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234 Essentials of neuromodulation
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Table 11.12 Complications and management table—cont’d
Complications Cause Management
Persistant
perspiration
No effect Consider Zinc deficiency
Initial dose not adequate,
injection to deep or
missed a spot
Consider Zinc deficiency
Add additional dose in areas of
persistent sweating
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
Duration
Neuromodulators last anywhere from 2 to 4 months. The average duration
is about 3 months. However, in this particular treatment it is common for it
to last 6–9 months. It is essential to the clients to let them know they will not
be completely sweat free the entire duration of the treatment. It will take
about 2 weeks to become fully effective.
Follow up and special consideration
At the 2 weeks follow up:
It is common for some patients to still have some sweating in the area
treated after treatment. Persistent sweating can be caused by inadequate dosing. Adding more neuromodulation at the follow up will help to complete
the treatment along with the patients satisfaction.
CHAPTER 12
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Complications
Potential complications
Complications section
Tips to Limit negative sequela or displeasing results
(1) Know your injection anatomy.
(2) Understand dynamic expression.
(3) Understand the equal and opposing areas that can aid in the remedy to
complications post-treatment.
(4) Know the depths and relative dimensions of the structures you are
injecting.
(5) Educate yourself with more than just 1-weekend course.
(6) Comprehensively understand the pharmacokinetics and pharmaco-
dynamics of the neuromodulator in use.
(7) Proper and in-depth facial assessment is critical in excellent outcomes.
(8) Strict adherence to the state board and regulatory parameters.
(9) Know your Scope of Practice for the state you are practicing in
(10) Have a comprehensive understanding of the aging process
Poor patient satisfaction can be due to a number of causes; insufficient dosing, placement, improper handling, reconstitution, storage and anatomical
variations of the client. Paresis is directly correlated to the dose and placement of the BoNT-A administered. This is where the concept of “the art of
medicine” comes to light. It is essential to understand the drug you are utilizing but is also necessary to understand patients’ individual features and specific esthetic goals.
Reconstitution is similar to Botox, Xeomin, and Jeuveau yet is vastly different regarding Dysport. All products went to FDA for approval, with the
use of the preservative-free normal saline 0.9%. However, it has been
reported that the use of bacteriostatic 0.9% saline with benzyl alcohol
improves the longevity of the drug post reconstitution, decreases pain at
the injection site, and also provides for a decrease in post-injection infections
(American Society of Plastic Surgery ASPS, 2019).
Essentials of Neuromodulation Copyright © 2021 Elsevier Inc.
https://doi.org/10.1016/B978-0-323-89920-8.00025-4 All rights reserved.
235
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Toxin spread
BoNT-A is generally safe in properly trained individuals partly due to its
ability to stay localized to the injection. Toxin spread to unwanted areas
can lead to ptosis or many other undesirable outcomes. The structures, muscle, compartments, are so compact and sit so close to unwanted and untargeted muscles it poses a greater risk for adverse effects. For example, when
treating the corrugator muscle’s lateral tail, it is common for the untrained
injector to inadvertently inject the levator palpebrae superioris muscle and
cause a lid ptosis. The inadvertent injection into the levator palpebrae superiors is because the LPSM sits directly under the tail of the corrugator at the
mid pupillary line 1 cm above the orbital rim. The minimal thickness of tissue from the epidermis to bone in the glabellar region is 2.9 mm, and a
31 gauge needle, commonly used for botox is roughly 0.261 mm. With
the small space demonstrated, you could see how easy it is to inadvertently
injected and underserved muscle if not carefully and knowledgeable in anatomy (Chestnut, 2018).
When we discuss spread, it is the mechanical force of the product traveling from the original site. If you increase your extrusion force while plunging the BoNT-A you will increase your spread and thus potentially have
negative sequela. On the other hand, diffusion would refer to the toxin’s
passive movement due to the kinetic dispersion outside of the original site.
For example, the higher the volume used to reconstitute the BoNT-A the
greater the potential for diffusion. The initial injection site would have
higher concentrations of the drug than the secondary endpoint. When
injected, the product will go from a very high concentration to a lower concentration no matter what the reconstitution preparation was, when we
speak in terms of migration, that would be referring to the BoNT-As ability
to travel along the nerve channel or by accidental hematogenous transport
by accidental injection into a vessel.
Four main risk categories in botulinum toxin A injections
(1) Poor injector technique, which includes poor anatomical
understanding
(2) Overdosing a patient
(3) Patient fails to adhere to aftercare instructions
(4) In rare cases, product reactions, such as sensitivity or even more rare
instances of allergic reaction to the drug or an additive in the drug
If the injector improperly places the neuromodulator into the wrong muscle,
an undesired effect can occur. The drugs intended effect is functional
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weakness; therefore, it is imperative to understand the anatomical structures
and their role in dynamic expression in which you are working to only interact with the appropriate muscles intended for functional weakness. A patient
may want paralysis or functional weakness for the movement between their
eyebrows, but they do not want functional weakness at the arch in their
brow. Dosing is also essential as you want to be sure each area is treated
uniquely and individually. Too much neuromodulator can also create a
sense of depression.
There are post-care instructions that the patient should adhere to, and if
they do not, they could be left with an undesired esthetic look. The good
news is that it is temporary and will resolve the injector’s bad news is that the
patient will not likely come back.
Allergic reactions to neuromodulators are infrequent. Hypersensitivity
reactions have been reported to include anaphylaxis, urticaria soft-tissue
edema, and dyspnea (Weiss, Silver, Lennard, & Weiss, 2007).
Neuromodulation, when performed correctly, can provide beautiful
esthetic results as well as pain relief.
(1) A plethora of potential side effects due to BoNT-A injections
(2) Excessive muscle weakness
(3) Adverse effects due to the spread of the BoNT-A
(4) Tenderness
(5) Bruising
(6) Swelling
(7) Ectropion (lower lid eversion)
(8) Blepharoptosis (drooping eyelid)
(9) Burning or sting at the injection site
(10) Herpes outbreak
(11) Lagophthalmos (incomplete lid closure)
(12) Xerophthalmia (dry eyes)
(13) Epiphora (excessive tears)
(14) Diplopia (Double vision)
(15) Photophobia (light sensitivity)
(16) Lip Ptosis
(17) Hoarseness
(18) Dysphagia (difficulty swallowing)
(19) Dysarthria (difficulty articulating)
(20) Muscle weakness (treatment the paracervical region aka treatment of
the platysmas bands can result in the inability to support the head as
well as dysphagia).
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(21) Facial asymmetry
(22) Systemic allergic reaction including anaphylaxis
(23) Urticaria
(24) Edema
(25) Dyspnea
(26) Antibody development in 1–2% of the population resulting in inef-
fective treatments
Immunogenicity is the ability of a protein to elicit antibody formation
within the host (your patient). Immunogenicity and secondary nonresponders are two different concepts and will be teased apart through
the remaining chapters.
Immunogenicity—development of antibody formation
Primary Non-Responder—no response to initial or subsequent
treatment
Secondary Non-responder—response to initial treatment but failure to
achieve the desired outcome on subsequent treatments. The botulinum
toxin A can induce an immune response similar to other proteins; thus,
the host heads it as a foreign body and blocks it is transmission to the
nerve terminals.
Dynamic assessment with a solid understanding of agonist and antagonist
muscles is critical in good outcomes. Every time one muscle is being manipulated, it is essential to understand how will the treatment affect the opposing
muscle or muscles?
As impressive as neuromodulators are; also recognize their
limitations
Complications
Transient ptosis
Brow ptosis is the most common complication as injectors treat with a standardized approach versus an individual approach. Utilizing too much neuromodulation and or injecting too low in the frontalis muscle can create
ptosis. Initially, when the glabellar region and the frontalis muscle are treated
together, the patient will occasionally report that their brow feels heavy for
the first few days. The frontalis muscle is a thinner muscle; therefore, the
neuromodulation kicks in quicker than in the glabellar region. It is essential
to understand the impact neuromodulators have on muscles as separate entities and a functional group. Teaching the patients this concept will help
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educate the patient and minimize the number of panicked phone calls the
office will receive.
When injecting the frontalis muscle, do not inject too low. Stay 2–3cm
above the brow bone.
Use the bone as the landmark, not the brow. Many brows are penciled in
or tattooed and this gives the injector a false landmark lending to adverse
events.
If the patient does end up complaining of a heavy brow or brow ptosis,
inject the corrugator muscle to help lift the area. The frontalis muscle is an
elevator, and the muscles within the glabellar region are a depressor muscle.
Once these areas are treated with neuromodulators; they have the opposite
effect. Meaning the glabellar region becomes an elevator muscle, and the
frontalis muscle becomes a depressor. Understanding the agonist and antagonist effect and the direct effect neuromodulation has on an area can keep
the outcomes on point.
If it is left untreated, the brow ptosis usually corrects itself within
2–3 weeks.
Lid ptosis
Lid ptosis occurs from injecting the glabellar region to close to the orbital
rim. The levator palpebrae superioris has been injected and cause the inner
and outer canthus lid to droop. A droop of the eyelid is a sure way to lose a
patient. Iopidine, 0.5% drops, can be prescribed with good effect. However,
the patient will have to instill the drops every few hours while awake. This
negative sequella can last weeks to months; however, it will feel like years to
the patient.
Cosmetic application dosing
Average dosing 50–90 with Botox, Xeomin, and Jeuveau.
Dysport can be up to 150 units.
Hyperhidrosis or Torticollis dosing is 100–300 units. These two conditions are typically treated with Botox.
Glabellar region
Glabellar complex facial lines arise from the activity of the lateral corrugator
and vertical procerus muscles. These muscles move the brow medially, and
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the procerus and depressor supercilii pull the brow inferiorly. Activation of
these muscles creates a frown or “furrowed brow.” The location, size, and
use of the muscles vary markedly among individuals. Lines induced by facial
expression occur perpendicular to the direction of action of contracting
facial muscles. These can be readily identified by palpating the tensed muscle
mass while having the patient frown. Medical professionals administering
neuromodulators must understand the relevant neuromuscular and or orbital
anatomy of the area involved and any alterations to the anatomy due to prior
surgical procedures. An effective dose for facial lines is determined by gross
observation of the patient’s ability to activate the superficial muscles injected.
Frontalis muscle
The contraction of the frontalis muscles causes horizontal forehead wrinkles.
The frontalis muscles are two large fan-like muscles that extend from
the eyebrow region to the top of the forehead. The frontalis muscle originates from the galea aponeurotica and inserts at the skin of the eyebrows
and nose. Its functionality raises the eyebrows, resulting in wrinkles in
forehead skin.
Understanding ptosis
The risk of ptosis can be mitigated by careful examination of the upper lid for
separation or weakness of the levator palpebrae muscle (true ptosis), identification of lash ptosis, and evaluation of the range of lid excursion while
manually depressing the frontalis to assess compensation.
In order to reduce the complication of ptosis, the following steps should
be taken:
• Avoid injection near the levator palpebrae superioris, particularly in
patients with larger brow depressor complexes.
• Medial corrugator injections should be placed at least 1 cm above the
bony supraorbital ridge.
• Ensure the injected volume/dose is accurate and, where feasible, kept
to a minimum.
• Do not inject toxin closer than 1 cm above the central eyebrow.
Lateral canthal lines
Lateral canthal lines arise largely from the orbicularis oculi muscles’ activity
around the eye responsible for blinking and eyelid closure. Forceful
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contraction of the orbicularis oculi results in lateral and radially oriented
folds (crow’s feet lines), which originate from the lateral canthus. The distribution of these radial lines differs among patients.
Managing complications
Managing complications is very tricky concerning neuromodulation. The
reason being; is most mistakes can be fixed with only time. The best way
to manage a complication is to avoid it at all cost. The second best tool
for managing complications is to avoid them by properly educating the
patient on the treatment’s true potential and anticipated goal.
This patient has static and dynamic rhytids in the complex glabellar
region. It is essential in this situation to educate the client on what neuromodulation can do. The injector must tease out if the patient is looking to
get rid of the muscle activity that bothers them or if it is the lines that are
there at rest. Figs. 12.1 and 12.2 represent the patient in animation and at
rest without treatment. It is demonstrated in that she has static at rest rhytids.
Given that the patient has visible static rhytids means that she would need to
be counseled on what Neuromodulation can truly do for her. If this patient
Fig. 12.1 Animation photo without treatment.
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Fig. 12.2 At rest photo without treatment.
wanted the static creases gone with treatment and the injector administered
neuromodulators to the area, and the static lines are still present at 2 weeks,
then the patient would likely want a refund. Setting proper patient expectations is essential in all cases. However managing exceptions in unique situations is of the utmost importance. (See Table 12.1.)
Table 12.1 Understanding risk.
Muscles to
inject Intended outcome Complication risk Depth of injection
Frontalis Softens horizontal
rhytids
Corrugator
supercilii
Softens vertical lines
in-between the
brows
Brow ptosis Superficial
Medial brow ptosis
or lid ptosis if it
migrates to
levator palpebrae
muscle
Medially to
superficial
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Table 12.1 Understanding risk—cont’d
Muscles to
inject Intended outcome Complication risk Depth of injection
Depressor
supercilii
Raise medial
eyebrow
Lowers medial
eyebrows should
Superficial
the frontal be
injected
Procerus Raise the bridge of
the nose, softens
the horizontal
Medial brows drop
if the frontal is
injected
Medially deep
into the belly
of the muscle
rhytids on the
bridge of the nose
Nasalis Softens diagonal
rhytids on the
side of the nose
otherwise known
as “bunny lines”
Orbicularis
oculi
Softens the
horizontal and
diagonal rhytids,
raise the brows
and softens the
“crows feet”
Depressor
septi nasi
Raise the tip of the
nose
Drops the upper lip
if the levator labii
superioris alaeque
nasi (LLSAN) is
injected
May cause
asymmetrical
smile should the
zygomatic minor
or major be
injected
May limit the
function of the
Superficial
Superficial or
you will
increase risk of
bruising and
dropping the
smile
Deep
upper lip should
the orbicularis
oculi be injected
Orbicularis
oris
Softens the vertical
rhytids, everts the
Reduces phonation Extremely
superficial
lip
Masseter Slims jaw line,
reduces
symptoms of
May affect smile if
the risorius
muscle is injected
Very deep, needs
1/2 in. needle
TMD
Depressor
anguli
oris
(DAO)
Lifts the corners of
the mouth
If the depressor labii
inferioris (DLI) is
injected you may
cause
Deep but lateral
to avoid the
DLI
asymmetrical
smile
Continued
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