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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. 11.9 (A) Before photo. (B) After photo.
This early 40s patient was treated for frown lines to elevate her brows and
take care of the angry look she gets during concentration. Patients will often
describe the glabellar region’s expression as an angry face, a quizzical face, or
a concentration face. We are beginning to see the repeating theme here with
emotions tied to the expression on their face. As you can note between
Fig. 11.9A and B represents a slight under correction. As one can see in
Fig. 11.9B, there is a touch of movement in the medial and lateral corruga-
tor. She was initially treated with 20 units of Botox. Four units were placed
in her procerus, four units in each side of the medial corrugator, and four
units in each lateral portion of her corrugator. Additionally, 2 units were
placed on each side of the lateral tail of the orbicularis muscle. In
Fig. 11.9B, movement is still noticeable, especially in the corrugator’s medial
portion, so she received an additional 12 units in her glabellar complex to
complete the treatment to satisfaction. She constantly chews gum, which
can cause an increase in the patient’s dosing due to the constant mobility
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of all the facial muscles involved in chewing. It is important to tell clients that
this side of medicine is both art and science, and at times, it will be necessary
to add additional units to complete the look or compensate for the natural
compensatory mechanism of a neighboring muscle.
Initial treatment
Glabellar Complex 20 units Botox
Brow lift 4 units Botox
Photos 2 weeks apart
Follow up treatment
Glabellar complex 12 units Botox
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Essentials of neuromodulation
Fig. 11.10 (A) Before photo. (B) After photo.
This young female had beautiful, healthy skin that had been well kept from
the sun. She has sought out neuromodulation to preserve her youth and
hopes for a bit of a brow lift. She is an excellent example of a younger client
looking to get into the anti-aging process early on to avoid having to repair
later in life. Her mindset was to maintain and prevent aging. We did not
utilize much neuromodulation for her. Eighteen units of Botox total. Four
units in the procurus, 4 in each side of the medial corrugator, and two units
in each lateral corrugator. She had a slight asymmetry on the left brow seen
in Fig. 11.10A, so 2 units of Botox was placed in her left lateral tail of the
orbicularis oculi to elevate that brow at rest and help prevent it from dropping down when she smiles and or scowls. When she scowls, the left lid
becomes a touch heavier than her left as noted in Fig. 11.10A, and the lid
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Fig. 11.11 (A) Before photo. (B) After photo.
lays over the lash line. Fig. 11.11A and B demonstrates the neoromodulation
effect from an alternate angle. Assessments and photos are essential to be
taken in all ages and in all forms of animation. The lateral tail of the orbicularis oculi treatment was to help lift the tissue off of the lash line and create
a greater sense of alertness or a more awake look; some may refer to it as
brighter.
Treatment
Glabellar complex 16 units Botox
Brow lift 2 units Botox
Photos 2 weeks apart
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Essentials of neuromodulation
Fig. 11.12 (A) Before photo. (B) After photo.
Here is another very young lady looking to prevent the formation of static
lines in her glabellar complex. Her brows are asymmetrical, and this is exacerbated upon animation seen in Fig. 11.12A. Bilaterally her lids become
heavy when she scowls; noticed in Fig. 11.12A, there is much less heaviness,
and the attention has been shifted from the asymmetrical inner brows seen in
Fig. 11.12B. We are able to see more of her eyes in Fig. 11.12B. Overall she
had a gentle softening in the area and a general improvement of the asymmetry and reduced heaviness of the lids with animation as seen in
Fig. 11.12B. She received 16 units of Botox in the glabellar complex and
4 to treat the lateral orbicularis to help elevate the brow’s tail. Her treatment
was completed with 4 units in the procerus, 4 units in each side of the medal
corrugator and 2 units in each later portion of the corrugator. She was
thrilled with her appearance after treatment and is excited to repeat her
injections in 3 months to help prevent the signs of aging and maintain
the lifted brows.
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Treatment
Glabellar complex 16 units Botox
Brow lift 4 units Botox
Photos 2 weeks apart
Neuromodulation for the frontalis-forehead wrinkles
The activation of the frontalis muscle creates the transverse rhytids on the
forehead. The use of neuromodulation in this area reduces the transverse
rhytids, aka forehead lines, by inhibiting the muscle contraction, which
smooths the skin overlying the muscles treated. The frontal muscle is directly
responsible for the patient’s eyebrow shape and position. Careful attention
needs to be given when treating this area. Proper injection technique in this
area will yield a brow lift, and improper technique could result in an
eyebrow and or lid ptosis.
Indication for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of moderate to severe forehead lines associated with the
hyperdynamic activity of the frontal muscle in adults.
Emotions
Surprise
Shock
Disbelief
Excitement
Muscles in the treatment area
Frontalis
Orbicularis oculi
Levator palbebrae
Muscles to be treated in the target zone
Frontalis
Special consideration
1. Eyebrow position and shape. Typically women prefer high arched
eyebrows, where men prefer a flat, broad eyebrow shape. Do not
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over-promise the correction of asymmetry or a significant eyebrow lift as
the muscle can only be elevated or depressed as much as the size allows.
2. Dermatacholsis-excessive skin laxity or baggy skin of the upper eyelid
and or of the lower lid. This condition is a contraindication for the treatment of the frontalis muscle with neuromodulation. As the injector
becomes more experienced, this can be reconsidered for treatment.
Complimentary locations to increase the efficacy
Glabellar Complex Region
Procerus
Corrugator
Depressor Supercilli (depending on the space between the medial brows)
Treatment goals
The goal of this area is to reduce or obliterate dynamic forehead lines. Over
time the static lines can improve with continued use of neuromodulation. If
an eyebrow lift is desired, then a partial dose reduction in the lateral portion
of the forehead will be necessary for treatment. It is the author’s suggestion
that the area only be treated if the glabellar complex is also treated. If only the
frontalis muscle is treated, than the frontalis will become depressed and will
rest on the glabellar region, which is a naturally depressed area. By treating
the glabellar with the frontalis, the injector can enhance the elevation and
prevent a sense of heaviness. It is common for a 2-week follow-up to maintain and or create a good eyebrow position.
Dosing
Women 4–24 units Botox, Jeuveau, and Xeomin
Women 7.5–40 units Dysport
Men 12–24 units Botox, Jeuveau, and Xeomin
Men 7.5–40 units Dysport
Documentation
Medical history including allergies
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
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The treatment area and specific dose per injection point
How the patient tolerated the procedure
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 in. non-woven gauze
Alcohol
Ice
Bottle opener
Marking pencil
BD insulin Syringe 31 gauge ultra-thin
Non-sterile gloves
131Neuromodulation injection technique procedural steps
Assessment
The patient must be assessed at rest and in motion. Ask them to frown, smile,
and raise their eyebrows. Watch the patient as they speak and assess them
while they are naturally animating in conversation. Assess for dermatochalasis (skin laxity of the upper and lower eyelid). It is vital to be especially
mindful of the dermatochalasis of the upper eyelid area. Further, look for
eyebrow (low set droopy brows) and eyelid ptosis. Patients with these conditions often have significant transverse forehead lines as they utilize the
forehead to compensate for the laxity in the brow and lid. These are the type
of patients that perhaps one would treat the glabellar complex first and then
consider treating the forehead at their 2-week follow-up. Neuromodulation
of the frontalis muscle will soften the dynamic expression lines, but it will
likely create a worsening of the lid and brow ptosis, further exacerbating
the dermatochalasis. Once the ptosis is enhanced or exacerbated by the neuromodulation treatment, it can make the patients feel like that area is heavy,
and it can even change their peripheral vision. As experience and wisdom are
gained, providers may choose to treat this more challenging patient
(Fig. 11.13).
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Essentials of neuromodulation
Fig. 11.13 Treatment rows for neuromodulation.
Pre-Procedure steps
1. Consultation
2. Have patient sign consent and pre- and post-procedure guidelines
3. Photographs at 3 angles at rest and animated 50 degrees both left and
right 45 degrees both left and right straight on
4. Have patient comfortable 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
you do not inject through the marking pencil as you can tattoo the
patient
8. Calculate dosing according to desired look, anatomy, and area being
treated
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9. Draw ups medication being sure not to dull your needle by touching
the sides of the glass bottle or going through the rubber stopper with
your intended injection needle
10. Cleanse the face thoroughly with a double cleanse and then chlorhexidine or alcohol (allow to dry)
Technique
1. Identify the treatment danger zones.
2. Mark out the treatment zone paying close attention to the lateral edges of
the frontalis muscle and the peak of the brow.
3. Be sure the patient is still cleansed and has not touched the treatment area
since proper cleansing was performed in the pre-procedural steps. Have
the patient activate the muscles to be treated and begin in the center of
the frontalis muscle. Insert the needle at a 30 degree angle into the medial
portion of the frontalis. You will inject into the muscle ridge not the
crease. The belly of the muscle lives in the ridge not the crease. With
gentle pressure you will instill 2 units of Botox, Jeuveau, Xeomin or
5 units of Dysport. It is common that a patient would need another injection point above near the hair line. A common novoice mistake would
be to skip this injection and the patient is left smooth everywhere but that
one spot. This is a dead giveaway that the patient had treatment. Most
patients want to go unnoticed.
4. The injector will then continue along the frontalis muscle moving the
injection points up or with consideration of the brow position. Each
injection point will typically be 2 units of Botox, Jeuveau, Xeomin or
2.5 to 5 units of Dysport. There is not a clean cut dose or placement
in this treatment area. Many considerations play a role for this special
area. As you move along to the lateral sides of the frontalis muscle the
spacing will be 2–4 cm apart and the smaller the forehead the closer
you will be to the hairline and less injections will be performed.
5. When you are above the maximal point of eyebrow peak, place your
injection 2 cm below the hairline. It may be necessary to cut the dose
in half for this injection point.
6. Repeat on the contralateral side.
7. Do NOT press, rub, or manipulate the wheels of product. If the patient
happens to bleed you may apply gentle pressure to stop the bleeding.
GENTLE!!! It is not advised that you manipulate the product from
the site as adverse events and product migration can occur.
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