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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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134 Essentials of neuromodulation
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Results
Within 3–10 days, patients will start to see gradual improvement of the
dynamic wrinkles in the treated area. 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. It is
strongly advised that the patient come back in for a follow-up evaluation
at 2 weeks. 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 being
about 3 months. It is essential to the patients 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’ time,
the neuromodulator will start to “break.” Break, meaning a little bit of
expression or movement will start to come back, and the patient will notice
this. Be sure always to keep photos for the record so that it is a point of reference to compare. 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 considerations
Follow up appointment should always occur after 2 weeks but within
3 weeks post-treatment. At this visit, the assessment of treatment is crucial
to the long term relationship with the client. Assess for effectiveness, overall
satisfaction of the treatment, patient feelings on the treatment, and assessment of the brows.
Should the patient develop a spock brow or a peaked brow, aka a
quizzical look, additional dosing is necessary. This look is most noticeable
in animation. Let us discuss why this happens,
Under dosed
Strong frontalis
Lateral injections were omitted or not lateral enough.
The correction would be to add 1–2 units of Botox, Jeuveau or Xeomin
or 2.5–5 units of Dysport at the apex of the frontalis muscle’s peak above
the brow.
135Neuromodulation injection technique procedural steps
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Education at the initial consultation can help the patient expect certain
expressions based on the assessment and consultative process. It is advised
that they understand that a bit of a peak in the eyebrow can happen at
any point during the 2-week phase. Be sure to let them know that many
years have been dedicated to the craft and education as the injector.
The patient should feel confident that their injector is competent and understands the anatomy to manage this should it last beyond the 2 weeks settling
out phase. It is common for patients to experience this peak, spock, or surprised look temporarily during the 2-week phase, and then it settles out on
its own. They may call and demand touch up. Stand firm and counsel them
that this is normal and that a touch can not happen till the 2-week mark, or
they could risk ptosis (Table 11.2).
Table 11.2 Complications and management table.
Complications Cause Management
Bruising Penetration of a vessel Arnica ointment
Swelling Penetration of skin,
inflammatory reaction
Pain Trauma Ice and acetaminophen
Headache Anxiety Acetaminophen and real
Eye brow ptosis
(eye brow
droop or
depression)
Blepharoptsois
(eye lid droop)
Spock brow Injections in the frontalis to
Frontalis muscle injected to
low
Uncommon with frontalis
injections. Caused by
lateral corrugator treated
with penetration or
migration into the levator
palpebrae
high or not lateral
enough
Ice
dark cocoa
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
Iopidine gtts and time
Inject at the apex of the peak
1–2 units of Botox,
Jeuveau, Xeomin or 2.5
units of Dysport
Continued
136 Essentials of neuromodulation
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Table 11.2 Complications and management table—cont’d
Complications Cause Management
Eyebrow
asymmetry
Natural
May be a result of a drop and
or a spock on one side or
the other
If the relatively symmetrical
patient presents at follow
up with asymmetry. Treat
the lateral frontalis
“spock” 1–2 units
posterior to the peak of
the brow and 2 units at the
lateral tail of the
orbicularis oculi
No effect Consider Zinc deficiency
Report to the medical
science liaison of the
maker of the
neuromodulation for
further guidance
Review medical history
again, 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 Antihistamine
Follow up with primary care
or Allergist
Notate in chart new allergy
Before and after photos
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Neuromodulation injection technique procedural steps
137
Fig. 11.14 (A) Before photo. (B) After photo.
Fig. 11.15 (A) Before photo. (B) After photo.
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Fig. 11.16 (A) Before photo. (B) After photo.
139Neuromodulation injection technique procedural steps
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Young male patient with thick sebaceous skin. He was treated for static and
dynamic rhytids of the forehead. As we can see in Figs. 11.14A,B, 11.15A,B,
and 11.16A,B, he has had a significant improvement in all angles while animating. Because he was treated in the frontalis, we also treated his glabellar
complex, including his procerus, medial and lateral corrugators. We discussed his glabellar treatment in the previous section, where he received
24 units in the glabellar complex. The critical piece is noting that he was
treated in his glabellar complex as if he was not, he very well could have been
left with a heaviness of his brows and forehead. The procerus and corrugator
muscles are depressor muscles, and the frontalis is an elevator muscle. In
regards to this patient, had he only been treated in the forehead with neuromodulation, he would have felt very heavy. As his only elevator would
have become a depressor muscle sitting on top of a depressor group of muscles (procerus and corrugators). So it would have been a heavy feeling and
could have made him look and feel tired and run down. By treating the glabellar complex, we could counteract some of the heaviness by giving him lift
in-between the brows before we paralyzed his only elevator muscle in the
upper face, the frontalis. He received a total of 20 units of Botox in the frontalis muscle. Note in Fig. 11.14A, the tail of his left brow is a bit droopy. In
Fig. 11.14B, it has been perked up. He was treated with 2 units at the left
lateral tail to help give that section a bit of lift to even out his brows and open
up that eye. Taking note of these subtle asymmetries is very important in
measuring the patient’s overall satisfaction. Most patients are not aware of
their subtle asymmetries until after they receive their treatment. If injectors
have not gently addressed the patient’s asymmetry prior to treatment, it is
common for the patient to feel that the treatment has created the asymmetry.
Find a gentle yet subtle way to point out the asymmetry prior to the initiation of the treatment. Do not over-promise the correction of the asymmetry. Treat accordingly and attempt to correct it but do not over-promise.
Asymmetries can be difficult to treat as sometimes the cause is structural
or trauma-related.
Treatment
Glabellar Complex 24 units Botox
Frontalis 20 units Botox
Photos 2 weeks apart
Fig. 11.17 (A) Before photo. (B) After photo.
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Fig. 11.18 (A) Before photo. (B) After photo.
Neuromodulation injection technique procedural steps
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141
Fig. 11.19 (A) Before photo. (B) After photo.
This male patient in his 40s was seeking treatment for the glabellar complex
in combination with his frontalis. He wanted his forehead treated for his
severe static forehead rhytids. He was treated in the glabellar complex to
combat the heavy feeling he otherwise could have experienced posttreatment. A total of 24 units of Botox was utilized in this patient’s glabellar
complex along with 24 units of Botox in his forehead. A single row of injections was utilized on the lateral frontalis, and a double row was used medially, where the majority of his activity was focused. Caution was used on the
lateral portions of the frontalis, given his hooded lids at rest. The laxity of his
upper eyelid is noticed in Fig. 11.17A even in animation. This is the type of
client that needs careful attention with the frontalis treatment. If too much
neuromodulator is used or the treatment is too low, they can have a severe
heavy sensation of their lids can become even heavier. Take note of the
patient’s frontal view (Fig. 11.17B). Since he had the heavy lids to start with,
142 Essentials of neuromodulation
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a conservative approach was taken in regard to the lateral frontalis portion.
The lateral portion of his frontalis muscle was still moving at 2 weeks seen in
Fig. 11.17B, so additionally, 2 units were placed 1 cm up from the brow and
1 cm over from the mid pupillary line. Please take note of Fig. 11.17A,
Figs. 11.18 and 11.19A as he does present with a significant amount of creas-
ing on the right compared to the left side. This can be an indication that the
right side may need more neuromodulation than the other side. Unique variations are the very reason why aesthetic medicine is referred to as both art
and science. It takes an aesthetic eye to create harmony among the anatomy
(Figs. 11.20–11.23).
Treatment
Glabellar Complex 24 units Botox
Forehead 24 units Botox
Photos taken 2 weeks apart
Neuromodulation injection technique procedural steps
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143
Fig. 11.20 (A) Before photo. (B) After photo.
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