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Botox Presentation 25 Oct 2008 colour slides

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Botox Presentation 25 Oct 2008 colour slides Powered By Docstoc
					Introduction to the cosmetic
   uses of botulinum toxin

   Dr Ashley Hague MBBS MA (Cantab.)
            October 25th 2008
Agenda Outline
•   Starting off with BOTOX®
•   Neurotoxin Pharmacology
•   Dilution & Storage
•   Contraindications
•   Technique Tips
•   Patient Selection and Treatment Options
•   Cosmetic Enhancement of the Upper Face
     -   Glabellar Frown Lines
     -   Crows Feet
     -   Forehead Lines
•   Dealing with complications of treatment
•   Advanced techniques and combination treatment
•   Strategies for success
•   Workshop demonstrations

                                                    Agenda
    Disclaimer
The material presented in this course represents the clinical experience of
the BOTOX® trainers’ faculty, as well as current information obtained from
 the medical literature and includes discussions of un-licensed indications.
   Certification of this course is on an attendance basis only and is not
                  necessarily a statement of competency.
  The course tutor does not take any responsibility for your technique or
        subsequent actions as a result of attending this course.
The use of the course tutor’s name as proof of suitability of yourselves as
                        an injector is not allowed.




                                                        Disclaimer
            Why learn about Botox®?
  Botox® is now the most common aesthetic procedure performed in the US
                    50-fold increase from 1997 to 2005
                       Nearly 500,000 in UK in 2007


3,500,000

3,000,000

2,500,000                                             B t ®
                                                      Botox
2,000,000                                             Laser Hair Removal
1,500,000                                             Dermal Fillers
1,000,000                                             Microdermabrasion
 500,000                                              Chemical Peels
       0

                                                          Statistics
          y p
 It is very important
                      ®
to learn that BOTOX
       is both an
     t d
  art and a science
                i
   before you start


              Art and Science combined
                         ®
  Starting BOTOX
How can you introduce it into

       y    practice?
       your p




                         Starting BOTOX®
Starting BOTOX®
                            ®
Getting started with BOTOX can b
G tti    t t d ith             be
            p
the hardest part…

e.g. collecting patients,
     advertising,
      q p
     equipment, ,
     insurance…



                            Starting BOTOX®
Before offering BOTOX® to patients

• Attend a training course
• Watch a training video
              g
• Review Allergan / other literature
• Develop a consent form
• Practise on partner, family, close
  friends


                             Starting BOTOX®
 Neurotoxin
Pharmacology
 Botulinum neurotoxin development
•1944 - toxin isolated from C. botulinum

                 y
•1950s - discovery of NMJ blockade

              y p
•1970s - monkey experiments

•1980 - first use of BTX-A in humans

             pp                       p p
•1989 - FDA approval for non-cosmetic purposes

             pp          g
•2002 – FDA approval for glabellar lines
                     Neurotoxin Pharmacology
Botulinum Neurotoxin Serotypes
                                          COOH        NH2
•   Seven serotypes
     - A, B, C1, D, E, F, G                     S-S
•   Intracellular target varies
    I t    ll l t      t    i     Light
     - SNAP-25                    Chain                     Heavy
                                                            Chain
     - Synaptobrevin
     - Syntaxin
                                          NH2     S
•   Only intact molecule works                    S
•   Does not penetrate the skin
•        p      pp
    No topical application
                                                       COOH



                              Neurotoxin Pharmacology
       BOTOX® - Mode of Action




   1. Before BOTOX®            2. Binding        3. Internalisation
E d l t sits upon muscle
Endplate it           l    Neurotoxin binds to        N     t i
                                                      Neurotoxin
          fibre              nerve terminal        internalised via
                                                 receptor-mediated
                                                     endocytosis.



                                Neurotoxin Pharmacology
     BOTOX ® - Mode of Action




      4. Blocking                5. Sprouting and re-
                               establishment of sprouts
Light chain blocks fusion
   of neurotransmitter       Endplate expands and collateral
   vesicle with nerve        axonal sprouts emerge. Sprouts
 membrane by cleaving          subsequently retract and are
        SNAP-25.             eliminated; parent terminal is re-
                                       established.
                            Neurotoxin Pharmacology
Warning: Botulinum Toxin Products
    Are NOT Interchangeable

• Botox®/Vistabel® (Allergan)
                   (     g )
   - 100 units per vial           Simple Dose
• Dysport (Ipsen)                  Ratios Are
   - 500 units per vial          Inappropriate
                                 I         i t




         1 unit Botox® ≠ 1 unit Dysport®

                          Neurotoxin Pharmacology
Warning: Botulinum Toxin Products
    Are NOT Interchangeable
• Product dosing and performances differ


• Safety margins and side effects differ


  Neurotoxin protein exposures differ
• N    t i      t i            diff
   - Botox® : 4.8ng per vial
   - Dysport :12.4ng per vial


                           Neurotoxin Pharmacology
               Botox®
    Current UK Botox® Approvals
 Gl b ll li
•Glabellar lines
 Blepharospasm
•Blepharospasm
•Cervical Dystonia
•Cerebral Palsy
 H if i l
•Hemifacial spasm
•Focal Spasticity Associated with Stroke
        p       y
•Hyperhidrosis of the Axillae
                     Neurotoxin Pharmacology
 Other Cli i l C diti       T t d ith
 Oth Clinical Conditions Treated with
                  (off-
           BOTOX® (off-license)
•Migraine
•Tension Type Head-Ache
 Back
•Back Ache
•Achalasia
•Hypersalivation
•Myofascial Pain Syndrome
 Anal
•Anal Fissure
                   Neurotoxin Pharmacology
Dilution &
 Storage
Dilution of Vial

• Volumes of 1 to 10 ml have been used with varying
      lt
  results

  Consensus of experts is 2.0 ml dilution, although
• C           f
  some use 1 ml with accurate injection technique

• Unpreserved 0.9% saline recommended on
  p    g g
  packaging

• Bacteriostatic/Preserved saline 0.9% often used


                                 Dilution & Storage
 BOTOX® Dilution Chart
    Diluent Added        Resulting Dose
(0.9% Sodium Chloride   (units per 0.1 mL)
       Injection)

      1.0 ml                10.0 U

      2 0 ml
      2.0                    5.0
                             50U

      2.5 ml                 4.0 U

      3.0 ml                 3.3 U

      4.0 ml                 2.5 U


                            Dilution & Storage
Reconstitution

•   Flip ff lid i         bb        ith    dl    d li t f ‘hi ’
    Fli off lid, pierce rubber cap with needle and listen for ‘hiss’

•                      25
    Use 21G needle and 2.5 ml syringe


•             45                          20      0.9%
    Insert at 45° angle and slowly inject 2.0 mls 0 9%
    bacteriostatic saline into BOTOX® vial


•   100 units in 2.0 mls saline = 5 units in 0.1 ml

•   Record reconstitution date, expiry date and batch number


                                           Dilution & Storage
Factors Which May Affect Potency

• Storage time and temperature of diluted toxin


• Agitation of the bottle or syringe


• Bubbles




                                  Dilution & Storage
Storage
• Unreconstituted:     store in a fridge at 2 – 8 °C
                       or in a freezer at – 5 °C or below


• Reconstituted:       Allergan approved storage time is
                       4 hours


• Current clinical practice regarding reconstituted storage time
 varies
• Group patients together in early phases of business to
 prevent wastage


                                         Dilution & Storage
Storage

• DO NOT FREEZE BOTOX® ONCE RECONSTITUTED
   - Ice crystals may form which damage the toxin
     and reduce potency
                                      C
• Store in the refrigerator at 2 – 8 °C
• Any residual Botox® should be inactivated with
                        (0 5%)
  hypochlorite solution (0.5%)
• Used vials should be autoclaved



                                   Dilution & Storage
Contraindications
      andd
    cautions
 Contraindications
• Patients with infection at proposed injection site

• Patients with known hypersensitivity to any ingredient in
  BOTOX®

• Administration of BOTOX® is not recommended during
  pregnancy or lactation

• Generalised disorders of muscle activity (e.g. myasthenia gravis)

  Co-administration
• Co administration with aminoglycosides or other agents interfering
  with neuromuscular transmission

• Bleeding disorders or anticoagulant therapy



                           Contraindications & cautions
Cautions

• History of Bell’s Palsy

• Dysmorphophobia

• Clopidogrel, aspirin and other NSAIDs

  Vitamin E i k bil b      d St J h W t
• Vit i E, ginkgo biloba and St. Johns Wort




                    Contraindications & cautions
  Some general
technique tips for:
• optimal treatment success
• satisfied, repeat patients
General Injection Technique Tips

• Patient should be seated or slightly reclining to best
  observe facial expressions


• Try to make the treatment as pleasant as possible


• An experienced patient copes better with more than 2
  areas injected in one session - new patients may not




                                         Technique Tips
General Injection Technique Tips

•   Try to change insulin syringe after every 4 - 5 injections.


•   Gloves should be worn at all times, non-latex is recommended
    due to the potential for patient reaction.


•   Mark injection sites prior to injection – remember to use a non
    tattooing pen!


•   Record technique thoroughly on a patient worksheet so you can
    duplicate successful treatment and modify over- or under
    treatment.


                                                Technique Tips
General Injection Technique Tips

• Never advise to discontinue aspirin/clopidogrel


• Stop other NSAIDs, vitamin E etc. 7 – 10 days prior
                             g
  to decrease risk of bruising


                          non-injecting
• Hold a gauze pad in the non injecting hand so you
  can apply gentle pressure to any site that bleeds
  to minimise chances of bruising


                                     Technique Tips
Preparing to Inject
•   Wipe i j ti   it    ith l h l/ l      i
    Wi injection sites with alcohol/cleansing wipe & allow to dry
                                               i      ll   t d


•                           comfort
    If required for patient comfort, chill the injection sites first


•   EMLA will relieve sensation of injection into skin but is messy


•                  p              g        j     g
    EMLA cannot stop the mild sting from injecting fluid into the
    muscle




                                                  Technique Tips
Preparing to Inject
   a e photo a o ed
• Take a p oto if allowed


  Have th patient pull faces and contract muscles
• H    the ti t ll f           d    t t       l


• Mark (when learning) or plan the injection sites


• Inject selected dose with 30 gauge needle


• Inject with patient’s muscle relaxed for comfort
                                     Technique Tips
Patient selection and
 treatment options
           Glogau wrinkle scale

 Type I                                       Type
                                               II




Type III                                      Type
                                               IV


             Patient Selection and Treatment Options
Treatment options
Type I (No lines)
    - Topical therapy


Type II (Dynamic lines)
    - BOTOX® plus topicals


Type III (Static lines and folds)
              l fill          l l
    - BOTOX® plus fillers, peels, laser


Type IV (Nothing but lines and folds)
    - BOTOX® and then laser resurfacing or deep phenol/TCA
      peel. Consider surgery.
  Patient Selection and Treatment Options
Cosmetic Indications
• Glabellar Frown Lines
  Crow s
• Crow’s Feet
• Forehead Lines
             Facial Anatomy

BOTOX® is an intramuscular injection.



Thorough knowledge of the complex facial
musculature is essential for success.


Spend some time reviewing facial anatomy



                           Cosmetic Indications
Target Muscles for BOTOX® Treatment




                          Depressor Supercilii m.

                          Orbicularis oculi




                    Cosmetic Indications
            Actions of Facial Muscles
Muscle                 Action                   Expression Lines

Frontalis              Brow elevator            Horizontal forehead
                                                lines

Corrugators            Pull eyebrows medially   Frown lines

Procerus &             Brow depressors          Frown lines &
Depressor supercilli                            Horizontal nasal lines

Orbicularis oculi      Brow depressors -        Crows Feet
                       especially laterally
                         p      y         y




                                         Cosmetic Indications
Factors Influencing BOTOX® Dosing

• Sex
          y
• Ethnicity
• Skin Type
• Muscle mass
• Extent of wrinkles
• Previous response to BOTOX® treatment




                                 Technique Tips
 Glabellar
Frown Lines
Target Muscles for Frown Lines

                          Procerus



                           Corrugators




                 Cosmetic Indications
   Glabellar lines: Injection sites




Normal Dose = 5units/site Dose Range can be 20 - 80 units

     Cosmetic Indications - Glabellar Frown Lines
    Glabellar lines: Injection technique

Non-dominant thumb protects
orbital rim

Non-dominant hand rests
securely on patient’s face

Injecting hand rests on non-
dominant hand for accuracy
and security

Syringe rests on non-dominant
thumb


              Cosmetic Indications - Glabellar Frown Lines
Glabellar lines: how not to inject!


Injecting down
towards the eye

2.5 ml syringe

No gloves or
gauze!




        Cosmetic Indications - Glabellar Frown Lines
            Glabellar lines
Post injection:
Post-injection: you can advise patient to frown
       as much as possible for 1   hour




     Cosmetic Indications - Glabellar Frown Lines
         Glabellar lines
         Female 32 years old




Before
B f                             f
                               After




Cosmetic Indications - Glabellar Frown Lines
         Glabellar lines
          Male 42 years old




Before
B f                            f
                              After




Cosmetic Indications - Glabellar Frown Lines
Glabellar lines: follow Up
• Patients to return in 2 weeks to:
   - assess results/technique
   - photograph patient
   - touch up (if necessary)


• Re-injection schedule
   - Patient dependent
   - 3 - 4 month intervals for first year
     Less frequent after repeated treatments
   - L    f         f           d



         Cosmetic Indications - Glabellar Frown Lines
                   y              g                          y
                 Physician’s Rating of Glabellar Line Severity at REST
                    Responder Rates Over 3 BOTOX® Treatments


                               1st BOTOX® Treatment                 2nd BOTOX® Treatment        3rd BOTOX® Treatment
               100
                90                                                  *                           *    *      *
         ers




                80                                                                                                *
   esponde




                70
                60
                50
% Re




                40
                30
                20
                10      0      30      60      90    120/0     30       60   90   120/0    30   60    90    120
                       Arrow indicates BTX-A injection
                                                                                    ay
                                                                             Study Day
               *Significantly greater than same time point after
               one or both previous treatments
          Most common treatment related adverse events following
                 BOTOX®
           each BOTOX® treatment


                                 1st BOTOX® Treatment           2nd BOTOX® Treatment     3rd BOTOX® Treatment
  Adverse Event
                                        (n=501)                        (n=362)                  (n=258)


  All events                               23.0%                           6.1%                 3.5%


  Headache                                  9.8%                           2.2%                 0.8%


  Blepharoptosis                            3.0%                           2.2%                 0.8%




    Carruthers A, Lowe N, Gibson J, et al. For the BOTOX® Glabellar Lines Study Group.

(Incidence ≥2% in any treatment cycle)

                           Cosmetic Indications - Glabellar Frown Lines
Crow s
Crow’s Feet
       Target Muscles for Crow’s Feet

Orbicularis oculi




                    Cosmetic Indications - Crow’s Feet
                Crow’s Feet

• Examine individual variation by getting patients to
  smile & squint fully


             y
• Look closely for blood vessels and avoid


      orbic laris oculi      superficial muscle
• The orbicularis oc li is a s perficial m scle –
  there is no need to inject deeply




                 Cosmetic Indications - Crow’s Feet
Intradermal injections




             Intradermal injections
                  Crow’s Feet

• Patient at full smile


• Note upper and lower
  b d      f th      ’
  borders of the crow’s
  feet




                  Cosmetic Indications - Crow’s Feet
                 Crow’s Feet
• Inject 1cm outside the
    bit l i
  orbital rim
• 3 injection sites 1cm apart
• Inject 2 - 5 units of BOTOX®
                                          x x
  per injection site
• 12 units total per side
• May inject around to the
  mid pupillary line
                                   REQUIRED
• Extreme caution under eye      x OPTIONAL- IF PATIENT HAS LINES
• Stay above zygoma

                 Cosmetic Indications - Crow’s Feet
         Crow’s Feet
         Female 39 years old




Before                         After




          Cosmetic Indications - Crow’s Feet
         Crow’s Feet
         Female 40 years old




Before                         After




          Cosmetic Indications - Crow’s Feet
  Horizontal
Forehead Lines
    Anatomy - Frontalis Muscle
   g        p
Origin: occipitofrontalis
Insertion: skin of eyebrows and root of nose
Action: elevate brows, draw scalp posteriorly


Frontalis muscle




   Cosmetic Indications - Horizontal Forehead Lines
Horizontal Forehead Lines


• Very careful evaluation required
• Leave some facial expression
• Males have more muscle mass than many females
• Look for pre-existing brow ptosis which the patient
may be elevating their frontalis to compensate for
• Look for any brow asymmetry




    Cosmetic Indications - Horizontal Forehead Lines
         Horizontal Forehead Lines
•   Approach should be conservative
     - 14 20 Units BOTOX® in 4-10 divided doses
       14-20                 4 10

•   In the lateral to mid-pupillary line, stay 1 finger width
    above the supra-orbital rim
                                                        Avoid ptosis by
                                                              j     g
                                                        not injecting
                                                        shaded area




      Cosmetic Indications - Horizontal Forehead Lines
 Horizontal Forehead Lines




  Standard technique: 2.5 units in 5 injection sites

Cosmetic Indications - Horizontal Forehead Lines
 Horizontal Forehead Lines




          Optional injection sites

Cosmetic Indications - Horizontal Forehead Lines
 Horizontal Forehead Lines




     Additional sites to consider for males

Cosmetic Indications - Horizontal Forehead Lines
 Horizontal Forehead Lines
            Male 36 years old




  Before                        After




Cosmetic Indications - Horizontal Forehead Lines
 Horizontal Forehead Lines
           Female 40 years old




  Before                            After
                           Note enhancement of brow
                               shape to soft flare



Cosmetic Indications - Horizontal Forehead Lines
Managing complications
 of   BOTOX®   treatment
                Potential complications
Bruising

Swelling

Headache
H d h

Eyelid ptosis

Brow ptosis

Brow
     iti i
repositioning

Diplopia
                           Managing complications
         Treating ptosis

Alpha-2 agent with
weak alpha-1 activity
[eg, apraclonidine 0.5%
(Iopidine®, Alcon Inc)]

Alpha-1 adrenergic
stimulation of Müller’s
muscle (eg, adrenaline)




                           Managing complications
Treating ptosis
Usually resolves in 1-6 weeks
Iopidine eyedrops 1 drop q.d.s. will temporarily resolve




 Ptosis left lid                 20 minutes after Iopidine®
                             Managing complications
Brow ptosis
Wait f     t   l     l ti
W it for natural resolution
Consider injection of 2 units at tail of eyebrow to lift




                                    After BOTOX® to glabellar and brow

                                Managing complications
   Brow repositioning

Excessive brow elevation


  • “Quizzical” or “Mr Spock”
    brows


  • Correct with 2 - 4 units of
    BOTOX® injected into the
    frontalis 2cm above the
    lateral brow




                            Managing complications
Potential Side Effects

• Bruising
   • avoid aspirin & NSAID’s 10 days prior to
     BOTOX® treatment
   • apply gentle pressure immediately,
     then ice
• Local temporary swelling
• Diplopia - rare




                        Managing complications
Advanced techniques require a degree of
  judge e t ga ed o app o       ate y
  judgement gained from approximately
      12 months BOTOX® cosmetic
               experience
Advanced Cosmetic Techniques
•   Suborbital region
•   Facial asymmetry
•   Upper lip wrinkles
•   Nasal scrunch (“bunny lines”)
•   Nasal flare
•   Nasolabial folds
•   Marionette lines
•   Correction of downturned mouth corners
•   “Poppy” chin
•   Platysmal bands
    Pl t    lb d



Advanced techniques and combination treatment
Strategies for
   success
 Customer service
• Prompt service availability is essential
• The wait time for BOTOX® is best kept short
• More than two weeks is too long
    y          g           y
• Try and arrange BOTOX® days for efficient use
 of material
  Be flexible i      h d li         i     l   h
• B fl ibl in your scheduling – mornings, lunch,
 evenings and weekends



                             Strategies for success
      Pricing Policy

• Free consultations
  Price t h     i
• P i match promise
• Price according to number of facial areas
• Try to avoid treating only one area!
• Vouchers/referral/loyalty rewards




                               Strategies for success
   Marketing


                                       toxin”-
Don’t advertise BOTOX® or “Botulinum toxin”
it contravenes Advertising Standard Authority
guidelines regarding the promotion of
Prescription Only Medicines.




                          Strategies for success
   Minimise Patient Disappointment

  Consent f
• C                 i    ll id ff t
        t form covering all side effects
• Make sure that you and the patient have realistic
    t       bj ti
  outcome objectives
• When treatment results are not up to expectations,
  admit it and do something about it
• Use patient information materials to set
  appropriate expectations




                               Strategies for success
Patient Disappointment


• If results are minimised because of additional
        l        it   t    l i  ith    i
  muscle recruitment, explain with a mirror


• Refer patients back to initial photographs


• Make no guarantees concerning duration.
  Ranges are from 3 – 9+ months


                           Strategies for success
    Optimizing Success

BOTOX® is considered by many
     ti      titi      t b th
cosmetic practitioners to be the
  most successful cosmetic
      procedure available




                  Strategies for success
        g BOTOX®
 Ordering BOTOX® and
other aesthetic products
         Please still use our Guernsey address for all correspondence:
                             Healthxchange Pharmacy
                             Healthxchange Pharmacy
                                   Albert House
                                 South Esplanade
                                   St Peter Port
                                Guernsey GY1 1AJ
                                Guernsey GY1 1AJ
                       Tel: 01481 736837 Fax: 01481 736677

If you would like to collect goods in person our meet our pharmacy team you will be 
                                                  p        y
              made welcome at our new modern pharmacy located at:
                             79 Great Portland Street,
                                     London
                                   W1W 7LS




                                                                          Ordering BOTOX®
Allergan




 Allergan manufactures Botox®-Vistabel®
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