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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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284 Appendix 7
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back to the manufacturer and a new vial will be used following the same
procedure.
7. Botulinum Toxin A (Jeaveau, Botox, Xeomin) will be reconstituted
using 2.5–5.0 mL of unpreserved or
preserved saline as a diluent,
resulting in a 4–2 units per 0.1 cc. Dysport will be reconstituted with
1.5–3 mL of unpreserved or preserved saline resulting in 20–10 units
per 0.1 mL. A 3–5 cc syringe containing preserved saline is attached
to the 18–27 guage needle and
the saline to
flow down the sides of the vial, thus minimizing air
SLOWLY injected into the vial. Allow
bubble formation and not damaging the delicate Botulinum Toxin
A (see Appendix 1 for additional acceptable dilution tables for advanced
injectors).
8. Botulinum Toxin A is gently drawn up into a 0.3–1 mL syringe using a
18–27 guage needle. The injection is to be administered with a
30 guage-33 gauge—½ in. needle.
9. Patients are injected while in a seated position.
10. Patients are asked to demonstrate dynamically the function of the mus-
cle groups to be injected.
11. Prior to administration the medical professional will map out points of
injection according to landmarks and location of muscle belly. The
areas of administration will be the corrugator, procerus, frontalis,
and orbicularis oculi muscles. (Corrugator and procerus muscles for
frown lines, frontalis muscle for horizontal forehead lines, and orbicularis oculi muscle for crow’s feet mentalis, masetter, nasalis, pltysma.)
Note: Increased toxin dose may be necessary in older and male patients.
(See diagrams of each area.)
12. Caution will be taken to administer at least 1 cm above the orbital rim
and 1–1.5 cm from the lateral canthus to reduce the chance of Ptosis or
other complications. Complications are a rare occurrence. If mild ptosis
should occur the nurse will instruct the patient that this will resolve
within a few weeks and in the use of OTC, Vasocon to assist in alleviating the ptosis. Ptosis or any other complications will be immediately reported to the Medical Director and/or the Advanced Nurse
Practitioner and documented in the patient record along with photos.
13. Syringe is inserted perpendicular to the skin and completed at a depth
just beneath the dermis, when injecting the Procerus or Orbicularis
Oculi (crow’s feet). When injecting the Glabellar or Frontalis muscles,
needle will advance to just in front of the periosteum, this is to insure
penetration to or into the belly of these muscles. Botulinum Toxin
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A 0.025–0.1 mL is injected into all sites according to patient
treatment plan.
14. After each injection, a cold compress consisting of a clean 4 4 gauze
dipped in ice water is applied and gently massaged for a few seconds
over the injection site.
15. When procedure is completed the patient will be educated not to rub
or manipulate the injection sites, not to lie down for a period of 4 h, no
over exertion, and to report any problems or complications to the
office immediately. Further the patient should be instructed not to have
a massage, facial or wear hats for 3 days.
Development of plan
The Medical Director, Administrator, and the Advanced Practice Registered Nurse have developed this Standardized Procedure and Protocol for
the Administration of Botulinum Toxin A by trained Medical Professionals
as a comprehensive working model.
This model will be reviewed annually at an annual management meeting
and documented in the minutes of the meeting and will be kept in the
Administration office.
This Standardized Procedure and Protocol has been approved by:
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APPENDIX 8
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Photo consent form
I consent to and authorize Surface Medical Esthetics, PLLC, its affiliates,
agents, representatives and all persons or entities acting with its permission
or upon its authority (collectively “Surface Medical Esthetics, corporation”)
to use my photographs and digital images (the “Material”) being taken to
evaluate treatment effectiveness, for medical education, training, professional publications or sales purposes. No photographs or digital images
revealing my identity will be used without my written consent. If my identity is not revealed, these photographs and digital images may be used,
shared, and displayed publicly without my permission. I further grant Surface Medical Esthetics, PLLC the right to incorporate and use the Material in
video, print ads, still photographs, catalogs, packaging and package inserts,
web site and all other media (the “Advertising”), and to reproduce, exhibit,
broadcast, transmit and distribute Advertising containing the Material.
I hereby assign to Surface Medical Esthetics, PLLC all of my right, title
and interest in and to the Material, and any rights, including copyrights that
may result from the use of any Material in any Advertising.
I further waive any right to inspect or approve the Advertising incorporating the Material and the uses to which it may be applied.
I HAVE READ THE FOREGOING RELEASE AND FULLY
UNDERSTAND IT AND AGREE TO THE TERMS OUTLINED.
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In addition to the above Consent, I further consent to have my identity
revealed with full face photos or photos of my body even with identifying
markings. I further consent to all the previous language of release of the
photos within this consent.
APPENDIX 9
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Neuromodulation supply list
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Mckesson
Supply
BD 3/10 ML
insulin syringe
Bacteriostatic
saline
Botox $601
Newtox $463
Dysport 540.87
Xeomin
18 Guage
needles 1.5
3 cc syringes 100 Pack ¼ $6.8
Gauze (4 4) 200
Skin marking
pen
Rubbing
alcohol
Germicidal
cleanser
Patient
drapes/towels
Head band $1.69
Gloves 200
Ice
Camera
Mirror
mms.
mckesson.com
100 count 37.5
1 ¼ 2.67
Avg use 2–10
25 pack ¼ $24.70
30 cc ¼ $0.98
Avg use 1–5cc
100 Pack ¼ $4.95
1 ¼ $0.05
1 ¼ $0.07
Avg use 3–9
count ¼ $
Avg use 6
$1.52 $1.11
Bottle $1.70 Bottle $1.70
16 FL Ounces
$12.07
$0.13 $0.35
Reusable
Count ¼ $12.69
4.72
Anda Meds
andameds.com Allergan Galderma Evolus Merz
100 Count $9.55
1 ¼ $0.96
Avg use 2–10
25 Pack ¼ $28.75
30 cc ¼ $1.15
Avg use 1–5cc
100 Pack ¼ $6.46
1 ¼ $0.07
100 Pack ¼ $7.87
1 ¼ $0.08
Avg use 3–9
200 Count ¼ $2.65
Avg use 6
16 FL Ounces
$7.99
$1.69
Reusable
200
Count ¼ $13.6
Necessary forms
Intake form
Consent
Pre and post
care
Treatment
record
Photo release
Policy and
procedure for
admin
SDS
Glossary of common terms
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Blepharoptosis Blepharoptosis is referred to as a droopy lid. Droopy eyelids are common
complications if the levator palpebral is inadvertently injected or improper treatment
within the infraorbital space. If a patient presents with blepharoptosis, naturally caution
should be used when treating the frontalis.
Corrugator crease The corrugator crease is where the skin creases between the medial and
lateral corrugator compartments. Perforators from the supratrochlear artery most often
clearly outline the crease, a specific landmark for where the supratrochlear artery lies.
The supraorbital artery lays within the seat of the lateral corrugator crease.
Corrugator supercilii The corrugator supercilii are two small pyramid-shaped muscles
located at the medial portion of each eyebrow. They lay deep to the frontal portion
of the frontalis and orbicularis oculi muscles. The length of this muscle spans to and
at times across supraorbital creases. This muscle works with the orbicular oculi muscle
and the procures in order to pull the eyebrows medially and downward in an attempt to
shield the eyes in bright sunlight. When these muscles are contracted, the muscle comes
to the surface, and the supratrochlear and supraorbital arteries retract back to the forehead bone.
Depressor anguli oris muscle (DAO) The DAO is a superficial lower facial muscle that
depresses or lowers the oral commissures (corners of the mouth). Even though it is noted
that the DAO is superficial, it is important to note that the insertion point is deep, and it
is imperative to make a note of this anatomical landmark should the injector be treating
the platysmas area. It is considered to be a part of the lower lip muscle. Constant and
repetitive contraction of these muscles contributes to the cheek lip crease. The DLI is
often accidentally hit during this injection. Understand landmarks and safety zones is key
to reproducible and esthetically-pleasing outcomes.
Depressor labii inferioris (DLI) The DLI is a deep quadrilateral muscle that originates
from the oblique line of the mandible between the menti and the mental foramen.
It is continuous with the platysma and is responsible for depressing the lower lip. This
muscle is responsible for drawing the lip down and outward laterally a bit with mastication. When active, the muscle is responsible for the emotional show of sorrow, melancholy, and doubt. It is not advised to treat this muscle with neuromodulation as the lip
would push up and become rigid. The patient would likely present with oral
incompetence.
Depressor septi nasi (DSN) This deep muscle arises from the maxilla’s incisive fosa and
inserts into the septum and the rear portion of the ala. An active depressor septs muscle
can accentuate the nasal tip droop seen in the aging face. It is also responsible for the
shortening of the upper lip in animation. The DSN narrows the nostrils and draws
the septum down. As we age, the tip of the nose pulls down, and the upper lip area
lengthens, and the nares flair. By treating this muscle with neuromodulation, you
can raise the tip of the nose, begin to lessen the flair of the nares and shorten the upper
lip length. There are two approaches to treatment here with neuromodulators. The
injector can perform one deep injection point at the base of the septum or two injection
points, one on the right and one on the left of the septum.
Depressor supercilii The depressor supercilli is a depressor muscle that sits laterally to the
procerus muscle on both the left and the right. It originates from the orbital rim from the
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Glossary of common terms
fascia of the nasal bone. Its function is to pull the medial portion of the brows inward and
downward. Some literature will describe this muscle as part of the orbicularis oculi muscles instead of being its own structure and function. This particular area is an area that
men often do well with treating to hidden the medial brows. However, generally speaking, most women do not want a hidden medial position of the brow.
Dermatochalasis Dermatochalasis is a condition known to medical professionals referring
to the laxity or bagging of the upper and lower eyelid region. Neuromodulation can
enhance this conditioned aid in the correction. Being mindful of patient selection is
essential to this condition.
Diplopia Diplopia is a condition in which the patient develops double vision. Double
vision can occur when treating a patient with neuromodulation in the lateral cantonal
lines. When the needle is aimed toward the globe, the risk for injection into the extraocular muscles (EOM) increases. Direct or indirect injection into the EOM will cause
diplopia.
Dysphagia Dysphagia is the term used for difficulty swallowing. Patients can experience
dysphagia after treatment with neuromodulation due to the inadvertent injection or
spread into the pharyngeal muscles. Dysphagia is most frequently seen as an adverse
event when injection the sternocleidomastoid (SCM) muscles.
Dyspnea Dyspnea is shortness of breath or difficulty breathing. This labored form of breath-
ing can happen as a result of a physical and or emotional trigger. It can be seen in relationship to neuromodulation treatment in regards to the patient’s anxiety typically.
Ectropion Ectropion is a condition in which the eyelid turns out. Ectropion is commonly a
disease in the elderly population but can be a complication of neuromodulation. Typically it occurs when too much neuromodulation is placed in the infraorbital space.
Making sure the patient is a proper candidate for treatment is essential. If the patient
presents with scleral show below the iris, they are not candidates for treatment with neuromodulation in the infra-orbital space.
Edema Edema is known as excess fluid trapped in the skin. When a patient has a slower or
poorly functioning lymphatic system under the eyes, neuromodulation can cause edema
in this area. The orbicularis oculi muscle acts as a mechanical force to squish excess fluid
out of the area that the lymphatic system can not handle. Therefore, when muscle activity is reduced due to neuromodulation use, the area can present with edema. Time and
lymphatic drainage can help this situation.
Epiphora Epiphora is a medical condition in which excessive tearing or hyperlacrimation.
Neuromodulation can help this condition by placing the product into the lacrimal
gland. Placing neuromodulation into the gland will prevent the release of acetylcholine,
thus decreasing excessive tearing.
Facial nerve The 7th cranial nerve is the facial nerve. This cranial nerve is a motor nerve to
the mimetic facial muscles. It is responsible for the movement of the skin and muscles of
the face. This nerve’s complex course can be predicted based on very specific landmarks
seen on each patient or subject.
Festoons Festoons are caused by lax skin and weakening of the orbicularis oculi muscle.
Cascading hammock of skin and muscle in the infraorbital rim, which may or may
not contain fat. Festoons typically reside from the mid to lateral canthus. Festoons
are treated surgically and best left alone regarding dermal filler and neuromodulators
in the novice injector.
Glossary of common terms
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Frontalis The frontalis muscles are two large fanlike muscles that extend from the eyebrow
area to the top of the forehead. The frontalis is where the frontal branch of the facial
nerve takes its name. The frontalis muscle is responsible for the elevation of the brows.
When elevation of the frontalis muscle occurs, horizontal forehead rhytids appear over
time the lines will become etched in static lines at rest. When treating this area, it is smart
to take a finger and place it on the forehead where the injection point is planned and
then press down toward the brow. The goal is to assess how much skin laxity is present
to help the injector determine if this is a good point for an injection of neuromodulation.
Glabellar region The glabellar region is comprised of the procerus and corrugator muscles.
This complex region is where the supratrochlear and supraorbital arteries and nerves
reside.
Lagopthalmos Lagophthalmos is a condition in which the eyelid can not completely close.
Improper treatment with neuromodulation can create lagophthalmos. Use caution
when treating patients that have had eyelid surgery and have reduced tissue and scaring
in the area as this can lead to improper closing of the eyelid.
Levator labii inferioris (LLI) The LLI is considered to be an accessory muscle to the orbi-
cularis oris muscle. The LLI draws the ala of the nose down and, compresses the nostrils.
Levator labii superioris (LLS) The LLS begins at the maxilla and zygomatic bone above
the infraorbital foramen. It is responsible for elevating and everting the upper lip. The
LLS can help to raise the angle of the mouth. This muscle also aids in the flair/dilation of
the nose.
Levator labii superioris alaeque nasi muscle (LLSAN) The LLSAN is a superficial mus-
cle of the nose and lip, creating facial expression. This muscle stems from the upper part
of the maxilla and passes obliquely down and laterally inserting into the alar cartilage and
the LLS. There are said to be two slips to the LLSAN; a medial slip and a lateral slip. The
lateral slip raises the upper lip and causes it to evert and assists in the dilation of the nostril.
The medial portion is responsible for the flair of the alar. This muscle is responsible for a
gummy smile in patients. With the proper administration of neuromodulation in the
LLSAN it can reduce the gummy smile and slow the deepening of the nasolabial folds
development.
Levator palpebrae superioris muscle The levator palpebrae superioris muscle is an eyelid
elevator muscle that lies mid pupillary line of the lid and extends up approximately 1 cm
above the boney orbital rim. The muscle is often inadvertently injected by new providers when treating the corrugator’s lateral portion. When treating the corrugator’s lateral portion, one must take great caution to be mindful of depth and position with their
injection. If the levator palpebrae muscle becomes paralyzed by neuromodulation injections, the client will not be able to lift their lid.
Malar edema Malar edema is a collection of fluid over the malar eminence below the infra-
orbital rim. Edema can be temporary or chronic soft tissue swelling and varies in
severity.
Malar eminence Malar eminence is the most prominent point on the zygomatic bone. In
terms of esthetics, it is a significant land mark to understand as it flattens the landscape of
the face changes and ages rapidly. The malar eminence is essential in the beauty industry
and should be round and full with natural transition points. The rest of the face is balanced from the malar eminence.
Malar mound Malar mound is soft tissue swelling over the malar eminence resting between
the infraorbital rim and mid-cheek. The distinguishing characteristic between malar
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