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CHAPTER 7
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Common myths about
neuromodulators
Common myths
Common myths about Neuromodulators are vast and sometimes silly from
the patient’s point of view. It is essential to know the common myths and
fears that patients have so that injectors can demystify them and earn the trust
and respect along with their business.
FAQs from the patient
Will I be frozen?
Paralyzed is a better term.
I heard it is excruciating.
Proper technique and reconstitution decrease the pain associated with
injections.
Will it get rid of my deep lines?
No, that is reduced by lasers and volume restoration as well as effective
at-home skin care.
Will I become addicted?
Absolutely! In the hands of a skilled provider, patients will have a natural
and youthful appearance. However, in all seriousness, technically, the
answer is no.
Is it safe?
Yes, it is. It is temporary and does not cross the blood-brain barrier preventing it from ever causing botulism. 100% of the studies conducted
showed complete re-innervation.
What is the potential side effects?
Bruising, headache, unsatisfactory results due to poor consultative process. It is of the utmost importance to set up proper expectations for the
patient.
Essentials of Neuromodulation Copyright © 2021 Elsevier Inc.
https://doi.org/10.1016/B978-0-323-89920-8.00014-X All rights reserved.
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Can I go to the gym after?
Not for 24–48 h after as you can increase the metabolization of the product, therefore decreasing its efficacy.
Is there downtime?
Minimal downtime includes physical restrictions such as the gym, facials,
massages and the wearing of hats and helmets.
Is it snake venom?
No, not at all.
I heard you are injecting botulism into me?
Patients will receive injections of an isolated protein from the toxin
Clostridium botulinum.
Is it permanent?
No, it will last roughly 3–4 months. Re-sprouting will begin to occur at
about 6 weeks.
Can it be used to correct the volume loss in my face?
Neuromodulation is only used to block the acetylcholine at the neuromuscular junction, preventing the muscles from moving. Volume loss
can be slowed down, however, with the proper use and placement of
Neuromodulators. For example, it is thought that the constant muscle
activity creates a shearing effect and aids in the break down and redistribution of fat pads in the face.
Should I start Neuromodulators after the lines appear?
You may, however, prevention will yield a more satisfied client with
their appearance and the overall treatment.
If I just have a facelift, I will not need Neuromodulators.
This statement is false. A facelift is often best when done in combination
with other treatment modalities. Lifting older skin that is not at optimal
health performance will not yield the best result. It is ubiquitous for surgeons to offer skin tightening and or resurfacing procedures with the
facelift. These treatments work synergistically with one another. Aging
is happening at the level of the skin, vessels, muscles, and fat pads. Ultimately, the aging face is becoming compromised at every layer. Therefore, a one-trick pony does not exist yet. Neuromodulation often is best
when used in combination. Another combination will be a facelift and
dermal filler to add volume.
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Will I look worse afterward if I decide to stop Neuromodulators?
The answer is no. Technically, Neuromodulation is not causing any
damage to tissues, so anatomically, they will not be any worse than they
had never been treated with neuromodulators. After 10 years of use, if
you stop neuromodulators, one may perceive that they look worse
because they have not seen the accurate representation of their aged muscle and skin position in those 10 years. Studies have shown those that
have neuromodulation have a decrease in static rhytids compared with
non-user.
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CHAPTER 8
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Anatomy
Beginning to understand facial anatomy
There are six main anatomical concerns for anatomy when we are injecting
for cosmetic purposes (Figs. 8.1–8.7)
Skin
Muscles
Vessels
Fat
Nerves
Bone
Fig. 8.1 Layers of the skin.
Essentials of Neuromodulation Copyright © 2021 Elsevier Inc.
https://doi.org/10.1016/B978-0-323-89920-8.00005-9 All rights reserved.
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Soft tissue
Four distinct tissue planes are recognized on the face:
1. Integumentary system (skin, hair, nails)
2. Hypodermis (subcutis, otherwise known as the subcutaneous layer or
fibroadipose tissue)
3. Superficial musculoaponeurotic system (SMAS)
4. Parotid-masseteric fascia
Within the skin, there are two distinct layers
1. Epidermis
2. Dermis (blood, nerve endings, sebaceous glands)
Within the epidermis, there are four distinct layers
1. Stratum corneum—outer most layer and is exposed to the elements of
the world
2. Stratum granulosum
3. Stratum spinous
4. Stratum basale
Within the dermis, there are two distinct layers
1. Papillary layer
2. Reticular layer
As outlined in the previous list, there are four layers to the soft tissue of the
face. The four layers are; skin, the subcutaneous layer of fibro adipose tissue,
superficial musculoaponeurotic system (SMAS), and the parotid mesenteric
fascia. These layers all age in a chaotic pattern leaving hollows in some parts
of the face decades earlier than in other areas of the face. It is common to see a
hollowing in one region, and then about a decade later, there is a shift in the
volume of the adipose tissue. The shifting of fat pads leads to jowling and other
displeasing aging characteristics. The focus of neuromodulation should be on
the aging patient’s goals alongside the individual’s unique assessment. When
referring to the word aging, begin thinking in terms of clinical aging concepts
and processes. Many patients believe that neuromodulators can tighten and lift
when, in reality, they are responsible for preventing muscle movement. If a
patient requests lift and tightening at a consult for neuromodulation, the injector must reset the expectations; otherwise, the patient will be dissatisfied.
It is a well-known fact that skin is the largest organ of the body. The skin
accounts for roughly 15% of a person’s body weight. It is part of the integumentary system, and the integumentary system consists of skin, hair, nails,
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and exocrine glands. Skin is broken down into three layers, the epidermis,
the dermis, and the subcutaneous tissue. Each of these layers is further broken down within each layer. Surprisingly, the skin is only a few millimeters
in thickness, yet 15% of the body weight. The outermost layer is the epidermis, followed by the dermis and the third layer is the subcutaneous structure.
In terms of neuromodulation, the esthetic injector must understand where
the muscles lay and how the skin can affect dosing, product placement, and
the patient’s overall satisfaction. To practice holistically, injectors must
understand each layer of the skin and how they function in tandem with
the muscles and fat pads within the face. Understanding how the skin behaves
in response to intrinsic and extrinsic factors related to aging is vital in the
face of esthetic treatments. An emerging understanding of the skin’s functions
can help injectors better deliver BoNT-A treatment effectively to patients.
We uncovered early on that the aging process is happening on multiple
multidisciplinary systems as we age. Therefore, we must understand the
integumentary system, how we understood the nervous system, and the
muscular anatomy.
The skin’s primary function is to protect the body from external physical
force, both chemically and biologically. It also prevents water loss in conjunction with its thermoregulatory system. Later in the reading, the treatment of hyperhidrosis with neuromodulation will be reviewed.
Therefore, the thermoregulatory function of the skin will be an essential
concept to understand when treating hyperhidrosis. Patients that sweat profusely on there forehead do see a reduction in the sweat production of their
forehead when treated with neuromodulation of the frontalis, procerus, and
corrugators.
The outermost layer of the skin is the epidermis, and this layer is always
rejuvenating itself. The renewal process slows as we age, and that is where
chemical peels come into play in the esthetic arena. A chemical peel will do
the slowed epidermal layer’s job in terms of manual sloughingof the outermost
layer. The basal cells within the epidermal layer give rise to the epidermal
layer’s renewal process. The epidermis consists of four layers; the basal layer
(stratum germinativum), squamous cell layer (stratum spinosum), granular cell
layer (stratum granulosum), and lastly, the cornfield layer (stratum corneum).
Given the focus is on esthetics, another critical cell to comprehend in the epidermis is the melanocyte. This cell is responsible for pigment within the skin.
Melanin is produced by the melanocytes in response to protect the skin from
ultraviolet radiation from sunlight. Melanin is the darker spots seen in outer
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layers of the skin. Melanin is a response to the activation of the melanocyte in
an attempt to shield itself from external forces such as ultraviolet light.
As clients begin to volumize and iron out the wrinkles on their faces with
neuromodulation, the next request is often to address sun damage. Developing a greater understanding of melanocytes and melanin will help to elevate
treatment outcomes. In order to deliver exceptional results in regards to pigment problems, the esthetic provider needs to understand how the melanocytes work in combination with the basal cell layer. The melanocytes
primarily reside within the basal layer of the epidermis. When patients complain of dull, sun-damaged skin, typically, the health and function have slowed
naturally. Chemical peels give rise to the manual exfoliation to turn over the
dead cells and present the healthier layer waiting underneath. Peels can restore
the patient’s glow and aids in sloughing off sun damage or hyperpigmentation.
There are specific cells known as the keratinocytes within the epidermal layer along with the melanocytes. The keratinocytes make up nearly
80% of this layer. These are essential cells i n the protecti ve function o f the
epidermis. The epidermal layer is the rea son clients are dissatisfied with
their topicals products. Topical products often need to make it to the
dermal layer to elicit change, but the epidermal layer acts as a barrier.
The keratinocytes in the epidermis originate in the basal layer and eventually migr ate to the skin’s surface. These cells are eventually shed and
replaced by new healthier cells.
Moving deeper into the layers of the skin is the dermal layer. It is made
up of primary collagen. Collagen is a protein that acts as fibrous structural
support to the skin. The dermis has two layers; papillary and reticular layer.
The papillary layer resides just beneath the epidermal layer. Eccrine,
apocrine sweat glands, and pilosebaceous units reside in the dermal layer,
specifically the dermal-epidermal junction. When patients are treated in
the axilla for hyperhidrosis, this area is the target for effect. The dermal layer
makes up the bulk of the skin and is responsible for collagen, hyaluronic acid,
and elastin formation.
Moving beyond the skin layers, as described previously in this chapter’s
beginning, there are four planes to the face. We will not spend much time on
the remaining three as these layers are a more advanced topic regarding neuromodulation. Circle back to understanding the four tissue planes in greater
depth as master emerges with the use of neuromodulation. Then begin to
move forward in an advanced knowledge base of esthetics.
Let us now look at what structures are beneath the skin. These layers will
become increasingly more critical when injecting filler and performing skin
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resurfacing and tightening procedures. The focus is on the superficial skin in
regards to gaining an understanding of neuromodulators. However, if each
one of these structures and layers is essential when talking about facial
esthetics and addressing the aging face.
Hypodermis
This layer is referred to as the hypodermis, the subcutis, or the subcutaneous
layer of the fibroadipose tissue. They all are referring to the layer just beneath
the dermis. It is not a part of the skin but has finger-like projections that connect to the dermis.
The hypodermis layer is made up of fat, otherwise known and lipocytes.
The fat is a layer that adds volume to the appearance of the skin. The thickness of the subcutaneous layer varies from patient to patient and over different parts of the face. The fatty layer above the upper lip is often very thin.
However, when we look at the malar eminence (the apple of the cheek),
that area has much greater subcutaneous tissue volume. This subcutaneous
layer also stores energy. The fatty layer of the skin will be most valuable in
the discussion of dermal filler implantation. Nonetheless, it is necessary to
understand the entire system as injectors emerge from novice to proficient
in their emerging knowledge acquisition of the anatomy and the industry.
Typically, the two subcutaneous tissue sections can be broken down into
the medial compartment and the lateral compartment. The lateral compartment is in the preauricular region (just before the ear). According to many
anatomists, this area comprises a tiny, thin layer that is dense and highly vascular. The superficial temporal artery and vein snuggle in tight to the preauricular space. The medial part is softer, more pliable as well as has
significantly more volume in nature. The zygomatic ligament and perforators create a boundary by the malar eminence separating the medial portion
from the malar compartment. This layer is what adds volume to the face giving a youthful appearance. As the name mentions, this layer is more fibrous
than fatty. The word fibrous means that it is a bit more rigid and less buoyant
than other subcutaneous tissue types. This tissue is not uniform throughout
the face. Different sections of the face will present with varying thickness. As
we age, this layer will change along with the degree of adiposity. The fat
content of the cheek mass and the malar fat pad is primarily made up of this
subcutaneous adipose tissue type. The fibrous septi separates the subcutaneous fat into compartments. The deflation of these fat pads occurs laterally first
then progress to the medial portion of the face.
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