Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_19_библиотеки_им_акад_М_И_Перельмана
.pdf
224 Essentials of neuromodulation
https://t.me/medicina_free
Indications for treatment
Neuromodulation for injection is indicated for the temporary improvement
in the appearance of neckbands.
Emotion/movement
Tension
Muscles in treatment area
Lateral Platysmal
Anterior platysma
Sternocleindomastoid
Laryngeal muscles
Muscles to be treated in the targeted zone
Lateral Pltaysma
Special considerations
It is essential to properly place the injection points. If the injection points are
not accurate, it can make it extremely difficult for the patient to lift their
head and swallow. Poorly placed injection points can inadvertently affect
the deeper muscles or the laryngeal muscles. It tends to be easier to treat this
area in animation. The band will be resistant to the needle and will feel like a
rope or chord. It is thought that the constant strain and stretch from the platysmal bands are partly responsible for the skin laxity in the neck as the
patient ages. By inhibiting the band’s activity, it is thought that the elasticity
of the skin can be preserved (Fig. 11.46).
Neuromodulation injection technique procedural steps
https://t.me/medicina_free
Fig. 11.46 Underlying structure when treating the platysmal bands.
225
Complimentary locations to increase efficacy
Depressor Anguli Oris (DAO)
Mentalis
Treatment goals
Softening of the anterior platysmal bands to create a softer looking neck
without tension.
Dosing
Women total dose 12–36 units; 6 units per band Botox, Jeuveau, and
Xeomin.
Women total dose 15–45 units; 7.5–22 units per band Dysport.
Men total dose 12–36 units; 6 units per band Botox, Jeuveau, and
Xeomin.
Men total dose 15–45 units; 7.5–22 units per band Dysport.
Documentation
Medical history including allergies
226 Essentials of neuromodulation
https://t.me/medicina_free
Medication
Dose
Lot number
Expiration date
Provider
Equipment used
Treatment area and specific dose per injection point
How the patient tolerated
Treatment plan
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 0.5-in. needle
Non-sterile gloves
If needed, hemostat helps remove tight needles from Luer lock or remove
the metal portion of the bottle of neuromodulator.
Assessment
Have the patient strain the neck to elicit the bands. Have them make a
“lizard neck,” or say EEK. Mark the area. The safety area will be 1 cm lateral
to the trachea and extends up to the commissure lines and back down to the
clavicle. The placement should be 2 cm inferior to the mandible and at least
4 cm to the clavicle.
Pre-procedure steps
1. Consultation
2. Have patient sign consent and pre and post-procedure guidelines
227Neuromodulation injection technique procedural steps
https://t.me/medicina_free
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 Platysmal bands and mark out the safety zones.
3. The injector should be positioned on the treatment side or in front of the
patient if seating allows.
4. Treat the patient with their head resting back against the headrest of the
chair and eyes closed.
5. Be sure that the patient is still cleansed and has not touched the treatment
area since proper cleansing performed in the pre-procedural steps.
6. This injection should be performed while the muscle is animated.
7. Have the patient animate and firmly grasp the band and directly inject the
needle 2 mm into the band and inject 2 units of Botox, Xeomin, or Jeuveau or 5 units of Dysport per site. Depending on the band’s length, it
will be necessary to inject three to six sites about 1–2 cm from the previous injection.
8. Repeat this for each band.
9. 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.
228 Essentials of neuromodulation
https://t.me/medicina_free
Results
Softened platysmal bands reducing the tension seen within the neck.
Improved contour of the neck.
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
(Table 11.11).
Table 11.11 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
Persistant
static lines
Dysarthria Inadvertant injection into the
Initial dose not adequate
Muscle stronger than
anticipated
Sun damage
Poor skin routine
platysmal muscle versus the
band. The muscle does
have an impact on the
corners of the mouth and
you can see this with the
articulation problems
Acetaminophen and real dark
cocoa
Consider Zinc deficiency
Add additional dose in areas of
movement
Laser resurfacing
RF micro needling
Repeat treatment
Sun screen
At home skin care
Time
Table 11.11 Complications and management table—cont’d
https://t.me/medicina_free
Complications Cause Management
Dysphagia Spread of the neuromodulator
to the deeper muscles such
was the laryngeal muscles
or the sternocleidomastoid
muscle
No effect Consider Zinc deficiency
Time
Lower the dose on the next
treatment at 3–5 months
and review safety land
marks to identify critical
structures
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
229Neuromodulation 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.
230
https://t.me/medicina_free
Essentials of neuromodulation
Before and after photos
Fig. 11.47 (A) Before photo. (B) After photo.
This patient has developed some skin laxity of her neck and submittal
area. She was partially treated to show the compensatory mechanism
of action when on ly part of the area is treate d. In Fig. 11.47A, five bands
are noted. Her initial treatment was of the band just off-center to the
left. Then in the after photo, it is noted that the remaining four bands
have become even more hyperactive, see Fig. 11.4 7B. She received
12 units of Botox in her band just to the left of midline. A complete
treatment would have include d all five bands and a total of three injections with 2 units of Botox a piece in each band. Moving toward the side
of the neck, it is an area to use caution in as it is necessary to avoid
injecting into the Sternocleindomastoid as they can have significant
heaviness holding their neck upri ght. Another area to take note of is
the laryngeal muscles surrounding the larynx. If these muscles are
injected it can lead to hoarseness and difficulty swallowing. See the
picture above for underlying structures.
Treatment
Treatment 12 units of Botox in platysmal bands Photos two weeks apart
231Neuromodulation injection technique procedural steps
https://t.me/medicina_free
Hyperhidrosis injection technique
Hyperhidrosis is an idiopathic medical condition in which excessive sweating is produced by the sweat glands of the palms, axillae, and or the soles of
one’s feet. When antiperspirants are not enough to control sweating and
odor, neuromodulation can help. One’s thermoregulatory system is not
altered in other body areas when neuromodulation is appropriately injected
into the palms, soles of the feet, or the axillae. Onabotulinum toxin A is currently the only neuromodulation that is FDA approved for hyperhidrosis.
Patients can expect 4–12 months’ worth of relief from their excessive sweating when treating for hyperhidrosis. Results kick in within 4 to 5 days. With
this treatment, the sweat glands are infused with the toxin, thus inhibiting
the acetylcholine release, which in turn decreases the patient’s sweet
production.
Indication
Primary Axillary Hyperhydrosis Treatment is anticipated to last roughly
6 months.
Safety
Be aware that the safe dose of Botox, Xeomin, and Jeaveau in 3 months is
360 units. Be sure that the dose is calculated in combination with the
patient’s other aesthetic procedures to be sure they are within the safe
doe threshold.
Pricing
It is not advised to price this by unit but, better yet, the treatment. The range
is $999–$1200.
Target anatomy
Sweat glands
The sweat glands are located within the dermis. The gland is affected by the
inhibition of acetylcholine, which decreases sweat production.
Reconstitution will differ here compared to the treatment of other
areas. The Botox, Xeomin, or Jeuveau will be reconstituted with 5 mL
of bacteriostatic saline. Resulting in 2 units per 0.1 cc. Each injection wil l
be 0.1 mL.
232 Essentials of neuromodulation
https://t.me/medicina_free
Treating the axillae
Perform a Minors’ Iodine or a starch test.
The patient should shave the area and be prepped and cleaned as per protocol. They should refrain from the use of deodorant for 24 h prior to the
treatment.
Lay the patient flat and have them raise their arm above their head to
expose the area.
Clean the area with alcohol and let dry.
Paint betadine solution on the patient’s skin and allow to completely dry.
Sprinkle corn starch on the area and brush off the excess.
Wait roughly 10–20 min. The sweat will begin to slowly turn the corn
starch and betadine mixture purple in the areas of increased sweating.
Once the area has turned purple or blue, outline the outer edges. The
outer perimeter will be the treatment boundary, and all injections will
be within this zone.
Gently wash off the betadine and starch while protecting the outline.
Always properly clean the skin before an injection.
Reconstitute a 100 unit vial of OnabotulinumtoxinA with 5 cc of Bacteriostatic saline. The larger the volume of diluent, the great the spread.
Treatment of axillae
50 units of Botox, Xeomin or Jeuveau will be used per side for a total of
100 units.
Inject 0.1 to per injection point about 20 injection points per side.
2 mm deep.
1–2 cm apart.
Bevel up.
Lay the needle flat to the skin surface and only 2 mm deep so that the
product’s wheel can be visualized.
Change the needle every four to six injections to keep the patient feeling
comfortable and to minimize bruising.
Repeat the treatment on the contralateral side.
*Note if betadine and starch are not available at the time of treatment, follow
the hair follicle pattern as that is typically the target zone in the axillae.
Each palm, sole, or axillae will take 50 units per side.
Touch-ups may be needed, and the patient should be warned about the
potential need for additional units so they can adequately plan their budget.
233Neuromodulation injection technique procedural steps
https://t.me/medicina_free
Treatment of the palms
The iodine starch test is not necessary when treating the entire palm.
Always correctly cleanse the skin before injection.
This treatment is much more painful than the axillae, and most patients.
will require a digital nerve block or topical anesthetic before treatment.
Reconstitute a 100 unit vial of Botox, Xeomin, or Jeuveau with 5 cc of
Bacteriostatic saline. The larger the volume of diluent, the great the spread.
It is advised that new injectors treat one hand at a time and start with the
nondominate hand. Due to the risk of muscle weakness, it is advised to tread
lightly with this treatment for beginners in neuromodulation.
50 units of Botox, Xeomin, or Jeuveau will be used per side for a total of
100 units.
Inject 0.1 mL per injection point except for the pulp of the fingertip,
where most patients will be more resistant to the injection. At the pulp,
inject 0.2 mL per injection point.
2 mm deep.
1–2 cm apart.
Bevel up.
100 point grid for the palms, including injections in-between the fingers and
the proximal wrist fold.
Change the needle every four to six injections to keep the patient feeling
comfortable and to minimize bruising.
Each palm, sole, or axillae will take 50 units per side.
Touch-ups may be needed, and patients should be warned about the
potential need for additional product to adequately plan their budget. Effects
will kick in in about 2 weeks and last up to 6 months and on occasion longer
(Table 11.12).
Table 11.12 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
neuromodulation
Avoid sun exposure to reduce the
risk of hemosideren staining
Acetaminophen and real dark
cocoa
Continued
Соседние файлы в папке Библиотека им академика М.И. Перельмана