Aesthetic Medicine: Surgical Pearls

Conduct an assessment of the patient.

Note the location and depth of rhytids.

Obtain a history of the patient's concerns.

• Brow position is important.

• Check for the presence or absence of compensatory brow elevation.

• Check for blepharochalasis and dermatochalasis.

• Check for collagen depletion.

• Measure the width of the forehead (a wide forehead would need more neuromodulator/Botox).

• Assess strength of frontalis muscle and length of corrugator.

Take a preoperative photograph.

Apply a eutectic mixture of local anesthetics (EMLA) 30 minutes prior to procedure.

Give counseling about potential complications.

Obtain consent.

The lumps on the area injected will go down in 15 to 30 minutes.

Do not rub or apply pressure on the area that was injected with Botox.

For 6 hours, avoid bending or stooping down; instead lie down flat on your back.

Do not go to the gym or do any sports until the next day.

Follow up after 10 days.

Take a postoperative photograph.

Conduct a general assessment of the patient.

The patient should avoid aspirin (any product containing acetylsalicylic acid), vitamin E, and other dietary supplements, including gingko, evening primrose oil, garlic, feverfew, and ginseng, for 2 weeks.

The patient should also avoid blood thinners such as aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn) 1 week before the treatment.

Enquire about history of cold sores (or fever blisters) prior to treatment.

Optionally, the patient can start taking an Arnica tablet for 1 week prior to treatment and 4 days posttreatment. The standard dosage is three Arnica tablets (30 CH) three times a day 30 minutes before or after a meal.

Enquire about allergy or sensitivity to lidocaine.

Mild bruising is common and can last 7 to 14 days.

Take a preoperative photograph.

Apply EMLA 30 minutes prior to the procedure.

Give counseling about potential complications and obtain consent.

Follow up after 2 weeks for touch-up.

Take a postoperative photograph.

Counsel the patient that the volume will go down by approximately 20%.

Give Voltarol for pain relief.

Massage with Arnica.

Avoid hot beverages after the dental block (for lip augmentation).

Avoid cold compression to prevent headache (in the temporal area).

Minimize movement of the treated area.

Avoid applying heat to the treated area until bruising or any swelling has resolved.

On the day of treatment, avoid activities that cause facial flushing including consuming alcohol, hot tub or sauna use, exercising, hot wax, and tanning. Avoid extreme-cold activities, like skiing or hiking outdoors.

Gently apply a cool compress or wrapped ice pack to the treated areas for 15 minutes every few hours as needed to reduce discomfort, swelling, or bruising up to a few days after treatment. When bruising occurs it typically resolves within 7 to 14 days.

Results last approximately 6 to 12 months.

For more than 4 cc of filler used, prednisolone 40 mg with Nexium 40 mg daily for 2 days after meals may be considered.

Check the brow position (this is important).

Check for the presence or absence of compensatory brow elevation.

Check for blepharochalasis or dermatochalasis.

Check for collagen depletion.

Assess the strength of muscle.

Measure the width of the forehead.

The brow elevator (frontalis) and depressors (corrugator, procerus, depressor supercilli [DSC] for the medial brow and the superolateral fibers of the orbicularis oculi for the lateral brow) should be treated as a single unit to prevent brow ptosis.

Preventing brow ptosis should be the priority.

This can be achieved by full treatment to the corrugator, procerus, and DSC, a conservative dose to the frontalis, and a later touch-up to the frontalis if required in 10 days.

Treatment of the superolateral fibers of the orbicularis oculi will also help to maintain an elevated brow position.

Assess the activity of DSC. If DSC overactivity is missed, the patient may come back with descent of the medial brow (an angry look).

If there is previous history of heaviness of brow after treatment, inject only in the central forehead.

For the technique, see Video 2.1 .

Injections placed above the midpupillary line for the corrugator should be at least 1 cm above the bony orbital rim to help prevent lid ptosis caused by diffusion of Botox to levator muscles.

Some return for a touch-up in 10 days.

Lid ptosis

Brow ptosis

The temporal fossa is occupied by the temporalis muscle. There are three planes for injecting the filler:

• the subcutaneous plane (which can lead to irregularities and less longevity)

• between the leaves of the superficial and deep temporal fascia (difficult to localize)

• under the muscle above the periosteum (which is safer and easily located).

The injection point is 1 cm behind the temporal crest and 1 cm above the lateral orbital rim, just above the periosteum. Avoid branches of subtemporal artery.

Give local anaesthetic intradermally raising a weal on the skin (0.1 mL Xylocaine + adrenaline).

I prefer Restylane as it is soft and flows easily, hence we can use a smaller, finer 30-gauge needle.

Keep your nondominant thumb near the hairline to prevent wastage of material into the hairline.

0.5 mL to 1 mL is required for each fossa.

For the technique see Video 2.3 .