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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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114 Essentials of neuromodulation
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movement will start to come back, and the patient will notice this. Be sure
always to keep photos for the records to compare pre and post-treatment. At
times patients will call at 6 weeks and state that ALL of their neuromodulators wore off, and they need to be re-seen or re-treated. Pictures will come
in handy here as it is likely they see the beginning stages of the reinnervation
with baby sprouts of the nerve terminals. It is not necessary to wait till all of
the patient’s movement is back. Retreat at 3 months before the full expression is restored; this way, they can train the muscles.
Follow up and special consideration
It is common for patients to still demonstrate movement in the area treated
after treatment. Therefore, it is necessary to assess the patient in animation
and add additional units according to the previously treated muscles with
movement. Additional dosing ranges from 2–4 units of Botox, Jeuveau,
Xeomin per site, or 5–10 units of Dysport per site.
If the patient only had the glabella complex treated when they frown,
they may activate their frontalis muscle. At which time, the injector could
advise that the patient take treatment in the forehead. A patient’s potential to
need additional dosing at a follow up is an important discussion point to have
before the initial treatment. Informed consent starts with ensuring the
patient has proper expectations of the treatment goals and effect. Patients
can quickly feel like they had a bad or botched injection treatment if the
expectations were not identified.
If the glabellar complex is treated without the forehead; the patient’s
brows may seem extremely high, peaked, or spocked. If this is the case, then
treat the frontalis accordingly. The patient must be informed that this can happen before treatment. The patient needs as much information upfront to
make informed consent, plan their budget, and anticipate the progression
of the treatment as it takes effect till they get to their end result at 2 weeks out.
If the patient is not appropriately counseled on the use of neuromodulation, they will often come back and say that the treatment did not work
because they have lines still. The patient must be educated that the treatment
is only working on the muscles and the motion and that it is not intended to
reduce the static lines. Of course, there is a caveat; in the younger patients, it
can reduce the appearance of static lines, but this is not something the injector should promise. Always teach the client that the treatment is for the
hyperdynamic muscle movement, not the static line (Table 11.1).
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Table 11.1 Complications and management table.
Complications Cause Management
Bruising Penetration of a vessel Arnica ointment
Swelling Penetration of skin,
Ice
inflammatory reaction
Pain Trauma Ice and acetaminophen
Headache Anxiety Acetominophen and real dark
cocoa
Eye brow ptosis
(eye brow
droop or
depression)
Injection into frontalis
muscle
Do nothing
You may consider adding
more units to the medial
corrugators, procerus and
lateral tail of the orbicularis
oculi. Add more only if the
patient can still move the
muscles in that area
Medial eyebrow
splaying
To much neuromodulator
Depressor Supercilli
Best course of action is time
injected
unintentionally or in
the wrong candidate
Blepharoptsois
(eye lid droop)
Inadvertent injection into
the levator palpebrae
Iopidine gtts and time
No effect Consider Zinc deficiency
Report to the medical science
liaison of the maker of the
neuromodulation for
further guidanc e
Review medical history, are
they on chelators, are they
zinc deficient, do they have
an underlying disease not
disclosed concerning
possible increased
metabolization
Review the reconstitution,
injections, dosing and
placement
Dysport allergy Cows milk protein allergy Antihistamine
Follow up with primary care
or Allergist
Notate in chart new allergy
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Essentials of neuromodulation
Details on Dysport allergy
If using Dysport and the patient is allergic, the patient will complain of
flu like symptoms or feeling run down like they are experiencing seasonal allergies or experiencing a sinus infection. Not all patients know
that they have a milk protein allergy, and treatment with Dysport
uncovers the allergy. Typically no int ervention is needed as it will
self-resolve.However,itisappropriatetosuggestoverthecounterantihistamines or see th eir primary care or alle rgist for further test ing and
lifestyle modifi cations.
Before and after photos
Fig. 11.3 (A) Before photo. (B) After photo.
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Fig. 11.4 (A) Before photo. (B) After photo.
This before and after picture in Fig. 11.3A and B demonstrates, inadvertently, an improvement within the static lines after treatment with neuromodulators. However, keep in mind, it is not the intended goal. The
goal is to prevent the muscle from animating and causing the further breakdown of the skin. This male patient in his 40s has a healthy turgor to his skin,
some laxity, and photodamage. The skin on his forehead is a bit thicker than
females, but not quite as thick as one may commonly cross with male patents. It is appreciable to note the eyelid laxity of this male patient in
Figs. 11.3A and 11.4B. Figs. 11.3A and 11.4A demonstrates the enhanced
lid laxity with animation. After he received neuromodulation and attempts
to scowl, note the lack of eyelid depression in both Figs. 11.3B and
11.4B. When a patient has hooded eyes, the injector needs to be cautious
when treating the corrugator’s lateral tail and the frontalis to not make
118 Essentials of neuromodulation
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the brow or lid any heavier. In Fig. 11.4B, during the scowl, his lash line on
the left side shows his lash line, but in Fig. 11.4A, the scowl obliterates the
lash line. These differences may appear subtle in the picture, but they can be
night and day in terms of a feeling to the patient. When depressor muscles
lose their tension, they can become very heavy, and patients feel like they are
carrying them around. With appropriately placed neuromodulation, they
can have a sense of a weight lifted. The patient’s side profile view in animation shows a remarkable difference in the lid heaviness in this patient’s after
photo. In the after photo his lash line is visible, whereas in the animated
before picture the lash line is obliterated. Look at the amount of scleral show
in the after photo compared to the before photo. This is representative of a
home run for both the patient and the injector. This patient photo is an
excellent reminder to take photos and assess the patient from all angles
and in animation at all angles. This patient was treated with 24 units of Botox
in the glabellar region. He had 4 units in the procerus, 6 units to each medial
corrugator, and 4 units to each lateral corrugator.
Treatment
Glabellar complex 24 units Botox
Photos 2 weeks apart
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119
Fig. 11.5 (A) Before photo. (B) After photo.
Thirty-year-old female in good health with some hyperpigmentation from
intermittent skin eruptions. The patient’s goal for treatment with neuromodulation was to have a more youthful presentation with a lift of the upper
face and prevent the rapid onset of aging. Fig. 11.5B demonstrates a nice
opening of her eye when she is frowning. This leaves the focal point on
her beautiful brown eyes while she is expressing disdain. She is able to maintain more of a wide-open look to her eyes after treatment with neuromodulation as opposed to her before photo in Fig. 11.5A. Her brow position
stays more upright in animation after successful treatment with neuromodulation as noted in Fig. 11.5B. Her treatment was successful for the reduction
of the frown lines, as seen in Fig. 11.5B. She received a total of 20 units of
Botox. Four units in her procerus, four units in the medial corrugator. Four
units on the right and four units on the left medial corrugator and then two
units in each of lateral tails of the right and left corrugator. Then she received
two units on each side of the later tail of the orbicularis oculi.
Treatment
Glabellar Complex 20 units Botox
Brow lift 4 units Botox
Photos 2 weeks apart
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Essentials of neuromodulation
Fig. 11.6 (A) Before photo. (B) After photo.
This female patient was treated for the improvement of moderate to severe
frown lines. The brightening of her eye and the lift she has received from the
neuromodulation treatment is beautiful. In Fig. 11.6A, her gorgeous spider
leg, long lashes are hidden under the skin fold during animation. Once the
neuromodulator kicked in, we could capture the beauty of her lashes as they
cascade toward her brow was uninterrupted by the laxity of the upper eyelid
as seen in Fig. 11.6B. Take note that there is a noticeable reduction of the
frown lines between the eyebrows and the ancillary services that the neuromodulation treatment provided in Fig. 11.6B. Look at the medial brow
where the depressor supercilii rests and look at the wrinkling in that tissue
space in Fig. 11.6A. Fig. 11.6A shows three strong deep creases. If this area
were left untreated, it would become static lines at rest. In Fig. 11.6B, those
three medial lines at the beginning of her brow are gone. This reduction of
creasing changes the light’s ability to reflect in different areas highlighting a
121Neuromodulation injection technique procedural steps
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youthful appearance. She received a total of 20 units of Botox for the treatment of her glabellar region. She received 4 units in her procerus, 4 units in
each side of her medial corrugator, and 4 units in each side of the lateral corrugator muscles. Also, she received a small amount for a brow lift. Each lateral tail of the orbicularis oculi received 2 units per side.
Treatment
Glabellar Complex 20 units Botox
Brow lift 4 units Botox
Photos 2 weeks apart
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Essentials of neuromodulation
Fig. 11.7 (A) Before photo. (B) After photo.
This is a young man has thick olive toned sebaceous skin. He is a youthful
male seeking treatment for prevention as well as restoration. He has developed some static lines, given the thickness and strength of his animation. In
Figs. 11.7B and 11.8B you can see significant improvement in the hooding
of his eyes; beyond the obvious reduction of glabella activity. Preneuromodulation in Fig. 11.7A his brows force the lids down and create a heaviness
over the eye in this young patient. Yet, in Figs. 11.7B and 11.8B, while he is
in animation, one can see much more of his sclera and the iris of his eye, and
even his pupil. Creating openness gives the impression of youth, awake,
alert, and vibrance. This is where we can begin to attach emotions to the
findings just as the patient would. So far, each patient shown has presented
differently, even though their goals have all essentially been the same, maintenance, prevention, and youth. A tremendous amount of hyperdynamic
movement is not necessarily evident in the glabellar region in
Fig. 11.7A. However, what is most prominent is the drawn down pulling
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Fig. 11.8 (A) Before photo. (B) After photo.
of the brows medially. Fig. 11.8A demonstrates the dynamic expression lines
better than forward-facing. His treatment was to lift the skin folds off his lash
line to create openness in animation instead of the forceful contraction
noted. This shows the importance of animated photos in every position with
all animation variations such as a scowl, smile, resting, surprised, and sad face.
This young man received 24 units total in his glabellar complex. There were
4 units in his procerus, 6 units in each medial corrugator both right and left,
and 4 units in each lateral tail of his corrugator. Given the natural flattening
of the brow and how it compressed so much to obliterate the patient eyes
when he scowled, he was treated with 2 units of Botox in each lateral tail of
the orbicularis oculi.
Treatment
Glabellar Complex 24 units Botox
Brow lift 4 units Botox
Photos 2 weeks apart
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