedure guidelines
3. Photographs at three angles at rest and animated
50 degrees both left and right
45 degrees both left and right
Straight on
4. Have the patient comfortably seated in an upright position
5. Ensure adequate overhead lighting
6. Mark out danger zones
7. Additionally, mark out treatment areas with a marking pencil. Be sure
not to inject through the marking pencil as this can create a
permanent tattoo.
8. Calculate dosing according to the desired look, anatomy, and area
being treated.
9. Draw up the medication, being sure not to dull the needle by touching
the sides of the glass bottle, or going through the rubber stopper with
the intended injection needle.
10. Cleanse the face thoroughly with a double cleanse and then chlorhexidine or alcohol (allow to dry) (Fig. 11.2).
112
https://t.me/medicina_free
Essentials of neuromodulation
Fig. 11.2 SAFE ZONE for injection into the glabellar complex.
Technique
1. Identify the treatment danger zones.
2. Mark out the treatment zone paying close attention to the lateral edges of
the corrugators. This area can be elicited by having the patient frown.
Often, a bit of a divot is seen where the corrugator ends, and the levator
palpebrae inserts onto the forehead above the mid pupillary line.
3. Be sure that the patient is still cleansed and has not touched the treatment
area since proper cleansing performed in the pre-procedural steps.
4. Have the patient activate the muscles to be treated and begin at the procerus muscle. Inject in the middle of the procerus belly. The needle will
be inserted about halfway into the skin if using a 31 gauge 5/16
needle. Inject 4 units of Botox, Jeaveau, Xeominor 10 units of Dysport
to the belly of the procerus. Do not hit the periosteum. If the periosteum
is struck, back the needle out before pushing the product into the muscle.
When the periosteum is struck, change the needle or the syringe as it will
be lead to an increase in the sheering of the skin and vessels, leading to an
increased risk of bruising. Should a two-point injection be necessary to
the procerus, place one injection toward the bottom of the procerus and
one at the top of the procerus muscle. If the patient has a deep crease that
runs straight to the insertion at the nasal bridge, it will be necessary to split
the injection and do half on either side of the split. So this time inject 2
units of Botox, Jeuveau, Xeomin or 5 units of Dysport bilaterally into
both bellies of the procerus (Fig. 11.2).
00
(8 mm)
113Neuromodulation injection technique procedural steps
https://t.me/medicina_free
5. The next injection point will be placed into the corrugator muscle about
1 cm inferiorly to the previous injection of the procerus muscle. Angle
the needle toward the procerus muscle. The needle depth will be about
1/2 way into the skin. Slowly inject 4 units of Botox, Jeuveau, Xeomin
or 10 units of Dysport at this insertion point.
6. Now move to the lateral corrugator. Have the patient contract the targeted muscles for the best visualization of the area. Insert the needle
about 1–2 cm above the supraorbital ridge at the lateral margin of the
corrugator muscle. It is essential that the injector angle the needle toward
the procerus muscle and insert the needle 1/4–1/2 in. (depth depends on
individual patient anatomy) way in and deliver 2–4 units of Botox,
Jeuveau, Xeomin or 5–10 units of Dysport depending on the desired
dose. Be sure to push slowly with the bevel down. The reason for injecting toward the procerus muscle is to avoid inadvertent spread or diffusion
to the frontalis or levator palpebrae muscle.
7. Repeat steps five and six on the opposite side.
8. Do not press or rub on the injection sites. If the patient happens to bleed,
apply gentle pressure to stop the bleeding. GENTLE!!! It is not advised
that manual force and manipulation occur in the area post-injection.
Manual manipulation can force the product from the intended site,
and the patient may suffer from an adverse event.
Results
Within 3–10 days, patients will start to see gradual improvement of the treated area’s dynamic wrinkles. At no time during the 2 weeks should more
neuromodulator be injected in the same area. It takes a full 2 weeks for
the product to take effect. All good things come to those who wait. At
2 weeks’ time, it is strongly advised that the patient come back in for a
follow-up evaluation. Discuss how the patient feels, how they like their
results. Take after photos in the exact positions as the before photos.
Duration
Neuromodulators last anywhere from 2 to 4 months. The average length is
about 3 months. It is essential to the clients to let them know they will not be
completely frozen the entire treatment duration. It will take about 2 weeks
to become fully effective, and then at about 6–8 weeks, the neuromodulation will start to “break.” Break, meaning a little bit of expression or
Соседние файлы в папке Библиотека им академика М.И. Перельмана