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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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254 Essentials of neuromodulation
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(2) Asymmetries exist; point them out.
When evaluating the patient, be sure to take note of subtle asymmetries in their features. Use caution with word choice when pointing
out the patient’s asymmetries as we do not want to hurt their feelings or
make them feel bad. Use positive words instead of negative word
phrases. Point out the asymmetry on the more proportionate side.
For example, if the patient has softer static rhytids on the right side
compared to the left. You might want to say; “I notice the fine lines
you are concerned about are very soft and subtle on the right compared
to the left. This is common among all of our patients to have variations
from side to side. It has a lot to do with lifestyles, such as sleeping patterns, driving, sunscreen, and genetics. Some things are in our control,
and things like genetics and sleeping really are not in our control. My
goal in chatting with you about this very subtle difference is to evaluate
your progress and overall satisfaction together. These subtle differences
from side to side can impact the dose of the treatment as well as the
outcome.” The patient will over-analyze their face after treatment
and may feel that the injector created the asymmetry as the patient
may not have otherwise noted it prior to treatment unless it is mentioned at the initial consult.
(3) Photos are crucial in the injector’s success.
Photos are the most accurate and non-biased form of documentation a provider has. The photos are free from emotion and judgment by
both the provider and the patient. RX photo is a user-friendly app to
take and store patient photos. The floor should be marked so that every
angle is in the exact position as before. A neat feature on the RX app is
that there is a ghosting option so that the photos can be lined up exactly
for before and after. Having a consistent backdrop that does not provide glare is of the utmost importance. A matte black background typically produces the least amount of glare and light reflection distortion.
A simple curtain rod with a black curtain is also useful for a backdrop.
Photos should be taken at rest in all angles and animation at all
angles.
Rest,
Smiling,
Pouting,
Frowning,
Raising the brows,
Pursing the lips
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It is important to have a baseline of the patient at rest and in animation. For every action we take injecting the neuromodulation, we often
impose an opposing reaction in another area as we paralyze one area.
Take pictures of the patients in animation, even if they are not treating
that particular area.
The face should be properly cleaned before photos are taken with
the hair pulled back or with a head wrap. Many practices also take
photos immediately after the injections. This quick additional step
can help to document any bruising or skin discoloration immediately
after treatment. When treating for neuromodulator, it is advised that
the patient come back in 2 weeks when the effect is complete. Set a
follow-up appointment for the patient after treatment on day
15 through day 20.
The before photos taken can be used as a part of the consult instead
of the mirror. Use the photos and zoom in on the troubled area, this is
not something that can be done in a mirror. Often, the patient will
position their face in the mirror in the most flattering light in the treatment chair, but then after treatment, they will view their face in an
unflattering light in the privacy of their own home.
Follow up treatments are scheduled on day 14 – 19 after the initial
treatment date. At this visit, the effectiveness o f the tr eatment will be
evaluated. Additional units can be added at the follow up if the
patient would like to tweak the treatment. Neuromodulation treatment is no t an exact science, and the treatment is unique to the
patientdesiresandgoals.Itisexpectedthatpatientsmayneedmore
neuromodulation at the follow-up visit. Additional units will be
charged accordingly to the patient at the follow-up visit. Followups visits are not recommended after 19 days. Honor the work
within the 14–19dayfollowuptimeframefromtheoriginaltreatment but be aware that it is common that a patient may need more
units to complete the treatment. If a patient does not attend their
recommended follow-up appointment within the 14–19-day time
frame, advise the patient that the treatment effects can not be evaluated as they are outside of the recommended follow-up time frame.
Having the patient call at 6 weeks post-treatment saying that their
treatment did not work would be a clear indicator that they perhaps
the patient did not listen at the consult (only 10% of information is
retained at a visit) or that the injector did not properly explain how
the neuromodulation works.
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When the 2-week follow-up is insisted upon by the practice, it can
enhance the injectors’ understanding and knowledge of the treatment
effect. Further, the injector will be able to collect the patients after
photos. When the patients can see the before and after photos and
the success of the treatment in color on screen, it creates excitement
within the patient. This excitement is an opportunity for the injector
to begin discussing how great they look and poses as an opportunity to
ask if their beautiful photos can be used on social media. Most clients
are excited to be asked to be featured on social media. It makes them
feel beautiful and special.
(4) Educate
Explain to the patient about static and dynamic rhytids. Layman terminology is best used in the consultation with the patient, so they can
truly understand the concepts. Patients will understand terms such as a
crease, line, or wrinkle. The consultative process should be further
expanded to review with the patient that the neuromodulation is only
working on the muscle, and it is not working on repairing the break
down in the skin caused by the muscle movement over the years. Take
time to have them animate and relax in the mirror and get them to
explain what they do not like. Is it the expression they want gone,
or is it the static lines they want gone, or perhaps it maybe both? Here
is an opportunity to teach the patient about the reality of what a neuromodulator treatment can accomplish. If the patient is not properly
counseled, they will complain that the neuromodulation treatment
did not work after the muscle has been properly frozen. The reason
is that the patient may have had goals of the at-rest creasing being taken
care of and the muscles being frozen. The education provided in the
consultation is the difference between a happy client and a dissatisfied
client. Sending out what to expect email is excellent before the
patient’s appointment and then a follow-up appointment email reiterating what was said in the consult. It is best to standardize the before
appointment email as well as the follow up email. Creating a standard,
informative, yet straightforward email can be drafted in most software
systems and cut down on phone calls and patient ambiguity. Esthetic
treatments are expensive, and often the patients that can afford them
have high expectations for the treatment. It is of the utmost importance
that the injector properly educates the patient in the consult and with a
follow-up email. Within the informative portion of the consultation, it
can be a time to discuss further areas to be treated to help in the form of
prevention. Every moment is an opportunity to educate. Educating is
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often a softer way to sell than the cold hard sale. Patients are savior than
ever with the onslaught of social media and google.
(5) Confidence Tools
Marking out the patient can be very beneficial to both the injector
and the patient. Marking out the patient does not have to be done just
by the novice injectors. When the injector marks out the treatment
areas, the patient sees it as a plan of action, and this action can instill
confidence in the patient that they made the right choice. Using a
white makeup pencil to mark the face where the injections will go
is used by many as a confidence tool even if they are advanced enough
to perform the treatment without the markings. If the injector chooses
to mark the patient, be sure that the injection points do not go through
the color or permanently tattoo the patient. Advanced injectors will
gather an additional confidence tool such as a pair of calipers and measure the face and point out areas of symmetry, harmony, and beauty.
The calipers can also be used again to deliver confidence to the patient
that the injector has a real stronghold on their craft.
(6) Ice
Ice is used twofold with esthetics clients. It is used to prevent syncopal episodes as well as a buffer to help minimize the potential for
bruising. If ice is going to be used on the patients, face where they will
be treated, ensure that the ice is properly cleansed before they place it
on their cleaned face. An additional measure of safety will be to alcohol
the treatment area after the patient applies the ice before the injections.
Infection can occur with any injection despite the depths and or relatively seemingly harmless nature of a neuromodulation injection’s pinpoint entry. When the patient applies ice prior to the injections, it can
create vasoconstriction that can minimize the risk of bruising. The iceaesthesia will also help to decrease the patient’s amount of discomfort
with each injection. Every patient will experience varying levels of discomfort during the treatment. In addition to minimizing bruising and
discomfort, another reason for using ice is to aid in the comfort of the
nervous patients. The nervous patients or the patients who have had
syncopal episodes in the past with injections are less likely to feel anxious or syncopal with the use of ice. A patient’s heart rate variability can
cause a syncopal event, and the ice will help regulate the variability preventing a syncopal event by keeping the heart rate lower. As a patient
becomes stressed, the heart rate will go up, and then the blood pressure
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will drop, thus clamping down blood flow to the extremities and forcing it to the core circulation. Vasoconstriction is when the patient will
become syncopal in the chair during treatment. An effective and interesting trick that is used in emergency medicine when a patient is
experiencing Supraventricular tachycardia (SVT) is a bucket of ice
water. The patient presenting to the emergency room with SVT will
have their face submerged into a bucket of ice and water. Shockingly
enough, it is enough to lower the patient’s heart rate, decrease the
patient’s peripheral vascular response, and restore normal oxygenation
and ventilation. The concept of using ice to bring the heart down is
referred to in the literature as the divers reflex. It has been reported that
when divers are submerged in ice-cold water, they experience apnea,
bradycardia, along with an increased peripheral vascular resistance
(PVR). These three unique but very individual physiologic changes
work together to preserve the patient’s oxygen level Godek and Free-
man (2020). So to a lesser extent, the use of ice in the esthetic setting
can help prevent syncopal episodes. If the patient is anxious, have them
hold the ice or place it on the nape of the neck or their chest between
the breasts.
(7) Reconstitution
Reconstitution is of the utmost importance. Keeping the reconstitution consistent and documented can reduce medical errors. Medical
errors in the esthetic industry can cost a pretty penny when having to
refund the patient. Understanding reconstitution, spread, and extrusion
force all play a role in the outcome of the treatment. Newer injectors
should reconstitute according to the manufacturers recommended, and
FDA approved guidelines in the package labeled as prescribers guidelines to prevent confusion in the beginning. The only caveat recommended is to substitute bacteriostatic saline as the diluent for
reconstitution instead of the 0.9% preservative-free saline. When
speaking with the client during the reconstitution process of the neuromodulator, do not make the mistake of saying that you are diluting
the product. Dilute to the patient means something very different to
them as it does to us in the medical world. Dilute to them means the
product is becoming less potent. The product lot number, expiration
date, and the agent used to reconstitute the neuromodulator should
be documented in the chart each and every time a patient is injected.
(8) Aftercare instructions
No matter how many times the patient has been seen for treatment,
it is necessary to review the aftercare instructions before leaving.
A good place to start this conversation is in the pre-scripted email to the
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patient before they even have treatment. Send them a what to expect
email, including what to expect at the visit (this helps to cut down on
anxiety and impatient patients), pre-treatment guidelines, and aftercare. Once they are in the office be sure that the pre and post-care
guidelines are part of the consent. No matter how many times the
patient has had neuromodulation treatment in the office, the patient
must sign a new consent to treat on that particular day of treatment.
Each treatment is a new treatment. A new consent should be signed
even 2 weeks later at the patient’s follow-ups visit if they are to get
more. A proper consent is not one that the patient signs real quick
on an iPad. Talk with the patient about what to expect face to face
and go over the pertinent details. Then send them an aftercare visit
email reiterating what had been spoken about at the visit and copy
and paste the aftercare guidelines from the consent right into the email.
Now with that amount of information shared, the patient can truly sign
an informed consent.
(9) Follow up Call
Patients lead busy lives, and it seems that gone are the days when a
card is sent in the mail or a quick little gesture of kindness is presented.
A follow-up phone call the following day is a nice touch. Even if the
call is simply to state that it was nice to meet them and welcome them to
the practice. The injector may want to check in on the new patients to
acknowledge that it was their first time seeing how they are feeling and
if they had any further questions. Take notes in the chart of their child’s
names or an event that was discussed during the consult. This little
touch is the difference between a one time client and a life long client.
We must create and foster long term clients. Shopping around for the
cheapest and quickest injector is not in the patient’s best interest.
Develop strong relationships with the clients from the get go to ensure
the foundation of the relationship. This way, they become long term
patients with exceptional outcomes. It is difficult to get a proper treatment plan in place when the patients bounce from practice to practice.
(10) Documentation
We began talking about documentation when it came to the
photos section; however, documentation is more than just photos.
When the novice injectors journey begins, it is common to remember
every patient’s name and each injection point. Injectors even remember and even how the tissue responded. Fast forward a few years; and
on some days, it is hard to remember your own name let alone each
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Essentials of neuromodulation
dose placed in every injection point. Scribing a total dose in one area
does not equate to proper documentation. The injector will want to
document all of the injection points accurately in each area and note
the exact dose used along with the reconstitution process. Document
if the skin is tanned, dry, red, and any other characteristic that was
assessed. Documentation helps the injector at subsequent visits; it is
a legal document, so be thorough in case the treatment chart is called
into court, and lastly, if another provider in the office treats the
patient, the outcome is consistent. Consistency is important in developing the patient’s confidence in the practice and the injectors. They
have options all around them. Be the reason they never look to the
competition for treatment. It is helpful when injectors document
the presentation of line formation or static creasing. Also, be sure
to document bruising and if the pressure was applied or ice or whatever other alleviating treatment that was initiated. The same rules
apply here as they do with bedside nursing, the right patient, the right
dose, the right drug, the right route, and the right time. It can also add
here since it is elective, the right reason. Body dysmorphia is a real
diagnosis, and it is a common diagnosis in the esthetic world. Be sure
that the patient has filled out a medical history form, a consent for
treatment, a photo consent if willing for the use on social media,
and supply them with a copy of the pre and post care guidelines.
Remember neuromodulators are a drug and require the development
of a prescriptive treatment plan to care for the patient. Do not get distracted by the fact this is an elective treatment. Esthetic injectors are
injecting the world’s most deadly neuromodulation known to mankind into their patient. Be confident, precise, and accurate. As much
as the esthetic industry pertains to beauty, it is still medicine; always
remember that.
Reference
Godek, D., & Freeman, A. M. (2020). Physiology, diving reflex. In StatPearls. Treasure Island
(FL) StatPearls Publishing. [Updated 2020 Sep 29]. Available from https://www.ncbi.
nlm.nih.gov/books/NBK538245/. (Accessed October 2020).
Appendices table of contents
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1. Aesthetic new patient history
2. Pre care guidelines email
3. Post care guidelines email
4. Neuromodulation consent
5. Neuromodulation pre treatment instructions
6. Neuromodulation post treatment instructions
7. Policy and procedure for neuromodulation administration
8. Photo consent form
9. Neuromodulation supply list
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APPENDIX 1
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Aesthetic new patient history
Aesthetic New Patient History
First Name : _______________________ Last Name: __________________________ Date: ________
Address:____________________________ City: ___________________ State: ________ Zip: ______
Cell Phone: _______________________ Other: _______________________Birth Date: ____________
Email:______________________________________ Occupation:______________________________
How did you hear about us?___________________________ Ethnic Background:_________________
List of medications and/or vitamins you are currently taking:___________________________________
____________________________________________________________________________________
Allergies:________________________ Are you taking Antibiotics at this time?____________________
Collagen Tested:_________________ Date: ___________Were there complications? _______________
Pharmacy Name & Number: ____________________________________________________________
Are you in the process of having any major dental work completed? Yes or No? If so please explain:
___________________________________________________________________________________
MEDICAL HISTORY
Conditions (Check all that apply) Yes N o
Myasthenia Gravis
Muscle Weakness
History of Cold Sores
Hepatitis
Multiple Sclerosis
Sensitivity/Allergy to Lidocaine
Eye Disease
Allergy to Beef or Dairy
Numbness
List and/or explain other medical conditions not listed above:__________________________________
___________________________________________________________________________________
@2013 Surface Medical Esthetics, PLLC Aesthetic Medical Intake Page of Patient Initials_______13
Conditions (Check all that apply) Yes N o
Lupus
Keloid Formation
Autoimmune Disease
Amyotrophic Lateral Sclerosis
Vision Problems
Neurological Disorders
Lambert-Eaton Syndrome
Hypersensitivity to Medications
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