Veritas De Vena Truth Concerning Veins
Dr. Ronald Bush, MD FACS
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Chapter 7 Advanced Training in Cosmetic Techniques for the Vein Surgeon Laura Ellis, MD
Laura Ellis, MD
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Examination of the aging face, the Cosmetic Consultation and BTX-A injection techniques Objectives of this series
Understand the aging face Learn how to perform a comprehensive cosmetic consultation Understand available treatment options Learn how to recommend the best treatment options Learn how to perform cutaneous cosmetic procedures with best technique Appreciate facial muscular anatomy Understand the similarities and differences between Dysport® and Botox® Cosmetic Properly handle, design dosage and perform treatment with botulinum toxin type A products
Etiology of the Aging Face
Intrinsic chronologic factors –Repetitive movement of facial musculature –Redundant skin due to gravity and loss of elasticity –Changes in underlying skeletal and soft tissue structures “Photoaging” from chronic UV light exposure –Cumulative sun exposure is responsible for a large portion of premature unwanted aesthetic effects Smoking
Evolution of the approach to aesthetic improvement of the aging face Historically, surgical skin excision and redraping of the forehead, face and neck Prior to 1990’s dermal fillers (silicone, autologous fat and bovine collagen) Since 1990’s refinement of laser resurfacing and dermal fillers and introduction of botulinum toxin Current philosophy: restoration of facial symmetry, volume and contour with improvement in skin elasticity (combination therapy) with minimal downtime prior to consideration of or in conjunction with the surgical face-‐lift.
The Cosmetic Consultation an anatomic approach
Allow ample time (45 min) Listen to the chief complaints/concerns Discuss the 3 main elements of the aging face while examining the face/skin together Describe treatment options Show B & A photos Make a priority list Perform/schedule treatment
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Chief complaints/concerns
I look tired/sad/old but I don’t feel that way People ask me if I’m angry but I’m not I just don’t look like I used to I want you to tell me what I need
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Examination of The Aging Face Leonardo da Vinci’s aesthetic thirds 3 main elements: •Skin Quality •Volume •Color
Skin Quality
Elasticity v. laxity Thickness v. thinning Wrinkles –static and dynamic
Skin Quality
Ablative laser resurfacing-‐historical use, now for discrete lesions primarily Fractional laser resurfacing-‐for face, neck, chest, arms, hands
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Skin Quality
elasticity, wrinkles, thickness
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Skin Color
“Reds and Browns” “age spots”, melasma, dyschromia Telangiactasia, rosacea IPL, Modified Klingman’s formula, UV protection, hormonal etiology “age spots”
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Volume
Loss of the malar fat pad, appearance of the tear troughs NLF’s LMF’s Lips Pre jowl sulcus Temporal wasting
Cheek Volume
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Cheek Volume
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Lip Volume
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Volumizers Dermal fillers
Physical fillers Hyaluronic acid gels(Juvederm, Restylane) Growth stimulators Poly-‐L-‐lactic acid (Sculptra) Combination Calcium hydroxylapatite (Radiesse) PMMA (Artefill), permanent Volumizers Dermal fillers Choose filler type based on Location Volume correction needed Desired longevity Cost
Photography
Standardization for reliable photographs •Lighting •Distance •Angle Organization At EVERY visit to document and monitor outcomes and for marketing
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Botulinum Toxin Type A
History Type A vs. Type B Brands-‐similarities and differences Mechanism of action Muscular anatomy Type of syringe and needle Determination of dose and placement Response assessment and retreatment intervals History of Botulinum Toxin Clostridium botulinum-‐an anerobic, spore-‐forming bacterium that can create a toxin noted to cause flaccid paralysis and even death when ingested. Serologic types: Type A vs. Type B Use of the BTX-‐A in medicine –the most common cosmetic procedure in the US –Proven to be effective and safe in the short and long terms BTX-A brand similarities and differences They have the same neurotoxin. Same effect, same duration. Dysport may diffuse more widely and onset of action may be 1-‐2 days more rapid Due to molecular size and protein coat differences their unit measurements differ. Most drugs are measured by weight. Doses of BTX are so small that they are in the nanogram range so it is measured in units of biologic activity rather than weight. Equivalent doses are 2.5u Dysport:1u Botox
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Botulinum Toxin Type A Mechanism of action The toxin binds to proteins within the presynaptic nerve terminal and acts as a zinc-‐dependent endoprotease inhibiting the release of acetylcholine at the neuromuscular junction of striated muscle fibers creating a flaccid paralysis of the muscle.
Botulinum Toxin Type A Muscular anatomy Dosage and placement Discussed with each following example
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Reconstitution of BTX-A
Release vacuum form vial Add 2.5cc of bacteriostatic saline to Botox and label 4u/0.1ml Add 3cc of bacteriostatic saline to Dysport and label 10u/0.1ml Refrigerate for up to 6 weeks
Syringe and needle Low volume loss 1cc syringe 30g ½” needle
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Botulinum Toxin Type A
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Lateral orbital wrinkles result from a combination of muscle activity and photoaging. They can be softened with BTX-A but it is not advisable to attempt to paralyze the orbicularis oculi due to its important functions-voluntary and involuntary closure of the eyelids. Avoid tx in those with laxity of the lateral canthal tendon or lower lid retraction. Snap test: Pull the lower eyelid downward and assess how long it takes to return to a normal position. A return of less than 1 second (without blinking) is normal.
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Usual number of injections sites is 2-5 using 12-30u of Botox or 30-75u of Dysport. 1.5cm from lateral canthus and 1cm apart
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Treatment of DAO Tx
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Patient Instructions and Follow Up
Post tx recommendations: No massage of the treatment site for 4 hours after treatment Muscles will begin to relax within 2-‐4 days and will become maximally relaxed for the dose given within 7-‐10 days. Follow up 14 days post treatment for all new patients and patients who may need touch up Retreat in 3-‐4 months
Contraindications to Treatment With BTX-A
1. Patients with peripheral motor neuropathic diseases or neuromuscular functional disorders ie: myasthenia gravis or Eaton-‐Lambert syndrome 2. Patients on aminoglycoside antiboitoics (may potentiate the effect of BTX-‐A) 3.Patients with inflammatory skin conditions at the injection site 4.Pregnant patients 5.Lactating patients
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Review
Understand the aging face Perform a comprehensive cosmetic consultation Understand available treatment options Recommend the best treatment options Disucss facial muscular anatomy Know the similarities and differences between Dysport® and Botox® Cosmetic Properly handle, design dosage and perform treatment with botulinum toxin type A products
Click here to see this course online!
Video Course 4 - Advanced training in cosmetic techniques for the Vein Surgeon Original Release Date: December 20, 2010 Price: $199 - No CME credits are offered with this course Presented by Laura Ellis, MD - In-office cosmetic procedures seem to naturally accompany many successful vein practices. Varicose and spider vein patients often request laser skin treatments, dermal fillers and botulinum toxin A. Providing these services can allow you to advance your practice and enhance your business income. To maximize your return on investment you must begin wisely with proper training: learn how to provide a comprehensive consultation, recommend the proper procedures and perform them with the best technique.
Use your password: VE2012 & remember to check update!
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