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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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204 Essentials of neuromodulation
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very deep injection, either. As noticed in Figs. 11.37B and 11.38B she has a
significant reduction of the gingival show without altering her natural smile.
Treatment
2 units Botox right Levator labii Alaeque nasi
2 units Botox left Levator labii Alaeque nasi
Total dose 4 units Botox
Photos taken 2 weeks apart (Figs. 11.39 and 11.40)
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205
Fig. 11.39 (A) Before photo. (B) After photo.
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Essentials of neuromodulation
Fig. 11.40 (A) Before photo. (B) After photo.
Treatment
2 units Botox right Levator labii Alaeque nasi
2 units Botox left Levator labii Alaeque nasi
Total dose 4 units Botox
Photos taken 2 weeks apart (Fig. 11.37 and 11.38)
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Neuromodulation technique of marionette lines
Neuromodulation of the depressor anguli oris
As the aging process continues to pull everything downward it also tends to
pull in centrally as well. Patients will feel tired, drawn down, tense and begin
to have central fullness, aka jowls and marionette hollowing with the formation of bulky folds. Some patients frown with the lower face in their regular
conversations. While other patients preserve this function to show true sorrow. Watching your patients speak in the assessment naturally without force
is your best indicator to begin to see the treatment plan and how each treatment and area plays off of one another. Treating this area properly can
elevate the corners of the mouth.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of marionette lines and down turned smile.
Emotion/movement
Angry
Tension
Aged
Sad
Joker
Muscles in treatment area
Depressor Anguli Oris (DAO)
Orbicularis Oris
Depressor Labii Inferioris (DLI)
Superior aspect of the platysma
Buccinator
Muscles to be treated in targeted zone
Depressor Anguli Oris (DAO)
Special considerations
If the patient has deflated oral commissures along with deep marionette lines,
filler may be consider to help support the neuromodulation treatment. It is
essential that the DLI is avoided in this area to prevent an indavertant lower
lip drop. The DLI keeps the lip in an upright position and if your injection
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point is to medial to the commissure you will hit the DLI and drop the corner of the lip. The complexity and importance of the oral muscles needs
careful attention to detail and anatomical understanding. A mm off and
you can create a very unpleasant appearance, one that mimics a palsy.
You can be sure you will losethat patient. Time is the only remedy in this
area. In other areas the injector can attempt to inject another area or the
opposite side for balance. But once there is oral incompetence, creating
more oral incompetence is not ever advised.
Complimentary locations to increase efficacy
Mentalis
Obicularis oris for smokers lines
Platysmal
Treatment goals
Partial inhibition of the Depressor Anguli Oris Muscle. Due to the complex
and essential natural of this muscle in the region it is advised that it be partially inhibited.
Dosing
Women total dose 2–4 units; 1–2 units per side Botox, Jeuveau and
Xeomin.
Women total dose 5–10 units; 2.5–5 units per side units upper and lower
Dsyport.
Men total dose 2–8 units; 1–4 units per side Botox, Jeuveau and Xeomin.
Men total dose 5–15 units; 2.5–7.5 units per side Dsyport.
Documentation
Medical history including allergies
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
Treatment area and specific dose per injection point
How the patient tolerated
Treatment plan
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Equipment
Medication
Botox
Jeuveau
Xeomin
Dysport
Bacteriostic 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 removal of tight needles from luer lock or
removing the metal portion of the bottle of neuromodulator.
Fig. 11.41 Lower face muscles and vessels.
Assessment
The patient should be assessed in animation and at rest. Have the patient
force a smile as hard as they can and have them force a down turned smile.
Your zone of treatment will fall within 2 cm of the mandibular margin.
When the patient forces the down turn smile a hollow will be created
and then you will notice posterior to the hollow a significant bulge.
This is your landmark. If the patient can not make this face on demand it
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is not advised to treat the area. As the act of the movement is how the injector pin points the location for anatomical boundaries.
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
7. Additionally, mark out treatment areas with a marking pencil. Be sure
you do not inject through the marking pencil as you can tattoo the
patient.
8. Calculate dosing according to 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 face thoroughly with a double cleanse and then chlorhexidine or alcohol (allow to dry).
Technique
1. Identify the treatment danger zones.
2. Locate the Depressor Anguli Oris (DAO) by having the patient force a
down turned smile (Fig. 11.41).
3. Identify the point of injection and place your markings. This injection
will be done with out the patient animating. You will be treating the
inferior portion of the DAO. A point of reference could be the medial
limbus line and draw a line straight down to about 2 cm above the mandibular margin. This should be about where your injection point will
end up.
4. The injector should be positioned on the treatment side.
5. Treat the patient with their head resting back against the head rest of the
chair and eyes closed.
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6. Be sure that the patient is still cleansed and has not touched the
treatment area since proper cleansing performed in the preprocedural steps.
7. This injection should be performed while the muscle is at rest however
if the patient can hold the position you may treat in animation. The
injection will be about 1 mm lateral to the oral commissure (corner
of the lip) as you want to be sure to avoid the Depressor Labii Inferioris.
8. Inject subdermally and deposit 2 units of Botox, Jeuveau or, Xeomin,
and 5 units of Dysopot into the Depressor Anguli Oris muscle (DAO).
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 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.
Results
Reduction of downturned corners of the mouth. The patient should expect
to see an elevation of the corners of their mouth. Be thoughtful not to over
promise correction in this area as it often needs to be supported with filler in
the upper face and in the actual marionette area.
Within 3–10 days patients will start to see gradual improvement of the
dynamic and static 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 being
about 3. It is an important note to your 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 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 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
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neuromodulation 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.
It is common and necessary for patients to still demonstrate movement in
the area treated after treatment. However the goal is for reduction not complete paralysis.
If adjacent hyper dynamic movement is the cause it is advised to treat
additional areas (Table 11.9).
Table 11.9 Complications and 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
Persistent
movement
Lip ptosis Inadvertant injection into
Oral
incompetence
and drooling
Cheek
abnormality
Initial dose not adequate
Muscle stronger than
anticipated
the Levator Labii
Superioris Alaeque
Nasi
Inadvertant injection into
the Depressor Labii
Inferiorosis
Due to injection or
migration of product
into the buccinator
muscle
Acetaminophen and real dark
cocoa
Consider Zinc deficiency
Add additional dose in areas of
movement
Time
Careful placement of a
corrective injectio n
Time
Time
Table 11.9 Complications and 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.
213Neuromodulation 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.
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