Minimally invasive procedures in an aesthetic practice have grown over the past decade. Plastic surgery practices are embracing the incorporation of injectables and lasers as adjuncts to their surgical procedures. The use of botulinum toxin, hyaluronic acid fillers, and lasers has made a significant impact on the authors’ practice. The authors describe the important considerations, consultation goals, and procedural steps with injectables and fillers. The novel use of deoxycholic acid injections is also described. The authors strongly think that as options continue to expand, plastic surgeons will benefit from taking an active role in adopting these new innovations.
Key points
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Plastic surgery practices are embracing the incorporation of injectables and lasers as adjuncts to their surgical procedures.
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The use of botulinum toxin, hyaluronic acid fillers, and lasers have made a significant impact on the authors’ practice.
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The authors describe the important considerations, consultation goals, and procedural steps with injectables and fillers.
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The novel use of deoxycholic acid injections is also described.
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The authors strongly think that as options continue to expand, plastic surgeons will benefit from taking an active role in adopting these new innovations.
Introduction
The role of noninvasive and minimally invasive procedures have accounted for exponential growth in the cosmetic medicine and surgery industry. According to the 2014 American Society of Plastic Surgeons’ national survey, nearly 15,600,000 cosmetic procedures were performed. Among these procedures, 13,900,000 (89%) were nonsurgical procedures. This total represented a near 748% increase compared with 2000 survey data. According to the statistics, the top 5 minimally invasive procedures in 2014 were.
- 1.
Botulinum toxin type A (6,673,608)
- 2.
Soft tissue fillers (2,301,673)
- 3.
Chemical peel (1,250,059)
- 4.
Laser hair removal (1,100,000)
- 5.
Microdermabrasion (417,034)
For a plastic surgery practice, minimally invasive procedures may represent a significant portion of practice time and revenue. In addition, the role of the injector, which was traditionally dominated by the surgeon, can be expanded to a position where nurse practitioners and physician assistants play a more integrated role in injections, lasers, and other office-based procedures. Despite that, recent studies have indicated that nearly 77% to 81% of plastic surgeons surveyed reported that nurses “were not as capable as plastic surgeons in administering injectables,” although nurses rather than physicians are performing these cosmetic procedures in many practices. Others studies have shown that nearly 30% of practices would have a physician evaluate patients before the nurse performed the procedure, but in 35% of the cases the physician was not even on site. Regulations governing oversight and who can inject ultimately differ by state, but the overall trend represents a growing role of the physician extender in providing minimally invasive procedures to patients in a cosmetic practice.
Regardless of who is performing the procedure, plastic surgeons and core physicians should remain knowledgeable and serve as leaders with noninvasive and minimally invasive procedures. Patients who choose to undergo minimally invasive procedures may view the experience as an introduction or gateway to the cosmetic procedural field that may mature into a larger set of therapeutic antiaging options. Therefore, in addition to fulfilling current needs, minimally invasive procedures can provide an excellent opportunity to establish an early rapport with patients and maintain a robust continuity of care that can be mutually beneficial to patients’ best interests and contribute to a comprehensive practice.
This article provides a general overview of noninvasive and minimally invasive procedures performed in the senior author’s practice (AM) with a focus on neurotoxins, soft tissue fillers, and lasers. In practice, the authors’ use Botox (Allergan Inc, Irvine CA) for glabellar lines, lateral canthal lines, forehead rhytids, and platysma muscle. We use Juvederm Voluma (Allergan Inc, Irvine, CA) for malar/cheek augmentation and Juvederm Ultra Plus XC for nasolabial, lip, and perioral enhancement. The energy platform we use is InMode (InMode Aesthetic Solutions, Irvine, CA), which has the following capabilities; intense pulse laser, diode laser, fractional ablation, radiofrequency ablation, body contouring, and cellulite reduction.
Introduction
The role of noninvasive and minimally invasive procedures have accounted for exponential growth in the cosmetic medicine and surgery industry. According to the 2014 American Society of Plastic Surgeons’ national survey, nearly 15,600,000 cosmetic procedures were performed. Among these procedures, 13,900,000 (89%) were nonsurgical procedures. This total represented a near 748% increase compared with 2000 survey data. According to the statistics, the top 5 minimally invasive procedures in 2014 were.
- 1.
Botulinum toxin type A (6,673,608)
- 2.
Soft tissue fillers (2,301,673)
- 3.
Chemical peel (1,250,059)
- 4.
Laser hair removal (1,100,000)
- 5.
Microdermabrasion (417,034)
For a plastic surgery practice, minimally invasive procedures may represent a significant portion of practice time and revenue. In addition, the role of the injector, which was traditionally dominated by the surgeon, can be expanded to a position where nurse practitioners and physician assistants play a more integrated role in injections, lasers, and other office-based procedures. Despite that, recent studies have indicated that nearly 77% to 81% of plastic surgeons surveyed reported that nurses “were not as capable as plastic surgeons in administering injectables,” although nurses rather than physicians are performing these cosmetic procedures in many practices. Others studies have shown that nearly 30% of practices would have a physician evaluate patients before the nurse performed the procedure, but in 35% of the cases the physician was not even on site. Regulations governing oversight and who can inject ultimately differ by state, but the overall trend represents a growing role of the physician extender in providing minimally invasive procedures to patients in a cosmetic practice.
Regardless of who is performing the procedure, plastic surgeons and core physicians should remain knowledgeable and serve as leaders with noninvasive and minimally invasive procedures. Patients who choose to undergo minimally invasive procedures may view the experience as an introduction or gateway to the cosmetic procedural field that may mature into a larger set of therapeutic antiaging options. Therefore, in addition to fulfilling current needs, minimally invasive procedures can provide an excellent opportunity to establish an early rapport with patients and maintain a robust continuity of care that can be mutually beneficial to patients’ best interests and contribute to a comprehensive practice.
This article provides a general overview of noninvasive and minimally invasive procedures performed in the senior author’s practice (AM) with a focus on neurotoxins, soft tissue fillers, and lasers. In practice, the authors’ use Botox (Allergan Inc, Irvine CA) for glabellar lines, lateral canthal lines, forehead rhytids, and platysma muscle. We use Juvederm Voluma (Allergan Inc, Irvine, CA) for malar/cheek augmentation and Juvederm Ultra Plus XC for nasolabial, lip, and perioral enhancement. The energy platform we use is InMode (InMode Aesthetic Solutions, Irvine, CA), which has the following capabilities; intense pulse laser, diode laser, fractional ablation, radiofrequency ablation, body contouring, and cellulite reduction.
Botulinum toxin
After nearly 2 decades of clinical use, the Food and Drug Administration (FDA) granted approval for Botox cosmetic (Allergan Inc, Irvine CA) for use in moderate to severe glabellar lines. Shortly thereafter, clinical research began to focus on the use of Botox for other regions in the face, including the forehead, lateral canthal lines, perioral region, and neck. Neurotoxin use is a continued point of discussion and interest despite its longstanding use in cosmetic medicine.
How Neurotoxins Are Used in the Authors’ Practice
Consultation begins with a detailed medical history including contraindications dictated by the manufacturer. History of allergies/hypersensitivities, use of aminoglycoside antibiotics, neurologic conditions, bleeding disorders, respiratory disease, or facial muscle weakness is specifically asked. Patients are asked regarding efficacy of previous neurotoxin treatments, locations of use, and duration of effect. The authors find that past experiences often have a significant effect on patients’ expectations.
After the physical examination, a discussion then ensues regarding the type and amount of neurotoxin to be used with possible longevity of action. The authors select the neurotoxin based on onset of action, with Dysport (Galderma Laboratories LP, Fort Worth, TX) representing an earlier onset of action (1–3 days) compared with Botox (Allergan Inc, Irvine, CA) (3–5 days), or resistance to previously used Botox, representing Xeomin (Merz Aesthetics, San Mateo, CA). Patients are generally told that Botox will last approximately 3 to 4 months with gradual return of initial animation at approximately 6 weeks, and faster in males. Completion of this discussion concludes with written consent including all risks and benefits explained in detail.
Areas of treatment are determined. Recommended and approved doses are adopted for treatment with 2.5 mL used for reconstitution of a 100-U vial. The authors often use 20 U for treatment of glabellar lines. Four injections are placed into the corrugator muscles, and a single injection is used for the procerus muscle and/or bunny lines. A total of 24 U is used for treatment of lateral canthal lines. This injection begins at least 1.5 cm lateral to the lateral canthus with 2 to 3 injections placed on either side. Off-label use of forehead rhytids is performed in varying amounts beginning at least 1.5 cm superior to the brow if the patient wants to maintain brow movement and proceeds superiorly along the course of frontalis muscle. A transition zone approximately 1 cm superior to the brow is created with low-dose injection. An overall conservative approach is taken in order to avoid overtreatment ( Fig. 1 ) which may result in a lower brow.
Patients can return for a 2-week follow-up. The most common complication seen is undertreatment, which is readily addressed with minimal, balancing neurotoxin use. It is important to note that an ineffective result from botulinum toxin treatment can be due to recruitment of surrounding muscles, dermal atrophy, or antibody formation.
Soft tissue filler augmentation
Soft tissue augmentation is the second most commonly performed noninvasive medical procedure, to neurotoxins. Hyaluronic acid fillers account for most soft tissue augmentation used in the market and are advantageous because of the wide selection of types and reversibility.
Fillers must be injected into the subcutaneous or supraperiosteal plane. Superficial injection into the dermis may result in persistent dermal contour irregularities. The most common adverse events are injection-site erythema, swelling, pain, and bruising. Infection is uncommon, but injection in the perioral area can potentiate recurrence of herpes simplex virus. Hypersensitivity reactions are also very rare, occurring in approximately 1 in 5000 cases.
Injectable safety is of paramount concern. On May 28, 2015 the FDA issued a warning regarding the unintentional injection of soft tissue fillers into blood vessels that can result in “rare, but serious side effects.” This phenomenon may be a direct result of vascular embolization or through sidewall compression of facial vasculature due to overvolumization resulting in “vision impairment, blindness, stroke and damage and/or death of the skin (necrosis) and underlying facial structures.” High-risk areas are identified near named vessels and tributaries of the periorbital region, glabella, perinasal region, and forehead. The FDA’s general recommendations for health care providers have been provided.
Recent focus on adverse events and vascular injury with filler use resulted in heightened awareness of possible injuries and treatment protocols. The use of ovine testicular hyaluronidase, Vitrase (Bausch & Lomb Inc, Rochester, NY), or recombinant human hyaluronidase, Hylenex (Halozyme Inc, San Diego, CA), can dissolve injected hyaluronic acid (HA), which is highly useful if the product is misplaced. Recent consensus recommendations on the treatment of HA filler-induced impending necrosis have been published in the plastic surgery literature. Once recognized, the immediate use of 200 U of Vitrase is injected directly into the area of blanch or violaceous discoloration. One injection for every 3 to 4 cm of skin manifesting signs of necrosis is appropriate. If no improvement is seen within 60 minutes, additional quantities of hyaluronidase are injected, repeating in 3 to 4 cycles. A warm compress with massage should be applied immediately to the areas of injury for 5 to 10 minutes every 30 to 60 minutes. In addition to warm compress, massage nitroglycerin paste into the area of impending necrosis up to 3 times daily. Oral aspirin with a regimen of 2 pills of 325 mg daily to prevent further clot formation with a 1-week course is also recommended. A “crash cart” list is recommended to be posted and the products should be available on site should intravascular injection occur. Repeat the regimen daily with daily follow-up of patients. Aftercare includes supportive care and whatever wound care with debridement that is needed.
How Fillers Are Used in the Authors’ Practice
Consultation begins with a detailed medical history as described earlier. Patients are asked about previous filler treatments, locations of use, duration of effect, and if any reactions occurred. Patients are also queried regarding allergies to medications, including lidocaine and gram-positive bacterial proteins.
Physical examination proceeds in a similar, systematic manner with an overall emphasis placed on facial shape, symmetry, and harmony. The midface is examined with documentation of tear trough deformity, atrophy/descent of the malar eminence, and deflation of the lateral upper or midcheek. The soft tissue prominence along the zygomatic arch is examined with any note of atrophy or concavity in surface morphology documented. Next, the prominence and depth of the nasolabial folds are identified. The perioral region is seen and palpated with attention paid to the skin quality and depth of rhytids present. Laterally, the jowls are examined with its relationship to the surrounding jaw/neck region. Once this has been completed, the examination is once again performed with facial animation with more attention paid to the perioral region and nasolabial folds. The goal of the physical examination is to document all areas of age-related change that cause incongruous transitions in facial harmony.
Findings on the physical examination are shown to patients with a mirror and photography if necessary. Age-related changes are explained to patients as a tool to justify the use of different fillers to address different areas of the face. For example, patients are counseled that Voluma (Allergan Inc, Irvine, CA) may be used to create a lift in the malar region when injected, whereas Juvederm XC (Allergan Inc, Irvine, CA) may be used for enhancement of perioral rhytids, lip augmentation, nasolabial fold, and marionette lines. Patients are also informed that fillers may last about 4 months to up to 1 year (or even longer for Voluma in some studies) depending of the type of injectable and where it is placed. The discussion is complete with a plan of action and an informed consent that includes all risks and benefits.
Filler procedures always begin under sterile conditions. Sterile preparation of the skin with sterile gloves is used with targeted regions that are predetermined. Patients are told to apply cold compresses to the skin before injection. Aspiration is performed immediately before injection. Gentle massage is done after injection. Cheek augmentation is usually performed with Voluma with approximately 0.5 mL used per malar region. Horizontal markings are made along the cheek, split by a vertical line from the lateral canthus to oral commissure, creating a cheek grid ( Fig. 2 ). Injection begins in zone 1 along the lateral zygomatic arch in the supraperiosteal layer along the superior border. Small aliquots are placed proceeding medially. Zone 2 injection is a continuation of zone 1 with augmentation of the malar fat pad, creating a smooth cheek transition. Midprocedure analysis of zone 3 and 4 is made with determination of whether more volume is needed. Careful attention is paid to avoid inadvertent injury or injection adjacent to the angular artery and the infraorbital neurovascular bundle.
