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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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164 Essentials of neuromodulation
https://t.me/medicina_free
Complimentary locations to increase efficacy
Crows feet
Glabellar complex
Treatment goals
We are looking for partial inhibition of the superior lateral orbicularis oculi.
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 4–8 units; 2–4 units per side Botox, Jeuveau and
Xeomin.
Women total dose 5–10 units; 2.5–5 units per side Dysport.
Men total dose 4–8 units; 2–4 units per side Botox, Jeuveau and Xeomin.
Men total dose 5–10 units; 2.5–5 units per side Dysport.
Documentation
Medical history including allergies
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
Treatment area and specific dose per injection point
How 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
165Neuromodulation injection technique procedural steps
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2 2 non-woven gauze
Alcohol
Ice
Bottle opener
Marking pencil
BD insulin Syringe 31 gauge ultra thin
Non-sterile gloves
Hemostats assist in removing tight needles from luer lock or removing the
metal portion of the bottle of neuromodulator if needed.
Assessment
The patient should be assessed in animation and at rest. They should further
be assessed from all angles. Even if only treating the lateral tail of the superior
aspect of the lateral orbicularis oculi for an eyebrow lift, it is essential to
understand the relationship of the brows and the treatment area. If the
patient is having eye surgery in the future, be sure that injections stop
3 months before their scheduled surgery date. The surgeon needs to have
full expression of the muscles in order to surgical alter them permanently.
This treatment area is rich with vessels, so be sure to mark out the vessels
to minimize bruising; ice can help constrict vessels just before injecting.
Additional notation:
Lagophthalmos—incomplete closure of the eye
Excessive scleral show
Ectropion-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 patient comfortably seated in an upright position
5. Ensure adequate overhead lighting
6. Mark out danger zones
166 Essentials of neuromodulation
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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 dosing according to the desired look, anatomy and area being
treated.
9. Draw up 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 patients face thoroughly with a double cleanse and then
chlorhexidine or alcohol (allow to dry).
Technique
1. Identify the treatment danger zones.
2. Palpate the orbital rim. Identify the superior lateral portion of the orbi-
cularis oculi muscle by having the patient squint or forcefully close the
eyelids. An evident depression will be seen in the skin. Your first injection point will be outside of the lateral limbus line and 1 cm outside of
the orbital rim.
3. Mark out the injection points.
4. Be sure that the patient is still cleansed and has not touched the treatment
area since proper cleansing performed in the pre-procedural steps.
5. It is best to stand on the same side you are treating. Hold the skin taught
(be sure not to pull or manipulate the skin) so that the skin does not slide
away when you insert the needle. The first injection point will be performed while the patient is relaxed. The needle will be about 1.5 cm lateral to the lateral limbus line. The needle should be angled toward the
frontalis muscle away from the globe. Be careful to manage a slow
and steady extrusion force not to force migration into the levator palpebrae. Your depth will be subdermal and your dose will be 2 units of Botox,
Xeomin, Jeuveau, or 2.5 units of Dysport.
6. The second injection will be 1 cm medical to the first injection point
closer to the lateral limbus line. Again this injection will be subdermal
and only 1 unit of Botox, Xeomin, Jeuveau, or 2.5 units of Dysport.
7. Repeat the treatment on the contralateral side.
8. Do NOT press or rub on the injection sites. 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.
167Neuromodulation injection technique procedural steps
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Results
Lateral eyebrow elevation. Patient will notice an opening of the eye as well.
Within 3–10 days patients will start to see gradual improvement of the
dynamic wrinkles in 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.
At 2 weeks time it is strongly advised that the patient come back in for 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 is about
three. It is essential to the clients to let them know they will not be
completely frozen the entire duration of the treatment. It will take about
2 weeks to become fully effective and then at about 6–8 weeks time, the
neurotoxin 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 your photos for your records so that you can 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 are seeing the beginning stages of the reinnervation with baby sprouts of the nerve terminals. You do not need to wait
till all of the patients movement is back. Re-treat at 3 months before full
expression is restored; this way, they can train the muscles.
Follow up and special consideration
At the 2 week follow up.
If at your follow-up visit, it would be aesthetically pleasing to have a
greater lift than assess the superior lateral orbicularis oculi muscle’s function.
Should you notice significant contractility administer more neuromodulator
as you did at the previous visit. Total dose for touch up can be up to the same
amount as initial visit dose.
If your patient is not appropriately counseled on neuromodulation’s use,
they will often come back and say that the treatment did not work because
they have lines still. It is crucial that you educate the patient 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 your 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 11.4).
168 Essentials of neuromodulation
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Table 11.4 Complications management table.
Complications Cause Management
Bruising Puncture of a vessel Arnica ointment
Avoid Sun exposure to
reduce the risk of
hemosideren
staining
Swelling Trauma Ice
Pain Trauma Ice and acetaminophen
Headache Adverse event from
neuromodulation
Persistant
movement
Initial dose not adequ ate
Muscle stronger than
anticipated
Acetominophen and
real dark cocoa
Consider Zinc
deficiency
Add additional dose in
areas of movement
Static lines Late onset skin care
treatments
Sun exposure
Sun Screen
At home skin care
Skin resurfacing
treatments
Diplopia Injection in the
extrocular muscles
Inject away from the
globe
Time
Impaired
Rare Time
blink reflex
Bunny lines Can become more
Treat the nasalis muscle
prominent when
orbicularis oculi
becomes
incompetent
Worsening of
Festoons
Weakening of the
inferior medial
Time
orbicularis oculi
muscle
Epiphoria-
tearing
Weekend lacrimal
function if placed to
Time
medial to the mid
pupillary line
Lagopthalmos High dose and too deep Moistening drops
Ectropian High dose and two deep Moistening drops
Xeropthalmia Previous Lasik surgery Moistening drops
Globe truama Poor injection
Ocular specialist stat
technique
Table 11.4 Complications management table—cont’d
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Complications Cause Management
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 and
Allergist
Notate in chart new
allergy
169Neuromodulation injection technique procedural steps
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 intervention is needed as it will self-resolve. However, it is appropriate to suggest over the counter antihistamines or see their primary care or
allergist for further testing and lifestyle modifications.
170
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Essentials of neuromodulation
Before and after photos
Fig. 11.31 (A) Before photo. (B) After photo.
When this patient squints or smiles the lateral portion of her orbicularis oculi
compresses the corners of her eyes as seen in Fig. 11.31. If it is noticed during
animation, the lateral portion of her upper lid compresses down even over
her lashes seen in Fig. 11.31A, and she loses much of her iris. After treatment,
when she animates the skin of her upper eyelids remain off her lashes and she
has a bright eye in animation, noticed in Fig. 11.31B.
Treatment
Upper right lateral orbicularis oculi 2 units Botox
Upper left lateral orbicularis oculi 2 units Botox
Photos 2 weeks apart
Neuromodulation injection technique procedural steps
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171
Fig. 11.32 (A) Animated. (B) At rest.
The next patient is a unique case as she has chronic migraines and is treated
by a neurologist with Botox. Part of the migraine treatment includes the
neurologist treating the frontalis muscle. In general the neurologists are
focused on the migraine not always the aesthetic. It is common to see
patients with a flattened brow or a lid ptosis post-treatment for migraines.
Notice the patient’s medial brow has been depressed and has forced the tail
of her brow in an upwards fashion Fig. 11.32B. This is not an ideal patient
that would benefit from treatment of the tail of the brow. She is flipped up a
bit in Fig. 11.32B and in even more so with animation in Fig. 11.32A. This
situation is an excellent reminder of the importance of assessment at rest and
in animation.
172 Essentials of neuromodulation
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Neuromodulation technique in lower eyelid wrinkles
Neuromodulation for infraocular space
Static and dynamic lines can occur in this area with or without treatment in
concommitment areas. These lines may be there initially, or they may be
caused by treating the orbicularis oculi muscle. This muscle can be discerned
by examining for the presence of static lines. Should the patient have static
lines in this area, one can be sure the neuromodulation did not cause it. It
may, however, exacerbated it. Either way, it is an area that needs attention
and can be bothersome to the patients.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of moderate to severe infraocular rhytids. Treatment in
this area prevents complete contraction of the medial lower orbicularis oculi
which can also open the aperture. The infraorbital rhytids course horizontally and radiate laterally from the medial canthus to the lateral canthus.
1. Lower eyelid wrinkles
2. Plapebral aperture lengthening (distance between the upper and lower
eyelid margin and creates a rounding of the eye shape)
3. Eye bulge “jelly role.” This is different from a festoon
Emotion
No real emotion attached here, just aged appearance
Muscles in treatment area
Orbicularis oculi
Zygomaticus major
Zygomaticus minor
Levator Labii Superioris
Nasalis
Muscles to be treated in the targeted zone
Preseptal medial orbicularis oculi
Special considerations
Hyperdynamic function of the nasalis muscles
Severe lower eyelid dermatochalasis (skin laxity)
Abnormal snap test
173Neuromodulation injection technique procedural steps
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Festoons
Lagophthalmos
Excessive sceral show
Ectropion
Previous eyelid surgery (blepharoplasty)
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 note of due to its importance in the smile.
Complimentary locations to increase the efficacy
Bunny lines
Orbicularis oculi
Treatment goals
Partial inhibition of the inferior medial orbicularis oculi muscle
Dosing
Women total dose 3–6 units; 1–3 units per side Botox, Jeuveau, and
Xeomin.
Women total dose 5 units; 2.5 units per side Dysport.
Men total dose 3–6 units; 1–3 units per side Botox, Jeuveau, and
Xeomin.
Men total dose 5 units; 2.5 units per side Dysport.
Documentation
Medical history including allergies
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
The treatment area and specific dose per injection point
How the patient tolerated
Treatment plan
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