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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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194
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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. 11.35 (A) Before photo. (B) After photo.
Neuromodulation injection technique procedural steps
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Fig. 11.36 (A) Before photo. (B) After photo.
195
Whether the patient smokes or not, the pesky little barcode lines above the
upper lip can become a nuisance for the patients. Drinking through a straw,
kissing, sun exposure, a history of cold sores can all affect the breakdown of
this tissue. The orbicularis oris muscle is a powerful muscle with only a thin
layer of fat over it to protect it, so it is natural that this would break down in
the face of repetitive force. This area is best when treated in the preventative
phase. If the patient has severe static rhytids, they will most likely need a
proper prescription for rejuvenation; this would include CO
laser resurfa-
2
cing, a series of microneedling, filler, and an at-home quality skincare line.
This young patient had only 6 units of Botox placed just outside of the vermillion border to help lessen the hyper dynamism of the area. She had 4 units
of Botox placed above the upper lip and two below the lower lip. This
patient demonstrates a less forceful pursed-lip look in her after photo demonstrated in both Figs. 11.35A,B and 11.36A,B. Treatment in this area will
help to prevent the rapid onset of aging in this area.
Treatment
Upper lip border 4 units Botox
Lower lip border 2 units Botox
Photos taken 2 weeks apart
196 Essentials of neuromodulation
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Neuromodulation technique of gingival show AKA
gummy smile
Neuromodulation for gummy smile
A gummy smile is caused by a hyperdynamic levator labii superiors alaeque
nasi. Typically the gingival show is about 2 mm above the gum line. As the
lip pulls up, it also inverts or rolls inward, decreasing the amount of pink
show left. Overexertion of this muscle can create deeper nasolabial folds
as well. Other modalities can support much of what is done with neuromodulation. With the emerging proficiency in neuromodulation, the next step
should be dermal fillers and skin resurfacing with a medical-grade skincare
line to support and protect their in-office treatments.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of moderate to severe lip lines, aka smokers lines.
Emotion/movement
Angry
Tension
Aged
Whistle
Blow kisses
Muscles in treatment area
Levator Labii Superioris
Levator Labii Superioris alaeque nasi muscle (LLSAN)
Zygomaticus major
Zygomaticus minor
Levator anguli oris
Muscles to be treated in the targeted zone
Levator Labii Superior Alaeque nasi muscle (LLSAN)
Special considerations
Reducing the gingival show will elongate the patients’ upper lip, and in the
aged patient this may not be an ideal treatment; as a sign of aging is a lengthening of the upper lip.
197Neuromodulation injection technique procedural steps
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Complimentary locations to increase the efficacy
Depressor Anguli Oris (DAO)
Mentalis
Smokers lines
Treatment goals
Reduction of the gingival show when smiling. With the treatment of this
area, keep in mind, it is a partial inhibition in this area. A heavy-handed
dose would make the patient feel like t hey suffered paralysis and w ould
present awkward oral incompetence for eating, drinking, speaking, and
kissing.
Dosing
Women total dose 2–4 units; 1–2 units per side of Botox, Jeuveau, and
Xeomin.
Women total dose 5–10 units; 2.5–5 units per side units upper and lower
Dysport.
Men total dose 2–8 units; 1–4 units per side of Botox, Jeuveau and
Xeomin.
Men total dose 5–15 units; 2.5–7.5 units per side of 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
Equipment
Medication
Botox
Jeuveau
198 Essentials of neuromodulation
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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 helps remove tight needles from luer lock or remove
the metal portion of the bottle of the neuromodulator.
Assessment
The patient should be assessed in animation and at rest. Have the patient
force a smile as hard as possible; this way, the true degree of gingival show
can be displayed.
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.
199Neuromodulation injection technique procedural steps
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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 Levator Labii Superioris Alaeque Nasi Muscle (LLSAN)
muscle by asking the patient to smile as hard as they can.
3. Identify the point of injection and place the markings. This injection
will be done without the patient animating.
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 sneer or snarl. Specific populations will relate to the Elvis
Presley lip sneer he did with his left upper lip.
8. The first injection point will be at nearly the uppermost part of the
nasolabial fold. About 1–1.5 cm from the base of the nasal ala is where
to inject the needle. Inject the needle about halfway into the tissue.
Slowly inject 1–2 units of Botox, Xeomin, Jeuveau, or 2.5–5 units
of Dysport. Dosing will depend on the strength of the muscle and
the desired goal for relaxation of the muscle.
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
Lengthening of the upper lip, reducing the amount of gingival show, and a
softening of the nasolabial fold.
Within 3–10 days, pati ents will start to see gradual improvement of
the dynamic and static wrinkles in the treated area. A t no time during
the 2 weeks should more neuromodulator be injected in the same area.
200 Essentials of neuromodulation
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It takes a full 2 weeks for the product to take effect. All good things come
to those who wa it. 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 duration is about 3 months. It is essential to t he 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 6–8weeks,
the neuromodulator wi ll 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 co mpari son. At times, patients will call at 6 weeks and state
that all of their neuromodulator wor e 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.Itisnotnecessarytowaittillall of the patient’s movement is back.
Retreatat3monthsbeforethefullexpression is restored; this way, they
can train the muscles.
Follow up and special consideration
At the 2 weeks 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 11.8).
Table 11.8 Complications and management table.
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Complications Cause Management
Bruising Puncture of a vessel Arnica oin tment
Avoid sun exposure to reduce
the risk of hemosideren
staining
Swelling Trauma Ice
Pain Trauma Ice and acetaminophen
Headache Adverse event from
neuromodulation
Persistent
movement
Initial dose not adequate
Muscle stronger than
anticipated
Lip ptosis Inadvertant injection into
the Levator Labii
Superioris Alaequ e
Acetaminophen and real dark
cocoa
Consider Zinc deficiency
Add additional dose in areas of
movement
Time
Careful placement of a
corrective injectio n
Nasi
Oral
incompetence
and drooling
Inadvertant injection into
the Levator Labii
Superioris Alaequ e
Time
Nasi
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/
Allergist
Notate in chart new allergy
201Neuromodulation injection technique procedural steps
202
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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. 11.37 (A) Before photo. (B) After photo.
Neuromodulation injection technique procedural steps
https://t.me/medicina_free
203
Fig. 11.38 (A) Before photo. (B) After photo.
This patient has a captivating yet forceful smile. When she smiles, she presents with a gingival show seen in Figs. 11.37A and 11.38A. She has a mild
case of gingival show, but none the less it was essential to the client; therefore, we addressed it for her. Two units of Botox were placed in the right
and left levator labii superioris alaque nasi (LLSAN). About 3/4 cm from the
alar groove laterally is where this injection point will be placed. It is not a
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