CAUSES

The controllable causes can be sectioned into before, during and after treatment delivery

• Poor treatment design
• Factors effecting treatment delivery
• Post operative factors

• Before you start ensuring your field of direct vision is adequate and enables your patients face to be seen front on to avoid your vision and placement being altered by positioning
• Examine the face when muscles are relaxed and fully contracted
• Although difficult, it is not impossible to assess the face for differences in underlying anatomical structures. While at rest you can examine differences in fat pad and bone curvatures on the skins surface.
• Less fatty areas or areas with less bone tend to allow more movement of the muscles resulting in increased lines and wrinkles.
• Ensuring full muscle contraction on request and not just partial, when trying to asses the orbicularis oculi muscle for example, is a crucial assessment skill in order to reduce the risk of poor treatment outcome and asymmetrical results.

The best way to get full muscle contraction for different anatomical structures

• FRONTALIS ask patient to look up or towards the wall behind them
• ORBICULARIS OCULI say something that will really make them smile, like that fact that you’re really trying to make them smile
• GLABELLA COMPLEX can be difficult, can frown yourself and ask patient to copy you, or give them a mirror to do it into
• PLATYSMAL BANDS AND DAO of the lower portion of the face is also a difficult area of conscious muscle contraction. Asking the patient to do a sad face or turn their chin upwards as much as possible/ this may take a while

Observe for both asymmetry at rest and contraction closely, check the eyelids and orbital area where the skin of the forehead meets. These are high complaint areas for post operative asymmetry.

• Most asymmetry is caused across the frontalis muscle. This is by injections differing slightly on either side of the treated and untreated muscle laterally, where the muscle supports the eyebrows.

MARK UP INJECTION POINTS AND ANATOMY

Always consider your ptosis safety margins when marking up. Give consideration after doing so that fixation on one spot can prevail when working within close proximity of the face. Remember to take a step back and look at the face as whole again before treating to ensure everything looks how it should. Once you have marked, examine again, face on the muscles relaxed and under contraction for a final check. Take a photograph at this stage also.