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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. 11.21 (A) Before photo. (B) After photo.
Neuromodulation injection technique procedural steps
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Fig. 11.22 (A) Before photo. (B) After photo.
Treatment
Glabellar Complex 20 units Botox
Brow lift 4 units Botox total
Forehead 16 units Botox
Photos 2 weeks apart
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Essentials of neuromodulation
Fig. 11.23 (A) Before photo. (B) After photo.
Treatment
Glabellar complex 16 units Botox
Forehead 12 units Botox
Photos taken 2 week apart
Neuromodulation injection technique procedural steps
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Fig. 11.24 (A) Before photo. (B) After photo.
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Essentials of neuromodulation
Fig. 11.25 (A) Before photo. (B) After photo.
This beautiful young female patient in her 30s has a unique peaked expression of the brows in animation when her frontalis muscle is activated. When
she animates, she does not have much dynamic movement as noted in
Fig. 11.24A; however, the peaks really concerned her. A lighter dose was
used on her frontalis as she has a shorter forehead than average and without
a significant amount of activity. A total of 12 units of Botox was adequate to
help soften the sharp point in her brow with the activation of the frontalis.
Note her right eye in Fig. 11.24A, one can see that the frontalis muscle actually pulls the lid up and creates a different appearance to her eye shape.
Fig. 11.25 is to demonstrate the same patient in a different angle before
and after treatment.
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Neuromodulation technique in lateral canthal lines aka
crows feet
Neuromodulation for lateral canthal lines—Crows feet
injections
Static and dynamic crows feet occur due to the active contraction of the lateral portion of the Orbicularis oculi muscle.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of moderate to severe lateral canthal lines associated with
orbicularis oculi muscle activity in adult patients. Treatment in this area will
soften the lines and can elevate the lateral brow.
1. Crows feet (lateral canthal lines)
2. Lateral brow lift
Emotion
Happy when smiling
Squinting to see or avoid a bright light
Muscles in treatment area
Orbicularis oculi
Zygomaticus major
Zygomaticus minor
Muscles to be treated in the targeted zone
Orbicularis oculi
Special considerations
The lateral portion of the orbicularis oculi muscle acts as a depressor to the
lateral tail of the eyebrow. This directly contributes to the eyes’ closure and
more directly creates the crows feet, aka lateral canthal lines. This muscle acts
both in the involuntary reflex of blinking and the voluntary closure of the
lids. The orbicularis oculi muscle aids in the lymphatic drainage as well. It is
important to note that in some instances, the inhibition of this muscle can
create swelling under the eyes as fluid can be trapped in the trough due to the
reduction of the orbicularis oculi’s natural force. It typically works as a pump
mechanism to push the fluid out of the area down the lymphatic system’s
track. When a patient has static lines beyond the targeted treatment area’s
scope, it is essential to discuss the treatment area and the limitations.
150 Essentials of neuromodulation
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The patient often will not understand that the lines of expression that extend
beyond the eye area and down into and over the cheeks are not part of the
treatment. When the injector can talk about a treatment plan, perhaps consider laser resurfacing or the addition of dermal fillers.
Another special consideration is the lip elevator muscles. The lip elevator
muscles in the treatment area are the Zygomaticus major and Zygomaticus
minor. The levator labii superioris sits anterior to the Zygomaticus minor.
This muscle is typically far enough out of the treatment area but should be
made a note of due to its importance in the smile.
Complimentary locations to increase the efficacy
Bunny lines
Infraocular lines
Treatment goals
Complete paralysis of the orbicularis oculi muscle. 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. If movement is left
in this treatment zone, the results can wear off quicker. Do not let the patient
dictate the dose based on the price. Remember the injector is the expert, the
expert sets the dose, and the patient decides if the recommended dose works
within their budget.
Dosing
Women total dose 24–30 units; 12–15 units per side Botox, Jeuveau, and
Xeomin.
Women total dose 50–70 units; 25–35 units per side Dysport.
Men total dose 24–40 units; 12–20 units per side Botox, Jeuveau, and
Xeomin.
Men total dose 50–70 units; 25–35 units per side Dysport.
Documentation
Medical history including allergies
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
151Neuromodulation injection technique procedural steps
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The treatment area and specific dose per injection point
How the patient tolerated
Treatment plan
Equipment
Medication
Botox
Jeuveau
Xeomin
Dysport
Bacteriostatic saline or 0.9% preservative free saline
3 mL luer lock syringe
27 Gauge luer lock 1 1/2 needle
2 2 non-woven gauze
Alcohol
Ice
Bottle opener
Marking pencil
BD insulin Syringe 31 gauge ultra thin
Non-sterile gloves
If needed, Hemostats can remove tight needles from luer lock or remove 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 you are only treating the lateral tail
of the orbicularis oculi for eyebrow lift. It is essential to understand the
relationship of the brows and your treatment area. The smile and apple
of the c heek can change with treatment in this area as well. Therefore,
it is also necessary to have the pati ent smile as to assess how the smile
can interfere with eye opening and the apple of the cheek. If the patient
is having eye surgery in the future be sure that injections stop 3 months
prior to their schedule surgery date. The surgeon needs to have full expression of the muscles in order to surgically alter them permanently. Be cautious not to inject inside the orbital rim near the lateral canthus to avoid
diplopia. This treatment area is rich with vessels so be sure to mark out
the vessels in order to minimize bruising, ice can help to constrict vessels
just prior to injecting.
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Additional notation:
Lagopthalmos—incomplete closure of the eye
Excessive scleral show
Ectropian-Eversion of the eyelid margin
Xeropthalmia-decreased lacrimal flow
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
(i) 50 degrees both left and right
(ii) 45 degrees both left and right
(iii) 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 it can tattoo the patient.
8. Calculate the 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 patients face thoroughly with a double cleanse and then
chlorhexidine or alcohol (allow to dry).
Neuromodulation injection technique procedural steps
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Fig. 11.26 Suggested injection pattern depending on the positioning of the
canthal fan.
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Technique
1. Identify the treatment danger zones.
2. Palpate the orbital rim. All injections will be placed superficially (sub-
dermally) and 1 cm outside of the orbital rim. It is essential to know the
lateral orbicularis oculi muscle lies on top of the Zygomaticus major and
minor. When treating the top portion of the orbicularis oculi at the tail
of the eyebrow, it is essential to note that the orbicularis oculi sits on top
of the frontalis muscle. Lateral Limbus Line
3. Locate the orbicularis oculi muscle by having the patient force a big smile.
4. Mark out the injection points. There is a wide variety of anatomical
presentations in this area. Each presentation will need an individual
assessment and an individual treatment plan (Fig. 11.26).
5. Be sure that the patient is still cleansed and has not touched the treatment area since proper cleansing performed in the pre-procedural steps.
6. It is best to stand on the opposite side being treated. Have the patient
turn their face to assist in the proper position. The needle should always
be inserted into the skin away from the globe. Proper positioning will
also help to prevent inadvertent involvement of the deep extraocular
muscles that would cause diplopia (Fig. 11.27).
7. Typically there is three injection points for the crow’s feet, two is
common in younger patients or patients that do not like the reposition
of the apple in their cheek by the lowest injection point of the
crows feet.
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