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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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Essentials of neuromodulation
Before and after photos
Fig. 11.42 (A) Before photo. (B) After photo.
This patient was treated for the concern of hollowing in the oral commissures as well as feeling as if her smile was becoming down turned especially in
the face of animation. In the patients animated before picture it is noted that
when she makes a sad face she has a significant down turning of the corners
of her mouth. Over time if this is left untreated patients will have a breakdown and loss of fat in this area which creates a hollowing first and then
eventually a fold will develop leaving a static crease in the skin. In
Fig. 11.42B the patient is still able to express sadness but the force is
decreased. Many patients will benefit form neuromodulation as well as filler
for this area. Combining treatment can be the best restorative medicine. It is
essential that only the Depressor anguli oris be injected otherwise if the
depressor labii inferiors is accident injected the patients bottom lip on the
affected side will ride up over the bottom teeth.
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Treatment
2 units Botox in the right depressor anguli oris
2 units Botox in the left depressor anguli oris
Total dose 4 units Botox
Photos taken 2 weeks apart
Neuromodulation technique of the chin
Neuromodulation of the mentalis for a dimpled chin
and a robust mental crease
The lower face’s aging process is unique as the lower jaw begins to push forward, and the mentalis muscle will begin to engage to hold it back. The
mentalis engagement will cause a prominent mental crease, and the development of a peach pit chin can occur. Dimpling of the skin is corrected by
treating the mentalis muscle to help relax the muscle. It can also aid in the
illusion of an elongated jaw when that muscle is relaxed.
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of then puckered, cobble toning, or peach pit skin of the
chin. It can further elongate the jaw by dropping the chin if it is cooled in an
upward sigh fashion. The mental crease will become more pronounced and
will present a static line if the mentalis is not relaxed with neuromodulation.
Emotion/movement
Angry
Tension
Aged
Pout
Muscles in treatment area
Depressor Anguli Oris (DAO)
Orbicularis Oris
Depressor Labii Inferioris (DLI)
Mentalis
Muscles to be treated in the targeted zone
Mentalis
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Special considerations
This treatment area can cause some unique presentations while the neuromodulator begins to work. One side can work faster than the other, along
with overcompensation. Treatment of the mentalis should be considered an
advanced area, as managing the patient expectations can be challenging.
Much like the masseter muscle, the mentalis muscle is deep muscles, and
so the injection depth will be deeper but not on the bone.
Complimentary locations to increase the efficacy
Orbicularis oris for the smokers lines
Platysmal
Depressor Anguli Oris (DAO)
Treatment goals
Partial inhibition of the mentalis muscle to improve skin texture, elongate
the jawline profile, soften the mental crease.
Dosing
Women total dose 2–6 units; 1–3 units per side Botox, Jeuveau and
Xeomin.
Women total dose 5–15 units; 2.5–7.5 units per side units upper and
lower Dysport.
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 Dysport.
Documentation
Medical history including allergies
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
Treatment area and the specific dose per injection point
How the patient tolerated
Treatment plan
Equipment
Medication
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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 0.5-in. needle
Non-sterile gloves
If needed, hemostats helps remove tight needles from luer lock or remove
the metal portion of the bottle of the neuromodulation.
Assessment
The patient should be assessed in animation and at rest. Have the patient
force a smile as hard as possible. Then have them force a downturned smile.
The treatment zone will fall within 2 cm of the mandibular margin. When
the patient forces the downturn smile, a hollow will be created, and then it
will be noticed posterior to the hollow a significant bulge. This is the landmark for the injection to be placed. If the patient can not make this face on
demand, it is not advised to treat the area. As the act of the movement is how
the injector pinpoints 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 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.
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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 mentalis muscle by having the patient pout or pull up
their chin.
3. Identify the point of injection and place the treatment markings. This
injection will be done without the patient animating. Depending on
the strength of the muscle, it may be necessary to make three points
of injection. The safe zone will be in the medial portion of the chin.
Assess the patient’s natural fullness of their central lip. Typically injections will stay in that landmark. Another landmark that can be used is
drawing two straight lines down from the outer portion of the nostril,
then assessing the mentalis safety zone. Staying in this target zone with
the injections will keep the treatment delivered in the safe zone minimizing adverse events. Keep in mind that the DLI is on either side of
the mentalis and supports the bottom lip in an upright position.
4. The injector should be positioned on the treatment side or in front of
the patient if seating allows.
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.
8. Inject about halfway to the needle and deposit 2 units of Botox, Xeo-
min, or Jeuveau or 5 units of Dysport into the mentalis on the right side.
9. Repeat the same injections on the contralateral side.
10. Should the patient require a third dose, you will place it midline to the
lip and just above the right and left side injection points at the peak of
the bulge when the patient animates.
11. There are times when only a single injection point is necessary, and it is
typically the medial injection point. If a single injection point is necessary, 5 units of Botox, Xeomin or Jeuveau or 10 units of Dysport are
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standard. The injection will be deep and straight in with a slight angle.
Always insert the needle to the desired position and then slowly press on
the plunger. Once the dose has been delivered, remove the needle.
12. 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
Softened mental crease
Smoother skin over the chin
Elongated jawline profile
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
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 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
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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 11.10).
Table 11.10 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
Persistant
movement
Persistant static
lines
Lip ptosis Inadvertant injection
Oral
incompetence
and drooling
No effect Consider Zinc deficiency
Initial dose not
adequate
Muscle stronger than
anticipated
Sun damage
Poor skin routine
into the depressor
labii inferioris
Inadvertant injection
into the Depressor
Labii Inferiorosis
Acetaminophen and real dark
cocoa
Consider Zinc deficiency
Add additional dose in areas of
movement
Laser resurfacing
Repeat treatment
Dermal filler
Sun screen
At home skin care
Time
Careful placem ent of a corrective
injection
Time
Report to the medical science
liaison of the maker of the
neuromodulation for further
guidance
Review medical history, are they
on chelators, are they zinc
deficient, do they have an
underlying disease not
disclosed concerning possible
increased metabolization
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Table 11.10 Complications and management table—cont’d
Complications Cause Management
Review the reconstitution,
injections, dosing and
placement
Dysport allergy Antihistamine
Follow up with primary care and
allergist
Notate in chart new allergy
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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. 11.43 (A) Before photo. (B) After photo.
This patient was bothered by the dimpling of her chin along with the development of a static mental crease. When she would make a downturned face
or perhaps a sour face, so to speak, her chin dimpled extensively see
Fig. 11.43A. Neuromodulation was used in the mentalis muscle to elongate
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Essentials of neuromodulation
the profile, soften the skin’s dimpling, and prevent the static mental crease
(Figs. 11.44 and 11.45). In her Fig. 11.43B, she cannot pull up the chin to
cause the dimpling, and it can be noted that her chin is elongated, enhancing
her overall profile. The safety zone here would be to draw an imaginary line
from the outside corner of the nares (alar groove) straight down. The mentalis muscle resides in this space. If the treatment is to lateral to the safe zone,
the depressor labii inferiors could be accidentally injected, causing the bottom lip (from the corner of the mouth to the midline) to be forced unnaturally up over the bottom teeth. The other danger zone here is the depressor
anguli oris muscle. If this muscle is unintentionally injected, a corner of the
mouth could be forced upward in an unnatural position. Refer back to
the anatomical diagram of the lower face and note the mentalis is two
columellar like muscles. They work in unison but need their own individual
treatment.
Fig. 11.44 (A) Before photo. (B) After photo.
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Fig. 11.45 (A) Before photo. (B) After photo.
Treatment
2 units Botox in the right mentalis
2 units Botox in the left mentalis
Total dose 4 units Botox
Photos taken 2 weeks apart
Neuromodulation technique of platysmal bands
AKA the Nefertiti neck lift
Neuromodulation of the platysmal bands is done to soften the tension in the
neck and relax the bands, so they do not add stretch to the skin, increasing
the rapid onset of the aged appearance of skin laxity.
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