Botox Workshop2003.pdf

7/23/2019 Botox Workshop2003.pdf

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Botox WorkshopBy:

Moustafa AbouzaidProf. Dermatology & Andrology

Faculty of medicineAzhar University

Cairo Egypt2011


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Clostridium Botulinium

A gram positive,

Spore-forming,

Obligate anaerobic bacillus

Produces the most potent neurotoxins ,causing Botulism.Latin name: Botulus (black sausage)


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There are seven distinct antigenic toxins.:

1. BTX A,2. B , C ( C & C ),3. D,4. E,5. F &6. G

BTX-A is the most potent.

All are produced by different strains of clostridiumbotulinum.


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There are three forms of human botulism:

1. Food-borne (improperly preserved food containing

the preformed neurotoxin).

2. Infantile (ingestion of spores and production of thetoxin in infant's intestine).

3. Wound infection

Botulism


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History

1820.

First

collected

data onbotulism

1895.

Theanaerobicbacterium

was isolated

1922.

Theextracellular

toxin (crudeform) wasisolated

1930

Thecrystalline

(purifiedform) wasdeveloped

1946

BTX(clinicalproduct )

1973Animal

experiments

onstrabismus(Published).


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The cosmetic useof botulinium

toxinBy Jean Carruthers

in 1987.

FDA approved use

in adultstrabismus andblepharospasm in

1989.

BTX for blockingcholinergic

innervations tosweat glands forhyperhidrosis

1994 .


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2) Ophthalmological use1- Strabismus2- Blepharospasm3- Nystagmus

Clinical uses of Botox:

Hemifacial spasm Facial asymmetry Oromandibular dystonia Spasmodic dystonia Cervical dystonia

BTX-A was found safe and effective for:

Spasmodic torticollis Achalasia Gustatory sweating Hyperlacrimation Synkinesia

1) Neurologic use and excessive muscle activity


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3) Dermatologic use Hyper functional glabellar frown lines,

crow's feet & f orehead lines Brow ptosis and brow position Nasal scrunch and flare Upper lip wrinkles Marionette (sad lines ) Platysmal bands Palmar and axillary hyperhidrosis

4)Others uses: Anal fissures Pain management

Headache


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Glabellar frown lines

Crow's feetForehead lines

Marionette (sad lines )

Platysmal bands

Nasal scrunch and flare


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Temporary improvement in

the appearance of moderate to severe Glabellar lines

Fore head line

Crows feet

Adults 65 years

Indications for

Botulinum Toxin Type A


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Administering physicians1. Be well trained

2. Have knowledge of muscles controlling facialexpression

3. Should know the dynamics of aging


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The face and ageing

Ageing

Skin loseselasticity and

becomesthinner

Habitualexpressions &

constantmusclecontraction or

relaxation

Wrinklesand

creases


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Cosmetic Uses of BTX

Basic applications Horizontal

forehead lines Glabellar frown

lines Lateral and

medial brow lifts Crows feet

Advanced and otherapplications

Nasal scrunch and flare

Upper lip wrinkles Marionette (sad) lines Neck lines Platysmal bands Facial asymmetry Hyperhidrosis


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Why Botulinum Toxin?

Botulinum Toxin Type A is a therapeutic agentthat improves dynamic facial lines by targetingthe underlying responsible muscles

Mechanism of Action It works by blocking acetylcholine impulses that

trigger hyperactive muscle contractionsResult: CHEMICAL DENERVATION


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Neurotransmission

Neurons are specialized cells that

receive and transmit nerve impulses.

Dendrite

Soma/cell

Axon terminaland synapse

Axon


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Neurotransmission

Nerve impulses are conducted betweenadjacent cells across synapses, via the release of neurotransmitters.

Acetylcholine

Muscle

Axon

Axon branch

Muscle cell

Motor end plate

Axonterminal

Axon terminal

Axon

Neuro-muscular

junction


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The facial muscles muscle basics

Nerve impulse

Relaxed

Contracted

Body Muscles to

Move

Facial Muscles toGive our Features


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Botulinum Toxin

Type A :Mechanism of Action

Adapted from: dePaiva et al. PNAS 1999, 96:3200

1 2 3

4 5

Binding Internalisation Blocking

formation of thecollateral nerve sprouts

The sprouts retract andthe original nerve end

starts to work normally


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Diffusion Description

Particles of greater molecularweight diffuse more slowlythrough an aqueous mediumthan do smaller molecules so

long as charge and temperatureis the same

(Ficks first law, Fick 1855)


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Why is diffusion important?

Desired (larger molecule size) Needed for maximum local effect Access motor nerve terminal (NMJ)

Distribution within target muscle to reach nerve

terminal Not desired (smaller molecular size)

Excess local weakness Pharmacological effect on adjacent muscle

Distal weakness / dry mouth etc. Leakage from target muscle leads to spread via

blood stream


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BOTOX: Vial Dilutions

Saline diluentvolume

U/mL U/0.1 mL

1.0 mL 100.0 10.0

1.5 mL 66.7 6.72.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5

5.0 mL 20.0 2.0Only in axillary hyperhidrosis


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Dosage and Administration

Reconstitution Reconstitute with 0.9% sterile , non-preserved saline

Use 2.5 cc 5 cc syringe to draw saline solution

Insert at 45 angle and inject saline into Botulinum ToxinType A vial

Discard vial if vacuum doesnt pull diluent into vial Record date of reconstitution

Store reconstituted Botulinum Toxin Type A in a refrigeratorand use within 2 hours in room temperature

All details above refer to BOTOX


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Administration

Remove syringe used for reconstitution and useinsulin syringe with built-in 30-gauge needle.

Draw 0.5 mL into syringe and expel air bubbles

NOTE: In practice, it has been reported that:

Refrigerated vial without diluent remainseffective indefinitely

Efficacy maintained following reconstitution

Refrigerated and use it

for up to 4 weeks

Dosage and Administration (cont)


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Considerations for Treatment Botulinum Toxin Type A is contraindicated for the

following patients: Patients with infection at proposed injection site

Patients with known hypersensitivity to any ingredient in Botulinum Toxin A

Administration of Botulinum Toxin Type A is

not recommended during pregnancy

Co-administration with aminoglycosides or other agents interferingwith neuromuscular transmission should be performed with caution

The most common side effect s are injection-related andare transient are localized pain, tenderness &/or bruising


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Injection Considerations

Photograph the patient before injection. Instruct patient to animate to show

muscle activity Mark injection sites Use 30-gauge needle for comfort Inject into relaxed muscle Instruct patient to animate repeatedly

post-injection to maximise toxin absorption(2 - 4 hours) Provide patient with post treatment

instructions


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Follow-up

Pre-injection photos

Inform patients to return in 1-2 weeks forevaluation Compare results with Pre-injection photos

Correct any asymmetries / complains Set re-injection schedule


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Anatomy of the face


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Frontalis

Depressor supercilii Corrugatorsupercili

Procerus

Orbicularis oculi

Depressor labii inferiorus

Depressoranguli oris

Orbicularis oris

Zygomaticus minor

MentalisPlatysma

BuccinatorRisorius

Zygomaticus major


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CorrugatorSupercilii

Procerus

Frontalis

Orbicularis

Oculi

Key Muscles of the Upper Face


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Glabellar Aesthetics

Depression of the central

brow appears angry, sad,

Brow elevation appearsserene and calm


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Sites for Glabellar Injection

X

X X

X X XX

Saline diluent U/mL U/0 1 mL


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5 injection sites: 1 in procerus 2 in each corrugator

Total dose: 20 U (4 U/injection

site) 0.1 mL/injection

site (in case of 2.5mL dilution)

Carruthers A, Lowe NJ

CorrugatorSupercilii

Procerus

volumeU/mL U/0.1 mL

1.0 mL 100.0 10.01.5 mL 66.7 6.72.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5

Dosing

T i l B t li T i T A (BOTOX )


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Typical Botulinum Toxin Type A (BOTOX )Doses for the Female Glabellar

4

444 4

Corrugator

Supercilii

Procerus


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Procerus injection - massage

Firm upward pressure is used to move the BotulinumToxin Type A upward & outward toward depressor

supercillii

Flynn 2001

Gl b ll I j i T h i


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Glabellar Injection Techniques

Thumb of non-injectinghand protects orbital rim

Hand rests on patients faceto control the injection

Injections must be 1 cmaway from orbital rim

Flynn 2001


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Decrease in Glabellar Lines after Treatmentwith Botulinum Toxin Type A

Baseline Day 30

Unretouched clinical trial photos taken while frowning beforeBotulinum Toxin Type A and after Botulinum Toxin Type A . Individual

results may vary .


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The frontalis muscle ends

midway between thelateral and mid-brow.The orbicularis - oculi

depresses the portion of

the brow lateral to this.Injection of 2- 4 Mu of

Botox just below thelateral brow and lateralto the temporal fusionline can raise the lateralbrow, giving the patient a"chemical" brow-lift of

up to 2mm.

Lateral Brow Lifting


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Complications of glabellar injections

Brow ptosis, occurs when toxin affects the frontalis, asthe toxin spread 1-1.5cm (2-3cm in diameter)

Avoid injecting the glabella and whole forehead in one sessionespecially in patients with low-set brows, mild brow ptosis andpatients over 50 years (preinject the brow depressors).

Patient is advised to remain upright for 2 hours .To exercise muscles for the first 2 hours.Avoid rubbing or massaging for 2 hours.Responds to apraclonidine ( -adrenergic agonist) ophthalmiceye drops (2 drops / hour).


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Eyelid ptosis, when toxin migrates to

upper eyelid levator muscle, producing aweak paralytic effect as early as 48 hours oras late as 14 days and persisting for 2-12

weeks.

Avoid injection no closer than 1cm above thecentral eyebrow .Bothersome ptosis is treated byapraclonidine.


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Crows Feet

Superficial rhytides radiatingfrom the region of the lateralcanthus

Represents dynamichypertrophy of the orbicularisoculi coupled with static skinchanges

Coordinates with the smi le


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BOTOX: Crows Feet (cont)

xx

xx

Optimum dose 10 to 12 units per side


U/mL U/0.1 mL

1.0 mL 100.0 10.01.5 mL 66.7 6.7

2.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5


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BOTOX: Crows Feet

Optimum dose 10 to 12 units per side

Second treatment gave greater improvementand longer duration


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BTX: Crows Feet

After BOTOX

Before BOTOX


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BOTOX : Infraorbital Creases

Test skin laxity with asnap test

1-2 U of BOTOX

Lid margin in linewith the pupil

Lid margin slightlylateral to themidpoint betweenpupil and lateralcanthus

xx


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A more wide-eyed look can be obtained by injecting thelower eyelid at the lash margin by 2MU at mid pupil and2MU midway between pupil and outer canthus, some use

the first injection only.

This also helps smooth out fine lines under eyes.Do not do if patient exhibits a significant degree of scleralshow pretreatment, or had significant surgery under the eye,or if has a great deal of redundant skin under eye asexhibited by the snap test of the lower eyelid

X X


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Infraorbital Creases

Before BOTOX After BOTOX


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Reported complications of this area are :

Diplopia (cover eye) and send to ophthalmologist

Ectropion or a drooping lateral lower eyelid

Strabismus (send to ophthalmologist)Bruising

An asymmetric smile caused by the toxin diffusingto the zygomaticus major

Transient lymph edema


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Horizontal Forehead Lines

Horizontal lines andwrinkles across theforehead

Produced by excessive

contractions of thefrontalis


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BOTOX: Horizontal Forehead Lines

x x x x

For forehead 4-6 injections (a total of 10-20MU ) are placedacross the forehead in a uniform grid, visible blebs are temporarilyproduced. The lateral most injection should be vertically above themid-pupil, although with a wider forehead this can be extendedbeyond the pupil to the iris.


U/mL U/0.1 mL

1 0 L 100 0 10 0


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x x

xxx

xxx x

4-6 injections (A total of 10-20MU)

1.0 mL 100.0 10.01.5 mL 66.7 6.72.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5


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x

x x

x

x

xx

x

4-6 injections (A total of 10-20MU)


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BTX: Horizontal Forehead Lines

Before BOTOX

After BOTOX


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Botox (Botulinum toxin Type -A),Myobloc ( Botulinum toxin Type- B),

Dysport (Abobotulinumtoxin-A)


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Follow-up

New patients to return in 1-2 weeks for evaluation Compare results with pre-injection photos Correct any asymmetries / complains Set re-injection schedule


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- Regardless of botulinum toxin is chosen;- Follow the following tips to reducethe risk of both pain and bruising

Injection Pearls

American Society of Dermatologic Surgery in Orlando, Florida,


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THE MORE NEUTRAL PHAND THE BENZYL ALCOHOLDECREASE THE LESS THE STING OF

INJECTION.

1-Dilute with saline containing preservative

By pulling the skin toward the needle and pinchingthe skin lightly between the thumb and first finger(because the pressure sensation of the pull

overrides the sensation of pain).

2-Reduce the pain of the needle stick


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4-PLACE A WARM TOWELON THE FACE BEFORE

APPLYING TOPICAL ANESTHETIC

TO INCREASE THE ABSORPTION AND EFFICACY OF THEANESTHETIC.

3-Limit injections tono more that 4 per needle, after which the needle

starts to dull.


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5-TO MINIMIZE BRUISING,

Request that patients stop all Aspirin or Nonsteroidal anti-inflammatory drugs, Vitamin E, Ginkgo biloba, And garlic

14 days before botulinum injections .


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6- For periocular areas, Consider precooling to help vasoconstrict vesselsand thus reduce the chance of bruising.

In addition, use a specialized vein light to helpvisualize vasculature and thus avoid disturbing it.

7-To tamponade any oozing Use cotton-tipped applicators ; Apply ice

packs afterward to minimize bruising risk .


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Combination Therapy

BOTOX can be combined with manycosmetic procedures:

Fillers Ablative laser resurfacing Non-Ablative laser remodeling

IPL Peels Facial Surgery


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BOTOX + Ablative laser

BOTOX decrease mechanical disruption of healingprocess post laser treatment, improving collagenremodeling.

BOTOX

will prolong the smoothing wrinklereduction effect of laser. Combination useful in crows feet, forehead and

peri-oral areas. Inject BOTOX two weeks before ablative laser

treatment.


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BOTOX + Non-Ablative laser

Specific lasers (1320nm, 1450nm & 1540nm). Existing lasers (erbium-YAG, ND-YAG, Q-switched,

pulse-dye lasers) Radiofrequency technology (e.g. Thermage) BOTOX will improve and prolong the cosmetic

smoothing results.

Use BOTOX

few days prior or post laser to preventincreasing diffusion due to thermal inflamation.


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BOTOX + IPL

IPL is used to stimulate collagen and elastinsynthesis, resulting in softening the facial finelines.

Multiple sessions is needed to achieve this effect,usually 4-6 sessions. BOTOX will improve and prolong the cosmetic

smoothing results. Use BOTOX few days after the first IPL session.


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BOTOX + Peels

Chemical peels produce controlled injury followedby the wound healing process which producessmoother skin.

Selection of the right peel. Use BOTOX 2 weeks before peeling to prevent

increasing diffusion due to inflammation. Microdermabrasion usually doesnt produce

inflammation, so BOTOX can be injected rightafter this procedure.


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BOTOX + Facial Surgery

BOTOX and facial surgery have complementary effecton the aging face.

Recent reports suggested that BOTOX can reduce thetension exerted on the skin by the healing process,

resulting in reduced scarring. With blepharoplasty, relaxation of the local muscles

can allow for accurate resection of the skin and betterplacement of the incision during the surgicalprocedure.

Use BOTOX one week after surgery or at least threemonths before surgery.

Botox and Hyperhydrosis


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Procedure:1) Documentation of the problem :

1- Gravimetric measurement or.

2- The minor starch iodine test.First wiping the skin with a colored iodine tincture (must be brown-orange).

Several seconds are given to allow the iodine solution to dry (fan).The area is then lightly dusted with ordinary baking cornstarchpowder.


Th l i f h i i i


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The exact location of the active sweating isthen mapped and outlined with a marking

pen before beginning injections.

N.B. perform the test before applying any regional nerve blocks ortopical anesthetics like eutectic mixture of lidocaine (EMLA)(cause a hyperemic and a vasoconstrictive responserespectively interfering with the amount of sweating and can givemisleading results).

Take a photo.

B t d H h d i


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2) Anesthesia:The axillary, forehead and facial sweating can be treatedwithout anesthetic or by topical anesthesia.

Palmar and plantar with topical anesthesia , but mostpatients require regional nerve block anesthesia, such aswrist or ankle block.

Disadvantages of nerve blocks ------ causes reactivehyperemia thus increasing the tendency to bleed from

each small injection site, which may increase the loss of material from injection site and decrease the relativeeffectiveness of each injection.




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3) Injection technique:

Dilution

5 ml saline + 1 vial BTXUse 10 syringes ( 5 for each axillae i.e. 2.5 ml for Rt.

Axillae and 2.5 ml for Lt. Axillae).

Withdraw 0.5 ml for each syringe.

Inject 20 25 injections to every axillae i.e. 2 units for

each injection



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For axilla, usually involves placement of 10-20

individual intradermal injections (raising tinywheals) about 2.5cm apart , beginning at the periphery

of the hair-bearing skin and circling into the centre of

the axillary vault, keeping the needle bevel up andmore parallel to the skin surface.

Approximately 50U/axilla ,

duration of effect is

approximately 4-10 months .


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Focal Axillary Hyperhidrosis

Before BTX-A After BTX-A

Naumann Arch Dermatol 134 1998

Botox and Hyperhydrosis of Palm & Sole


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Palmar injections are placed approximately every1.5cm across the palmar surface. On the fingers the volarpad of each phalanx receives its individual dose. The fingertips usually receive two: one in mid pad and another at thevery tip. The dominant hand receives an extra row of injection along the ulnar side.

The palmar skin is comparatively stiffer and a wheal cannot

be raised, it is desirable to produce a small zone

of visible blanching , indicating that the material isin the deep dermis . Allow a second or two beforewithdrawing the needle or else the fluid flows back out of injection tract directly.


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C t & F f t t t


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Patients with large shoe size have correspondinglylarger hands and require more injections, e.g. aman with a size 43-45 shoe requires up to150U/palm whereas a woman with a size 36 shoerequires as little as 75U to cover the palm .

Inject approximately 120U/palm , duration of effectis 3-12 months (approximately 6 months).

Treatment is approximately twice a year.

Costs & Frequency of treatment


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. 37 shoes size requires 1.5 vials for both palmsi.e., 150 Us( 75U/ each palm).

. 38- 42 shoes size requires up to 2 vials for bothpalms i.e., 200 Us (100/ each palm).

. 43- 45 shoes size requires up to 3 vials for bothpalms i.e., 300 Us (150/ each palm)


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Injection of the soles follows the same technique and

pattern as the palms.

N.B. it may take several treatments before patient recognize

less than total response as successful.

Almost every patient develops a transient period of weakness and instability of the lumbrical muscles of the

hand, which is predictably spontaneously reversible, patient

can write, type and eat without difficulty, but opening up a

tight jar lid for example poses problems for a few weeks (3-

5). So, ma ybe treat one hand first then the second.


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Thank you

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