Comprehensive Overview & Practical Applications of Botulinum Toxin

2011

Basic & Advanced Applications
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ELITE Aesthetic, Medical & Business Training
Copyright 2008 ELITE

2011

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Dr. Mike Van Thielen
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Comprehensive Overview & Practical Applications
Presented by ELITE Aesthetic, Medical & Business Training

Copyright 2011 ELITE

Reference: Botulinum Toxin – Carruthers & Carruthers – 2nd Edition

Procedures in Cosmetic Dermatology Series, ISBN: 978-1-4160-4213-6

 Introduction & History
 Statistics of Aesthetics
 Etiology of Aging Face
 Pharmacology & Physiology of Botulinum Toxin
 Functional & Practical Anatomy
 Storage, Handling & Dilution
 Indications, Contraindications & Complications
 Treatment of Upper Face
 Treatment of The Lower Face & Neck
 Adjunctive Treatments
 Client Education & Realistic Expectations
 Hands-on Workshop and/or (live) Demonstrations.

Love for Beauty

Looking Young For Ideal proportions &
Biological Age Shapes

Normal
Harmony & Relationship
Balance Between Facial
Units

Muscles
Inelastic,
Attached To
Aging Skin Skin
Wrinkles
Skin Subject
Flaccid, Repetitive perpendicular
To Pull Of
Loose Skin Movement To Muscle
Gravity Fibers

Face Lift
BOTOX™
Brow Lift
Lasers &
Light, RF,
Meso

Redundant Skin Hyperdynamic Wrinkles

 Strong contrast with current use of BTX.
 Botulism:
◦ Form of food poisoning („botulus‟ = sausage).
 1895: Belgian picnic (34 people ill, 3 died after eating
raw, salted ham).
 Professor Emile Pierre Marie Van Ermengem identified
the etiologic agent and named it „bacillus botulinus‟.
 Renamed and reclassified as „Clostridium botulinum‟.
◦ Anaerobic, spore forming bacterium that under
certain conditions can germinate and create a toxin.

 Toxin:
 Resists alcohol, mild acid and enzymes.
 Not heat-resistant.
 Some animals (dogs, chickens) unaffected by toxin.

 Symptoms: blurred vision, nausea, dizziness, dry.
mouth – may progress to flaccid paralysis and death.

 Type A, B & E documented as causative strains for
human cases of botulism.

 1920:
 isolation of toxins initiated by Dr. Herman Sommer.

 1946:
 Type A Toxin isolated by Edward Shantz (for US Army).

 1949:
 Burgen discovered mechanism of action.

 1950‟s:
 Dr. Vernon Brooks: 1st. medical use of botulium toxin.

 1973:
 Dr. Alan B. Scott: 1st study demonstrating therapeutic
value of BTX was published.
 Attempts to treat strabismus showed that BTX effectively
weakens the eye muscles in primates.

 1977:
 Treatment for strabismus attempted in humans.

 1979:
 Dr. Schantz prepared 1st. Batch of 11-79, now called
Botox.
 The 150mg batch served as the source of all BTX-A used
in humans in USA until 1997.
 Limited FDA-approval to use of BTX-A for strabismus.

 1985:
 FDA-approval to include blepharospasm.

 1987:
 Carruthers & Carruthers performed joint dermatological-
ophthalmologica research with Dr. Alan B. Scott.
 Dr. Jean Carruthers observed significant improvement of
dynamic rhytides in glabellar region while treating
patients for blepharospasm.

 1989:
 Dr. Alan B. Scott‟s company Oculinum, Inc. acquired by
Allergan, Inc.
 Name of product changed to Botox.
 FDA-approval to include hemifacial spasm.

 1991-1992:
 Drs. Jean & Alastair Carruthers reported and published
initial findings of BTX-A for cosmetic usage,
demonstrating the safe & effective treatment of dynamic
rhytides in the glabella.

 1993:
 Blitzer and colleagues described use of BTX for rhytides of
the forehead and elsewhere.

 1997:
 BTX-A source by Allergan Inc. (Irvine, CA) FDA-approved.

 1999:
 New England Journal of Medicine – Editorial „One Man‟s
Poison – Clinical Applications of Botulinum Toxin‟
provides examples of historic uses:
 Lower limb and upper limb spasticity in children.
 Anal fissures.

 2003:
 FDA-approval for treatment of glabellar rhytides.

 Subsequent publications and usage expanded the use
of BTX to new area‟s of treatment:
 Crow‟s feet, neck (platysma), oricular muscles.
 Pain & spasms (migraine, torticollis).
 Hyperhydrosis.

Statistical data courtesy of:

THE AMERICAN SOCIETY FOR AESTHETIC PLASTIC
SURGERY (ASAPS)

 10 Million Cosmetic Procedures in 2009.

 Increase of 147 percent since1997.

 Repeat patients and those putting off surgery, are likely the
reason for the growth in non-surgical cosmetic procedures.

 Growth in demand will likely return as the recession eases
and baby boomer's offspring begin to explore cosmetic
procedures.

 Cronic UV-damage to the skin.
◦ Photo-aging due to cumulative sun exposure.
◦ Glogau Wrinkle Scale:

Type 1: 'Early Wrinkles' Type 2: 'Wrinkles in Motion'
Patient age: 20s to 30s Patient age: 30s to 40s
Early photo-aging Early to moderate photo-aging
Mild pigment changes Appearance of smile lines
Minimal wrinkles Early brown 'age spots'
No 'age spots' Skin pores more prominent
Early changes in skin texture

Type 3: 'Wrinkles at Rest'
Patient age: 50s & older
Advanced photoaging
Prominent brown
pigmentation
Visible brown 'age spots'
Prominent, small blood
vessels
Wrinkles, even at rest

Type 4: 'Only Wrinkles'
Patient age: 60s or 70s
Severe photoaging
Yellow-gray skin color
Prior skin cancers
Pre-cancerous skin changes (actinic keratosis)

 Loss of subcutaneous fat.
◦ Loss of volume and fullness/roundness.
◦ Flattened, sunken appearance.
◦ Facial contours and mouth.

 Hyperdynamic wrinkles due to repetitive
facial expression.
◦ Smoking, frowning, squinting etc.
◦ Muscles that insert into skin.
 Frontal, glabellar, periocular, nasolabial, perioral
◦ Initially only wrinkles with movement, later at rest.

 Loss of elasticity due to gravitational
changes.
◦ Facial soft tissues lose resiliency and can no longer
resist stretching forces and movement; no rebound.
◦ Facial soft tissues start to sag as a result of gravity.

 Remodeling of bony and cartilaginous
structures.
◦ Bone resorption results in decrease of facial
volume.
◦ Stretching of cartilage as a result of gravitational
forces results in drooping of facial structures (nasal
tip)
◦ Facial assymmetry may result.

Pharmacology

7 neurotoxins, serotypes A –G
• Antigenically distinct
• Similar molecular weights (~150 kDa)
• Dichain molecule (heavy and light)-
active molecule
• 3 functional domains:
• Binding domain (C terminus of H
chain)
• Translocation domain (N terminus
of H chain)
• Catalytic domain (C terminus of L
chain) Zn metalloprotease

Pharmacology
 Three step process
 Irreversibly binds to presynaptic terminal of motor end
plate
 Internalized into axon by endocytosis
 Cleavage of SNARE (receptor) proteins resulting in
inhibition of neurotransmitter release
 SNARE proteins:
 – N-ethylmaleimide sensitive factor attachment protein
receptor
 – Each serotype binds to a specific residue of one of
the docking proteins
(Botox=SNAP-25, Myobloc=VAMP)

 Solstice Neurosciences
(San Fransisco, CA)
 FDA-Approved
 Type-B
 2500, 5000 & 10,000U
 Less potent (50-150 times
dose of BTX-A)
 More rapid onset (48 hours),
lasts 10-12 weeks
 Larger diffusion
 More stable, shipped in liquid
form, no reconstitution
 May be kept refrigerated at 2-
8°C for 21 months
 May be used when no
response to Type-A
(antibodies to Type-A)

BOTOX® Myobloc

 In the United States, prescription drugs and biologics are
required to undergo rigorous laboratory, animal, and
human clinical testing before they can be put on the
market. The Food and Drug Administration (FDA) reviews
the results of these studies to: verify the identity,
potency, purity, and stability of the "ingredients," and
demonstrate that the drug is safe and effective for its
intended use.

 BOTOX® Cosmetic received FDA approval in 2003 for the
temporary treatment of moderate to severe frown lines
between the brows in people 18 to 65 years of age.
BOTOX® Cosmetic is available by prescription only.

 Currently known as Dysport in
UK (Ipsen, Inc., berkshire)  Puretox (Mentor)
 Type-A
 Marketed by Medicis Esthetics  Linurase (Prollenium)
(US)
 Neuronox (Medy-Tox, South
 300U and 500U vials
Korea)
 Excipient materials include
lactose and albumin  CBTX A (China)
 Recommended reconstitution
500U with 1ml of saline  Clinical Trials:
◦ Topical Botulinum – Type A
 Estimated 2.5 – 3 times dosage
compared with Botox

Dysport (Reloxin)
Other Type-A Toxins
FDA-approved 2009

 GFX Technology-Radiofrequency ablation
(www.acisurgery.com) and Radiage RF
(available).

 Lasers & Light-based systems.

The Brow Lifting
Muscle:

- Lifts eyebrows
- Draws the scalp
down
- Wrinkles two
sides
- Not always
bifurcated
- Fear, surprise
- Superficial
muscle
- Not attached to
skull
- Attention:
Migration
FRONTALIS

The Flaring Nostrils
Muscle:
 Small pyramidal
slip of muscle
(flame shaped)
 Helps to pull
that part of the
skin between the
eyebrows
downwards,
which assists in
flaring the
nostrils.
 Anger
 Produces
transverse
wrinkles or
„bunny lines‟
PROCERUS

The Frown
Muscle:

- Compresses
the skin
between the
eyebrows
- Frown,
concern,
concentration.
- Deep muscle
- Deep injection

CORRUGATOR

The Squinting
Muscle:

- Closes the
eyelids,
compresses
eye opening
- Encircles the
eye
- Close, wink,
tired
- Extends
superior over
eyebrow
- Note: injection
of brow lift

ORBICULARIS OCULI

The Smiling
Muscle:

- Raises the
mouth upward
and outward
- Smiling,
laughing
- Orbicularis
Oculi also
contracts when
smiling
- Note: attention
when injection
below eye; may
cause „bunny
cheeks‟
ZYGOMATICUS MAJOR

The Sneering
Muscle:

- Raises the
upper lip
beneath the
nostrils
- Disgust,
disdain
- Note: injections
administered
too low for
treatment of
„bunny lines‟
can cause
migration from
levator labii
superior into
levator anguli
oris! LEVATOR LABII SUPERIOR

The Facial Shrug
Muscle:

- Pulls the corner
of the mouth
downward
- Sadness,
crying,
miserable
- Also called:
Triangularis
- Injection will
lift corners of
mouth

DEPRESSOR ANGULI ORIS (DAO)

The Lift Mouth
Corner Muscle:

- Lifts the
corners of the
mouth
- Note: injection
into levator
labii superior
(too low if
treating „bunny
lines‟) can
cause
migration into
levator anguli
oris resulting in
drooping
mouth corners!
LEVATOR ANGULI ORIS

The Lower Lip
Curl Muscle:

- Pulls the lower
lip down and
out
- Around the lips
- Surprise
- Note: if
intending to
inject DAO but
wrongfully
inject the
depressor labii
inferior too
medially, cause
inward curl of
lower lip!
DEPRESSOR LABII INFERIOR

The Lip
Tightener
Muscle:

- Compress and
purses the lips
- Circles the
mouth
- Disdain,
repulsion
- Inject to treat
wrinkles
around mouth
and „smoker
lines‟.

ORBICULARIS ORIS

The Clenching
Muscle:

- Used to clench
teeth (and lift
lower jaw)
- Fear, yawn

MASSETER

The Lower Lip
Stretching
Muscle:

- Draws the
lower lip down
and outward
- Neck muscle
- Crying, terrified
- Also called:
Risorius

PLATYSMA

 Sodium chloride and albumin
act as stabilizers.

 Anti-body formation and
subsequent resistance to toxin
linked to total neurotoxin
protein dose.

 Reducing protein dose to 1/5
of original dose decreases risk
of resistance (only 1 reported
case in +5 million injections).

Vial of 100U of botulinum exotoxin A  Resistance seen in neurological
in lyophilized form (un-reconstituted patients frequently
product seen as a small white ring of administered 100-200U.
powder around base of vial) with
0.9mg of sodium chloride and 0.5mg
of albumin.

 BOTOX® is shipped frozen, and must be kept at refrigerator or
freezer temperatures; traditionally a frozen temperature of -5°C
is recommended prior to use (no evidence). Lower temperatures
reduce potency.

 Manufacturer recommends using BOTOX® within 4 hours of
reconstitution :
◦ Mandated by FDA for any product reconstituted with preservative-free saline
◦ For sterility issues, not a loss in efficacy!

 Potency controversy:
◦ Originally thought to degrade sharply:
 Gartland & Hoffman noted significant loss of toxicity within 12 hours of reconstitution.
 Lowe noted a 50% reduction in potency after 1 week.

◦ Other studies show effects up to 30 days:
 Garcia & Fulton reported continued potency 4 weeks after reconstitution.
 Hexsel found no statistical difference in efficacy or duration of action between
bottles of Botox reconstituted at the time of injection, 2 weeks, 4 weeks, and even
6 weeks prior to injection (recent controlled study with 88 patients).

 Storage:
◦ Keep refrigerated after use (4 hours – 30 days)

 Strong vacuum in vial.

 Use 1.0 or 2.5 cc sterile saline per 100 u vial (4U/0.1ml).

 Greater dilution results in greater diffusion.

 Use (preservative free) saline (NaCl 0.9%).

 Introduce saline VERY slowly into BOTOX® vial.

 Do not shake vial! Make every effort to avoid foaming
(foaming will denature protein).

Diluent added Resulting dose
(0.9% Saline, (Units per 0.1 ml)
sterile, non-preserved)

1.0 mL* 10.0 U*

2.0 mL 5.0 U

2.5 mL * 4.0 U*

4.0 mL 2.5 U

8.0 mL 1.25 U

Consensus Recommendations

 The manufacturing process is slightly different, which leads to
some potential, subtle differences in clinical practice.

 Some people feel that Dysport® may provide a slightly faster
onset of action (24 hours versus 72 hours for Botox®).

 It is important to know that the unit size of Dysport® is
smaller than the unit size of Botox®.

 According to the FDA, it takes a minimum of two times more
units of Dysport® to get the same effect as Botox®. So, if the
patient has opted for Botox® and received 20 units, the same
patient will need 40 units of Dysport® for an equivalent
treatment. (Cost for Botox® @ $9.99 per unit vs. Dysport® @
$3.99 per unit). However among physicians, it has been
debated, yet somewhat accepted, that 1 unit of Botox is
“similar” to 2.5 or 3 units of Dysport.

 Dysport® has been shown to “drift” or diffuse more than
Botox®, increasing the chances of an accidental droopy eyelid
or unintentional relaxation of a neighboring muscle due to
diffusion of the product.

Vial Size Concentration Dilution

300 U 1.5 cc 10U/0.05cc

300 U 2.5 cc 10U/0.08cc

500 U 5.0 cc 10U/0.1cc

 Digital camera.
 Soft eyeliner pencil (only if marking).
 Botox-vial & preserved saline (0.9% NaCL).
 Bottle opener (remove rubber stopper of vial).
 30 gauge ½ inch needle (for drawing larger
gauge).
 For skin preparation & sterility: alcohol
(wipes), gloves, cotton balls, 4x4 sterile
gauze.

 Ice (pack) pre/post tx.

 Syringes:
◦ 1ml syringes.

 Needles:
◦ 30 gauge ½ inch needles to administer.
◦ 21-25 gauge (1/2 – 1 inch) for mixing and drawing up
solution.

Muscles are in a dynamic
balance.

Treatment should affect specific
muscles while sparing the
surrounding muscles.

The more muscles or muscle
groups involved in causing a
furrow or wrinkle or when
muscles have attachments (i.e.
nasolabial furrows); the more
difficult to paralyze only selected
portions of the muscles.

 Have an infection where BOTOX® Cosmetic will be
injected (eyelids).
 Are allergic to any of the ingredients in BOTOX®
Cosmetic (eg. Albumin/egg allergy).
 Serious preexisting disease : DM1 or DM2 (not
controlled), CHF, uncompensated CAD, RA/SLE etc.
 Blood donors (can‟t donate after BOTOX® for a
period of time determined by the blood bank).
 Underage clients (need parental consent).

 Any diseases that affect your nerves and cause a
generalized impairment of muscle strength (i.e.
myasthenia gravis, Eaton-Lambert syndrome).
These diseases may increase your chance of side
effects with BOTOX® Cosmetic treatment.

 Pregnant or planning to become pregnant soon.

 Breastfeeding.

 Antibiotics used to treat infections, such as gentamicin,
tobramycin, clindamycin, and lincomycin.
 Treatment with A.S.A. or other non-steroidal anti-
inflammatory drugs 1 week prior to Tx (patient more
likely to bruise or bleed).
 Medicines used to treat heart rhythm problems, such as
quinidine; and anti-coagulants (coumadine).
 Medicines used to treat different conditions, such as
myasthenia gravis or Alzheimer‟s disease.
 Any over-the-counter medicines or herbal products.

This is not a complete list of medicines that can interact
with BOTOX® Cosmetic. Review the Professional Package
Insert for complete information.

 Glabellar frown lines
 Horizontal forehead lines
 Crow‟s feet

 Note: age-related loss of dermal elasticity
versus hyperactivity of facial muscles

 Assessment:
◦ Identify hyperkinetic lines by asking patient to
make facial expressions (maximal smiling and
frowning).
◦ The novice can use a soft eyeliner pencil to mark
hyperkinetic lines.
 Treatment:
◦ Reconstitute vial of BTX if indicated.
◦ Desired dose of BTX is drawn into the syringe.
◦ Follow standard procedures to ensure sterility and
skin preparation.
◦ No anesthesia necessary; ice post-tx.

 If alcohol is used, make sure injection site is
completely dry prior to injection (alcohol can
interfere with toxin).
 Injection is site-specific (in mass of facial
muscle, not necessary the hyperkinetic line)
and IM (some exceptions apply to reduce
bruising).
 Multiple injections may be necessary (less
diffusion in corrugator and orbicularis oculi
than in frontalis).

 Injection techniques:
◦ Have client make facial expression (frown, squint,
smile etc.) and inject during facial expression; or
◦ Have client make facial expression, let client relax
and inject; or
◦ Have client make facial expression, mark the
muscle mass (eyeliner or paper reinforcement
stickers), let client relax and inject; or
◦ Palpate muscle mass and inject.
◦ Inject into muscle mass (belly), if not sure go deep
to the periosteum and slightly retract needle (pain).
 Frontalis: superfical injections (frontalis not attached
to skull).
 Crow‟s feet: superficial injections (avoid bruising).

To identify proper dosage and injection site, one needs to consider:

Type of brow arch, brow asymmetry, whether the brow is drooping or
extends above the orbital rim, and the size of the muscle (muscle
mass in men is usually greater than in women)

 Common doses to treat glabellar frown lines
is 40-60 units for males and 20-40 units for
females.
 If more units are indicated, one can reduce
the total volume by reducing the amount of
saline used to reconstitute the BTX.
 Patient seated position.
 Regardless the brow position, the injections
are always above or outside of the supra-
orbital ridge.

PROCERUS

ORIGIN
Nasal bone and cartilages

INSERTION
Skin of medial forehead

ACTION
Wrinkles and 'frowns' forehead

NERVE
Temporal branch of facial nerve
(VII)

 2-6 units
 In midline
 Injection site;
◦ Below the line
connecting the brows
◦ Above the crossing
point of the „X‟
formed by lines
connection medial
brow with opposite
inner canthus.

CORRUGATOR SUPERCILII

ORIGIN
Medial superciliary arch

INSERTION
Skin of medial forehead

ACTION
Wrinkles forehead

NERVE
Temporal branch of facial nerve
(VII)

 4-6 units/injection
 Other frown injections are
lateral to supratrochlear
vessels.
 2 bilateral injections just
superior brow and directly
above inner canthus
(corrugator)
 2 more bilateral injections
superiorly and at least 1
cm laterally to previous
injection (orbicularis oculi)

 If patient has
horizontal brows,
inject additional
2-6 units into the
point 1 cm above
the supra-orbital
ridge in line with
the middle of the
pupil.

 Post-injection instructions:
 Remain vertical for 3-4 hours.

 Do not scratch, press or manipulate injected area.

 Frown every minute for a minimum of 2 hours.

 Follow-up appointment scheduled in 2 weeks:
 Touch-up injections if indicated.

 Post-treatment photograph.

 Deep furrows:
 Multiple treatments or in combination with fillers.

FRONTALIS

ORIGIN
Occipital : highest nuchal line and
mastoid process. Frontal: superior
fibers of upper facial muscles

INSERTION
Galeal aponeurosis

ACTION
Wrinkles forehead and fixes galeal
aponeurosis

NERVE
Posterior auricular and temporal
branches of facial (VII)

 20 – 40 units.
 Injections must be well above the brow to
avoid ptosis as well as loss of expression.

 Injections into frontalis, but also into the
depressors (procerus and lateral ocicularis
oculi) to avoid lowering of the brow (angry
expression).

 Avoid lateral forehead - “Bermuda Triangle”.
 No muscle, just nerves. Paralyzing this area
can cause ptosis of the eyebrows.
 From anterior ear to temporal ridge.

“Spa Brow” (raising lateral brow)

 Commonly seen as a result of treating the
glabella and/or forehead lines:
◦ Injections are only administered to the frontal plane
of the forehead, therefore paralyzing the frontal
part of the frontalis muscle.
◦ The lateral part is not injected (“bermuda triangle”)
and the increase in tone results in a lateral brow
lift.
 Eyebrow position and shape:
◦ Can be influenced by the dosage injected in the
frontalis muscle. Moving the treatment area more
medially or laterally can effect eyebrow shape.
◦ Treatment of eyebrow asymmetry is possible.

ORBICULARIS OCULI

ORIGIN
Medial orbital margin and lacrimal
sac (orbital, palpebral and lacrimal
parts)

INSERTION
Lateral palpebral raphe

ACTION
Closes eyelids, aids passage and
drainage of tears

NERVE
Temporal and zygomatic branches
of facial nerve (VII)

“Ideal” male eye brow,
“Ideal” female eye brow, with a
positioned at the supra-orbital
gentle gull-wing shape.
rim with an almost horizontal
shape.

 Inject 2 units into
Orbicularis Oculi
just above lateral
tip of the eyebrow.

 Note: Orbicularis
Oculi extends
superior over the
eyebrow, and
depresses eyebrow.

Courtesy of Allure Medica
Courtesy of Mark Berkowitz

 2-3 injections into the lateral Orbicularis Oculi
muscle, lateral to the lateral orbital rim.
 Equal doses of 2-6 units/injection site (or a total of
6-18 units/eye) are administered.
 Few and superficial injections recommended to
prevent bruising.
 Have the client smile maximally and identify the
center of the crow‟s feet; this is your 1st injection
site (approximately 1-2cm lateral to the lateral
orbital rim).

 Never inject the crow‟s feet while client is smiling!
This may affect the zygomaticus major/minor
muscles and result in ptosis of the upper lip.
 The 2nd & 3rd injection are approximately 1-1.5cm
above and below the 1st injection site.

Attention: Due to the baggy, loose skin under the eyes, BTX may migrate
into unwanted area’s and cause drooping op the mouth (by affecting the
levator labii superior and consequently the levator anguli oris).

 Hypertrophic orbicularis.
 Activity of pretarsal
orbicularis oculi (blink
reflex) while smiling tends
to decrease palpebral
aperture.
 Hypertrophy of the muscle
may result in a „jelly roll‟
appearance of the lower
eyelid.
 2U of BTX (lower pretarsal
orbicularis) opens aperture.

 Located on nasal ala
due to over-activity of
procerus.

 Inject 1-2 units on
both sides of the
„bunny‟ lines.

 Note: do not inject too
low! Migration into
levator labii superior
may occur.

 The eyelid muscles around
the eye close involuntarily.
This may cause loss of
vision, especially while
reading, headaches, and
eyebrow strain.

 The early symptoms of
blepharospasm include
increased blink rate (77%),
eyelid spasms (66%), eye
Copyright © 1997-2008 EyePlastics.com
irritation (55%), midfacial or
lower facial spasm (59%),
brow spasm (24%), and
eyelid tic (22%) .

 Medical Therapy:
◦ Anticholinergics have been the most common and
effective drugs with GABA-ergic drugs as the
second most effective group.
 Anderson procedure (1970's): Dr. Rick Anderson
described a procedure called "full myectomy" in
which the surgeon meticulously excises virtually all
of the orbicularis muscle as well as the corrugator
superciliaris and procerus muscles.
 BTX-A approved in 1989 by the FDA and replaced a
full myectomy procedure as the treatment of
choice.

BTX-A:

◦ Long-term follow-up studies have shown it to be a
very safe and effective treatment, with up to 90
percent of patients obtaining almost complete relief
of their blepharopspam.
◦ Side effects include ptosis, blurred vision, and
double vision (diplopia). Lagophthalmos, ectropion,
sagging of the mouth, brow droop, epiphora.
◦ The sites of the injection will vary slightly from
patient to patient and according to physician
preference.
◦ The injection is usually given on the eyelid, the
brow, and the muscles under the lower lid.

 BTX-A safety well established:
◦ Extremely safe
◦ NO long-term side-effects or health hazards

 Adverse reactions are mild & temporary:
◦ Local bruising, erythema and swelling, mild
headache, flu-like symptoms
 Poor injection technique
 Poor patient selection
 Neglect of post-treatment instructions

 Lowering of eye brow results in an extremely
negative appearance (looking angry) that may
persist up to 3 months.

 Poor client selection.
 Poor injection technique
into glabellar region,
forehead or brow with too
much toxin affecting the
frontalis.
 Lower concentration
migrate easier; radius of
denervation at each point
of injection is 2-3cm
(toxin spreads 1-1.5cm in each
direction).

 Plenty experience/practice.
 Importance of post-treatment instructions.
 Use higher concentrations (dilute with 1.0ml saline).
 Appropriate client selection: avoid injecting frontalis
in clients with significant brow ptosis!
 Pre-injection of brow depressors if indicated (clients
with low-set brows/mild ptosis and older clients).
 Inject frontalis above lowest fold when client elevates
frontalis or 3 cm above brow.
 Inject glabella and forehead in multiple sessions.

 Post-treatment instructions + Lean head back.

 No effective treatment!

 Evident 48 hours – 14 days post-injection.
 May last 2 – 12 weeks.
 Causes:
◦ Poor technique: toxin diffuses through orbital
septum and effects elevators of eyelid; usually with
treatment of glabellar complex.
 Prevention:
◦ Accurate technique: injections no closer than 1 cm
above the central bony orbital rim; no injections at
or under the mid-brow!
◦ Post-treatment instructions.

 Apraclonidine 0.5%.

 1-2 drops, 3x/day
until ptosis resolves.

 Lifts eyelid 1-2mm.

 Apraclonidine (Iopidine 0.5%):
◦ Alpha-adenergic agonist ophthalmic eye drops.
◦ Stimulate Müller‟s muscle.
 Compensates for weakness of levator palpebrae superioris.
 This is a short muscle controlled by the sympathetic nerves of
the body. It generally is contracted while you are awake so that
it lifts the eyelid. When tired or asleep, it is relaxed letting the
eyelid sag and droop. The eyelids can now close with minimal
orbicularis tone.
◦ Disguises eyelid ptosis.
◦ Allergic contact conjunctivitis may occur with
long-term use.

 Lateral fibers of frontalis pull
lateral eyebrow upward.
 Quizzical or cockeyed
appearance.

 Cause:
 Inappropriate injection of medial fibers of
frontalis muscle.

 Prevention:
◦ Keep glabellar treatments more medial with future
treatments so the increased tone in frontalis causes
a smooth arch to the brow.

 Treatment:
◦ 2-3 units of BTX into the fibers of lateral forehead.
◦ Caution: overcompensation may result in an
irreversible and unsightly hooded brow that
partially covers the eye!

 Bruising
 Diplopia
 Ectropion
 Drooping lower
eyelid
 Lagophthalmos

 2-4 weeks

 Inject superficially (blebs); not IM.
 Inject 1cm outside bony orbit, or 1.5 cm
lateral to lateral canthus.
 Do not inject close to inferior margin of
zygoma.
 Use ice pre-and post-treatment.
 Use pressure post treatment.
 Use arnica or traumeel post-treatment.

More challenging:

 Muscles serve
important
functions
(oration,
expression,
mastication).
 Muscles work
synergistically.
 Not for novice!

 Hypertrophic orbicularis oris; intensified by
age, sun expore and smoking (using straw).
 BTX is good treatment for mild wrinkles; for
moderate wrinkles use bTX in combination
with fillers, chemical peels and/or laser
resurfacing.
 BTX by itself can cause lip eversion resulting
in more upper lip fullness.

ORBICULARIS ORIS

ORIGIN
Near midline on anterior surface of
maxilla and mandible and modiolus
at angle of mouth

INSERTION
Mucous membrane of margin of lips
and raphe with buccinator at
modiolus

ACTION
Narrows orifice of mouth, purses lips
and puckers lip edges

NERVE
Accessory parts are incisivus labii
superioris and inferioris

 Conservatively: 1-2 U
superficially at 4 evenly
spaced sites along the
vermillion border (to
assure symmetry).
 If lower lip wrinkles,
inject 1-2 U evenly in
lower vermillion border
(1cm medial to oral
commissure).  Patient return in 2 weeks for
supplemental injections (outer
orbicularis, higher dose).
 Results don‟t last as long.

 Difficulty with swishing and spitting,
puckering, sipping from a straw, whistling,
kissing, and pronouncing letters „p‟ and „b‟.
 Sphincter dysfunction = dose-specific!
 Treat conservatively, assess response and
inject more only if indicated!
 Asymmetry: plan carefully and inject evenly.

Treatment of the „gummy smile‟

 Upper lip retracted abnormally high due to
contraction of levator labii superioris results
in „gummy smile‟(exposure of bases of upper
teeth and gum line).

 Treat conservatively (highly functional area!).

LEVATOR LABII SUPERIORIS

ORIGIN
Medial infra-orbital margin

INSERTION
Skin and muscle of upper lip

ACTION
Elevates and everts upper lip

NERVE
Buccal branch of facial nerve (VII)

 1 U into levator at
nasofacial complex,
just inferior to
nasomaxillary
groove.
 1 injection just
above periosteum.
 2-3 week follow-up;
increase gradually up
to 5 U if indicated.
 Note: treatment of
depressor labii
inferioris may be
indicated.

 Caution:

◦ Client who already exhibits drooped mouth corners!
◦ Asymmetry.
◦ Too high dose may cause:
 Upper lip ptosis (takes longer to dissolve: 6 weeks).
 Excessive lengthening.
 Lower lip protrusion.

 BTX indicated for mild to moderate
nasolabial fold accentuation.

 Controversy:
◦ Treatment of levator labii superioris.
 Refer to lip lengthening for technique!
 Note: this treatment will also lengthen lips!
◦ Treatment of zygomaticus major/minor (caution:
disfigured smile).

 Other treatment options: dermal fillers,
implants, mid-face lift.

 Vertical „drool‟ grooves starting at mouth corners
(may cause angry or frustrated look).
 Treatment of DAO (depressor anguli oris) allows
zygomaticus muscles to elevate mouth corners.
 BTX combined with fillers for better results.

DEPRESSOR ANGULI ORIS

ORIGIN
Outer surface of mandible
posterior to oblique line

INSERTION
Modiolus at angle of mouth

ACTION
Depresses and draws angle of
mouth laterally

NERVE
Mandibular branch of facial nerve
(VII)

 Into mid & lower 1/3 of muscle (intertwined
with fibers of platysma).
 1-2 U bilaterally:
◦ lateral to oral commissure (diffusion into depressor
labii inferior may cause lower lip protrusion).
◦ Medial to buccinator (diffusion into buccinator may
predispose client to biting and cause trauma to
buccal mucosa).
 Optimal results in combination with fillers;
BTX will only slightly lift the mouth corners.

“peach pit” chin or “apple dumpling” deformity

MENTALIS

ORIGIN
Incisive fossa on anterior aspect
of mandible
INSERTION
Skin of chin

ACTION
Elevates and wrinkles skin of
chin and protrudes lower lip

NERVE
Mandibular branch of facial
nerve (VII)

 Hyperactive mentalis muscle:
 Expression, habit contraction.
 Excessive innervation.
 Inject 2-6 U at mental
protuberance (to avoid lip
problems and also affecting
orbicularis oris).
 Clefted chin: treat each muscle
belly and inject 2-6 U
bilaterally.
 Caution: paresis of depressor
labii inferior & orbicularis
oris may affect speech and
sphincter function!

DEPRESSOR LABII INFERIORIS

ORIGIN
Outer surface of mandible along
oblique line

INSERTION
Skin of lower lip

ACTION
Depresses and draws lower lip
laterally

NERVE
Mandibular branch of facial
nerve (VII)

Asymmetrical smile:

 Lower lip position varies from one side to the
other due to imbalance of depressor labii
inferior:
◦ Hyperactivity: lower lip depression on affected side.
◦ Hypoactivity: lower lip elevation on affected side.
 1-3 U into overactive depressor labii inferior.
◦ Use minimum dose to correct asymmetry.
◦ Too much may cause excessive weakening and
therefore elevate the lower lip (overcorrection).
 Caution: close proximity to DAO, orbicularis
oris and mentalis!

Platysmal bands & horizontal „necklace‟ lines

PLATYSMA

ORIGIN
Skin over lower neck and upper lateral
chest

INSERTION
Inferior border of mandible and skin
over lower face and angle of mouth

ACTION
Depresses and wrinkles skin of lower
face and mouth. Aids forced depression
of mandible

NERVE
Cervical branch of facial nerve (VII)

Comprehensive Overview & Practical Applications of Botulinum Toxin

Comprehensive Overview & Practical Applications of Botulinum Toxin

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