Botox Presentation 25 Oct 2008 colour slides

Document Sample
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

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.

            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



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

          y p
 It is very important
to learn that BOTOX
       is both an
     t d
  art and a science
   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
the hardest part…

e.g. collecting patients,
      q p
     equipment, ,

                            Starting BOTOX®
Before offering BOTOX® to patients

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

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

•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
     - Synaptobrevin
     - Syntaxin
                                          NH2     S
•   Only intact molecule works                    S
•   Does not penetrate the skin
•        p      pp
    No topical application

                              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
          fibre              nerve terminal        internalised via

                                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-
                            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
    Current UK Botox® Approvals
 Gl b ll li
•Glabellar lines
•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
           BOTOX® (off-license)
•Tension Type Head-Ache
•Back Ache
•Myofascial Pain Syndrome
•Anal Fissure
                   Neurotoxin Pharmacology
Dilution &
Dilution of Vial

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

  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

• 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)

      1.0 ml                10.0 U

      2 0 ml
      2.0                    5.0

      2.5 ml                 4.0 U

      3.0 ml                 3.3 U

      4.0 ml                 2.5 U

                            Dilution & Storage

•   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
• 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
• Group patients together in early phases of business to
 prevent wastage

                                         Dilution & Storage

   - Ice crystals may form which damage the toxin
     and reduce potency
• 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
• Patients with infection at proposed injection site

• Patients with known hypersensitivity to any ingredient in

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

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

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

• Bleeding disorders or anticoagulant therapy

                           Contraindications & 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

                                                Technique Tips
General Injection Technique Tips

• Never advise to discontinue aspirin/clopidogrel

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

• 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

                                                  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

Type III                                      Type

             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

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

                                 Technique Tips
Frown Lines
Target Muscles for Frown Lines



                 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

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

Injecting down
towards the eye

2.5 ml syringe

No gloves or

        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

B f                             f

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

B f                            f

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
                90                                                  *                           *    *      *

                80                                                                                                *

% Re

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

• 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

                  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
• 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
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


H d h

Eyelid ptosis

Brow ptosis

     iti i

                           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”

  • 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
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
 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

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,
                                   W1W 7LS

                                                                          Ordering BOTOX®

 Allergan manufactures Botox®-Vistabel®
Q   ti
Medical Aesthetics Training Courses
   -                                  py
       Botox-Chemical Peels-Mesotherapy-Radiesse-Dental Block-Advanced Botox and Dermal
       Fillers Combined-Developing a Cosmetic Practice Course.

The Beauty Advice Centre
Promoting your cosmetic specialty on the web
   -   6 months free membership for all K-T Training delegates.

K-T S l ti
K T Solutions
Practice and business consulting for medical and aesthetics clinics.

                         K-T Medical Aesthetics Training and Solutions
K-T Medical Aesthetics Training
Tel: 01793 323786
For Aesthetics Contacts (distributers, resources, marketing, ect) please visit.

For more information on Building and Developing your Cosmetic Clinic courses and
   consulting please contact us.

                                                                  Thank You

Shared By: