University of Washington School of Dentistry Neurotoxin ......Orbicularis oris Levator anguli oris...
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Copyright Maple Leaf CE- 2020™ University of Washington School of Dentistry Neurotoxin Training 2020
Transcript of University of Washington School of Dentistry Neurotoxin ......Orbicularis oris Levator anguli oris...
Copyright Maple Leaf CE- 2020™
University of Washington School of Dentistry
Neurotoxin Training 2020
7/24/2020
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Timothy A Hess, DDS, MAGD
Affiliate Faculty Oral Medicine
University of Washington School of Dentistry
Determining Incisal Edge Position
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Guidelines for maxillary incisal edge position‐ a pilot study: the key is the canine.
Misch, CE
J Prosthodont. 2008 Feb:17(2):130‐4
Is The Dentist An Appropriate Healthcare Provider To Deliver Chemo‐Denervation Via
Neurotoxin?
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RCW 18.32.020 Practice of Dentistry Defined
“The practice of dentistry includes theperformance of any dental or oral andmaxillofacial surgery. “
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RCW 18.32.020 Practice of Dentistry Defined
A person practices dentistry, within themeaning of this chapter, who….
(4) engages in any of the practices includedin the curricula of recognized and approveddental schools or colleges
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ORAL MEDICINE CLINICAL ELECTIVE: OralM 550c
DESCRIPTION OF COURSE CONTENT:
This course will focus on aesthetic and therapeutic procedures that the dentist uses to treat patients. This course will include two lectures and demonstrations of BTX‐A administration.
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ORAL MEDICINE CLINICAL ELECTIVE: OralM 550c
DESCRIPTION OF COURSE CONTENT:
Administration of BTX‐A will be performed by senior dental students for both treatment of orofacial pain conditions as well as facial aesthetics, including the oral, glabellar, forehead and lateral canthal regions.
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Like any new technique/skill requires training and practice.
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Excellent ReferenceVermillion Dollar Lips
Lip & Perioral Augmentation for the
Cosmetic Dentist
Robert Gordon, DDS
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Websites as References www.merzusa.com
www.allergan.com
www.dysportusa.com
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JAMA Dermatology 2014
Adverse events occur in less than 1% of patients,and most of these are minor and transient.
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• Introduction of Botulinum toxin‐ serotype A.
• Discuss the mechanism of action of BTX‐A.
• Reconstitution and storage of BTX‐A.
• Discuss treatment indications and techniques.
• Review anatomy for effective use of BTX‐A.
• Observe and perform BTX‐A injections.
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History of Botulinum Toxin 1817 German physician Jutinus Kerner describes“sausage poison”
Botulus means “sausage” in Latin.
1897 Emile van Ermengen identifies Clostridiumbotulinum as producer of botulinum toxin.
1949 Burgen identifies botulinum toxin blocksneuromuscular transmission.
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History of Botulinum Toxin 1980 Alan Scott, MD a ophthalmologist used BTX‐A totreat Strabismus (crossed eyes) and Blepharospasm(uncontrolled blinking).
1992 Carruthers & Carruthers publish study on BTX‐Afor treatment of glabellar frown lines.
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FDA Approval of BOTOX® 1989 approved for Strabismus and Blepharospasm.
12 years of age
1990 approved for Cervical Dystonia.
16 years of age
2002 approved for treatment of Glabellar Frown Lines.
Not recommended younger than 18 years of age
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FDA Approval of BOTOX® 2004 approved for Axillary Hyperhidrosis.
18 years of age
2010 approved for Upper Limb Spasticity.
18 years of age
2010 approved for Chronic Migraine.
18 years of age
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FDA Approval of BOTOX® 2013 Overactive Bladder
18 years of age.
2013 Lateral Canthal Lines
18 years of age.
2016 Lower Limb Spasticity
18 years of age.
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FDA Approval of Xeomin® 2010‐ Cervical Dystonia
2010‐ Blepharospasm
2011‐ Glabellar Lines
2015‐ Upper Limb Spasticity
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Off‐Label Use November 1997‐ New Provision in Federal Food, Drugand Cosmetic Act
Allows any legally marketed, FDA approved product to be administered for any condition within a doctor‐patient relationship.
Example: AlloDerm‐ FDA approved for extraoral grafts used in periodontal surgeries.
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Blocks messages from nerve to muscle by inhibiting acetylcholine (ACh) release.
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Botulinum Neurotoxin Seven Serotypes
A, B, C, D, E, F and G
Botulinum Toxin A XEOMIN®‐incobotulnumtoxinA: MERZ
BOTOX®‐onabotulinumtoxinA: Allergan/ Actavis
DYSPORT®‐abobotulinumtoxinA: Galderma
Botulinum Toxin B MYOBLOC®‐rimabotulinumtoxinB: Solstice Neuroscience
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BTX‐A Structure: 900 kD Complex
150 kD Neurotoxin Core
Heavy chain and light chain connected by a disulfide bond.
BOTOX® and Dysport®: Hemagglutins (HA)
Non‐toxic, non‐HA Proteins (NTNH)
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BOTOX® vs Dysport® vs Xeomin® BOTOX®:
900kDa
5ng Protein
0.9mg NaCl
0.5mg Human Serum Albumin
Vacuum‐Dried
50‐100 Units per Vial
Store in Freezer ‐5°C
Dysport® 500‐900kDa
2.61ng Protein
2.5mg Lactose
0.125mg Human Serum Albumin
Lyophilized
300 Units per Vial
Store in Fridge 2‐8°C
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BOTOX® vs Dysport® vs Xeomin® Xeomin®
150kDa
0.6ng Protein
4.7mg Sucrose
1mg Human Serum Albumin
Lyophilized
50‐100 Units per Vial
Store at Room Temperature
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BOTOX® Equivalencies: 1 Units of Xeomin® equals 1 Unit BOTOX®
3 Units of Dysport® equals 1 Unit BOTOX®
50 Units of Myobloc® equals 1 Unit BOTOX®
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BOTOX® vs Xeomin®
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What is a Unit of BOTOX®?
Definition of a “Unit”: the amount of BOTOX® that when injected into an 18‐20 gram Swiss‐Webster female mouse is lethal for 50% of the animals.
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What is a Unit of BOTOX®? This definition of a “Unit” is unique to BOTOX®.
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• BTX‐A binds to the motor nerve terminal.
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• BTX‐A is selective for cholinergic nerve terminal receptors that release the neurotransmission chemical, acetylcholine (ACh).
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• BTX‐A is internalized by endocytosis, to form a toxin‐receptor vesicle.
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• The light chain of the molecule is then released into the fluid center of the cell (cytoplasm).
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• Light chain has been shown to hold the nerve transmission blocking properties.
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• Acetylcholine release is blocked by the light chain cleaving SNAP‐25 on the cell membrane
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• SNAP‐25 is a cytoplasmic protein on the cell membrane that is required for the release of ACh.
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• The affected terminals are inhibited from releasing acetylcholine and stimulating muscle contraction.
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• BTX‐A does not affect the synthesis or storage of ACh or the conduction along the nerve fiber.
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• Chemical denervation by BTX‐A results in stimulation of collateral axonal sprouts.
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• Nerve sprout establishes a new neuromuscular junction.
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• Muscle activity gradually returns.
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• The new nerve sprout will retract and the original junction returns to functionality.
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Clinical Information Lesions were proceeded by prodromal pain.
Sense of paresthesia.
Clusters of small blisters (vesicles) that quickly ruptured to form small superficial ulcers.
Lesions on both keratinized and non‐keratinized mucosa.
Lesions up to, but did not cross the midline.
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Differential Diagnosis‐ Ulcerated Lesion of Palate Apthous ulcer
Recurrent intraoral herpes
Herpes zoster
Primary herpetic gingivostomatitis
Herpangina
Erythema multiforme
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Diagnosis‐ Shingles (Varicella zoster) ETIOLOGY
Acute recurrent infection caused by Varicella zoster virus.
Initial infection with no previous exposure is called varicella zoster (Chickenpox).
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Diagnosis‐ Shingles (Varicella zoster)
ETIOLOGY
Virus remains latent in sensory ganglia (latent virus in the trigeminal ganglion can cause intraoral lesions).
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Diagnosis‐ Shingles (Varicella zoster)
ETIOLOGY
Reactivation of the virus occurs by local trauma, immunosuppression (cancer chemotherapy, AIDS), and malignancy (especially leukemia and lymphoma).
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Trigeminal Nerve
V1‐ Ophthalmic
V2‐Maxillary
V3‐Mandibular
Dermatomes of Trigeminal Nerve
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Treatment of Shingles
Acyclovir (Zovirax®), Valacyclovir (Valtrex®) or Interferon (Intron A®) may be indicated.
Acyclovir 800mg: 5 times/day for 7 – 10 days.
Valacyclovir 1 gm: 3 times/day for 7 days.
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Treatment of Shingles
Severe pain caused by post herpetic neuralgia may persist for months after the oral mucosal lesions resolve.
Recurrent episodes of herpes zoster may be associated with undiagnosed malignancy.
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Trigeminal Nerve‐V Cranial
V1‐ Ophthalmic Sensory
V2‐Maxillary Sensory
V3‐Mandibular Sensory and Motor
Muscles of Mastication
Head and Neck Nerves
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Bell’s Palsy
Short‐term weakness or paralysis of the muscles that control one side of the face.
Anything that causes swelling to the facial nerve, such as an infection or injury, may cause this problem.
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Bell’s Palsy
Herpes (cold sore)(HSV1) and Epstein‐Barr viruses have been implicated.
Need to rule out potential causes of facial paralysis.
Stroke
Lyme disease
Brain tumour
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Bell’s Palsy
Signs are a drooping eyelid or corner of the mouth to one side, or drooling from the mouth.
Sometimes, one eye will not fully close.
This illness may go away after a month or two. May take up to 6 months to years to get back to normal.
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Bell’s Palsy Treatment Self healing.
Often steroids or antivirals are prescribed.
Antivirals are ineffective beyond steroids alone.
Eye drops and patching of eye may be required.
Rest and relaxation.
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Facial Nerve‐ VII Cranial
Temporal
Zygomatic
Buccal
Mandibular
Cervical
Posterior Auricular
Head and Neck Nerves
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Innervation of Tongue
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3D4MedicalMuscle + Skeleton Anatomy
Head and NeckMuscles
3D4 Medical.com Muscle + Skeleton Anatomy
Most Treated Muscles Orbicularis oris
Levator anguli oris
Mentalis
Nasalis
Depressor septi nasi
3D4 Medical.com Muscle + Skeleton Anatomy 61
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Most Treated Muscles
Frontalis
Deep masseter
Scalenes
3D4 Medical.com Muscle + Skeleton Anatomy 62
Most Treated Muscles
Superficial masseter
Zygomaticus major
Zygomaticus minor
3D4 Medical.com Muscle + Skeleton Anatomy 63
Most Treated Muscles
Levator labii superioris
Corrugator supercilli
Sternocleidomastoid
3D4 Medical.com Muscle + Skeleton Anatomy 64
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Most Treated Muscles
Procerus
Orbicularis oculi
Levator labii superioris alaeque nasi
Depressor anguli oris
Platysma
3D4 Medical.com Muscle + Skeleton Anatomy 65
Most Treated Posterior Muscles
Semispinalis capitis
Splenius capitis
3D4 Medical.com Muscle + Skeleton Anatomy 66
Most Treated Posterior Muscles
Occipitalis
Levator scapulae
3D4 Medical.com Muscle + Skeleton Anatomy 67
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Most Treated Posterior Muscles
Sternocleidomastoid
Trapezius
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BTX‐A Prophylaxis of headaches in adult patients with Chronic Migraine.
Chronic Migraine: >14 days per month with headache lasting 4 hours a day or longer.
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Head/Neck Area Recommended Dose (Number of Sitesa)Frontalisb 20 Units divided in 4 sitesCorrugatorb 10 Units divided in 2 sitesProcerus 5 Units in 1 siteOccipitalisb 30 Units divided in 6 sitesTemporalisb 40 Units divided in 8 sitesTrapeziusb 30 Units divided in 6 sitesCervical Paraspinal Muscle Groupb 20 Units divided in 4 sites
Total Dose: 155 Units divided in 31 sites
Recommended Injection Sites for Prophylaxis of Chronic Migraine
155 Units in 31 Sites
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Injection Sites for Migraine
Frontalis 20 Units divided in 4 Sites.
Corrugator 1o Units divided in 2 Sites.
Procerus• 5 Units in 1 Site.
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Injection Sites for Migraine Temporalis
40 Units divided in 8 Sites.
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Injection Sites for Migraine
Occipitalis
30 Units divided in 6 Sites.
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Injection Sites for Migraine
Cervical Paraspinal Muscle Group
20 Units divided in 4 Sites.
Trapezius
30 Units divided in 6 Sites.
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Name the Condition
Food Stimulus
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Frey’s Syndrome
Also known as:
Baillarger’s syndrome, Dupuy’s syndrome, Auriculotemporal syndrome or Frey‐Baillarger syndrome
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Frey’s Syndrome
Causes:
Surgery, accidental trauma, local infections, sympathetic dysfunction and pathologic lesions within the parotid gland.
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Frey’s Syndrome
Mechanism:
Auriculotemporal branch is a part of the Mandibular Nerve (Trigeminal‐ V).
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Frey’s Syndrome
Mechanism:
Parasympathetic “crosses over”.
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Frey’s Syndrome
Mechanism:
Gustatory stimulation will cause sweating.
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Frey’s Syndrome
Signs and symptoms:
Erythema (redness/flushing) and sweating in the cutaneous distribution of the Auriculotemporal Nerve.
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Frey’s Syndrome
Signs and symptoms:
Sometimes pain in the same area (burning in nature).
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Frey’s Syndrome
Signs and symptoms:
Sometimes numbness or other altered sensations (anesthesia or paresthesia). “Gustatory Neuralgia"
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Frey’s Syndrome Treatment:
Similar to treating axillary hyperhidrosis.
Iodine‐Starch test.
Botulinum Toxin
Units vary based on size of affected area.
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BTX‐A for TMD Issues
•Hypertrophic Masseters•Lateral Pterygoid Spasm or other Myospasms.
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BTX‐A for TMD Issues
•Hypertrophic Masseters•Lateral Pterygoid Spasm or other Myospasms.
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Botulinum Toxins in Dentistry‐ The New Paradigm for Masticatory Muscle HypertonicityKatz, H. Singapore Dental Journal 2005;27:7‐12
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Sialorrhea (drooling or excessive salivation): common problem in the neurologically impaired (i.e., those with mental retardation or cerebral palsy) & Parkinson’s disease or have had a stroke2
It is most commonly caused by poor oral and facial muscle control.
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•Masseter•5‐10 Units/site
•1‐4 sites.• 15 ‐ 50 Units per
side common.•Guide: Have patient clench and check for maximum muscle projection.
Hypertrophic Masseter
Image from 3DMedical
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Muscle Origin Insertion Action
Superficialmasseter
Anterior 2/3zygomatic arch and zygomatic process of maxilla
Lateral surface of ramus and angle of mandible
Elevation, adduction and protrusion of mandible
Deep masseter Deep surface of zygomatic arch
Upper half of ramus and lateral surface of coronoid process
Elevation, adduction and retrusion of mandible
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•Temporalis•5‐10 Units/site
•1‐4 sites.•5‐20 Units per side.
•If TMJ/Facial pain treat with Masseter.
Facial Pain in Temporalis
Image from 3DMedical
Facial Pain Categories Neuropathic
Peripheral or CNS disorders.
Electrical, burning, itching or cutting.
Paresthesia, hyperalgesia or allodynia.
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Facial Pain Categories Neurovascular
Toothache or migraine.
Throbbing, pounding or sharp.
Pain worsens with temperature change, posture, may wake patient or occur spontaneously.
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Facial Pain Categories Musculoskeletal
TMD and myofascial pain.
Ache, maybe dull, throbbing or sometimes sharp.
Function, parafunction or stress makes worse.
May improve with relaxation or heat/cold.
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Musculoskeletal Disorder Categories Myositis
Muscle inflammation.
Spasm/ Trismus
Inhibition of muscle function. Usually painful.
Myalgia
Localized muscle tenderness only.
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Musculoskeletal Disorder Categories Myofascial Pain
Muscle tenderness with referred pain (Trigger Point).
Dystonias/ Oromandibular Dystonia
Continuous pain, cramping, and relentless muscle spasms due to involuntary muscle movements.
General, focal or segmental.
Other motor symptoms are possible including lip smacking
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Dystonia
Continuous pain, cramping, and relentless muscle spasms due to involuntary muscle
movements.
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Trigger Points Reference•Travell & Simons•Oral Medicine‐ UWSoD
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Origin of Trigger Points• Taut Band
• Nodule
• Revealed with flat or pincer palpation.
• Rolling band under fingertip creates local “twitch” response
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Trigger Points‐Masseter
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Trigger Points‐ Temporalis
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Trigger Points‐Medial Pterygoid
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Trigger Points‐ Lateral Pterygoid
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Trigger Points‐ Digastric
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Trigger Points‐ Sternocleidomastoid
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Neck Muscles
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Trigger Points‐ Trapezius
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Trigger Points‐ Suboccipital
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Trigger Points‐ Semispinalis Muscles
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Trigger Points‐ Splenius Cervicis
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Treatment of Trigger Points Vapocoolant spray. (Ethyl Chloride)
Demonstration in Workshop of stretch‐and‐spray technique.
Dry needling.
Saline injections.
Local Anesthetics. 3% Mepivacaine (Carbocaine or Polocaine)
0.1ml t0 0.4ml
BTX‐A.
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Pilot Study of 10 Myofascial/ Orofacial Pain Patients at UWSoD
Study: If local anesthetic into trigger points resulted in pain relief for hours to days.
We considered use of neurotoxin.
Protocol: Injected increments of 10 units in each masseter muscle.
Injected between 30 –60 units per masseter.
Injections were 10 to 15mm deep in body of masseter.
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Pilot Study of 10 Myofascial/ Orofacial Pain Patients at UWSoD
Subjects: 8 females, 2 males, Aged 24
to 60 All had myofascial pain
recalcitrant to previous treatments.
Injected 30 to 60 units of BTX‐A in each masseter muscle.
Results: At 2 weeks self assessment
of pain relief disappointing.
At 3 months all patients wanted treatment again.
All have shown some improvement.
Greatest improvement seen in patients with dystonias.
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DystoniaPersistent Or Intermittent Muscle Contractions Causing
Abnormal, Often Repetitive, Movements, Postures, Or Both.
May Be Painful!
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Botulinum Toxin Preparation Allergan, Inc. is one manufacturer.
For 25 years it has been used to treat a variety of medical conditions.
Approved in >75 countries and widely researched.
BTX‐A is a purified protein from Clostridium botulinum
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Botulinum Toxin Preparation BOTOX® is vacuum‐dried and Dysport® is lyophilized.
Keep in BOTOX® in freezer or fridge.
Allergan recommends freezer.
Dysport® can be kept in fridge.
Xeomin® is packaged in a lyophilized vial.
No refrigeration necessary prior to reconstitution.
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Remember:
1cc (Cubic Centimeter) Equals 1mL
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BTX‐A Storage Reconstitute with “preserved” 0.9% Sodium Chloride (Saline)
Store in fridge for up to 6 weeks.(Hexcel, 2003)
Benzoyl alcohol in “preserved” saline acts as local anesthetic.
Allergan recommends “non‐preserved” saline and use of BOTOX® within 4 hours.
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MERZ &Allergan Recommendations: 0.9% Sterile Sodium Chloride (Saline) Non‐preserved.
Add 2.5mL to 100 Unit Vial through stopper.
Dose is drawn through the stopper.
Resulting Dose: 4 Units per 0.1mL
0.3mL Diabetes Syringe contains 12 Units Total.
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Canadian/Braun Recommendations: 0.9% Sterile Sodium Chloride (Saline) Preserved
Add 1.0mL to Unit Vial through stopper.
Remove stopper.
Dose is drawn by inserting into vial.
Resulting Dose: 10 Units per 0.1mL
0.3mL Diabetes Syringe contains 30 Units Total.
Use “left to right” sterile technique. Move only to right with clean gloves to start.
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Reconstitution of BTX‐A Xeomin
100 Unit Vial
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Reconstitution Supplies 0.9% Sodium Chloride
Bacteriostatic
30 ml
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1mL Luer Lok Syringe
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Reconstitution SuppliesBottle Opener Kebby DeCapper‐ 20mm
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0.3mL Diabetes Syringe
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Syringes Compared
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BTX‐A Dilutions: 100 Unit VialBTX‐A Units Saline Volume Units/mL Units/ 0.1mL Units/ .3mL
Syringe100 1.0 mL 100 10 30100 2.0 mL 50 5 15100 2.5 mL 40 4 12100 4.0 mL 25 2.5 7.5100 5.0 mL 20 2 6
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Review Medication Guidelines: Insert in every package of Xeomin®, Dysport® and BOTOX®.
FDA instructs it must be provided and contents reviewed with patient.
Add to your consent form that Medication Guidelines were reviewed with patient.
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Spread of Toxin Effect Post marketing safety data: BTX‐A effects may be observed beyond injection site.
Symptoms:
Asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and difficulty breathing.
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Spread of Toxin Effect
No definitive serious adverse event reports of distant spread of toxin effect associated with the dermatologic use of BOTOX® Cosmetic at the labeled dose of 20 Units.
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Contraindications to BTX‐A Infection in proposed injection sites.
Pregnant/Lactating women.
Age restrictions based on therapy.
Neuromuscular disorders.
Hypersensitivity to any ingredient in BTX including Human Serum Albumin.
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Contraindications to BTX‐A
Problems clotting or anticoagulant therapy.
Previous allergic reaction to any other botulinum toxin product such as BOTOX®, Dysport®, Xeomin®, or Myobloc®.
Unrealistic expectations or Psychological issues.
Use caution when treating musicians and actors.
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Possible Drug InteractionsPotentiation of the Effect Drugs such as aminoglycoside
antibiotics (eg gentamicin)
Drugs with neuromuscular effect (eg tubocurarine type muscle relaxants)
Increase in Potential Predisposition to Bleeding
Anticoagulants
Aspirin
Weaking of the Effects 4‐aminoquinoline (eg chloroquine)
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Glabellar Lines‐ “11’s”
Lateral Canthal Lines
Crow’s Feet
Lateral Browlift
Forehead Lines
Nasal Scrunch
Bunny/Wolf ‘s Nose
Perioral Rhytids
Smoker’s Lines
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Hypermobile Lip
Gummy Smile
Labiomental Fold
Creased/Witches Chin
Mouth Frown/Downturned Commissures
Neck Lines
Platysmal Bands
Neck Lace Lines
Mini Neck Lift
Nefertiti Lift
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American Society of Plastic Surgeons (ASPS)
American Society for Aesthetic Plastic Surgery (ASAPS)
www.plasticsurgery.org
www.surgery.org
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Other Points:
Re‐importation of FDA‐approved drugs/products is illegal.
Only FDA‐approved uses may be commercially advertised.
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Other Points:
ASPS and ASAPS disapprove of the administration of drugs outside the clinical setting. (BOTOX® Parties)
Inadequate post‐treatment supervision, patient selection, etc.
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Aging of the Face
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Aging of the Face
Youthful Face
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Aging of the Face
Aged Face
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Aging of the Face Nasolabial folds increase.
Upper lip flattens and lengthens.
Thinning of lips.
Cupid’s bow loses its shape.
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Aging of the Face
Perioral rhytids (lines) increase.
Commissures turn down.
Pre‐jowl sulcus increases.
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Aging of the Face• Prolapse of Brow Fat
• Crow’s Feet
• Palpebromalar Groove
• Prolapse of Suborbital Fat
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Suborbital Fat Prolapse
Deep Medial Fat
Suborbital Fat
Eye
Orbital Septum
Maxillary Bone
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Aging of the Face
• Tear (Lacrimal) Trough
• Marionette (Mentolabial) Fold
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Points to Remember:
BTX‐A works best on Dynamic Lines rather than Static Lines.
Wrinkles are Perpendicular to Muscle Pull.
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Points to Remember:
Inject into Muscle not Periosteum.
BTX‐A takes 60‐90 Minutes to Bind to Nerve.
Treatment will last 3‐6 Months.
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Points to Remember:
Relaxing muscles allows “creases” of skin to fade.
Thinning of skin can increase the appearance of dynamic lines.
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Points to Remember:
Repeated treatment may allow the injector to use less BTX‐A for desired result.
Repeated treatment may increase time before next treatment.
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Soft Tissue Lines
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Men will generally require more Units per site.
Judge size of muscle and its relative strength and adjust dosing accordingly.
Points to Remember:
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Static Lines, Wrinkles & Folds
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“A patient will not remember the wrinkles that were removed nearly as well as they see the flaws that remain.”David R Harris, MDClinical ProfessorStanford University School of Medicine
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Pre‐Operative Records
Take for medical/legal reasons.
Important to show patient existing conditions.
Allows doctor and patient to clearly see treatment results.
160
158
159
160
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Pre‐Operative Records
Great way to evaluate your technique.
Able to show other patients expected results.
Good for communication regarding treatment with another doctor.
161
Workshop Forms Patient Information & Health History
Model Consent
Medication Guidelines
Post Op Instructions
Tx Record
163
161
162
163
7/24/2020
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PhotoMed Portrait Set Upwww.photomed.net
164
Camera Set Up: Program Exposure Mode
Auto Focus
Flash
Canon‐ ETTL
Nikon‐ TTL BL or iTTL
Position Diffuser towards ceiling
Exposure Compensation (+/‐) Button
Take some “practice” shots and adjust.
Consider using an Eye‐Fi Card to automate uploads.
165
Pre‐Operative Photograph #1Face at Rest (No Smile)
166
164
165
166
7/24/2020
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Pre‐Operative Photograph #2Smile Photograph
167
Preoperative Photograph #3Raising Eyebrows
168
Pre‐Operative Photograph #4Scrunch/ Scowl
169
167
168
169
7/24/2020
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Pre‐Operative Photograph #5Pucker
170
Pre‐Operative Photograph #6Profile at Rest
171
Pre‐Operative Photograph #7Profile with Smile
172
170
171
172
7/24/2020
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Post Operative
Patient returns in 2 weeks for follow up.
Take same 7 photographs and place side by side.
173
Post Operative
Touch‐ups or other areas can be addressed at this appointment.
Make sure patient knows at initial appointment that there is a fee for touch‐ups.
Discuss 3‐4 month reinjection interval.
174
175
173
174
175
7/24/2020
59
Head and NeckMuscles• Masseter
• Temporalis
• Sternocleidomastoid
• Platysma
Image from 3DMedical
•Frontalis
•Procerus
•Orbicularis oculi
•Platysma
Image from 3DMedical
Head and NeckMuscles
•Occipitalis
•Trapezius
•Splenius capitis
•Semispinalis capitis
Image from 3DMedical
Head and NeckMuscles
176
177
178
7/24/2020
60
•Levator labii superioris alaeque nasi
•Levator labii superioris
•Depressor anguli oris
Image from 3DMedical
Head and NeckMuscles
•Nasalis
•Orbicularis oris
•Mentalis
Image from 3DMedical
Head and NeckMuscles
• Depressor labii inferioris•Results in lip asymmetry, difficulty articulating, lip biting and drooling
Muscles to Avoid
Image from 3DMedical
Image from 3DMedical
179
180
181
7/24/2020
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• Corrugator supercilli
Image from 3DMedical
Head and NeckMuscles
183
BTX‐A in Dental Literature
Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile).
Polo M.
Am J Orthod Dentofacial Orthop. 2008;133(2):195‐203
184
182
183
184
7/24/2020
62
BTX‐A in Dental Literature
Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile).
Polo M.
Am J Orthod Dentofacial Orthop. 2008;133(2):195‐203
5 mm Reduction
185
Global Diagnosis
186
Global Diagnosis
A New Vision of Dental Diagnosis and Treatment Planning
JW Robbins & JS Rouse
2016 Quintessence
•Levator labii superioris alaeque nasi
•1‐3 Units per site
Hypermobile Lip
Image from 3DMedical
185
186
187
7/24/2020
63
Muscle Origin Insertion Action
Levator labii superioris alaeque nasi
Nasal bone Nostrils and upper lip
Dilates the nostril; elevates the upper lip and wing of the nose
188
Hypermobile Lip Injection Sites
•Levator labii superioris alaeque nasi‐Hypermobile Lip
190
188
189
190
7/24/2020
64
Glabellar Lines‐ At Rest
191
Glabellar Lines‐ Dynamic
192
•Procerus•5‐10 Units•May do 2 sites if muscle long.
GlabellaImage from 3DMedical
191
192
193
7/24/2020
65
•Corrugator Supercilli•5‐10 Units in “Head” (medial aspect)•3‐5 Units in “Tail” (lateral aspect)
•May not do any based on size and length of muscle.
GlabellaImage from 3DMedical
•Corrugator Supercilli•Stay above supraorbital rim.•Stay medial to midpupillary line.•Stay “in” the muscle.
GlabellaImage from 3DMedical
Muscle Origin Insertion Action
Procerus Lower part of nasal bone
Skin of foreheadbetween the eyebrows
Pulls skin of the medial side of eyebrows down towards nose
Corrugator supercilli
Nasal part of frontal bone
Skin above middle of eyebrows
Draws the medial sides of the eyebrows towards the middle and down
196
194
195
196
7/24/2020
66
•Levator palpebrae superioris
Muscles to Avoid
•Levator palpebrae superioris
Muscles to Avoid
Eyelid Ptosis
Rare event with proper technique.
Can occur when injecting into tail of corrugator in midpupillary line.
199
197
198
199
7/24/2020
67
Eyelid Ptosis
Avoid by not injecting deep and staying 1 cm above supraorbital rim.
Do not inject into periosteum.
200
Eyelid Ptosis vs. Brow Ptosis Ask patient to lift brow.
If can’t lift brow then they have Brow Ptosis not eyelid ptosis
Applying eye shadow
Easier on affected side probably Lid Ptosis
Harder of affected side probably Brow Ptosis
201
Eyelid Ptosis vs. Brow Ptosis
Brow Ptosis is often caused when treating only the Frontalis and not the Glabella.
202
200
201
202
7/24/2020
68
Treatment of Eyelid Ptosis Use Alpha2 Agonist‐ Ophthalmic
Iodopine (Apolonidine) 0.5%‐ $50.00
Use 4‐6 times per day.
Stimulates Mueller’s muscle that is associated with Levator palpebrae superioris.
Reduces ptosis to less than 2 weeks.
Visine‐A®, Napcon‐A®, Opcon‐A®(Naphazoline)‐ $5.00
Can be used with Iodopine or alone.
203
Blepharospasm Treatment
41 Units per Eye204
Glabella Injection SitesProcerus
Head of Corrugator Supercilli
Tail of Corrugator Supercilli
Obicularis Oculi‐Lateral Brow Lift
203
204
205
7/24/2020
69
206
Forehead‐ At Rest
207
Forehead‐ Dynamic Lines
208
206
207
208
7/24/2020
70
Eyebrow‐ Changes with Time
209
•Frontalis•1‐3 Units/site•Stay at about 2cm above supraorbital rim.•Do not inject “low” lateral to midpupillary line.•Angle needle.•Do not hit periosteum.
ForeheadImage from 3DMedical
•Frontalis•May need to treat center of muscle depending on shape of muscle.
ForeheadImage from 3DMedical
209
210
211
7/24/2020
71
•Frontalis•Initially avoid injecting Frontalis in “Red Triangle” to avoid Brow or Eyelid Ptosis.
ForeheadImage from 3DMedical
•Frontalis•“Lateral Brow Lift” is created when Superior‐Lateral aspect of Orbicularis oculi is injected.
Lateral Brow LiftImage from 3DMedical
Muscle Origin Insertion Action
Frontalis Epicranialaponeurosis
Skin of foreheadand the eyebrows
Raises eyebrows and wrinkles forehead
214
212
213
214
7/24/2020
72
Frontalis Injection SitesLower Row
Upper Row
Hairline
Lateral Canthal Lines
216
Crow’s Feet‐ At Rest
217
215
216
217
7/24/2020
73
Crow’s Feet‐ Dynamic Lines
218
•Orbicularis oculi•2‐5 Units/site•Inject away from eye.•May need a second row lateral to first.•Do not rub or push towards eye.
Crow’s FeetImage from 3DMedical
Muscle Origin Insertion Action
Obicularis oculi Nasal part of frontal bone and frontal process maxilla
Palpebral part: skin of upper and lower eyelids
Blinking, squinting, forcefulclosure of eyes
Orbital part: attaches to skin or orbit, forehead & cheeks
220
218
219
220
7/24/2020
74
•Orbicularis oculi•Do not inject below Zygomatic ridge.
Crow’s FeetImage from 3DMedical
•Zygomaticus major• Injection creates
facial droop similar to Bell’s Palsy
Muscles to Avoid
Image from 3DMedical
Image from 3DMedical
• Zygomaticus minor• Stay superior to
Zygomatic arch when injecting Orbicularis oculi
Muscles to Avoid
Image from 3DMedical
Image from 3DMedical
221
222
223
7/24/2020
75
Crow’s Feet Injection Sites
Obicularis Oculi‐Lateral Brow Lift
Obicularis Oculi‐ Crow’s Feet
•Orbicularis oculi•3‐5 Units/site
• Use less if treating with Crow’s Feet.
•Stay superior and lateral to supraorbital rim.•Inject away from eye.•Do not inject deep.•Do not rub or push towards eye.
Lateral Brow LiftImage from 3DMedical
•Orbicularis oculi•Use the Ala of nose and Lateral Canthus guide location.
•Hint: often it is exactly where a women tweezes the lateral part of her brow to.
Lateral Brow LiftImage from 3DMedical
224
225
226
7/24/2020
76
Smoker’s Lines
Lipstick Lines
227
Lip Lines‐ At Rest
228
Lip Lines‐ Dynamic
229
227
228
229
7/24/2020
77
•Orbicularis oris•1‐2 Units/site•Inject 3mm above vermillion border.
•May enhance vermillion border.
Perioral Lip LinesImage from 3DMedical
•Orbicularis oris•Do not inject too lateral.•Advise patient they may not be able to whistle or suck through straw for 4 weeks.
Perioral Lip LinesImage from 3DMedical
Muscle Origin Insertion Action
Obicularis oris Mandible &maxilla
Upper & lower lip Closes and purseslips
232
230
231
232
7/24/2020
78
•Orbicularis oris•Very superficial injection•Enhances vermillion border•Inject at vermillion border•Works well on young/youthful lips•Total 6 Units•Lasts around 8 weeks
“Lip Flip”
Image from 3DMedical
Golf Ball Chin
Popply Chin
Angry Chin Crease
Bumpy Chin
234
•Mentalis•3‐5 Units/site•Inject deep.•Works well with Fillers.•Inject closer to chin if it is more Bumpy Chin than Mental Crease.
Mental CreaseImage from 3DMedical
233
234
235
7/24/2020
79
Muscle Origin Insertion Action
Mentalis Anterior mandible Skin of chin Elevates skin of chin and protrudeslower lip
236
Downturned Commissures
Marionette Lines
237
•Depressor anguli oris•3‐5 Units/site•Superficial muscle‐do not inject deep.
Mouth Frown
Image from 3DMedical
236
237
238
7/24/2020
80
Muscle Origin Insertion Action
Depressor anguli oris
Lower edge of mandible
Angle of mouth, cheek
Pulls angle of mouth and platysma downwards
239
•Depressor anguli oris•Do not inject too medial.•Avoid the Depressor labii inferioris•Can be tricky‐ need to advise patient they may need touch up.
Mouth Frown
Image from 3DMedical
•Depressor anguli oris•Guide to location is 1 cm lateral to commissure and above the inferior edge of mandible.•Have patient grimace to help locate DAO.
Mouth Frown
Image from 3DMedical
239
240
241
7/24/2020
81
Lower Face Injection Sites
Obicularis Oris‐ Perioral Lines.
Mentalis‐ Labiomental Fold
Depressor Angular Oris‐Mouth Frown
Bunny Lines
Wolf ’s Nose
243
•Nasalis•Extends from inner canthus to bridge of nose.•3‐5 Units/site•Usually can soften but not eliminate.
Nasal ScrunchImage from 3DMedical
242
243
244
7/24/2020
82
Muscle Origin Insertion Action
Nasalis Maxilla Nasal bone Compresses bridge, depresses tip of nose, elevates corners of nostrils
245
Nasalis Injection Sites
Nasalis‐ Bunny Nose
Aging Neck
247
245
246
247
7/24/2020
83
•Platysma•2‐3 Units/site•Grasp between thumb & forefinger.•Space about 2cm apart.
Platysmal BandsImage from 3DMedical
Muscle Origin Insertion Action
Platysma Base of mandibleand parotid fascia
Skin caudally of clavicle and pectoral fascia
Draws the corners of the mouth inferiorly and widens it
Draws the skin of the neck superiorly when teeth are clenched
249
Neck Injection Sites
Platysma‐ Vertical Neck Bands
248
249
250
7/24/2020
84
Aging Neck
Necklace Lines
251
•Platysma•1‐2Units/site•Space about 2cm apart.•Response varies.
Horizontal Neck Lines
Image from 3DMedical
Neck Injection Sites
Platysma‐ Horizontal Neck Lines
251
252
253
7/24/2020
85
Jaw Line Redefinition
Nefertiti Lift
254
•Platysma•2Units/site•6 sites spaced out along edge of mandible.•Good for patients with mild neck laxity.
Mini Neck LiftImage from 3DMedical
Neck Injection Sites
Platysmal‐Mini Neck Lift
254
255
256
7/24/2020
86
Cara: 253‐939‐2424
Dr. Mark Drangsholt
Dr. Ed Truelove
Cara Thayer, RDA
Valerie Bartoli
Carrie Kruse, RDA
Sara Johnson, RDA
Dr. Nick Parque
Dr. Keith Phillips
Jennifer Inscore, RDH
Dr. Darrin Rapoport
257
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April 23, 2013
Timothy Hess, DDS, MAGD Treasurer, Seattle-King County Dental Society 1268 E. Main Auburn, WA 98002
Dear Dr. Hess:
The University of Washington, School of Dentistry (UWSoD) is in the process of making significant changes to its curriculum. It is clear that “esthetics in dentistry” must be a central topic throughout the four years of dental education. To meet the demands of today’s patient, the general dentist must have training not only in necessary therapeutic services but as well as esthetically driven procedures. “Esthetics in dentistry” no longer encompasses only the peri-oral structures but may include the entire head and neck.
Recently, Massachusetts has approved the administration of Botox and dermal fillers within the scope of the practice of dentistry. It is logical to assume because of the low morbidity that the administration of these agents for cosmetic and therapeutic purposes will also receive approval by the State of Washington.
Botox and dermal fillers are an important element to an “esthetic dentistry” curriculum and have generated great interest from the practicing general dentist. Many universities are evaluating these agents for inclusion in their “esthetic dentistry” curriculum. As an Affiliate Faculty member experienced in performing and teaching these procedures, I would like you to develop curriculum content regarding the use of Botox and dermal fillers to teach undergraduate and graduate students at the UWSoD. Course content should include relevant cosmetic and therapeutic treatments for the head and neck. Content must include anatomy of head and neck, neurophysiology, patient selection, pharmacological effects and contraindications, management of complications, informed consent and hands-on training on the administration of the agents. Please obtain input from the Departments of Oral Medicine, Periodontics, Prosthodontics and Orthodontics as you develop a curriculum.
I would like to have an initial Botox and dermal fillers curriculum proposal for my review by July 30, 2013. Should you require more guidance in developing a curriculum please contact me directly.
Sincerely,
Joel H. Berg, DDS, MS Dean
Office of the Dean 1959 NE Pacific Street D322 Box 356365 Seattle, Washington 98195-6365 206.543.5982 Fax 206.616-2612 www.dental.washington.edu
RCW 18.32.020
Practice of Dentistry Defined
A person practices dentistry, within the meaning of this chapter, who (1) represents himself or herself as being able to diagnose, treat, remove stains and concretions from teeth, operate or prescribe for any disease, pain, injury, deficiency, deformity, or physical condition of the human teeth, alveolar process, gums, or jaw, or (2) offers or undertakes by any means or methods to diagnose, treat, remove stains or concretions from teeth, operate or prescribe for any disease, pain, injury, deficiency, deformity, or physical condition of the same, or take impressions of the teeth or jaw, or (3) owns, maintains, or operates an office for the practice of dentistry, or (4) engages in any of the practices included in the curricula of recognized and approved dental schools or colleges, or (5) professes to the public by any method to furnish, supply, construct, reproduce, or repair any prosthetic denture, bridge, appliance, or other structure to be worn in the human mouth.
The fact that a person uses any dental degree, or designation, or any card, device, directory, poster, sign, or other media whereby he or she represents himself or herself to be a dentist, shall be prima facie evidence that such person is engaged in the practice of dentistry.
X---ray diagnosis as to the method of dental practice in which the diagnosis and examination is made of the normal and abnormal structures, parts, or functions of the human teeth, the alveolar process, maxilla, mandible or soft tissues adjacent thereto, is hereby declared to be the practice of dentistry. Any person other than a regularly licensed physician or surgeon who makes any diagnosis or interpretation or explanation, or attempts to diagnose or to make any interpretation or explanation of the registered shadow or shadows of any part of the human teeth, alveolar process, maxilla, mandible or soft tissues adjacent thereto by the use of X--- ray is declared to be engaged in the practice of dentistry, medicine, or surgery.
The practice of dentistry includes the performance of any dental or oral and maxillofacial surgery. "Oral and maxillofacial surgery" means the specialty of dentistry that includes the diagnosis and surgical and adjunctive treatment of diseases, injuries, and defects of the hard and soft tissues of the oral and maxillofacial region.
[2011 c 336 § 477; 1996 c 259 § 1; 1957 c 98 § 1; 1957 c 52 § 20. Prior: (i) 1935 c 112 § 6; RRS § 10031---6. (ii) 1943 c 240 § 1; Rem. Supp. 1943 § 10031---6a.]
Medication Guide XEOMIN® (Zeo-min)
(incobotulinumtoxinA) for injection, for intramuscular use
Read this Medication Guide before you start receiving XEOMIN® and each time XEOMIN® is given to you. There may be new information. This information does not take the place of talking to your doctor about your medical condition or your treatment. You should share this information with your family members and caregivers.
What is the most important information that I should know about XEOMIN®? XEOMIN® may cause serious side effects that can be life threatening. Call your doctor or get medical help right away if you have any of these problems after treatment with XEOMIN®: • Problems with swallowing, speaking, or breathing. These
problems can happen hours to weeks after an injectionof XEOMIN® if the muscles that you use to breathe and swallowbecome weak after the injection. Death can happen as acomplication if you have severe problems with swallowing orbreathing after treatment with XEOMIN®.
• People with certain breathing problems may need to use musclesin their neck to help them breathe. These patients may be atgreater risk for serious breathing problems with XEOMIN®.
• Swallowing problems may last for several months. People whocannot swallow well may need a feeding tube to receive food andwater. If swallowing problems are severe, food or liquids may gointo your lungs. People who already have swallowing or breathingproblems before receiving XEOMIN® have the highest risk ofgetting these problems.
• Spread of toxin effects. In some cases, the effect of botulinumtoxin may affect areas of the body away from the injection siteand cause symptoms of a serious condition called botulism. Thesymptoms of botulism include:» loss of strength and muscle weakness all over the body» double vision» blurred vision and drooping eyelids» hoarseness or change or loss of voice» trouble saying words clearly» loss of bladder control» trouble breathing» trouble swallowing
These symptoms can happen hours to weeks after you receive an injection of XEOMIN®. These problems could make it unsafe for you to drive a car or do other dangerous activities. See “What should I avoid while receiving XEOMIN®?”
What is XEOMIN®? XEOMIN® is a prescription medicine that is injected into muscles and used: • to treat the abnormal head position and neck pain that happens
with cervical dystonia (CD) in adults.• to treat abnormal spasm of the eyelids (blepharospasm) in adults
who have had prior treatment with onabotulinumtoxinA (BOTOX).
• to improve the look of moderate to severe frown lines betweenthe eyebrows (glabellar lines) in adults for a short period of time(temporary).
It is not known whether XEOMIN® is safe or effective in children.
Who should not take XEOMIN®? Do not take XEOMIN® if you: • are allergic to XEOMIN® or any of the ingredients in XEOMIN®.
See the end of this Medication Guide for a list ofingredients in XEOMIN®.
• had an allergic reaction to any other botulinum toxin productssuch as rimabotulinumtoxinB (MYOBLOC®), onabotulinumtoxinA(BOTOX®, BOTOX® COSMETIC), or abobotulinumtoxinA (DYSPORT®).
• have a skin infection at the planned injection site.
What should I tell my doctor before receiving XEOMIN®? Before you take XEOMIN® tell your doctor about all your medical conditions, including if you: • have a disease that affects your muscles and nerves (such as
amyotrophic lateral sclerosis [ALS or Lou Gehrig’s disease],myasthenia gravis or Lambert-Eaton syndrome).See “What is the most important information I should knowabout XEOMIN®?”
• have allergies to any botulinum toxin product• have had any side effect from any other botulinum toxin in the past• have a breathing problem, such as asthma or emphysema• have a history of swallowing problems or inhaling food or fluid into
your lungs (aspiration)• have bleeding problems• have drooping eyelids• have plans to have surgery• have had surgery on your face• are pregnant or plan to become pregnant. It is not known if
XEOMIN® can harm your unborn baby.• are breastfeeding or plan to breastfeed. It is not known if XEOMIN®
passes into breast milk.Tell your doctor about all the medicines you take, including prescription and nonprescription medicines, vitamins and herbal supplements. Using XEOMIN® with certain other medicines may cause serious side effects. Do not start any new medicines until you have told your doctor that you have received XEOMIN® in the past. Especially tell your doctor if you: • have received any other botulinum toxin product in the last four
months
• have received injections of botulinum toxin such asrimabotulinumtoxinB (MYOBLOC®), onabotulinumtoxinA (BOTOX®,BOTOX® COSMETIC) and abobotulinumtoxinA (DYSPORT®) in thepast. Be sure your doctor knows exactly which product you received.The dose of XEOMIN® may be different from other botulinum toxinproducts that you have received.
• have recently received an antibiotic by injection• take muscle relaxants• take an allergy or cold medicine• take a sleep medicine• take a blood thinner medicine
Ask your doctor if you are not sure if your medicine is one that is listed above. Know the medicines you take. Keep a list of your medicines with you to show your doctor and pharmacist each time you get a new medicine.
How will I receive XEOMIN®? • XEOMIN® is a shot (injection) that your doctor will give you.• XEOMIN® is injected into your affected muscles.• Your doctor may change your dose of XEOMIN® until you and your
doctor find the best dose for you.
What should I avoid while receiving XEOMIN®? XEOMIN® may cause loss of strength or general muscle weakness, blurred vision, or drooping eyelids within hours to weeks of taking XEOMIN®. If this happens, do not drive a car, operate machinery, or do other dangerous activities. See “What is the most important information I should know about XEOMIN®?”
What are the possible side effects of XEOMIN®? XEOMIN® can cause serious side effects. See “What is the most important information I should know about XEOMIN®?” • XEOMIN may cause other serious side effects including
allergic reactions. Symptoms of an allergic reaction to XEOMIN®
may include: itching, rash, redness, swelling, wheezing, asthmasymptoms, or dizziness or feeling faint. Tell your doctor or getmedical help right away if you get wheezing or asthma symptoms, orif you get dizzy or faint.
The most common side effects of XEOMIN® include: • dry mouth• discomfort or pain at the injection site• tiredness• headache• neck pain• muscle weakness• eye problems, including: double vision, blurred vision, drooping
eyelids, swelling of your eyelids, and dry eyes. Reduced blinking canalso occur. Tell your doctor or get medical help right away if you haveeye pain or irritation following treatment.
Tell your doctor if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of XEOMIN®. For more information, ask your doctor or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1- 800-FDA-1088.
General information about XEOMIN®
Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. XEOMIN® should not be used for a condition for which it was not prescribed. This Medication Guide summarizes the most important information about XEOMIN®. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about XEOMIN® that is written for healthcare professionals. For more information go to www.Xeomin.com or call 888-493-6646.
What are the ingredients in XEOMIN®? Active ingredient: incobotulinumtoxinA Inactive ingredients: human albumin and sucrose
Distributed by: Merz Pharmaceuticals, LLC 4215 Tudor Lane Greensboro, NC 27410
and
Merz Aesthetics, Inc. 4133 Courtney Road, Suite 10 Franksville, WI 53126
This Medication Guide has been approved by the U.S. Food and Drug Administration.
Issued 07/2011
© 2011 Merz Pharmaceuticals, LLC Merz Aesthetics is a trademark and XEOMIN is registered trademark of Merz Pharma GmbH & Co. KGaA. Patent pending.
Botox®, Botox® Cosmetic, Dysport®, and Myobloc® are registered trademarks of their respective owners. EM00674-00
Informed Consent for Botulinum Toxin Injections Botulinum toxin A (BTX-A) therapy is an injection treatment useful for both therapeutic and cosmetic purposes. When providing therapeutic injections for conditions such as muscle pain/disorders and migraine headaches, cosmetic effects may be observed. BOTOX® (Allergan) and Xeomin® (Merz Aesthetics) are the trade names for botulinum purified protein. Other companies also produce BTX-A and may be used for your therapy. When tiny amounts of BTX-A are injected into a muscle responsible for movement, weakening of the muscle occurs that may reduce certain painful conditions. BTX-A therapy will have a cosmetic effect on "dynamic" lines and wrinkles, but is less effective for fine textural changes on the skin surface, and for those lines present at rest.
BTX-A therapy is temporary, meaning it will have to be repeated on a regular basis to remain effective. An average response is 3 to 6 months of diminished muscle contraction, although there have been reports of more than 6 months of efficacy following a single injection. Individual responses may be longer or shorter depending on the degree of skin sun damage, depth of the lines, the size of the muscle, and the amount of BTX-A used in the injection. After a BTX-A injection, the effect gradually begins over several days and is not complete for two weeks, and sometimes longer. The effects of BTX-A therapy often become longer after repeated injections.
For maximal results it is recommended that after receiving BTX-A you do not vigorously rub or massage the treated area for 2 hours. You should actively contract the treated muscles (for example, frown or grimace) to increase the response of the BTX-A for two hours following the treatment.
There is no known permanent side effect of BTX-A therapy. BTX-A therapy has been used since 1980 and is considered an extremely safe procedure by doctors. There are several possible temporary side effects, which include pain and possible bruising at the injection site; transient muscle twitching with muscle asymmetry, which can be treated with touchup injections; and transient numbness. Less than 1% of patients receiving BTX-A can experience temporary eyebrow or eyelid drooping and/or double vision if the BTX-A affects the muscles, which move the eye and eyelid. These effects usually only last up to four weeks.
Some patients may be less sensitive to BTX-A, and the therapy will not work as well for them as expected. Contraindications to BTX-A therapy include pregnancy, breastfeeding, active skin infection in the treated area, neurological diseases like myasthenia gravis, and the drug penicillamine. Alternatives to BTX-A therapy include no treatment, cold spray and stretching, local anesthetics, acupuncture, topical creams, chemical and laser peels, photorejuvenation or a surgical face, brow, or eyelid lift.
Payment at time of service is requested. The price of BTX-A therapy depends on the amount of BTX-A injected, which varies from person to person. You may request a price quote prior to treatment that will consist of an estimated range of the cost for the site that you wish to be treated.
Our clinic needs to see you in 2 weeks for a follow up assessment. This is to ensure your facial muscles reacted to your treatment accordingly. If you require more BTX-A to fine tune/adjust your results, it can be applied during this appointment for an additional cost. Alternatively, additional product may not be required. Your results will be photographed at this time.
By signing below, I agree that I have read and understood the above information and received and reviewed the Medication Guidelines for BTX-A. My questions have been fully answered to my satisfaction, and I have made an informed decision regarding Botulinum Toxin therapy. I understand the practice of BTX-A therapy is not an exact science, and that results cannot be guaranteed.
Name: Date:
Signature:
MLCE: Informed Consent- BTX-A 04/18/2017
Insurance Contacts BTX---A/ Dermal Fillers Matthew French Director of Insurance Services Washington Dentist’s Insurance Agency 126 NW Canal Street Seattle, WA 98107 (206) 441-6824 (206) 269-1922 Fax [email protected] www.nordicins.com
Renee Kunz Pacific Underwriters 12611 Des Moines Memorial Drive PO Box 6887 Seattle, WA 98168 (206) 248-2254 Direct (800) 562-5226 Toll Free (206) 248-0130 Fax [email protected] www.pacificunderwriters.com
Angela L. Ackerman Dental Service Associate The Medical Protective Company 5814 Reed Road Fort Wayne, IN 46835-3568 (260) 492-4656 Direct (800) 463-3776 x 6656 Toll Free (972) 543-9218 Fax [email protected] www.medpro.com
MLCDE: Insurance 6/6/2014
Supply List For BTX-A Administration
Forms: 1. Informed Consent 2. Medication Guide 3. Pre-Operative Instructions 4. Post-Operative Instructions 5. Facial Diagram- Treatment Record
Insulin Syringes: 3/10ml (Up to 30 Units), 8mm or 12.7mm Length, 29, 30 or 31Gauge UltiCare Ulti-Thin II Syringes $13.70 per 100 Syringes https://www.adwdiabetes.com/ Order online or from pharmacy such as Costco Pharmacy.
Tuberculin Syringe: 1ml Luer-Lok- #309628 18Guage Needle (BD Blunt Fill) #305180 www.bd.com (Becton Dickinson) Order online or from pharmacy.
Saline: 0.9% Bacteriostatic Sodium Chloride 20ml $4.95 per Vial www.mountainside-medical.com 1-888-687-4334 Order online or from pharmacy.
Botulinum Toxin-A:
XEOMIN® (incobotulinumtoxinA) http://www.merzusa.com 1-866-862-1211
Order From STATDDS 800-693-9076 http://statdds.com/
BOTOX® (onabotulinumtoxinA) www.botoxcosmetic.com 1-800-433-8871 Eastside- Shanna Segle 425-275-7610 [email protected]
Vial “Decapper” Kebby Decapper
www.kebbyindustries.com (Kebby Industries Inc- Blue 20mm)
Miscellaneous: Ice Pack 2X2’s Bromelain- Reduces bleeding/ swelling/ bruising. Mirror Sharps Container Bottle Opener Camera
***Many of the supplies are available online from multiple vendors at varying prices.
Botulinum Toxin-A Dilution
Original Manufacturer Recommendations: Use 0.9% Sterile Sodium Chloride (Saline) Non-preserved. Add 2.5 mL to 100 Unit Vial BTX-A through the stopper. Resulting Dose: 4 Units per 0.1 mL 0.3 ml Diabetes Syringes (12 Units Total per Syringe) Dose is drawn up by inserting through the stopper.
Canadian/Braun Recommendations: Use 0.9% Sterile Sodium Chloride (Saline) Preserved Add 1.0 mL to 100 Unit Vial of BTX-A through the stopper. Resulting Dose: 10 Units per 0.1 mL Remove stopper. Use “left to right” sterile technique. Move only to the right and clean gloves to start. 0.3 mL Diabetes Syringes (30 Units Total per Syringe) Dose is drawn up by inserting into the vial careful not to “touch the glass”.
**This is a tricky skill to master but comes with time.
Points to Remember:
1 cc (Cubic Centimetre) equals 1 mL
What is 1 Unit of BOTOX®?: The definition of a unit is the amount of BOTOX® that when injected into an 18-20 gram Swiss-Webster female mouse is lethal for 50% of the animals. This definition is unique to BOTOX®.
BTX-A Dilutions: BTX-A Units Saline Volume Units/mL Units/ 0.1mL Units/ .3mL
Syringe 100 1.0 mL 100 10 30 100 2.0 mL 50 5 15 100 2.5 mL 40 4 12 100 4.0 mL 25 2.5 7.5 100 5.0 mL 20 2 6
BTX-A Units Saline Volume Units/mL Units/ 0.1mL Units/ .3mL
Syringe 50 1.0 mL 50 5 15 50 2.0 mL 25 2.5 7.5 50 2.5 mL 20 2 6 50 4.0 mL 12.5 1.25 3.75 50 5.0 mL 10 1 3
MLCDE: Dilution Guide 4/18/2017
Hess Botulinum Toxin References- 2020
(1-105)
1. Zuniga C, Piedimonte F, Diaz S, Micheli F. Acute treatment of trigeminal neuralgia with onabotulinum toxin A. Clinical neuropharmacology. 2013;36(5):146-50. 2. Lin CS, Wu CY, Wu SY, Chuang KH, Lin HH, Cheng DH, et al. Age- and sex-related differences in masseter size and its role in oral functions. Journal of the American Dental Association (1939). 2017;148(9):644-53. 3. Di Martino S, Dalise S, Lamola G, Venturi M, Rossi B, Chisari C. A Beautician's Dystonia: Long-Lasting Effect of Botulinum Toxin. Case Rep Neurol Med. 2014;2014:686181. 4. Okeson JP. Bell's Oral and Facial Pain Seventh Edition. 2014. 5. Botox affects how we communicate. Dental Abstracts. 2019;64(6):365. 6. Gordon RW. BOTOX cosmetic for lip and perioral enhancement. Dentistry today. 2009;28(5):94-7. 7. Sidebottom AJ, Patel AA, Amin J. Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study. The British journal of oral & maxillofacial surgery. 2013;51(3):199-205. 8. Yoshida K. Botulinum Neurotoxin Injection for the Treatment of Recurrent Temporomandibular Joint Dislocation with and without Neurogenic Muscular Hyperactivity. Toxins. 2018;10(5). 9. Cuadrado ML, Garcia-Moreno H, Arias JA, Pareja JA. Botulinum Neurotoxin Type-A for the Treatment of Atypical Odontalgia. Pain medicine. 2016;17(9):1717-21. 10. Safarpour D, Jabbari B. Botulinum toxin A (Botox) for treatment of proximal myofascial pain in complex regional pain syndrome: two cases. Pain medicine. 2010;11(9):1415-8. 11. Laskin DM. Botulinum toxin A in the treatment of myofascial pain and dysfunction: the case against its use. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2012;70(5):1240-2. 12. Fedorowicz Z, van Zuuren EJ, Schoones J. Botulinum toxin for masseter hypertrophy. The Cochrane database of systematic reviews. 2013;9(9):CD007510. 13. Soares A, Andriolo RB, Atallah AN, da Silva EM. Botulinum toxin for myofascial pain syndromes in adults. The Cochrane database of systematic reviews. 2012;4(4):CD007533. 14. Brown EA, Schutz SG, Simpson DM. Botulinum toxin for neuropathic pain and spasticity: an overview. Pain Manag. 2014;4(2):129-51. 15. Hartl DM, Cohen M, Julieron M, Marandas P, Janot F, Bourhis J. Botulinum toxin for radiation-induced facial pain and trismus. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2008;138(4):459-63. 16. Emara AS, Faramawey MI, Hassaan MA, Hakam MM. Botulinum toxin injection for management of temporomandibular joint clicking. International journal of oral and maxillofacial surgery. 2013;42(6):759-64. 17. Aizenbud D, Nachmani A, Silberstein E, Rosenberg L. Botulinum toxin injections for modulation of nasal and facial grimaces in a cleft lip and palate patient. Plastic and reconstructive surgery. 2009;124(1):170e-2e. 18. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair. Plastic and reconstructive surgery. 2014;134(3):511-6. 19. Tollefson TT, Senders CM, Sykes JM, Byorth PJ. Botulinum toxin to improve results in cleft lip repair. Arch Facial Plast Surg. 2006;8(3):221-2. 20. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair: a double-blinded, randomized, vehicle-controlled clinical trial. PloS one. 2014;9(12):e115690.
21. Botulinum toxin treatment. Dental Abstracts. 2019;64(6):407. 22. Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2008;133(2):195-203. 23. Al-Qattan MM, Al-Shanawani BN, Alshomer F. Botulinum toxin type A: implications in wound healing, facial cutaneous scarring, and cleft lip repair. Ann Saudi Med. 2013;33(5):482-8. 24. Fu KJ, Teichgraeber JF, Greives MR. Botulinum Toxin Use in Pediatric Plastic Surgery. Ann Plast Surg. 2016;77(5):577-82. 25. Seidman LM, Brooks JK, Bashirelahi N. Botulinum toxin: a review of applications for the head and neck. General dentistry. 2019;67(2):55-8. 26. Freund B, Schwartz M, Symington JM. Botulinum toxin: new treatment for temporomandibular disorders. The British journal of oral & maxillofacial surgery. 2000;38(5):466-71. 27. Shehata HS, El-Tamawy MS, Shalaby NM, Ramzy G. Botulinum toxin-type A: could it be an effective treatment option in intractable trigeminal neuralgia? The journal of headache and pain. 2013;14(1):92. 28. Melo G, Duarte J, Pauletto P, Porporatti AL, Stuginski-Barbosa J, Winocur E, et al. Bruxism: An umbrella review of systematic reviews. Journal of oral rehabilitation. 2019. 29. Evatt ML, Freeman A, Factor S. Chapter 37 - Adult-onset dystonia. In: William JW, Eduardo T, editors. Handbook of Clinical Neurology. Volume 100: Elsevier; 2011. p. 481-511. 30. Sendra LA, Montez C, Vianna KC, Barboza EP. Clinical outcomes of botulinum toxin type A injections in the management of primary bruxism in adults: A systematic review. The Journal of Prosthetic Dentistry. 2020. 31. Delpachitra SN, Sklavos AW, Dastaran M. Clinical uses of botulinum toxin A in smile aesthetic modification. British dental journal. 2018;225(6):502-6. 32. Yoshida K. Computer-Aided Design/Computer-Assisted Manufacture-Derived Needle Guide for Injection of Botulinum Toxin into the Lateral Pterygoid Muscle in Patients with Oromandibular Dystonia. Journal of oral & facial pain and headache. 2018;32(2):e13-e21. 33. Motta-Junior J, Aita TG, Pereira-Stabile CL, Stabile GA. Congenital Frey's syndrome associated with nontraumatic bilateral trifid mandibular condyle. International journal of oral and maxillofacial surgery. 2013;42(2):237-9. 34. Frevert J. Content of botulinum neurotoxin in Botox(R)/Vistabel(R), Dysport(R)/Azzalure(R), and Xeomin(R)/Bocouture(R). Drugs R D. 2010;10(2):67-73. 35. Carruthers A, Kane MA, Flynn TC, Huang P, Kim SD, Solish N, et al. The convergence of medicine and neurotoxins: a focus on botulinum toxin type A and its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part I: botulinum toxin in clinical and cosmetic practice. Dermatol Surg. 2013;39(3 Pt 2):493-509. 36. Carruthers J, Fournier N, Kerscher M, Ruiz-Avila J, Trindade de Almeida AR, Kaeuper G. The convergence of medicine and neurotoxins: a focus on botulinum toxin type A and its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part II: incorporating botulinum toxin into aesthetic clinical practice. Dermatol Surg. 2013;39(3 Pt 2):510-25. 37. Garland K, Matic D. Current approaches to cleft lip revision. Current opinion in otolaryngology & head and neck surgery. 2019;27(4):287-93. 38. Costa LE, 2nd. The dentist, botox, and injectable fillers. Journal of esthetic and restorative dentistry : official publication of the American Academy of Esthetic Dentistry [et al]. 2014;26(1):1-4. 39. Tiigimäe-Saar J, Taba P, Tamme T. Does Botulinum neurotoxin type A treatment for sialorrhea change oral health? Clinical oral investigations. 2016;21(3):795-800.
40. Zelken J, Yang SY, Chang CS, Chang CJ, Yang JY, Chuang SS, et al. Donor Site Aesthetic Enhancement With Preoperative Botulinum Toxin in Forehead Flap Nasal Reconstruction. Ann Plast Surg. 2016;77(5):535-8. 41. Baker JS, Nolan PJ. Effectiveness of botulinum toxin type A for the treatment of chronic masticatory myofascial pain: A case series. Journal of the American Dental Association (1939). 2017;148(1):33-9. 42. Shim YJ, Lee MK, Kato T, Park HU, Heo K, Kim ST. Effects of botulinum toxin on jaw motor events during sleep in sleep bruxism patients: a polysomnographic evaluation. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2014;10(3):291-8. 43. Fernandez-Nunez T, Amghar-Maach S, Gay-Escoda C. Efficacy of botulinum toxin in the treatment of bruxism: Systematic review. Medicina oral, patologia oral y cirugia bucal. 2019;24(4):e416-e24. 44. Mynsberge M, Heidelman J, Bennett J. EMG guided lateral pterygoid muscle Botox--A injection for chronic temporomandibular joint dislocation: 2 patient case report. J Indiana Dent Assoc. 2014;93(1):22-6. 45. Suman T. Enhancing facial esthetics by other modalities. Int J Dent. 2011;2011:513957. 46. Schulte-Mattler WJ, Leinisch E. Evidence based medicine on the use of botulinum toxin for headache disorders. Journal of neural transmission. 2008;115(4):647-51. 47. Hallett M, Albanese A, Dressler D, Segal KR, Simpson DM, Truong D, et al. Evidence-based review and assessment of botulinum neurotoxin for the treatment of movement disorders. Toxicon : official journal of the International Society on Toxinology. 2013;67:94-114. 48. Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Rep. 2013;4(2):10. 49. Radlanski RJ, Wesker K. The face : pictorial atlas of clinical anatomy. [1st ed. London ; Chicago: Quintessence Pub.; 2012. 354 p. p. 50. de Sa Earp AP, Marmur ES. The five D's of botulinum toxin: doses, dilution, diffusion, duration and dogma. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology. 2008;10(2):93-102. 51. Chkadua TZ, Ivanova MD, Brusova LA, Pogabalo IV, Rassadina AV, Savvateeva DM. Functional disorders in patients with lip and nose deformity after cheilorhinoplasty. Stomatologiia (Mosk). 2016;95(4):44-8. 52. Lewin JS, Bishop-Leone JK, Forman AD, Diaz EM, Jr. Further experience with Botox injection for tracheoesophageal speech failure. Head & neck. 2001;23(6):456-60. 53. Duruel O, Ataman-Duruel ET, Tozum TF, Berker E. Ideal Dose and Injection Site for Gummy Smile Treatment with Botulinum Toxin-A: A Systematic Review and Introduction of a Case Study. The International journal of periodontics & restorative dentistry. 2019;39(4):e167-e73. 54. Kane MAC, Sattler G. Illustrated guide to aesthetic botulinum toxic injections : basics, indications, uses. London: Quintessence; 2013. 160 pages p. 55. Brignardello-Petersen R. Important uncertainty regarding the effects of botulinum toxin in patients with temporomandibular disorders or bruxism owing to serious limitations of a systematic review. The Journal of the American Dental Association. 2019;150(11):e175. 56. Evidente VG, Truong D, Jankovic J, Comella CL, Grafe S, Hanschmann A. IncobotulinumtoxinA (Xeomin(R)) injected for blepharospasm or cervical dystonia according to patient needs is well tolerated. Journal of the neurological sciences. 2014;346(1-2):116-20. 57. Walshe M, Smith M, Pennington L. Interventions for drooling in children with cerebral palsy. Cochrane Database of Systematic Reviews: John Wiley & Sons, Ltd; 2012.
58. Charous SJ, Comella CL, Fan W. Jaw-opening dystonia: Quality of life after botulinum toxin injections. Ear, nose, & throat journal. 2011;90(2):E9. 59. Yershov D, Partridge R. Life Threatening Delayed Complication of Botulinum Toxin Injection for Treatment of Spasmodic Dysphonia. Prague Medical Report. 2020;121(2):114-7. 60. Ramirez-Castaneda J, Jankovic J. Long-term efficacy, safety, and side effect profile of botulinum toxin in dystonia: a 20-year follow-up. Toxicon : official journal of the International Society on Toxinology. 2014;90:344-8. 61. Okeson JP. Management of temporomandibular disorders and occlusion. 7th ed. St. Louis, Mo.: Elsevier/Mosby; 2013. p. p. 62. Alam M, Kakar R, Nodzenski M, Ibrahim O, Disphanurat W, Bolotin D, et al. Multicenter prospective cohort study of the incidence of adverse events associated with cosmetic dermatologic procedures: lasers, energy devices, and injectable neurotoxins and fillers. JAMA dermatology. 2015;151(3):271-7. 63. Sakar O, Matur Z, Mumcu Z, Sesen P, Oge E. Multidisciplinary management of a partially edentulous patient with oromandibular dystonia: A clinical report. The Journal of Prosthetic Dentistry. 2018;120(2):173-6. 64. Koerte IK, Schroeder AS, Fietzek UM, Borggraefe I, Kerscher M, Berweck S, et al. Muscle atrophy beyond the clinical effect after a single dose of OnabotulinumtoxinA injected in the procerus muscle: a study with magnetic resonance imaging. Dermatol Surg. 2013;39(5):761-5. 65. Travell JG, Simons DG. Myofascial pain and dysfunction : the trigger point manual. Baltimore: Williams & Wilkins; 1983. 66. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102. 67. Guardiani E, Sadoughi B, Blitzer A, Sirois D. A new treatment paradigm for trigeminal neuralgia using Botulinum toxin type A. Laryngoscope. 2014;124(2):413-7. 68. Oliveira AT, Camilo AA, Bahia PR, Carvalho AC, DosSantos MF, da Silva JV, et al. A novel method for intraoral access to the superior head of the human lateral pterygoid muscle. BioMed research international. 2014;2014:432635. 69. Lyseng-Williamson KA, Frampton JE. OnabotulinumtoxinA (BOTOX(R)): a guide to its use in preventing headaches in adults with chronic migraine. CNS drugs. 2012;26(8):717-23. 70. Suber JS, Dinh TP, Prince MD, Smith PD. OnabotulinumtoxinA for the treatment of a "gummy smile". Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery. 2014;34(3):432-7. 71. Bell WE. Orofacial pains : classification, diagnosis, management. 4th ed. Chicago: Year Book Medical Publishers; 1989. xxii, 448 p. p. 72. Shehata HS, El-Tamawy MS, Mohieldin N, Edrees M, Bohlega S. Oromandibular dystonia in yemeni patients with khat chewing: a response to botulinum toxin treatment. Neurology international. 2014;6(2):5385. 73. Schneider R, Hoffman HT. Oromandibular dystonia: A clinical report. The Journal of Prosthetic Dentistry. 2011;106(6):355-8. 74. Maestre-Ferrin L, Burguera JA, Penarrocha-Diago M, Penarrocha-Diago M. Oromandibular dystonia: a dental approach. Medicina oral, patologia oral y cirugia bucal. 2010;15(1):e25-7. 75. Sinclair CF, Gurey LE, Blitzer A. Oromandibular dystonia: long-term management with botulinum toxin. Laryngoscope. 2013;123(12):3078-83. 76. Raphael KG, Tadinada A, Bradshaw JM, Janal MN, Sirois DA, Chan KC, et al. Osteopenic consequences of botulinum toxin injections in the masticatory muscles: a pilot study. Journal of oral rehabilitation. 2014;41(8):555-63.
77. Jost WH, Valerius K-P. Pictorial atlas of botulinum toxin injection : dosage, localization, application. 1st English ed. Surrey: Quintessence Books; 2008. viii, 264 p. p. 78. Dall'Angelo A, Mandrini S, Sala V, Pavese C, Carlisi E, Comelli M, et al. Platysma synkinesis in facial palsy and botulinum toxin type A. Laryngoscope. 2014;124(11):2513-7. 79. Diamond S, Dalessio DJ. The Practicing physician's approach to headache. 5th ed. Baltimore: Williams & Wilkins; 1992. xix, 295 p. p. 80. Brin MF, Kirby RS, Slavotinek A, Miller-Messana MA, Parker L, Yushmanova I, et al. Pregnancy outcomes following exposure to onabotulinumtoxinA. Pharmacoepidemiology and drug safety. 2016;25(2):179-87. 81. Kalf JG, de Swart BJM, Borm GF, Bloem BR, Munneke M. Prevalence and definition of drooling in Parkinson's disease: a systematic review. Journal of neurology. 2009;256(9):1391-6. 82. Friedman A, Potulska A. Quantitative assessment of parkinsonian sialorrhea and results of treatment with botulinum toxin. Parkinsonism Relat Disord. 2001;7(4):329-32. 83. Tzanidakis K, Moss C, Gibbons AJ. Re: Sidebottom AJ, Patel AA, Amin J. Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study. The British journal of oral & maxillofacial surgery. 2014;52(1):97. 84. Stark TR, Perez CV, Okeson JP. Recurrent TMJ Dislocation Managed with Botulinum Toxin Type A Injections in a Pediatric Patient. Pediatric dentistry. 2015;37(1):65-9. 85. Liu RK, Li CH, Zou SJ. Reducing scar formation after lip repair by injecting botulinum toxin. Plastic and reconstructive surgery. 2010;125(5):1573-4; author reply 5. 86. Bentivoglio AR, Ialongo T, Bove F, De Nigris F, Fasano A. Retrospective evaluation of the dose equivalence of Botox((R)) and Dysport ((R)) in the management of blepharospasm and hemifacial spasm: a novel paradigm for a never ending story. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2012;33(2):261-7. 87. Isaacson SH, Ondo W, Jackson CE, Trosch RM, Molho E, Pagan F, et al. Safety and Efficacy of RimabotulinumtoxinB for Treatment of Sialorrhea in Adults. JAMA Neurology. 2020;77(4):461. 88. Cavallini M, Cirillo P, Fundaro SP, Quartucci S, Sciuto C, Sito G, et al. Safety of botulinum toxin A in aesthetic treatments: a systematic review of clinical studies. Dermatol Surg. 2014;40(5):525-36. 89. See SJ, Tan EK. Severe amphethamine-induced bruxism: treatment with botulinum toxin. Acta Neurol Scand. 2003;107(2):161-3. 90. Lakraj AA, Moghimi N, Jabbari B. Sialorrhea: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins. 2013;5(5):1010-31. 91. Xiao L, Mackey S, Hui H, Xong D, Zhang Q, Zhang D. Subcutaneous injection of botulinum toxin a is beneficial in postherpetic neuralgia. Pain medicine. 2010;11(12):1827-33. 92. Grosset DG, Tyrrell EG, Grosset KA. Switch from abobotulinumtoxinA (Dysport(R)) to incobotulinumtoxinA (Xeomin(R)) botulinum toxin formulation: a review of 257 cases. Journal of rehabilitation medicine. 2015;47(2):183-6. 93. American Academy of Orofacial Pain., McNeill C, American Academy of Craniomandibular Disorders. Temporomandibular disorders : guidelines for classification, assessment, and management. 2nd ed. Chicago: Quintessence Pub. Co.; 1993. 141 p. p. 94. Li S, Lian YJ, Chen Y, Zhang HF, Ma YQ, He CH, et al. Therapeutic effect of Botulinum toxin-A in 88 patients with trigeminal neuralgia with 14-month follow-up. The journal of headache and pain. 2014;15:43. 95. Morra ME, Elgebaly A, Elmaraezy A, Khalil AM, Altibi AM, Vu TL, et al. Therapeutic efficacy and safety of Botulinum Toxin A Therapy in Trigeminal Neuralgia: a systematic review and meta-analysis of randomized controlled trials. The journal of headache and pain. 2016;17(1):63.
96. Kaya B, Apaydin N, Loukas M, Tubbs RS. The topographic anatomy of the masseteric nerve: A cadaveric study with an emphasis on the effective zone of botulinum toxin A injections in masseter. J Plast Reconstr Aesthet Surg. 2014;67(12):1663-8. 97. Tan EK, Jankovic J. Treating severe bruxism with botulinum toxin. Journal of the American Dental Association (1939). 2000;131(2):211-6. 98. Moller E, Werdelin LM, Bakke M, Dalager T, Prytz S, Regeur L. Treatment of perioral dystonia with botulinum toxin in 4 cases of Meige's syndrome. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 2003;96(5):544-9. 99. Pal US, Kumar L, Mehta G, Singh N, Singh G, Singh M, et al. Trends in management of myofacial pain. Natl J Maxillofac Surg. 2014;5(2):109-16. 100. Bohluli B, Motamedi MH, Bagheri SC, Bayat M, Lassemi E, Navi F, et al. Use of botulinum toxin A for drug-refractory trigeminal neuralgia: preliminary report. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 2011;111(1):47-50. 101. Fallah HM, Currimbhoy S. Use of botulinum toxin A for treatment of myofascial pain and dysfunction. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2012;70(5):1243-5. 102. Galarraga IM. Use of botulinum toxin in cheiloplasty: A new method to decrease tension. Can J Plast Surg. 2009;17(3):e1-2. 103. Singh JA. Use of botulinum toxin in musculoskeletal pain. F1000Res. 2013;2:52. 104. Alhazmi B, Aldekhayel S. The use of botulinum toxin type A to minimize scarring in cleft lip repair: A literature review. Arch Plast Surg. 2019;46(2):181-4. 105. DDS RG. Vermillion Dollar Lips: Vermillion Dollar Publications; 2007. 270 p.
Journal of Cosmetic and Laser Therapy. 2008; 10: 93–102
ORIGINAL ARTICLE
The five D’s of botulinum toxin: Doses, dilution, diffusion, duration and dogma
ANA PAULA DE SA EARP & ELLEN S. MARMUR
The Mount Sinai Medical Center, Dermatology, New York, NY, USA
Abstract The purpose of this review is to update cosmetic dermatologists and surgeons on the latest information about botulinum toxin injections for the treatment of the face and neck and to provide a practical guide to effective and safe technique. We review indications, recommended doses and dilutions, storage recommendations and injection techniques.
Key words: Botulinum toxin, dynamic rhytids
Introduction
The purpose of this review is to update cosmetic dermatologists and surgeons on the latest informa- tion about botulinum toxin injections for the treatment of the face and neck and to provide a practical guide to effective and safe technique. We critique some of the dogmas present in botulinum toxin literature. (The doses referred to in this article are specific to the botulinum toxin type A brand Botox; Allergan Inc.)
Anatomy
Successful injection technique requires a thorough understanding of the facial anatomy and interactions between the muscles. Physicians should be aware of the secondary compensation mechanisms that may occur when trying to paralyze or diminish the activity of a certain muscle or group of muscles.
Patient selection
Proper patient selection is essential to successful treatment with botulinum toxin. Patients should be instructed that only dynamics lines are likely to improve and that deep, static rhytids resulting from actinic damage or chronologic aging may not see improvement. Absolute contraindications for botuli- num toxin therapy include the presence of infection at the proposed site of injections and hypersensitivity
to any ingredient in the formulation (i.e. botulinum toxin, human albumin, and saline) (package insert). Relative contraindications are: (i) psychologically unstable patients or those who have unrealistic reasons and goals; (ii) people who are dependent on facial expression for their livelihood (e.g. actors and actresses); (iii) those afflicted with a neuromus- cular disorder (e.g. myasthenia gravis, Eaton– Lambert syndrome); (iv) those taking certain medications that can interfere with neuromuscular transmission and amplify the effects of botulinum toxin (e.g. aminoglycosides, penicillamine, quinine, and calcium channel blockers); and (v) pregnant or lactating women (botulinum toxin is classified as a pregnancy category C drug). There are a few reports in women who became pregnant after the injections or who were injected during early and late preg- nancy. These reports have not found any adverse effects to pregnancy or fetuses. Only one patient, who had experienced prior spontaneous abortions, suffered a miscarriage (1,2).
It should be known that botulinum toxin may interfere with neuromuscular blockade monitoring during general anesthesia because neuromuscular blockage is frequently monitored by facial nerve stimulation of the orbicularis oculi. Therefore, we suggest that patients should be told to inform their anesthesiologists if they have had botulinum toxin in the months anteceding surgery requiring this type of anesthesia. An alternative way to monitor neuro- muscular blockage in these patients is by peripheral
Correspondence: Ana Paula de Sa Earp, Rua Rita Ludolf 78/102 Leblon -Rio de Janeiro - RJ - Brazil- CEP 22440–060. E-mail: [email protected]
(Received 20 December 2007; accepted 25 December 2007)
ISSN 1476-4172 print/ISSN 1476-4180 online # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS) DOI: 10.1080/14764170701883660
94 A. P. de Sa Earp & E. S. Marmur
ulnar nerve stimulation of the adductor pollicis muscle (3).
Reconstitution technique
It was believed that botulinum toxin is a fragile toxin and that special attention should be paid in the reconstitution process. Early articles recommended that saline should be gently introduced into the vial to avoid formation of foaming during reconstitution. Also, the vial should not be shaken (4,5). Supposedly, bubbles associated with foaming could result in surface denaturation of toxin. Trindade de Almeida et al. (6) have reported that botulinum toxin (reconstituted with non-preserved saline) maintains its potency even if the vial is shaken and in the presence of foaming during the reconstitution process. Although this observation seems to agree with our clinical experience, further studies are needed to confirm these findings. Gentle reconstitu- tion is best.
Storage
The manufacturer recommends that once reconsti- tuted, botulinum toxin should be stored in the refrigerator (2–8˚C) and used within 4 hours. A recent study showed that routine refrigerator storage of botulinum toxin reconstituted with preserved saline does not result in microbial contamination of the contents even after serial re-extraction of solution from the vials, and after handling of such vials by multiple personnel. Storage and subsequent reuse of botulinum toxin appears to be safe for at least 7 weeks after reconstitution (7). Hexsel et al. have demonstrated that botulinum toxin reconsti- tuted with preservative-free saline may be injected up to 6 weeks after reconstitution without losing its effectiveness (8). However, they did not do bacterial assays to demonstrate the sterility of their solution. One must keep in mind that when using normal saline without preservative there is an increased risk of bacterial contamination and colonization of the solution the longer it remains unused. Anecdotally, the authors observed greater efficacy with freshly reconstituted botulinum toxin.
Dilution/diffusion
Each vial of botulinum toxin contains 100 U of toxin, 0.5 mg of human albumin and 0.9 mg of sodium chloride in a sterilized, vacuum-dried form without a preservative.
At present, the range of dilutions and injection volumes depends on the preference of the practi- tioner and the number of units to be injected. The subject is controversial. Some physicians advocate the use of more concentrated solutions to allow for
more accurate placement and fewer side effects from diffusion into adjacent muscles. Their opponents on the other hand argue that concentrated solutions are difficult to work with and can lead to waste of material. Plus, some believe that diffusion is an advantage, allowing us to use fewer units in areas such as the frontalis muscle.
Dilutions reported in the literature have varied from 100 U/ml to 10 U/ml (equivalent to diluting with 1 ml to 10 ml, relatively). Most dermatologists dilute botulinum toxin with 1–3 ml saline (100– 33.33 U/ml) when treating the face (4). Some studies have shown that dilutions between 100 U/ml and 10 U/ml appear to be equally effective and offer a similar duration of effect (5,9). One study examined the effect of injections in the forehead and found that higher dilutions were associated with a wider area of effect (10). On the other hand, Carruthers et al. showed that the more concentrated dose of botuli- num toxin (5 U per 0.05 ml) was slightly more effective in reducing orbital rhytids than the more diluted dose (5 U per 0.25 ml), but the difference was small and likely non-significant (the study was too small in number to apply inferential statistics and determine significance) (11). Higher volumes (lower concentrations), however, seem to be asso- ciated with more pain (5).
Hsu et al. suggested that the ideal strategy may be to inject concentrated toxin at a low volume to target smaller muscle groups, while using a larger volume for larger, broad muscle groups, such as the frontalis muscle (10). They suggest the use of a short-needle, 30-gauge, 0.3-ml insulin syringe (Becton Dickinson) for more concentrated solutions because it allows the delivery of a precise number of units and limits the waste of toxin (the needle design allows no dead space in the needle hub). Flynn et al. reported that with this syringe, full depression of the plunger leaves less than 0.01 ml in the needle itself, a contrast with the 0.07 ml that is retained in the dead space in a traditional 30-gauge needle (12) At a 100 U/ml dilution, this would mean a loss of 7 U of botulinum toxin (12). The syringe comes with a silicone-coated 30-gauge needle, which easily pene- trates the skin. The needle stays sharp for approxi- mately four to six punctures.
Although the manufacturer of botulinum toxin recommends that it should be diluted with pre- servative-free saline, some studies have shown that this is not necessarily required. A few studies have reported that dilution with preserved saline is less painful and is as effective and safe as dilution with non-preserved saline for the treatment of upper-face dynamic lines (13) and essential blepharospasm (14). They attributed this effect to the anesthetic properties of benzyl alcohol contained in the preserved saline since the pH of both salines is similar (13,14). A recent study reported that dilution with 2% lidocaine chlorhydrate was as effective as
dilution with saline for axillary hyperhidrosis and was less painful (15).
Injection technique/doses
In general, injections should be done perpendicular to the skin and intramuscularly, directed to the belly of the muscle. Figures 1–13 show the injection patterns for the various groups of muscles. Each patient requires individualized injection patterns. Most patients have slight facial asymmetry at base- line. This should be noted and ‘before’ photographs should be taken. For areas that require special attention, specific instructions are provided below.
When considering dosing, the total number of units to be injected depends on the area, muscle mass and strength, and should be individualized. Generally, men require more units than women. Recommendations for specific areas are given below.
Frown lines
Injection technique
The procerus injection is in the midline at the upper nasal bridge. The muscle can be grasped between the thumb and index finger of one hand and the free hand is used to inject. For the corrugators, different injection points have been described. To avoid diffusion to the levator palpebrae superioris muscle, which can cause blepharoptosis, the injections should be placed at least 1 cm above the orbital rim (16). Press with one finger inferior to the injection point. This help prevents pain and lessens bruising. The eyebrow should not be considered the landmark for placing injections because the brow itself may be ptotic, plucked, shaped, tattooed, dyed, and otherwise modified. A typical injection pattern is shown in Figure 1.
Figure 1. Injection points for frown lines.
The five D’s of botulinum toxin 95
Figure 2. Additional points for frown lines.
After treatment of the glabella, some patients compensate the paralysis of the corrugators with enhanced contraction of the horizontal fibers of the orbicularis oculi muscle. The effects are: (i) increased vertical lines above the eyebrow and (ii) medial pulling of the upper eyelid. In this case, the authors find it helpful to inject the orbicularis oculi in a few points just above the orbital rim (Figure 2). We inject 1–2 U in each injection point without brow ptosis.
Doses for frown lines
Hankins et al. (5) found a threshold for a demon- strable response to botulinum toxin for glabellar folds to be between 5 and 12.5 U (1–2.5 per injection site, five injection sites), whereas an effective starting dose was between 12.5 and 20 U. In this study, dose did not affect the longevity of treatment.
Carruthers et al. (17) compared the efficacy, safety, and duration of effect of four doses of botu- linum toxin (10, 20, 30 or 40 U) in the treatment of glabellar rhytids in females. A total of 20–40 U of botulinum toxin were significantly more effective and longer lasting than 10 U. There were no statisti- cally significant differences among the three higher- dose groups (20, 30 or 40 U). Most individuals experienced benefits for 3–4 months; some indivi- duals demonstrated an effect for up to 12 months. Among members of a consensus panel, 96% began treating women with either 20 or 30 U of botulinum toxin (18).
In men, a study comparing total doses of 20, 40, 60, or 80 U administered in the glabellar complex, found that 20 U was significantly less effective than the other doses (19). Among members of a consensus panel, 38% began treating men with 40 U and 30% frequently started with higher doses (45–120 U) (18).
96 A. P. de Sa Earp & E. S. Marmur
Forehead rhytids
Injection technique
Before injecting the forehead the patient should be evaluated for brow and lid ptosis, which is especially important in elderly individuals. People with brow and lid ptosis try to correct and compensate the depressed position of their brow/lid by constant contraction of the frontalis. These patients should not be injected because any weakness of the frontalis may compromise their visual field.
In general, avoid injecting the frontalis without injecting the glabella. The unopposed action of the brow depressors (corrugators and procerus) could theoretically lead to medial brow ptosis. This is less evident in young patients.
When injecting the forehead it is important that all injections remain at least 1 cm above the orbital rim to reduce the potential for brow ptosis. The recent trend is to inject the frontalis quite high (at least 2 cm above the orbital rim) to maintain some brow movement and avoid a frozen look.
The pattern of injection of the forehead varies considering the desired brow shape. Usually, it is aesthetically more appealing for women to have an arched eyebrow and for men to have a flatter, horizontal eyebrow. For women desiring a more arched brow, inject the central portion of the frontalis and omit the lateral portion. These women should be warned that this pattern of injection can leave them with residual wrinkles above the lateral eyebrow. Sometimes it can result in an exaggerated lateral brow lift and a quizzical appearance known as ‘Jack Nicholson’s look’. If this happens, placement of 1–2 U of botulinum toxin placed about 2 cm above the eyebrow at the line of maximum eyebrow elevation usually corrects the problem. For men, the whole frontalis should be injected, including the lateral portions. The typical injection pattern is shown in Figure 3.
Doses for forehead rhytids
Levy et al. (20) reported that 5 or 10 U were equally effective for the treatment of forehead dynamic lines. Doses did not affect duration of effect. The authors emphasized the role of low doses of botulinum toxin injections to obtain good clinical results without the freezing aspect (20). Unfortunately, this study did not disclose whether patients were female, male or both.
Carruthers et al. compared three doses of botuli- num toxin (16, 32 and 48 U) for female horizontal forehead rhytids. They found that higher botulinum toxin doses resulted in greater efficacy and longer duration of effect (21).
Among members of a consensus panel, 94% of panel members recommended a total starting dose of 10–20 U for women, with 61% recommending the lower dose. For men, 32% recommended starting with 20 U, and 46% recommended starting with 30 U. The calculated typical starting dose was 15 U for women and 20 U for men (18).
Eyebrow lift
Injection technique
Two common techniques for achieving an eyebrow lift are: (i) injecting the glabella alone and (ii) injecting the lateral orbicularis oculi (vertical fibers), lateral to the mid-pupillary line. Some perform injections for the lateral orbicularis oculi in only one point at the temporal fusion line (Figure 4).
The rationale for injecting the glabella alone can be explained in two ways. First, weakening of the muscular depressors of the brow (medial and lateral orbicularis oculi, procerus, corrugator, and depres- sor supercilii) may allow for unopposed action of the primary brow elevator (frontalis muscle) and result in brow elevation (22). Second, it may be due to diffusion of botulinum toxin into and partial
Figure 3. Injection points for forehead rhytids. Figure 4. Injection points for eyebrow lift.
The five D’s of botulinum toxin 97
inactivation of the medial fibers of the frontalis, with resulting increased muscle tone in the lateral and superior muscle fibers of the frontalis (23).
Doses for eyebrow lift
One study showed that injections of 20–40 U botu- linum toxin into the glabella alone (with the most lateral injection at the mid-pupillary line) led initially to a dramatic lateral eyebrow elevation, which was followed by a central and medial eyebrow elevation that peaked at 12 weeks after treatment (23). Interestingly, too little botulinum toxin (10 U) resulted in a mild brow ptosis and a brief fall in the eyebrow position. According to the authors, brow ptosis with low doses of botox could be caused by partial weakening of the frontalis without correspond- ing weakening of the strong depressor muscles (23).
Ahn and coworkers (24) demonstrated a statisti- cally significant elevation of the brow after injection of 7–10 U of Botox into the lateral orbicularis oculi muscle lateral to the mid-pupillary line.
Crow’s feet
Injection technique
Treatment for crow’s feet is directed to the lateral orbital portions of the orbicularis oculi muscle. Injec- tions should be superficial (because the orbicularis is very thin and superficial), kept lateral (approximately 1–1.5 cm from the orbital rim) and directed ‘outside’ the orbital rim to avoid diffusion to extra-ocular muscles and palpebral portion of the orbicularis oculi which can cause strabismus and lid ptosis. Injecting the area below the zygomatic arch should be avoided because diffusion to the zygomaticus major muscle can lead to lip and cheek ptosis, resulting in an appearance of peripheral facial paralysis. A typical injection pattern is shown in Figure 5.
Figure 5. Injection points for crow feet.
It is important to distinguish between lines caused
by orbicularis contraction and those produced by the zygomaticus muscles. These muscles push the cheek up towards the periorbital region, contributing in some patients to crow’s feet. The wrinkles produced by the zygomaticus action can only be treated if the zygomaticus complex is injected, which is risky and can lead to facial droop and an asymmetrical smile. There is a good way to distinguish between the wrinkles produced by the orbicularis and the ones produced by the zygomaticus. When evaluating the crow’s feet, instead of asking the patients to smile, ask them to close their eyes as hard as they can. The wrinkles produced by this movement are more likely to be due only to orbicularis oculi action and therefore be improved with botulinum toxin.
Doses for crow’s feet
Lowe et al. (25) found that 6, 12 or 18 U of botu- linum toxin (per side) were significantly superior to placebo for the appearance of crow’s feet (men and women were included in this study). They did not find a clear dose–response relationship.
In another dose-finding study (that compared 3, 6, 12 and 18 U (per side)), greater doses had a better and longer duration of effect. A clear difference between the 12 U and 18 U was not seen. The authors concluded that 12 U was the optimal dose (26).
Among members of a consensus panel, 96% started treating crow’s feet with 8–16 U per side in women and 89% used 12–16 U per side in men (18).
Infraorbital folds/opening of the eye
Injection technique
Injecting the lower eyelid can correct wrinkles in the area and cause an opening of the eyes. Careful selection of these patients is essential. Patients with lower eyelid laxity and those who have undergone previous eyelid surgery are more prone to complica- tions, particularly ectropion. Patients with pre- existing fat protrusion are not good candidates because when the musculature is weakened this condition can be aggravated (27). Other contra- indications are patients with Sjogren’s syndrome, other conditions associated with dry eyes (which can be worsened) and patients who have lower scleral show.
Injections should be directed to the pretarsal portion of the orbicularis oculi. The needle should be inserted from a lateral position, oriented horizon- tal to the ground and tangential to the lower eyelid to avoid puncture of the orbit if the patient moves during the procedure. Usually, one or two sites are injected, the first one being a point 3 mm below the ciliary margin in the mid-pupillary line and the
98 A. P. de Sa Earp & E. S. Marmur
Figure 6. Injection points for infraorbital folds and opening of the eye.
second being halfway beneath the mid-pupillary line and the lateral canthus (3 mm inferior to the ciliary margin) (Figure 6). In this area, injections should be kept superficial (subdermal) to avoid diffusion to the inferior oblique muscle (which can result in diplopia).
Doses for infraorbital folds/opening of the eye
One study reported the use of 2 U for the lower eyelid with mild improvement. In this study, better results were attained when the lower eyelids were treated in conjunction with the crow’s feet (28). Another study demonstrated a dose–response curve in the degree of improvement when 2, 4, or 8 U were used, with greater units showing better results (29). However, increasing the number of units was associated with more side effects. Five of eight patients in the 8-U study group were not happy with their treatment because of bothersome side effects such as photophobia, incomplete lid sphincter, and lower eyelid edema (29). Also, the authors reported that 8 U often produced an undesirable degree of increase in palpebral aperture (with patients report- ing a ‘sad’ look and exhibiting a good degree of scleral show) and an excessive lateral rounding of the lower lid (29). They suggest that 2 U should be used initially in the lower lid, alone (for eye opening) or along with the crow’s feet (for periorbital wrinkles), and the patient re-evaluated in 2 weeks. If no undesirable effects are noticed and further improve- ment is desired, another 2 U can be injected (29).
Bunny lines
Injection technique
Injections should be on the lateral aspect of the nasal wall above the nasofacial groove (Figure 7).
Figure 7. Injection points for bunny lines.
Massaging should be generally avoided, particularly in a downward direction, because diffusion to the levator labii superioris alaeque nasi muscle can cause ipsilateral lip ptosis.
Doses for bunny lines
Among members of a consensus panel, the usual total starting dose was 2–5 U. Men may receive a dose that is slightly higher by 1 U (18).
Perioral rhytids
Injection technique
Injections are done superficially at or above the vermillion border in the area of muscle contraction adjacent to the vertical creases (Figure 8). The corners of the mouth are not injected to prevent
Figure 8. Injection points for perioral rhytids.
weakness of the lateral lip elevators, which can lead to drooping of the lateral lip and drooling (30). Common side effects include difficulty whistling, saying ‘p’ and ‘b’, kissing, eating soup with a spoon and drinking through a straw. For this reason musicians or public speakers should not receive treatment in this area. Also, patients with a very thin/atrophic upper lip or a long columella-to- vermillion distance should not be injected. These patients may experience an even thinner lipped appearance because of the slight lengthening of the lip (31).
Doses for perioral rhytids
The goal is to inject as few units as possible to obtain good cosmetic results while preserving functionality of the mouth. Among members of a consensus panel, the average starting dose for the perioral area was approximately 5–6 U. Most panel members recommended 1–2 U per injection point (18).
It has been reported that perioral rhytids return more quickly than forehead and glabellar lines and patients usually need retreatment every 2–3 months (31).
Elevation of the corner of the mouth
Injection technique
Patients are usually asked to pull down the corners of their mouths or to show their inferior teeth to aid in the location of the depressor anguli oris muscle before the injection. The site of the injection is usually a point where the trajectory of nasolabial fold meets the jaw line. One injection in each side is the rule (Figure 9). It is important to localize the muscle before the injection; if the injection is too medial it can cause an ipsilateral weakness of the depressor
Figure 9. Injection points for elevation of the corner of the mouth.
The five D’s of botulinum toxin 99
Figure 10. Injection points for dimpled chin.
labii, if it is too high it can compromise the sphincter function of the orbicularis oris (30).
Doses for elevation of the corner of the mouth
In the depressor anguli oris muscles, low doses are used: 2–5 U in each site (18).
Dimpled chin
Injection technique
Injections should be placed deep because of the reasonable amount of fat that exits in the chin area. One injection in the midline or two (one in each side of the point of the chin) (Figure 10) are used in the mentalis at the most distal point from the orbicularis oris – the prominence of the chin. This injection site is chosen to avoid complications from oris orbicularis weakening (30).
Doses for dimpled chin
Among members of a consensus panel, the typical total starting dose was 5–6 U, with some experi- enced users going up to 12 U. In general, they found that 5–10 U should be adequate. Dosing is similar in women and men; occasionally, men who are treated may require a dose 2–3 U greater than that used for women. The total dose is divided evenly among sites if more than one injection point is used (18).
Elevation of the tip of the nose
Injection technique
The injection point is at the base of the columella (Figure 11). Caution should be taken with indivi- duals who already have a long columella-to-vermillion
100 A. P. de Sa Earp & E. S. Marmur
Figure 11. Injection point for elevation of the tip of the nose.
distance because there is a significant risk of lip ptosis with the procedure.
Doses for elevation of the tip of the nose
A total of 2–3 U are typically used in this area (30). Excessive gingival show (‘gummy’ smile)
Injection technique
Injections are placed bilaterally in the nasofacial groove into each levator labii superioris alaquae nasi (Figure 12). The injection site can be localized by placing a fingertip on the pyriform aperture just inferior to the nasomaxillary groove.
Doses for excessive gingival show
One unit per site is usually used.
Platysmal bands
Injection technique
To identify properly the platysmal bands, patients are asked to forcefully contract their necks by clenching their teeth. Each band is grasped indivi- dually and held firmly between the thumb and index fingers. Injections are placed directly into the platysmal band at 1.0- to 1.5-cm intervals along the band, starting at the jawline and descending all the way to the clavicular border (32). Adverse reactions include neck weakness (manifested by difficulty lifting the head off a pillow from the decubital position), dysphonia and difficulty swal- lowing (18).
Doses for platysmal bands
In the published literature, a wide range of doses has been used to treat platysmal bands. Brandt and Boker (32) and Matarasso et al. (33) agree that most patients need a total of 50–100 U to achieve optimal correction, while Kane (34) uses doses between 10 and 40 U. Among members of a consensus panel, doses were also quite variable, with total doses of 6240+ U per band (usually two bands are treated in a session) (18). The authors have success using 2 U per injection site spaced 1–2 cm apart along the length of the bands. Not all patients respond regardless of the dose.
Redefinition of the jaw line/mini neck lift
Injection technique
This is a new technique the authors have been using with good results for patients with mild laxity of the neck and poor definition of the jawline. We inject six points evenly distributed along the jawline (Figure 13).
Figure 12. Injection points for excessive gingival show. Figure 13. Injection points for mini neck lift.
The five D’s of botulinum toxin 101
Doses for redefinition of the jaw line/mini neck lift
Three to four units are used in the four lateral points of injection and 2 U in the central ones.
Other recommendations
Massaging the points of injection is a common practice. It helps to smooth the ‘bumps’ after the injection and some believe it helps with the diffusion of the toxin. To our knowledge, there are no studies looking at this particular subject. One should be cautious, however, when massaging areas where diffusion can be a problem such as the procerus and bunny lines. An alternative technique to massaging is the ‘press and hold’ technique, which helps with the ‘bumps’ and possibly with bruising.
It has been long taught that after injection of botulinum toxin, patients should exercise the affected muscles for up to 4 hours to enhance cellular uptake. There is no published data to document the need for this prolonged exercise. Data suggest that cellular uptake takes only 32–64 minutes in the nerves of actively contracting muscles (35). This suggests at most patients should exercise their injected muscles for up to 1 hour after treatment, not 4 hours.
Similarly, it is recommended by some physicians that patients should avoid bending their heads to reduce the chance of unwanted diffusion on the toxin. No controlled studies have been conducted to clarify whether bending of the head actually influ- ences diffusion. On a consensus panel published in 2004, 71% of the members did not recommend to their patients to avoid bending their heads (18). If one chooses to do so, the recommendation of staying upright should also be limited to 1 hour, since, as mentioned above, the toxin binding process takes only 1 hour (36).
Conclusion
Botulinum toxin injections are the most common aesthetic procedure performed in the United States. Our understanding and knowledge about the toxin has grown tremendously since it became available, which has led to an expansion of its use and indications. As new data became available, dogmas were left behind. A thorough understanding of the facial anatomy, the injection technique as well as proper dilution and storage are essential to a successful outcome without complications. This review of the 5 D’s is a practical up-to-date guide to safe and effective technique.
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