Keywords

Indications

Patients who wish to improve facial appearance by reducing the prominence of dynamic wrinkles and/or altering the position of facial structures. Common areas of treatment include the forehead, glabella, nasal bridge (bunny lines), periocular (crow’s feet), brows, perioral (lipstick lines), melolabial/labiomental folds (marionette lines), chin, and neck (platysmal bands). Patients should have been evaluated and deemed appropriate for such surgical intervention. Contraindications to treatment include prior allergic reaction, injection into areas of inflammation, breastfeeding, pregnancy category C, diseases of the neuromuscular junction, usage of aminoglycosides, sensitivity to or concern for human blood products (albumin), and static rhytids. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Essential Steps

  1. 1.

    Per FDA regulations, a copy of the Medication Guide must be provided to the patient for review prior to treatment.

  2. 2.

    Administration of topical anesthetic .

  3. 3.

    Reconstitute botulinum in vial to desired concentration with unpreserved, sterile saline.

  4. 4.

    Mark injection sites with patient in seated, upright position.

  5. 5.

    Prep skin with desired antibacterial agent.

  6. 6.

    Inject at desired locations at a 45° angle with a 1 cm3 syringe and 30 gauge needle.

  7. 7.

    Apply pressure if ecchymosis develops.

  8. 8.

    Document units injected per site, type of botulinum injected, lot number of botulinum vial(s) used, and response/reactions to previous treatments.

Complications

  • Hemorrhage/hematoma

  • Infection

  • Ecchymosis

  • Asymmetry

  • Ectropion

  • Eyelid ptosis

  • Eyelid retraction

  • Brow ptosis

  • Brow retraction

  • Lagophthalmos

  • Dry eye syndrome

  • Corneal exposure

  • Epiphora

  • Diplopia

  • Lip droop

  • Drooling

  • Swallowing difficulty

  • Difficulty maintaining head position

Template Operative Dictation

Preoperative diagnosis:

(1) Facial rhytids and ((2) platysmal banding)

Procedure:

(1) Botulinum toxin injections

Postoperative diagnosis:

Same

Indication:

This ____-year-old (race) (male/female) had developed (list symptoms from above) over the past ____ (months/years) and on clinical evaluation was found to have dynamic rhytids of the (list areas) (and malposition of the brows/oral angle/___). A detailed review of risks and benefits of the procedure(s), as well as treatment alternatives, was discussed with the patient. The patient was given the Medication Guide for (type of botulinum used) to review. Following this, the patient elected to undergo the procedure(s) and informed consent was obtained.

Description of the procedure:

The patient and operative site(s) were identified and marked with a surgical marking pen with the patient seated upright in the treatment chair. (Topical anesthetic consisting of ___ was applied to the injection areas.) The patient’s face was then prepped with ____ (alcohol/betadine/___). A time out was performed verifying correct patient, procedure, and operative site(s).

The (type of botulinum) was reconstituted with ____ mL of unpreserved, sterile saline per vial (lot numbers: __). Using an 18 gauge needle, the botulinum was drawn into a 1 cm3 syringe. A 30 gauge needle was then placed on the syringe for patient injection. Each previously marked site was injected at a 45° angle with the needle positioned (intramuscularly/immediately superior to the muscle). (Pressure was applied to (area) as ecchymosis developed following injection.) A total of ___ units of botulinum was injected at the sites as depicted in the diagram in the electronic medical records system . (If unable to produce a diagram due to the limitations of the medical records system, then you will need to list each injection site and the number of units injected at each.)

The patient tolerated the procedure well and left the office in stable condition.