Book 2

Owner InjectAbility¨ Institute

LESLIE FLETCHER, RN, MEP-C

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Advanced Botulinum Toxin- A

Advanced Botulinum Toxin- A LESLIE FLETCHER, RN, MEP-C

Owner InjectAbility¨ Institute

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

All materials are owned and copyrighted by InjectAbility Institute for Esthetic Education ¨

No part of this manual may be reproduced without written prior permission C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

ALL DRAWINGS HAVE BEEN USED BY EXCLUSIVE, WRITTEN PERMISSION FROM GARY FAIGIN, AUTHOR OF ÒTHE ARTISTÕS COMPLETE GUIDE TO FACIAL EXPRESSIONSÓ CELEBRITY PHOTOS HAVE BEEN PURCHASED AND REUSED FOR EDUCATIONAL PURPOSES. ALL PHOTOS ARE THE PROPERTY OF LESLIE FLETCHER, RN, MEP-C AND ARE NOT TO BE REPRODUCED.

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Disclosures LESLIE FLETCHER, RN, MEP-C IS ON THE SPEAKERS AND TRAINING BUREAU FOR BOTH ALLERGAN AND MEDICIS OFF LABEL DISCUSSION OF THE USE OF NEUROMODULATORS WILL TAKE PLACE DURING THIS PRESENTATION

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

The best way to treat a complication is to avoid one look for tips throughout lecture to see how to avoid complications and what to do if one occurs

COPYRIGHT 2013 LESLIE FLETCHER, RN, MEP-C

DYNAMIC LINES ¥deeper

¥appear

furrows with movement

STATIC LINES ¥dynamic

lines over years become static ¥unchanged with muscle activity

EXTRINSIC ¥sun

damage

¥smoking

¥pollution ¥illness ¥stress

o: ds t Lea damage to pho

INTRINSIC Resorption of: ¥bone to: ads loss e L ¥fat es e lum l chang o v a ¥muscle on itati ¥collagen grav ¥Elastin C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Possible Areas of use NEUROMODULATORS to enhance facial expression 26 FACIAL MUSCLES ~ 11 RESPONSIBLE FOR EXPRESSION

¥Forehead Lines ¥Glabellar Frown Lines ¥CrowÕs Feet ¥Nose contouring ¥Mouth Frown

¥Lips ¥Mentalis ¥Jaw contouring ¥Platysmal Bands ¥Masseter

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

APRIL 2011 SOCIAL PSYCHOLOGY AND PERSONALITY SCIENCE JOURNAL SAYS WE NEED TO BE ABLE TO MIMIC OTHER PEOPLEÕS EXPRESSIONS IN ORDER TO EMPATHIZE WITH THEIR EMOTIONS

We donÕt want to obliterate expressions but decrease the intensity of the negative ones and increase the frequency of the positive ones

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

MUSCLES ARE LIKE PUPPET STRINGS HOLDING AND PULLING OUR SKIN UP OR PULLING THEM DOWN

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

positive

HYPERANIMATION AT ITÕS FINEST

NEGATIVE

END RESULT AT REST

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

POSITIVE expressions GENERALLY MUSCLES THAT PULL UP, MOVE LATERALLY, WIDEN, EXPAND, AND ARE IN MOST CASES ÒNATURALÓ COULD BE CONSIDERED POSITIVE

ELEVATION OF BROWS- FRONTALIS CHEEK ELEVATION WITH SMILE- ZYGOMATICUS MAJOR AND MINOR LIP ELEVATION WITH SMILE- LEVATOR LABII SUPERIORIS WIDENING OF SMILE- RISORIUS COMBINED WITH PLATYSMA LIP EVERSION WITH SMILE- DEPRESSOR LABII, DEPRESSOR ANGULI ORIS

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Negative expressions GENERALLY MUSCLES THAT PULL DOWN, ADDUCT MEDIALLY, NARROW, PUCKER, OR ARE IN ANY WAY ÒEXAGGERATEDÓ CAN BE CONSIDERED NEGATIVE

FURROW- CORRUGATOR, PROCERUS SQUINT- ORBICULARIS OCULI, LEVATOR LABII SUPERIORIS FROWN- DEPRESSOR ANGULI ORIS, MENTALIS SNEER- LEVATOR LABII SUPERIORIS ALAEQUE NASI PURSE- ORBICULARIS ORIS NECK HYPER EXPRESSION- PLATYSMAL BANDS C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

History of Botox¨ Isolated in 1920Õs ¥Therapeutic testing on humans in 1978 (oculinum) ¥FDA approval strabismus in 1989 ¥FDA Glabellar frown lines 2002 ¥FDA Hyperhydrosis in 2004 ¥FDA Migraines 2010 ¥FDA CrowÕs Feet 2013 ¥

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Current FDA approved Neuromodulators ¨

ONABOTULINUM TOXIN- TYPE A

X O T BO

ABOBOTULINUM TOXIN- TYPE A

DYS

INCOBOTULINUM TOXIN- TYPE A RIMABOTULINUMTOXIN-B- TYPE B

¨ T R PO

¨ N I OM

XE

MYO

¨ C O BL

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Black Box Warning ¥Based

upon safety evaluation of all

toxin products- distant spread warning ¥Risk

Evaluation and Mitigation Strategy

(REMS) ¥Changed

drug names to reinforce

individual potencies ¥Potencies

are not equal C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Possible Areas of Use NEUROMODULATORS

¥Forehead Lines ¥Glabella Frown Lines ¥CrowÕs Feet ¥Nose contouring ¥Secondary smile lines ¥Preauricular creases ¥Mouth Frown ¥Lip Eversion

¥Lip Wrinkles ¥Mentalis ¥Jaw contouring ¥Platysmal Bands ¥Neck Waddle ¥Neck Laxity ¥Masseter ¥DŽcolletage

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Botox Reconstitution ¨

1.0 (10u per 0.1) 2.0 (5u per 0.1 ml) 2.5 (4u per 0.1 ml) 3.0 (3u per 0.1 ml) 4.0 (2.5u per 0.1ml)

O U T C O M E A N D L O N G E V I T Y O F D R U G I S D I R E C T L Y R E L A T E D T O D O S E

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Dysport Reconstitution ¨

•

1.0ml (30u per 0.1ml)

•

1.5ml (20u per 0.1 ml)

•

2.0ml (15u per 0.1 ml)

•

2.5ml (12u per 0.1 ml)

•

3.0ml (10u per 0.1ml)

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Reconstitution Considerations ¥precision...more volume = more migration ¥pain.... more volume = more pain ¥pain... smaller needle = less pain ¥swelling....more volume = more lumps ¥bruising.... more volume = more bruising ¥cost..... more volume = more cost ¥conversion...more volume = more math ¥onset.....more volume = longer onset *anecdotal C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Needle options: Insulin syringe

¥ZERO DEAD SPACE ¥NO CANNULA DEAD SPACE: 0.0004 ¥NO HUB DEAD SPACE: 0.1CC ¥NO LUER-TIP DEAD SPACE: 0.01CC ¥TOTAL SAVINGS PER SYRINGE:

(AVERAGE) 0.11ML SAVINGS PER SYRINGE USED (COMPARED WITH LL 1ML SYRINGE)

¥USED

FOR 1:1/ 1:1.2 DILUTION DIRECTLY OUT OF BOTTLE ¥DRAW UP ENOUGH FOR 3-4 INJECTIONS ¥DRAW

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Needle Options: Neuromodulators

LOW DEAD SPACE: SAVES 1% ¥ Used for any dilution ¥ Need to attach needle ¥ Either 30g 1/2 inch or 31g 1/2 ¥ Measurement in ml, not units ¥ Higher cost per syringe $1.25-$1.75

BRAUN LOW WASTE SYRINGE

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Needle Options: Neuromodulators 1 CC SYRINGE NON- LOW WASTE SYRINGE ¥ Used for any dilution ¥ Need to attach needle ¥ Either 30g 1/2 inch or 31g 1/2 ¥ Measurement in ml, not units ¥ Looses approximately 0.11ml with every syringe C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Full Face Anatomy **Average amounts of Botox¨ female dosing

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Upper Face anatomy The 4:1 Principle NOTE THAT RHYTIDS RUN PERPENDICULAR TO THE MUSCLE C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Muscles and their opposition Depressor Muscles

Corrugator Complex

pulls brow medially

Procerus

Recruitment

Elevator Muscles

Frontalis

elevates forehead and brows

pulls brow distally

Frontalis

elevates forehead and brows

Depressor Supercilii

pulls medial brow distally

Frontalis

elevates forehead and brows

Orbicularis Oculi

pulls lateral brow distally, and closes eye

*MuellerÕs muscle

elevates upper eye lid

Depressor Septi

pulls septum of the nose distal

Nasalis

elevates nasal skin (bunny lines)

Orbicularis Oris

pulls lips together in a pursing motion

*Zygomaticus major and minor

Elevates cheeks/ smiling motion

Depressor Anguli Oris (DAO)

pulls corners of the mouth down Òfrowning motion

*Zygomaticus major

Elevates corners of mouth smiling motion

Depressor Labii

pulls lower lip down in a ÒpoutingÓ motion

Mentalis

Elevates lower lip and dimples chin

Platysma

pulls entire face down

*Zygomaticus major and minor

Elevates cheeks

*AVOID AREA

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Lower Face Muscles and their opposition Depressor Muscles

Recruitment

Elevator Muscles

Orbicularis Oris

pulls lips together in a pursing motion

Zygomaticus major and minor

Elevates cheeks/ smiling motion

Depressor Anguli Oris (DAO)

pulls corners of the mouth down Òfrowning motion

Zygomaticus major

Elevates corners of mouth smiling motion

Depressor Labii

pulls lower lip down in a ÒpoutingÓ motion

Mentalis

Elevates lower lip and dimples chin

Platysma

pulls entire face down

Zygomaticus major and minor

Elevates cheeks

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

GLABELLAR COMPLEX: NEUROMODULATOR

Average Botox¨ units in this area women: 20-30u Men: 30-40u Average Dysport¨ units in this area women: 45-70u Men: 75-90u ¥Watch the patient animate to determine the best muscle to inject ¥Feel the muscle as the patient contracts to assess which muscle is

the strongest, inject more drug there ¥Assess the natural shape of the eyebrows. Look for preexisting asymmetry. ¥Ask the patient what their desires are for eyebrow shapes. ¥Be sure to get the entire corrugator muscle laterally if desired, place

one injection laterally at the tail end of each brow ¥Inject deeply along the orbital rim or up to 2 cm above C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

21 BOTOX¨ U 2

2

4

4

1

3 1

2

2

The Glabellar Complex

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

negative expression

Recruitment on lateral fibers can now be treated with Microtox C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

narrowed eyes....cured C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Neuromodulator Complications: ¥Caused by diffusion

into Levator or MullerÕs muscle ¥Correction: Iopidine 0.5%, Naphazoline, Vasocon-A, Naphcon-A, Opcon-A 1 drop 4-6 hrs to affected eye as needed ¥Ptosis lasts 4-6 weeks C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Levator or Mullerﾃ不 muscle Not to be injected

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ﾂｨ I N S T I T U T E

Lid and brow Ptosis

Fixed with MicroTox C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ﾂｨ I N S T I T U T E

Forehead: Neuromodulators 6-20 BOTOX¨ UNITS 12-40 DYSPORT¨ UNITS

¥Use small amounts in this area, so to

maintain some movement and avoid an unnatural look. Stay high on the forehead to maintain brow elevation ¥DonÕt forget to slip a small amount in right above the arch of the brow to avoid the ÒMephisto browÓ C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

BEFORE

AFTER

FRONTALIS IN ACTION C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Over active Frontalis Botox¨ C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

the look of surprise, but softened C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Asymmetry fixed C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Sadness B A

A C

C

muscles involved a: corrugator b:frontalis c:orbicularis Oculi E:mentalis C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

E

Sadness

eyes narrowed

CORRUGATORS AND FRONTALIS corrugators and frontalis

corrugators, frontalis, & narrowed eyes

MEDIAL HORIZONTAL medial horizontal BROW ELEVATION brow elevation

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

ANGER AND FRUSTRATION

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

this Òcome hitherÓ look may be sexy on keira knightley, but unless you are Keira Knightley, itÕs best not to exaggerate the uneven brow

PROBLEM: UNEVEN BROW

HANEL

SOLUTION: NEUROMODULATE 1-2 (B)UNITS

>*^

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

ft* NORDSTROM ¥ CHA

Perfect Female Brow design C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Long: horizontal

Round: arched

Oval: soft angled

Square: sharp angled

Ideal eyebrow positioning for facial shapes Diamond: curved

Heart: rounded

Goal: modify your neuromodulators to suit

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

The Flared Brow: Neuromodulator 5

4

2

1

MAXIMAL LATERAL BROW LIFT C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

The Arched Brow: Neuromodulator 2

5 5 1

MAXIMAL

MID

ARCH

BROW

LIFT

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

To Create a More Uniformly Arched Brow 5 5

5 1

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Crows Feet: Neuromodulator ¥ Stay very 4 3 2 1

1

2

superÞcialintradermal. Stretch skin to look for vascularity and avoid these areas ¥ If patient has a good Òsnap testÓ inject 1-2u midpupillary if lateral eyes are being injected as wrinkles may appear to only ÒmoveÓ medially if you donÕt.

¥ Midpupillary

injections may open the aperture of the eye up to 3 mm at maximal smile. Also helps withe Òjelly rollÓ Complications: dryness, ectropian. ¥ Do not go below the Zygomatic arch Complications: hitting the Zygomaticus major muscle can cause lip and cheek ptosis, changing the smile

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Crows Feet, eye opening: Neuromodulator

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Bunny Lines: Neuromodulators ¥SuperÞcial injections

One injection per side 3-5(B)units divided evenly and one 5(B)units dose in procerus if needed

5 2

2

2

¥Stay medial and superior to avoid lip ptosis

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

NASAL TIP ELEVATION: NEUROMODULATORS ¥Watch the patient smile, only inject if the nose goes downward when they smile ¥Place 2-4 (B)u directly below the nose superiorly in the midline NOT SMILING

SMILING

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Landmarks for perioral Neuromodulator treatment

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Neuromodulators: Lips CUPIDÕS BOW WILL ACCENTUATE

DEPOSIT

OR

THREAD

PLAN: ROMANCE C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

3 units of Botox¨

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

ANIMATION

REST

BEFORE BOTOX¨

AFTER BOTOX¨

PLAN: WRINKLE AFTER BOTOX¨ AND REDUCTION 1 JUVEDERM¨ COMBINATION THERAPY

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Before and after Botox¨ to the lips

PLAN: WRINKLE REDUCTION WITH BOTOX¨

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Perioral Rhytids: Neuromodulators ¥This treatment only lasts 7-9 weeks ¥Numbing cream is helpful ¥Units will vary greatly between

¥Be careful with older patients and

patients ¥It is not necessary to treat both the upper and lower lips, and is often better to treat just the upper, depending on the patients needs ¥SuperÞcial, small and symmetrical injections totaling 2.5u to 8u total ¥Keep injections medial, but stop before CupidÕs bow, for most patients ¥Start with smaller doses and have them return at 2 weeks for a recheck ¥If only treating the upper lip, start with 2-4u

¥Tell patients it could feel funny for

those with horizontal lip line as it could make this appear worse a week or so, when sipping etc. This usually only lasts the Þrst week

¥This treatment will expose more of the natural lip, making the lip appear fuller. It may change the shape slightly

¥ If lip wrinkles are worse in the body of the lip, you can inject directly into the lip, same units and areas apply

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Superior Border

Coronoid notch Identify area of maximum thickness

Anterior Border

TYPICAL DOSE 15-25U BOTOX¨ EACH SIDE

Posterior Border

Ear tragus

Inferior Border

Masseter injection: Neuromodulators C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Before and After Masseter injection 50u Botox¨

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

ANGER

BEFORE

5 (B) units bilaterally 2 (B) units mentalis

AFTER

DAO and mentalis treatment C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

5 (B) units DAO bilaterally 2 (B) units mentalis 12(B) units to Platysma bilaterally

DAO ~mentalis~platysma treatment C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

You probably donﾃ付 need this expression to this intensity D A O m e n t a l i s

facial shrug C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ﾂｨ I N S T I T U T E

DAO Ask patient to show you their bottom teeth Feel for the muscle then inject directly into the muscle anywhere from 3-5 (B)units Stay lateral to avoid Depressor Labii inferioris which will could make their smile asymmetrical Have patient bite down and map out masseter One finger away from masseter, inject C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ﾂｨ I N S T I T U T E

Mental Crease: Neuromodulator ¥Inject 1-2u per site, just

below the crease, staying medial ¥Best used in combination with Þllers 2

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Mentalis: Neuromodulator ¥Right in the center of mentalis, or two smaller

injections ¥Stay medial and inferior with injections so as not to hit the depressor labii which can cause an asymmetric smile ¥Alternate technique double dilute and superficial injections- MicroTox technique STRONG MENTALIS

PEBBLY CHIN

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

mentalis~

Unreliable/ Unsure

Not quite as.....

Unreliable/ Unsure

2 (B) units mentalis C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Complications Mentalis: Neuromodulator COMPLICATION: OVERCOMPENSATION IN ONE AREA

COMPLICATION: ASYMMETRY

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Complete rage m u s c l e s i n v o l v e d a: corrugator b:Orbicularis Oculi c:Orbicularis Oculi d:Levator nasi e:Orbicularis oris f:mentalis g:depressor anguli oris SQUARE SMILE, SNEERED NOSE ~REQUIRES EFFORT C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

4

lower face and neck anatomy

1. Risorius 2. Depressor Labii 3.Depressor Anguli Oris

4. Mentalis 5. Platysma 6. Sternocleidomastoid

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Platysmal Bands: Neuromodulators 10-20u for the entire length of each band Start High on jaw line with higher numbers and work your way down injecting every one inch or so Grasp the band with your nondominant hand and inject 90 degrees into the muscle

This treatment may last longer than average treatments (4-5 months) Higher numbers (50-100u) can cause weakness of neck flexors and dysphagia, dysphonia

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

T H E N E F E RT I T I L I F T TARGET MUSCLES: Platysma complex Named after greek Depressor anguli oris goddess Nefertiti, who was known to PATIENT SELECTION: have a strong, Patients with vertical neck bands dominant jawline Downturned oral commissures Modest laxity around the neck and jawline MECHANISM OF ACTION: Release the depressors allowing the antagonistic elevators, the levator anguli oris, and the zygomatic major and minor muscles to work harder LANDMARKS: Injection points from lateral end below the masseter muscle to the medial area under the depressor angularis oris.

DEPTH: Depth is submandibular, injected perpendicular to the skin. 4Ð7 injection points per side into the platysma. If bands have started to form under an overly prominent ÔjowlÕ a second or third injection could be placed in a second row.

AVERAGE DOSE: 15-20 botulinum toxin type A units per side, with 2-5 botulinum toxin type A units in each injection C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Nefertiti Lift

3

3

3

3

3 2

Optional for jowls

Average dosing for the Nefertiti lift would range from 15-20(B) units per side.

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Nefertiti Lift

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Nefertiti Lift

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Before and after Nefertiti lift C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Microtox Lift C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

MICROTOX LIFT Target muscles: ¥superÞcial Þbers of the platysma (neck) ¥superÞcial arrector pili muscle Recommended Reconstitution: ¥double dilution what you are used to (2:1) Wafßes Wu, MD coined the terms ÔmesobotoxÕ or ÔmicrobotoxÕ to describe this chemoresurfacing technique.

This microscopic band of tiny smooth muscle attaches to the base of every hair follicle on one end, and the dermal tissue on the other. When contracted, this muscleÕs role is to elevate the skin tissue; however, when injected with botulinum toxin type A, the smooth muscle will respond immediately with a skin retraction which could be likened to a Ôshrink wrapÕ contractive effect. The skin will subsequently appear to be tighter and more compressed, and Þne horizontal lines will disappear into the tissue.

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

MICROTOX LIFT

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C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Microtox Lift C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Microtox Lift

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Microtox Lift C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Microtox Lift C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Microtox Lift C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Microtox Lift C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

50 UNITS BILATERALLY

©2011 LESLIE FLETCHER, RN

AXILLARY HYPERHIDROSIS C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

Celebrity perfectionÉ how could you improve? *untouched celebrity photos

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

REFINING BEAUTY narrowed eyes 6 (b)units to orbicularis oculi 2 (b) units to depressor septi 3 (b)units to dao bilaterally

nose droop

marionettes / jowls C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

2 2 4

5

1

2

1

1 2

¥frontalis 2 (B)units ¥glabellar 12 (B)units ¥pretarsal orbicularis oculi 2 (B)units

4

5

1

¥orbicularis oculi 10 (B)units ¥levator labii superioris 2 (B)units ¥depressor septi 2 (B)units

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

How can we improve?

¥pretarsal orbicularis oculi

4(B)units ¥levator nasi 4 (B)units ¥depressor septi (B)2units ¥depressor labii (B)1unit ¥arrector Pili (B)4units C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

How can we improve? narrowed eyes

potentially dimply chin

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ﾂｨ I N S T I T U T E

How can we improve? brow ptosis crowﾃ不 feet smile asymmetry nose droop lip inversion jowls

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ﾂｨ I N S T I T U T E

C O P Y R I G H T 2 0 1 4 I N J E C TA B I L I T Y ¨ I N S T I T U T E

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