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Botox Workshop

By:
Moustafa Abouzaid
Prof. Dermatology & Andrology
Faculty of medicine
Azhar University
Cairo Egypt
2011

Clostridium Botulinium

A gram positive,
Spore-forming,
Obligate anaerobic bacillus
Produces the most potent neurotoxins ,causing Botulism.
Latin name: Botulus (black sausage)

There are seven distinct antigenic toxins.:

1.
2.
3.
4.
5.
6.

BTX A,
B, C ( C & C ),
D,
E,
F&
G

BTX-A is the most potent.


All are produced by different strains of clostridium
botulinum.

Botulism
There are three forms of human botulism:
1. Food-borne (improperly preserved food containing
the preformed neurotoxin).
2. Infantile (ingestion of spores and production of the
toxin in infant's intestine).

3. Wound infection

History

1820.

1895.

1922.

1930

1946

First

The
anaerobic
bacterium
was isolated

The
extracellular
toxin (crude
form) was
isolated

The
crystalline
(purified
form) was
developed

BTX
(clinical
product)

collected
data on
botulism

1973
Animal
experiments
on
strabismus
(Published).

The cosmetic use


of botulinium
toxin
By Jean Carruthers
in 1987.

FDA approved use


in adult
strabismus and
blepharospasm in

BTX for blocking


cholinergic
innervations to
sweat glands for
hyperhidrosis

1989.

1994.

Clinical uses of Botox:


BTX-A was found safe and effective for:

1) Neurologic use and excessive muscle activity


Hemifacial spasm
Facial asymmetry
Oromandibular dystonia
Spasmodic dystonia
Cervical dystonia

Spasmodic torticollis
Achalasia
Gustatory sweating
Hyperlacrimation
Synkinesia

2) Ophthalmological use
1- Strabismus
2- Blepharospasm
3- Nystagmus

3) Dermatologic use
Hyper functional glabellar
frown lines,
crow's feet & forehead lines
Brow ptosis and brow position
Nasal scrunch and flare
Upper lip wrinkles
Marionette (sad lines)
Platysmal bands
Palmar and axillary hyperhidrosis

4)Others uses:
Anal fissures
Pain management
Headache

Forehead lines

Marionette (sad lines)

Platysmal bands

Nasal scrunch and flare

Crow's feet

Glabellar frown lines

Indications for
Botulinum Toxin Type A
Temporary improvement in
the appearance of moderate to severe
Glabellar lines
Fore head line
Crows feet
Adults 65 years

Administering physicians
1. Be well trained

2. Have knowledge of muscles controlling facial


expression
3. Should know the dynamics of aging

The face and ageing


Skin loses
elasticity and
becomes
thinner

Wrinkles
and
creases

Ageing
Habitual
expressions &
constant
muscle
contraction or
relaxation

Cosmetic Uses of BTX


Basic applications
Horizontal
forehead lines
Glabellar frown
lines
Lateral and
medial brow lifts
Crows feet

Advanced and other


applications

Nasal scrunch and flare


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

Why Botulinum Toxin?


Botulinum Toxin Type A is a therapeutic agent
that improves dynamic facial lines by targeting
the underlying responsible muscles
Mechanism of Action
It works by blocking acetylcholine impulses that
trigger hyperactive muscle contractions
Result: CHEMICAL DENERVATION

Neurotransmission
Axon terminal
and synapse

Soma/cell

Dendrite

Axon

Neurons are specialized cells that


receive and transmit nerve impulses.

Neurotransmission
Axon

Axon
terminal

Axon

Axon terminal
Muscle

Neuromuscular
junction

Axon branch

Muscle cell
Motor end plate
Acetylcholine

Nerve impulses are conducted between


adjacent cells across synapses, via the release of neurotransmitters.

The facial muscles muscle basics

Relaxed
Nerve impulse

Contracted

Body Muscles to
Move

Facial Muscles to
Give our Features

Binding

Internalisation

Blocking
5

Botulinum Toxin
Type A :
Mechanism of Action
formation of the
collateral nerve sprouts
Adapted from: dePaiva et al. PNAS 1999, 96:3200

The sprouts retract and


the original nerve end
starts to work normally

Diffusion Description
Particles of greater molecular
weight diffuse more slowly
through an aqueous medium
than do smaller molecules so
long as charge and temperature
is the same
(Ficks first law, Fick 1855)

Why is diffusion important?


Desired (larger molecule size)
Needed for maximum local effect
Access motor nerve terminal (NMJ)
Distribution within target muscle to reach nerve
terminal

Not desired (smaller molecular size)


Excess local weakness
Pharmacological effect on adjacent muscle
Distal weakness / dry mouth etc.
Leakage from target muscle leads to spread via
blood stream

BOTOX: Vial Dilutions


Saline diluent
volume
1.0
1.5
2.0
2.5
3.0
4.0

5.0 mL

mL
mL
mL
mL
mL
mL

U/mL

U/0.1 mL

100.0
66.7
50.0
40.0
33.3
25.0

10.0
6.7
5.0
4.0
3.3
2.5

20.0
Only in axillary hyperhidrosis

2.0

Dosage and Administration


Reconstitution
Reconstitute with 0.9% sterile, non-preserved saline
Use 2.5 cc 5 cc syringe to draw saline solution
Insert at 45 angle and inject saline into Botulinum Toxin
Type A vial

Discard vial if vacuum doesnt pull diluent into vial


Record date of reconstitution
Store reconstituted Botulinum Toxin Type A in a refrigerator
and use within 2 hours in room temperature

All details above refer to BOTOX

Dosage and Administration (cont)


Administration
Remove syringe used for reconstitution and use
insulin syringe with built-in 30-gauge needle.
Draw 0.5 mL into syringe and expel air bubbles

NOTE:
In practice, it has been reported that:
Refrigerated vial without diluent remains
effective indefinitely
Efficacy maintained following reconstitution

Refrigerated and use it


for up to 4 weeks

Considerations for Treatment


Botulinum Toxin Type A is contraindicated for the
following patients:
Patients with

infection at proposed injection site

Patients with

known hypersensitivity to any ingredient in Botulinum Toxin A

Administration of Botulinum Toxin Type A is


not recommended during pregnancy
Co-administration with aminoglycosides or other agents interfering
with neuromuscular transmission should be performed with caution

The most common side effects are injection-related and


are transient are localized pain, tenderness &/or bruising

Injection Considerations
Photograph the patient before injection.
Instruct patient to animate to show
muscle activity
Mark injection sites

Use 30-gauge needle for comfort


Inject into relaxed muscle
Instruct patient to animate repeatedly
post-injection to maximise toxin absorption
(2 - 4 hours)
Provide patient with post treatment
instructions

Follow-up
Pre-injection photos
Inform patients to return in 1-2 weeks for
evaluation
Compare results with Pre-injection photos

Correct any asymmetries / complains


Set re-injection schedule

Anatomy of the face

Frontalis
Depressor supercilii
Zygomaticus minor

Procerus

Corrugatorsupercilii

Orbicularis oculi

Zygomaticus major
Risorius

Depressoranguli oris
Depressor labii inferiorus

Orbicularis oris
Buccinator
Mentalis
Platysma

Key Muscles of the Upper Face

Corrugator
Supercilii

Procerus

Frontalis

Orbicularis
Oculi

Glabellar Aesthetics

Brow elevation appears


serene and calm

Depression of the central


brow appears angry, sad,

Sites for Glabellar Injection


X X

X X

Saline diluent
volume
1.0
1.5
2.0
2.5
3.0
4.0

mL
mL
mL
mL
mL
mL

U/mL

Dosing
100.0
66.7
50.0
40.0
33.3
25.0

U/0.1 mL
10.0
6.7
5.0
4.0
3.3
2.5

5 injection sites:
1 in procerus
2 in each corrugator

Corrugator
Supercilii

Procerus

Total dose:
20 U (4 U/injection
site)
0.1 mL/injection
site (in case of 2.5
mL dilution)
Carruthers A, Lowe NJ

Typical Botulinum Toxin Type A (BOTOX)


Doses for the Female Glabellar
4

4
4

Corrugator
Supercilii
Procerus

Procerus injection

Flynn 2001

Procerus injection - massage

Firm upward pressure is used to move the Botulinum


Toxin Type A upward & outward toward depressor
supercillii

Flynn 2001

Glabellar Injection Techniques

Thumb of non-injecting
hand protects orbital rim
Hand rests on patients face
to control the injection
Injections must be 1 cm
away from orbital rim

Flynn 2001

Decrease in Glabellar Lines after Treatment


with Botulinum Toxin Type A
Baseline

Day 30

Unretouched clinical trial photos taken while frowning before


Botulinum Toxin Type A and after Botulinum Toxin Type A . Individual
results may vary.

Lateral Brow Lifting


The frontalis muscle ends
midway between the
lateral and mid-brow.
The orbicularis - oculi
depresses the portion of
the brow lateral to this.
Injection of 2- 4 Mu of
Botox just below the
lateral brow and lateral
to the temporal fusion
line can raise the lateral
brow, giving the patient a
"chemical" brow-lift of
up to 2mm.

Complications of glabellar injections


Brow ptosis,

occurs when toxin affects the frontalis, as


the toxin spread 1-1.5cm (2-3cm in diameter)

Avoid injecting the glabella and whole forehead in one session


especially in patients with low-set brows, mild brow ptosis and
patients over 50 years (preinject the brow depressors).
Patient is advised to remain upright for 2 hours.
To exercise muscles for the first 2 hours.
Avoid rubbing or massaging for 2 hours.
Responds to apraclonidine (-adrenergic agonist) ophthalmic
eye drops (2 drops / hour).

Eyelid ptosis,

when toxin migrates to


upper eyelid levator muscle, producing a
weak paralytic effect as early as 48 hours or
as late as 14 days and persisting for 2-12
weeks.

Avoid injection no closer than 1cm above the


central eyebrow .
Bothersome
ptosis
is
treated
by
apraclonidine.

Crows Feet
Superficial rhytides radiating
from the region of the lateral
canthus

Represents dynamic
hypertrophy of the orbicularis
oculi coupled with static skin
changes

Coordinates with the smile

BOTOX: Crows Feet (cont)


Saline diluent
volume
1.0
1.5
2.0
2.5
3.0
4.0

mL
mL
mL
mL
mL
mL

U/mL

U/0.1 mL

100.0
66.7
50.0
40.0
33.3
25.0

10.0
6.7
5.0
4.0
3.3
2.5

x
x

Optimum dose 10 to 12 units per side

BOTOX: Crows Feet

Optimum dose 10 to 12 units per side


Second treatment gave greater improvement
and longer duration

BTX: Crows Feet


After BOTOX

Before BOTOX

BOTOX: Infraorbital Creases


Test skin laxity with a
snap test
1-2 U of BOTOX
Lid margin in line
with the pupil
x

Lid margin slightly


lateral to the
midpoint between
pupil and lateral
canthus

A more wide-eyed look can be obtained by injecting the


lower eyelid at the lash margin by 2MU at mid pupil and
2MU midway between pupil and outer canthus, some use
the first injection only.

This also helps smooth out fine lines under eyes.


Do not do if patient exhibits a significant degree of scleral
show pretreatment, or had significant surgery under the eye,
or if has a great deal of redundant skin under eye as
exhibited by the snap test of the lower eyelid

Infraorbital Creases

Before BOTOX

After BOTOX

Reported complications of this area are:


Diplopia (cover eye) and send to ophthalmologist
Ectropion or a drooping lateral lower eyelid
Strabismus (send to ophthalmologist)
Bruising
An asymmetric smile caused by the toxin diffusing
to the zygomaticus major
Transient lymph edema

Horizontal Forehead Lines


Horizontal lines and
wrinkles across the
forehead

Produced by excessive
contractions of the
frontalis

BOTOX: Horizontal Forehead Lines

For forehead 4-6 injections (a total of 10-20MU) are placed


across the forehead in a uniform grid, visible blebs are temporarily
produced. The lateral most injection should be vertically above the
mid-pupil, although with a wider forehead this can be extended
beyond the pupil to the iris.

Saline diluent
volume
1.0
1.5
2.0
2.5
3.0
4.0

mL
mL
mL
mL
mL
mL

U/mL

U/0.1 mL

100.0
66.7
50.0
40.0
33.3
25.0

10.0
6.7
5.0
4.0
3.3
2.5

x
x

x
x

x
x

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

x
x

x
x

x
x

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

BTX: Horizontal Forehead Lines


After BOTOX

Before BOTOX

Botox (Botulinum toxin Type -A),


Myobloc ( Botulinum toxin Type- B),
Dysport
(Abobotulinumtoxin-A)

Follow-up

New patients to return in 1-2 weeks for evaluation


Compare results with pre-injection photos
Correct any asymmetries / complains
Set re-injection schedule

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

American Society of Dermatologic Surgery in Orlando, Florida,

1-Dilute with saline containing preservative


THE MORE NEUTRAL PH
AND THE BENZYL ALCOHOL
DECREASE THE LESS THE STING OF
INJECTION.

2-Reduce the pain of the needle stick


By pulling the skin toward the needle and pinching
the skin lightly between the thumb and first finger
(because the pressure sensation of the pull
overrides the sensation of pain).

3-Limit injections to
no more that 4 per needle, after which the needle
starts to dull.
4-PLACE A WARM TOWEL
ON THE FACE BEFORE
APPLYING TOPICAL ANESTHETIC
TO INCREASE THE ABSORPTION AND EFFICACY OF THE
ANESTHETIC.

5-TO MINIMIZE BRUISING,

Request that patients stop all


Aspirin or
Nonsteroidal anti-inflammatory drugs,
Vitamin E,
Ginkgo biloba,
And garlic

14 days before botulinum injections.

6- For periocular areas,


Consider precooling to help vasoconstrict vessels
and thus reduce the chance of bruising.
In addition, use a specialized vein light to help
visualize vasculature and thus avoid disturbing it.

7-To tamponade any oozing


Use cotton-tipped applicators; Apply ice
packs afterward to minimize bruising risk.

Combination Therapy
BOTOX can be combined with many
cosmetic procedures:

Fillers
Ablative laser resurfacing
Non-Ablative laser remodeling
IPL
Peels
Facial Surgery

BOTOX + Fillers

Selection of the right filler.


BOTOX first then filler after two weeks.
Combination useful in glabellar and peri-oral lines.
Results in more satisfaction and longer duration,
can reduce amount of fillers needed.

BOTOX + Ablative laser


BOTOX decrease mechanical disruption of healing
process post laser treatment, improving collagen
remodeling.
BOTOX will prolong the smoothing wrinkle
reduction effect of laser.
Combination useful in crows feet, forehead and
peri-oral areas.
Inject BOTOX two weeks before ablative laser
treatment.

BOTOX + Non-Ablative laser


Specific lasers (1320nm, 1450nm & 1540nm).
Existing lasers (erbium-YAG, ND-YAG, Q-switched,
pulse-dye lasers)
Radiofrequency technology (e.g. Thermage)
BOTOX will improve and prolong the cosmetic
smoothing results.
Use BOTOX few days prior or post laser to prevent
increasing diffusion due to thermal inflamation.

BOTOX + IPL
IPL is used to stimulate collagen and elastin
synthesis, resulting in softening the facial fine
lines.
Multiple sessions is needed to achieve this effect,
usually 4-6 sessions.
BOTOX will improve and prolong the cosmetic
smoothing results.
Use BOTOX few days after the first IPL session.

BOTOX + Peels
Chemical peels produce controlled injury followed
by the wound healing process which produces
smoother skin.
Selection of the right peel.
Use BOTOX 2 weeks before peeling to prevent
increasing diffusion due to inflammation.
Microdermabrasion usually doesnt produce
inflammation, so BOTOX can be injected right
after this procedure.

BOTOX + Facial Surgery


BOTOX and facial surgery have complementary effect
on the aging face.
Recent reports suggested that BOTOX can reduce the
tension exerted on the skin by the healing process,
resulting in reduced scarring.
With blepharoplasty, relaxation of the local muscles
can allow for accurate resection of the skin and better
placement of the incision during the surgical
procedure.
Use BOTOX one week after surgery or at least three
months before surgery.

Botox and Hyperhydrosis


Procedure:
1) Documentation of the problem:
1- Gravimetric measurement or.
2- The minor starch iodine test.
First wiping the skin with a colored iodine tincture (must be brownorange).
Several seconds are given to allow the iodine solution to dry (fan).
The area is then lightly dusted with ordinary baking cornstarch
powder.

The exact location of the active sweating is


then mapped and outlined with a marking
pen before beginning injections.

Take a photo.

N.B. perform the test

before applying any regional nerve blocks or


topical anesthetics like eutectic mixture of lidocaine (EMLA)

(cause a hyperemic and


a
vasoconstrictive response
respectively interfering with the amount of sweating and can give
misleading results).

Botox and Hyperhydrosis


2) Anesthesia:

The axillary, forehead and facial sweating can be treated


without anesthetic or by topical anesthesia.

Palmar and plantar with topical anesthesia, but most


patients require regional nerve block anesthesia, such as
wrist or ankle block.
Disadvantages of nerve blocks ------ causes reactive
hyperemia thus increasing the tendency to bleed from
each small injection site, which may increase the loss of
material from injection site and decrease the relative
effectiveness of each injection.

Botox and Hyperhydrosis


3) Injection technique:

Dilution

5 ml saline + 1 vial BTX


Use 10 syringes ( 5 for each axillae i.e. 2.5 ml for Rt.
Axillae and 2.5 ml for Lt. Axillae).
Withdraw 0.5 ml for each syringe.
Inject 20 25 injections to every axillae i.e. 2 units for
each injection

For axilla, usually involves placement of 10-20

individual intradermal injections (raising tiny


wheals) about 2.5cm apart, beginning at the periphery
of the hair-bearing skin and circling into the centre of

the axillary vault, keeping the needle bevel up and


more parallel to the skin surface.

Approximately 50U/axilla,

duration of effect is
approximately 4-10 months.

Focal Axillary Hyperhidrosis

Before BTX-A

After BTX-A
Naumann Arch Dermatol 134 1998

Botox and Hyperhydrosis of Palm & Sole


Palmar injections

are placed approximately every


1.5cm across the palmar surface. On the fingers the volar
pad of each phalanx receives its individual dose. The finger
tips usually receive two: one in mid pad and another at the
very tip. The dominant hand receives an extra row of
injection along the ulnar side.

The palmar skin is comparatively stiffer and a wheal cannot

be raised, it is

desirable to produce a small zone


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

Costs & Frequency of treatment


Patients with large shoe size have correspondingly
larger hands and require more injections, e.g. a
man with a size 43-45 shoe requires up to
150U/palm whereas a woman with a size 36 shoe
requires as little as 75U to cover the palm.
Inject approximately 120U/palm, duration of effect
is 3-12 months (approximately 6 months).

Treatment is approximately twice a year.

. 37 shoes size requires 1.5 vials for both palms


i.e., 150 Us( 75U/ each palm).
. 38- 42 shoes size requires up to 2 vials for both
palms i.e., 200 Us (100/ each palm).
. 43- 45 shoes size requires up to 3 vials for both
palms i.e., 300 Us (150/ each palm)

Injection of the soles follows the same technique and


pattern as the palms.
N.B. it may take several treatments before patient recognize
less than total response as successful.

Almost every patient develops a transient period of


weakness and instability of the lumbrical muscles of the
hand, which is predictably spontaneously reversible, patient
can write, type and eat without difficulty, but opening up a
tight jar lid for example poses problems for a few weeks (35). So, ma ybe treat one hand first then the second.

Thank you