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184 Essentials of neuromodulation
https://t.me/medicina_free
Duration
Neuromodulators last anywhere from 2 to 4 months. The average duration
is about 3 months. 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 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
to keep photos for the records so that they can be referred 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 some patients to still demonstrate movement in the area
treated after treatment. Persistent wrinkling can be caused by inadequate
dosing. Adding more neuromodulation at the follow up will help to complete the look in some instances.
If deep static wrinkling is persistent, educate the patient on the need for
repeat treatments and or laser resurfacing. If adjacent hyperdynamic movement is the cause, it is advised to treat additional areas (Table 11.6).
Table 11.6 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
Initial dose not adequate
Muscle stronger than
neuromodulation
anticipated
Avoid sun exposure to
reduce the risk of
hemosideren staining
Acetaminophen and real
dark cocoa
Consider Zinc deficiency
Add additional dose in areas
of movement
Table 11.6 Complications and management table—cont’d
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Complications Cause Management
Static lines Late onset skin care
treatments
Sun exposure
Diplopia Injection in the extrocular
Sun screen
At home skin care
Skin resurfacing treatments
Inject away from the globe
muscles
Lip ptosis Inadvertant injection into
Time
the Levator Labii
Superioris Alaequ e Nasi
(LLSAN)
Oral
incompetence
and drooling
Inadvertant injection into
the Levator Labii
Superioris Alaequ e Nasi
Time
(LLSAN)
Impaired blink
Rare Time
reflex
Epiphoria-
tearing
Weakend lacrimal function
if placed to medial to the
Time
mid pupillary line
No effect Consider Zinc deficiency
Report to the medical
science liaison of the
maker of the
neuromodulation for
further guidanc e
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
185Neuromodulation injection technique procedural steps
186
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Essentials of neuromodulation
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. 11.34 (A) Before photo. (B) After photo.
The primary concern for this patient was static and dynamic rhytids in the
infraocular space. We took a global approach to this patient. The emergence
of a greater understanding of the anatomy and the muscles’ relationships in
187Neuromodulation injection technique procedural steps
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more depth will move injectors away from treating the complaint, which
will increase patient satisfaction. Instead, they will begin to develop a panfacial approach to the treatment. A multifaceted approach to treatment will
lead to higher patient satisfaction and duration of the neuromodulator. Two
units of Botox were treated on each side of the nose. The nasalis muscle
works in combination with several other muscles to create movement.
The alar portion of the nasalis dilates the nares, also referred to as nasal flair.
The transverse section of the nasalis compresses the nasal aperture and wrinkles the nasal skin. Many believe that this muscle can become hyperdynamic
after years of treating the lateral canthal lines with neuromodulation. The
human body is an amazing entity. Each system or opposing muscle will
attempt to compensate for the weekend or affected side. It only makes sense
that after years of taking out the natural activity of one muscle that its counterpart would begin overcompensating to help. Fig. 11.34A and B demon-
strates a reduction in the infraocular rhytids as well as a significant softening
of the bunny lines.
Treatment
Right upper nasalis 2 units Botox
Left upper nasalis 2 units Botox
Photos taken 2 weeks apart
Neuromodulation technique of peri-oral rhytids aka
smokers lines
Neuromodulation for smokers lines
Static and dynamic lines can occur in this area with the contraction of the
orbicularis oris muscle. This hyperdynamic muscle, whether a person
smokes or not, will create the static appearance of rhytids. The act of chewing, drinking through a straw, and many other typical functions of the
mouth can all aid in the break down of the tissue by repeated use. Treating
with neuromodulation in this area will decrease the force of the muscle contraction and create a bit of a lip eversion. The eversion will help to give the
patient a bit more pink show of the lip.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of moderate to severe lip lines, aka smokers lines.
188 Essentials of neuromodulation
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Emotion/movement
Angry
Tension
Aged
Whistle
Blow kisses
Muscles in treatment area
Orbicularis oris
Levator Labii Superioris
Levator Labii Superioris alaeque nasi muscle (LLSAN)
Zygomaticus Major
Zygomaticus Minor
Depressor Anguli Oris (DAO)
Depressor Labi Inferioris (DLI)
Levator Anguli Oris
Muscles to be treated in the targeted zone
Orbicularis oris
Special considerations
The orbicularis oris muscle pulls the lip tissue in centrally and will invert the
lip. This muscles assist in eating, drinking, not drooling, whistling and
kissing.
Complimentary locations to increase the efficacy
Depressor Anguli Oris (DAO)
Mentalis
Treatment goals
Partial inhibition of the orbicularis oris.
Complete inhibition would yield great difficulty for the patient to chew,
drink through a straw, and or whistle.
Dosing
Women total dose 4–12 units; 2–6 units per side; 2–6 units upper and
lower Botox, Jeuveau and Xeomin.
Women total dose 5–15 units; 2.5–7.5 units per side; 2.5–7.5 units upper
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and lower Dsyport.
Men total dose 4–12 units; 2–6 units per side; 2–6 units upper and lower
Botox, Jeuveau and Xeomin.
Men total dose 5–15 units; 2.5–7.5 units per side; 2.5–7.5 units upper
and lower 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
189Neuromodulation injection technique procedural steps
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
Hemostat, if needed, to assist in removing tight needles from luer lock or
removing the metal portion of the bottle of neurotoxin.
190 Essentials of neuromodulation
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Assessment
The patient should be assessed in animation and at rest. Social history is
essential. If the patient continues to smoke, this treatment may not be advised.
Have the patient purse their lips, lick their lips, whistle, and blow a kiss.
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 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 orbicularis oris muscle by asking the patient to purse
their lips.
3. Identify the philtral columns.
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 at rest. Ask the
patient to purse the lips and mark the peaks for injection. We do not
treat the rhytids with neuromodulation; we treat the peaks as that is
where the most active muscle resides.
191Neuromodulation injection technique procedural steps
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8. Stay at least 1 cm from the corners of the upper lip and at least 2 cm
away from the lower corners of the lip.
9. Depending on the lip lines’ severity, two to four injection points may
be necessary on the upper lip. The lower lip can be two to three injection points.
10. The safety margin for this injection is just above the pink vermillion
border, up 0.5 cm.
11. Have the patient hold ice (that has been properly cleaned) on the treated area for about 30 s prior to your injections. This injection can make
the patient tear. Inject subdermally into the space and deposit 1 unit of
Botox, Jeuveau or Xeomin or 2.5 units of Dysport per site. The first
injection will be at the peak of the cupids bow.
12. Suppose the patient needs the second point of injection. The next
injection will follow the same dose and depth and will be 1 cm from
the peak of the cupids bow.
13. Repeat the same injections on the contralateral side. The lower lip
injections will be superficial, and be sure to avoid injection into the
DLI and the DAO. Depending on the anatomy, one central injection
may be required. Inject 1 unit of Botox, Jeuveau or Xeomin or 2.5
units of Dysport just out of the pink show of the vermillion border
but not more than 0.5 cm up the white lip.
14. Move 1 cm right and repeat injection of 1 unit of Botox, Jeuveau or
Xeomin or 2.5 units of Dysport per site. Then from the midpoint
move, 1 cm left and repeat the same dose and the same boundary.
15. 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 lip rhytids, lip eversion of the pink show.
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’ time. Discuss how the patient feels, how they like
their results. Take after photos in the exact positions as the before photos.
192 Essentials of neuromodulation
https://t.me/medicina_free
Duration
Neuromodulators last anywhere from 2 to 4 months. The average duration
is about 3 months. 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 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
to keep photos for the records so that they can be referred 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 some patients to still demonstrate movement in the area
treated after treatment. Persistent wrinkling can be caused by inadequate
dosing. Adding more neuromodulation at the follow up will help to complete the look in some instances.
If deep static wrinkling is persistent, educate the patient on the need for
repeat treatments and or laser resurfacing. If adjacent hyperdynamic movement is the cause, it is advised to treat additional areas (Table 11.7).
Table 11.7 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
Initial dose not adequate
Muscle stronger than
neuromodulation
anticipated
Avoid sun exposure to
reduce the risk of
hemosideren staining
Acetaminophen and real
dark cocoa
Consider Zinc deficiency
Add additional dose in areas
of movement
Table 11.7 Complications and management table—cont’d
https://t.me/medicina_free
Complications Cause Management
Static lines Late onset skin care
treatments
Sun exposure
Sun screen
At home skin care
Skin resurfacing treatments
Lip filler
Lip ptosis Inadvertant injection into
the Levator Labii
Superioris Alaequ e Nasi
Time
Careful placement of a
corrective injectio n
(LLSAN)
Oral
incompetence
and drooling
Inadvertant injection into
the Levator Labii
Superioris Alaequ e Nasi
Time
(LLSAN)
No effect Consider Zinc deficiency
Report to the medical
science liaison of the
maker of the
neuromodulation for
further guidanc e
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
193Neuromodulation injection technique procedural steps
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