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174 Essentials of neuromodulation
https://t.me/medicina_free
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 assist in the removal of tight needles from luer lock or
removing the metal portion of the bottle of neuromodulator.
Assessment
The patient should be assessed in animation and at rest. It is crucial to have
the patient squint, smile, close their eyes tight, and make a bunny face. The
hyperdyanism of these muscles can come from a variety of expressions. They
should further be assessed from all angles. Pinch the skin to assess for laxity.
Pinching of the skin is called a snap test. If the skin recoils quickly, the patient
can have treatment. If the skin has a delayed snap test for the skin to return to
normal, it is advised not to treat that particular area in the patient.
Other special instructions:
Review the medical history for surgery and whether the patient is about
to have eyelid surgery and or Lasik surgery.
Lagophthalmos—Incomplete closure of the eye. Lagophthalmos is an
absolute contraindication for the treatment of neuromodulation in
the area.
Excessive scleral show—If the patient has a crescent shape of the sclera
beneath the pupil; it is not advised to treat that the area as the neuromo-
dulator will exacerbate the scleral show.
Ectropion-Eversion of the eyelid margin.
175Neuromodulation injection technique procedural steps
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Xeropthalmia-decreased lacrimal flow.
Festoon—lower eye bags that require surgery. As the orbital septum
weakens over time, the orbital fat pad herniates and creates an eye bag
or what is called a festoon. A weakening of the orbicularis oculi over
a festoon can also exacerbate the festoon.
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
do 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 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).
Technique
1. Identify the treatment danger zones.
2. Palpate the orbital rim.
3. Identify the lateral canthal lines and mid pupillary lines.
4. The injector should be positioned on the treatment side.
5. Treat the patient with their head resting back against the headrest of the
chair and eyes closed.
6. Be sure that the patient is still cleansed and has not touched the treatment area since proper cleansing performed in the pre-procedural steps.
7. Medial lower eyelid injection. The medial lower eyelid injection will
be placed mid pupillary line and 0.5 cm below the eyelid margin. Angle
the needle bevel up and medially and parallel to the skin inject
176 Essentials of neuromodulation
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extremely superficial. Proper placement and depth will result in the
appearance of a fluid-filled wheal. Deposit 1 unit of Botox, Xeomin,
Jeuveau, or 2.5 units of Dysport here. Be mindful of tiny vessels as a
bruise in this area can become quite large.
8. The next injection will be lateral to the first injection point. Angle and
dose will be the same. Yet, the injection will be a bit lower at about
1 cm.
9. Repeat the same injections on the contralateral side.
10. Do NOT press or rub on the injection sites. If the patient happens to
bleed, apply gentle pressure to stop the bleeding. GENTLE!!! It is not
advised to manipulate the product from the site as adverse events, and
product migration can occur.
Results
Within 3–10 days, patients will start to see gradual improvement of the
dynamic and static 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. At 2 weeks, it is strongly advised that the patient come back in for
a follow-up evaluation of their treatment. Discuss how the patient feels, how
they like their results. Take after photos in the exact positions as the before
photos.
This patient was mainly concerned with the dynamic wrinkling under
her eyes when she made a bunny nose or made a face like she smelled something bad, as well as when she smiled big. 2 units of Botox were placed
extremely superficial and close to the lash line in the infraocular space.
One unit was placed superficially like a PPD plant mid pupillary line, and
the other was just a few millimeters to the lateral side and performed
extremely superficial. This treatment was done on the contralateral side.
Right infraocular space 2 units Botox
Left infraocular space 2 units Botox
Duration
Neuromodulators last anywhere from 2 to 4 months. The average is about 3.
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, 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
177Neuromodulation injection technique procedural steps
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photos for the records so that they can be refereed to for comparison. At
times patients will call at 6 weeks and state that all of their neuromodulator
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
At the 2 week follow up.
It is common for patients to still demonstrate movement in the area treated after treatment. Persistent wrinkling can be caused by underdosing.
More neuromodulation may be added at the follow-up visit if the patient
has not exhibited any of the following:
Lagophthalmos
Excessive scleral show
Ectropion
If deep static wrinkling is persistent, educate the patient on the need for
repeat treatments and perhaps cheek filler and or laser resurfacing. If adjacent
hyperdynamic movement is the cause, it is advised to treat additional areas
(Table 11.5).
Table 11.5 Complications and management table.
Complications Cause Management
Bruising Puncture of a vessel Arnica ointment
Swelling Trauma Ice
Pain Trauma Ice and acetaminophen
Headache Adverse event from
Persistant
movement
Static lines Late onset skin care
Initial dose not adequate
Muscle stronger than
Sun exposure
neuromodulation
anticipated
treatments
Avoid sun exposure to reduce
the risk of hemosideren
staining
Acetominophen and real dark
cocoa
Consider Zinc deficiency
Add additional dose in areas of
movement
Sun screen
At home skin care
Skin resurfacing treatments
Continued
178 Essentials of neuromodulation
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Table 11.5 Complications and management table—cont’d
Complications Cause Management
Diplopia Injection in the extrocular
muscles
Impaired
Rare Time
Inject away from the globe
Time
blink reflex
Bunny lines Can become more
Treat the nasalis muscle
prominent when
orbicularis oculi becomes
incompetent
Worsening of
Festoons
Weaking of the inferior
medial orbicularis oculi
Time
muscle
Epiphoria-
tearing
Weekend lacrimal function if
placed to medial to the
Time
mid pupillary line
Lagopthalmos High dose and too deep Moistening drops
Ectropian High dose and two deep Moist ening drops
Xeropthalmia Previous Lasik surgery Moistening drops
Globe truama Poor injection technique Ocular specialist stat
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
Neuromodulation injection technique procedural steps
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179
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.
Before and after photos
Fig. 11.33 (A) Before photo. (B) After photo.
This patient was mainly concerned with the dynamic wrinkling under her
eyes when she made a bunny nose or made a face like she smelled something
bad, as well as when she smiled big. Two units of Botox were placed
extremely superficial and close to the lash line in the infraocular space.
One unit was placed superficially like a PPD plant mid pupillary line, and
the other was just a few millimeters to the lateral side and performed
extremely superficial. This treatment was done on the contralateral side.
As noted in Fig. 11.33B her infraorbital creasing is reduced. Typically this
180 Essentials of neuromodulation
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treatment is best served as a combination therapy. For instance treating the
crow feet and the nasils muscle can help aid in the recovery of smooth skin in
this area.
Treatment
Right infraocular space 2 units Botox
Left infraocular space 2 units Botox
Photos 2 weeks apart
Neuromodulation technique of the bunny lines aka
nasalis lines
Neuromodulation for bunny lines
Static and dynamic lines can occur in this area with the contraction of the
nasalis muscle. It can be exacerbated when the patient smiles, frowns, or
squints. The bunny lines can be exacerbated by the use of neuromodulation
of the crows feet. The nasalis muscle contracts the sides of the nose upward
and creates the bunny line appearance.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of moderate to severe nasalis rhytids, aka bunny lines.
Emotion
Foul smell
Happy
Approval
Muscles in treatment area
Orbicularis oculi
Levator Labii Superioris
Levator Labii Superioris alaeque nasi muscle
Nasalis
Procerus
Muscles to be treated in the targeted zone
Nasalis
181Neuromodulation injection technique procedural steps
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Special considerations
Severe lower eyelid dermatochalasis (skin laxity).
Another special consideration is the lip elevator muscles. The levator
labii superioris sits anterior to the Zygomaticus minor. This muscle resides
the length of the side of the nose. This muscle is typically far enough out of
the treatment area but should be made note of due to its importance in the
smile. A transverse bunny line across the bridge of the nose can be seen at the
base of the procerus. Special considerations to anatomy make concomitant
treatments essential. Treating the glabellar complex along with the nasalis
muscle would be ideal in a patient that presents with a static rhytid across
the bridge of the nose.
Complimentary locations to increase the efficacy
Medial orbicularis oculi muscle
Lateral orbicularis oculi
Procerus
Medial and lateral corrugator
Treatment goals
Complete inhibition of the nasalis muscle
Dosing
Women total dose 4–8 units; 2–4 units per side Botox, Jeuveau, and
Xeomin
Women total dose 10–20 units; 5–10 units per side Dysport
Men total dose 4–12 units; 2–6 units per side Botox, Jeuveau, and
Xeomin
Men total dose 10–30 units; 5–15 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
182 Essentials of neuromodulation
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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
Hemostats assist in removing tight needles from luer lock or removing the
metal portion of the bottle of neurotoxin if needed.
Assessment
The patient should be assessed in animation and at rest. It is essential to have
the patient squint, smile, close their eyes tight, and make a bunny face. The
hyperdynasim of these muscles can come from a variety of expressions. They
should further be assessed from all angles. If the patient’s bunny lines result
from other active muscles, then it is advised to treat those areas as well. In
order to assess the muscle in the treatment area, ask the patient to scrunch
their nose or pretend they are smelling something foul.
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.
183Neuromodulation injection technique procedural steps
https://t.me/medicina_free
8. Calculate 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).
Technique
1. Identify the treatment danger zones.
2. Locate the nasalis muscle by asking the patient to scrunch up their nose.
3. Identify the lateral canthal lines and mid-pupillary lines.
4. The injector should be positioned on the treatment side.
5. Treat the patient with their head resting back against the headrest of the
chair and eyes closed.
6. Be sure that the patient is still cleansed and has not touched the treatment area since proper cleansing performed in the pre-procedural steps.
7. This injection should be performed while the muscle is active to be precise with the placement. Inject 2 units of Botox, Jeuveau or Xeomin or
5 units of Dysport into the subdermal lateral wall of the nose directly
into the nasalis muscle.
8. Repeat the same injections on the contralateral side.
9. At times a patient will need an injection point just on the dorsal portion
of the nose at the point of maximum wrinkling. Inject 2 units of Botox,
Jeuveau or Xeomin or 5 units of Dysport here at this site.
10. Do not press or rub on the injection sites. If the patient happens to
bleed, apply gentle pressure to stop the bleeding. GENTLE. It is not
advised to manipulate the product from the site as adverse events,
and product migration can occur.
Results
Reduction of hyperdynamic nasalis muscle AKA bunny lines
Within 3–10 days, patients will start to see gradual improvement of the
dynamic and static 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.
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