Improving quality of life
Dr Maryam McMillan discusses dermal filler correction and placement in a patient with Tourette Syndrome
A 54-year-old white German female attended the clinic requesting facial aesthetic treatment in order to improve her cosmetic appearance and self-esteem. Her medical history was unremarkable, with the exception of a diagnosis of severe Tourette Syndrome (TS), which has been present since childhood. She advised that she had recently undergone invasive surgery in the form of implantation of a deep brain stimulator (DBS) as part of an experimental treatment for her severe TS. following placement of the DBS, she developed significant depression symptoms, sleep disturbance, excessive nail-biting and a worsening of her verbal tic. Compounding this, she had recently had dermal fillers placed at another clinic and was unhappy with the cosmetic results, which has further worsened her self-esteem. The patient was distressed and tearful during the initial consultation as a result of her facial appearance and lack of self-esteem.
Patient examination, diagnosis and treatment plan
A validated full-facial assessment was carried out.1
In view of her mention of depression symptoms and the relatively high incidence of depression in patients with TS2, a standard 2-point validated depression screener was conducted, which was negative for significant depression symptoms.3 A validated 7-point body dysmorphic disorder screener was carried out, which again was negative.4
The following diagnosis was provided:
Multiple cosmetically unacceptable areas in the lips, cheeks and chin as a result of inappropriate placement of hyaluronic acid-based dermal filler (DF) combined with age-related facial wrinkles and loss of tear trough volume.
Following the assessment, the relative risks, benefits and costs of the various treatment options were discussed in accordance with current guidelines:1
- Leave the lips alone and allow the natural dissolution of the previous DF (advised that this would likely take around six months or more)
- Dissolution of the DF with hyaluronidase (it was explained that this was a recognised off-license use of hyaluronidase;5 and there is a small risk (approximately 0.5%)6 of allergic reaction to the hyaluronidase – which could be mitigated by the use of ‘patch testing’ prior to placement.)
- Consequent improvement in facial aesthetics – monotherapies or combination of botulinum toxin type A, thread lifts and DF.
Following discussion, she provided verbal and written informed consent to have the hyaluronidase and corrective DF treatment combined with botulinum toxin type A wrinkle reduction treatment, and MINTTM polydioxanone (PDO) thread lift. The aim of the treatment was explained to the patient – to create a natural-looking, cosmetically pleasing facial appearance through removal of the existing DF, placement of botulinum toxin type A, PDO thread lift and administration of new DF.
Treatment
Written consent for the use of standardised clinical photographs1 for publication was obtained.
A standard aseptic technique was employed in each treatment session, and the skin was cleansed with a chlorhexidine-based solution.7 Aftercare instructions were given verbally and in written electronic format.
1. The facial anatomical landmarks were identified, and the areas of the face were anaesthetised using topical 5% lidocaine ointment.
Hyaluronidase (Hyalase®) was reconstituted using the Aesthetic Complications Expert Group (ACE) guidelines.5 Hyalase® was reconstituted with 5 ml bacteriostatic 0.9% saline solution.
Intradermal patch testing was conducted prior to placement of the Hyalase®5 - 4 units of Hyalase® were injected subcutaneously into the left forearm following skin preparation using chlorhexidine solution. No reaction was observed after 30 minutes.
A total of 4500 units of Hyalase® (3 x 1500unit vials) were injected into the lips, cheeks and chin using a 4mm 30G needle (a new needle tip was applied prior to lip injections to avoid using a contaminated or blunted needle following the forearm placement). Following administration, the patient was observed for 60 minutes to ensure no adverse reactions occurred, and during this period, aftercare instructions were given.5
2. Clinical review two weeks after the Hyalase®, the patient reported some residual 'puffiness', and examination revealed some areas of residual DF in the lips and chin as a result of incomplete dissolution of the DF. Following this, the patient was reconsented for the placement of further Hyalase®, aseptic skin preparation and local anaesthetic were applied, and in keeping with the standard protocol, patch testing was conducted, and a total of 4500 units of Hyalase® were injected into the lips and chin, and the patient was observed for 60 minutes and given aftercare instructions.
3. Clinical review two weeks after the second course of Hyalase®, the patient reported no symptoms, and clinical examination revealed complete dissolution of the DF.
Further clinical photographs were taken.
AzzalureTM 125 speywood units were reconstituted with 0.63 ml bacteriostatic sodium chloride 9 mg/ml (0.9 %) solution for injection achieving 10 units/0.1 ml AzzalureTM. This was administered using a 32G needle – forehead (40 units), glabellar frown lines (50), outer canthus (15 on each side)
4. A clinical review was carried out three weeks post-AzzalureTM placement was conducted, and the patient was happy with the treatment outcome and was reconsented for PDO thread placement. Aseptic preparation was conducted as previously described, and the facial anatomical landmarks were identified.
MINTTM FINE (five on each side) and FIX PDO (two on each side) threads were used. The entry and exit points were determined in the face. The procedure was performed under local anaesthesia (2% lidocaine with adrenaline 1:80 000 ratio) at the needle insertion point and the exit point. In each entry point, a hole was made using a 18-G needle.
The small risk of treatment site infection was discussed, and she was advised that in the event of any excessive redness or pain, she should return for assessment as she may require a course of antibiotics. The patient was advised to take over-the-counter analgesics (paracetamol and ibuprofen) as required after the treatment. It was also recommended that the patient wear a post-surgical facial garment for one week.
5. Following the placement of the threads, a review was conducted at three weeks, which was uneventful and again at eight weeks. At this point, she was reconsented for DF placement and further clinical photographs were taken.
Aseptic preparation and local anaesthetic placement were conducted as previously described. The cheeks were treated with Teosyal Ultra Deep using a 25G cannula (1.2mL) and Teosyal RHA4 was placed in the cheeks using a 25G cannula with a further 0.6 mL placed in the midface using a retrograde technique and 0.6 mL placed each side accessing adjacent to the tragus. The lips were treated with Teosyal RHA2 with a 4-point entry technique using a 25G cannula. The entries were made 1.0-1.5cm below and above the commissures with a 23G pre-hole needle, and a 25G cannula was inserted into the upper and lower lips. The cupid’s bow was augmented using a 4mm needle. Overall, 1.2ml of DF was applied.
Teosyal Redensity II was used for the tear trough augmentation, with 0.5 mL placed under each eye using a 25G cannula.
6. A review at four weeks was conducted, and the patient was very satisfied with the cosmetic result and reported no postoperative complications. Final clinical photographs were conducted. The patient expressed that the treatment has not only addressed her aesthetic concerns but has also reduced her levels of anxiety and depression, which has made a huge difference in her life.
The patient said, “I have been dealing with Tourette’s syndrome throughout my entire life, but it significantly worsened during the COVID-19 pandemic. The severity of my condition led to my referral to participate in a ground-breaking trial surgery for individuals with Tourette’s.
“This procedure involved deep brain surgery, also known as Deep Brain Stimulation (DBS). In a six-hour surgery, a device was implanted in my chest, and two electrodes were placed in my brain. These electrodes are then stimulated with an electric current. Given the lack of existing studies, it’s very much a trial-and-error process, with the ability to adjust the current as frequently as necessary.
“Throughout these adjustments, I experienced severe depression that caused a significant impact on my self-esteem. This resulted in sleepless nights over the course of several weeks, excessive nail-biting, and an increase in my verbal tics.
“Thanks to the care and expertise of Dr Miriam, my confidence has been restored over the past six months. I now feel like a completely new person. Dr Miriam’s treatment has not only addressed aesthetic concerns but has also worked to reduce my levels of anxiety and depression, which has made a world of difference in my life.”