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Basic & Advanced Applications

Hands-On Workshop

Presented by

ELITE Aesthetic, Medical & Business TrainingCopyright 2008 ELITE

2011

Founded in 2008

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Participants will leave class feeling confident to incorporate the newly acquired knowledge/skills & procedures into their existing practice.

• Incorporate both ‘basic’ and ‘advanced’ applications.

• Extensive Hands-on workshop – LIVE models.

• Comfort level with these procedures will increase with experience.

Some providers may feel more comfortable beginning with friends

and family.


2011

9:00 am Botox® Cosmetic Didactic Presentation

11:30 am Break

11:45am Dermal Filler Didactic Presentation

1:00pm Lunch Break

2:00pm Demonstration Videos

3:00pm Hands-on Workshop on LIVE models

7:00pm Q&A, Evaluation & Certification


2011

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2011

Dr. Mike Van Thielen

Senior Instructor

Comprehensive Overview & Practical Applications

Presented by ELITE Aesthetic, Medical & Business Training

Copyright 2011 ELITE

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

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

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

Ideal proportions &

Shapes

Normal

Relationship

Between Facial

Units

Harmony &

Balance

Looking Young For

Biological Age

Redundant Skin Hyperdynamic Wrinkles

Face Lift

Brow Lift

Flaccid,

Loose Skin

Inelastic,

Aging Skin

Skin Subject

To Pull Of

Gravity

BOTOX™

Repetitive

Movement

Muscles

Attached To

Skin

Wrinkles

perpendicular

To Muscle

Fibers

Lasers & Light, RF,

Meso

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'

Patient age: 20s to 30s

Early photo-aging

Mild pigment changes

Minimal wrinkles

No 'age spots'

Type 2: 'Wrinkles in Motion'

Patient age: 30s to 40s

Early to moderate photo-aging

Appearance of smile lines

Early brown '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)

BOTOX® Myobloc

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)

In the United States, prescription drugs and biologics arerequired to undergo rigorous laboratory, animal, andhuman clinical testing before they can be put on themarket. The Food and Drug Administration (FDA) reviewsthe results of these studies to: verify the identity,potency, purity, and stability of the "ingredients," anddemonstrate that the drug is safe and effective for itsintended use.

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

Dysport (Reloxin)

FDA-approved 2009Other Type-A Toxins

Currently known as Dysport in UK (Ipsen, Inc., berkshire)

Type-A

Marketed by Medicis Esthetics (US)

300U and 500U vials

Excipient materials include lactose and albumin

Recommended reconstitution 500U with 1ml of saline

Estimated 2.5 – 3 times dosage compared with Botox

Puretox (Mentor)

Linurase (Prollenium)

Neuronox (Medy-Tox, South Korea)

CBTX A (China)

Clinical Trials:

◦ Topical Botulinum – Type A

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

Lasers & Light-based systems.

http://www.acisurgery.com/

FRONTALIS

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

PROCERUS

The Flaring NostrilsMuscle:

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‟

CORRUGATOR

The Frown Muscle:

- Compresses the skin between the eyebrows

- Frown, concern, concentration.

- Deep muscle- Deep injection

ORBICULARIS OCULI

The Squinting Muscle:

- Closes the eyelids, compresses eye opening

- Encircles the eye

- Close, wink, tired

- Extends superior over eyebrow

- Note: injection of brow lift

ZYGOMATICUS MAJOR

The Smiling Muscle:

- Raises the mouth upward and outward

- Smiling, laughing

- OrbicularisOculi also contracts when smiling

- Note: attention when injection below eye; may cause „bunny cheeks‟

LEVATOR LABII SUPERIOR

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 labiisuperior into levator angulioris!

DEPRESSOR ANGULI ORIS (DAO)

The Facial Shrug Muscle:

- Pulls the corner of the mouth downward

- Sadness, crying, miserable

- Also called: Triangularis

- Injection will lift corners of mouth

LEVATOR ANGULI ORIS

The Lift Mouth Corner Muscle:

- Lifts the corners of the mouth

- Note: injection into levatorlabii superior (too low if treating „bunny lines‟) can cause migration into levator angulioris resulting in drooping mouth corners!

DEPRESSOR LABII INFERIOR

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 labiiinferior too medially, cause inward curl of lower lip!

ORBICULARIS ORIS

The Lip TightenerMuscle:

- Compress and purses the lips

- Circles the mouth

- Disdain, repulsion

- Inject to treat wrinkles around mouth and „smoker lines‟.

MASSETER

The Clenching Muscle:

- Used to clench teeth (and lift lower jaw)

- Fear, yawn

PLATYSMA

The Lower Lip Stretching Muscle:

- Draws the lower lip down and outward

- Neck muscle- Crying, terrified- Also called:

Risorius

Vial of 100U of botulinum exotoxin Ain lyophilized form (un-reconstitutedproduct seen as a small white ring ofpowder around base of vial) with0.9mg of sodium chloride and 0.5mgof albumin.

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).

Resistance seen in neurological patients frequently administered 100-200U.

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(0.9% Saline,

sterile, non-preserved)

Resulting dose(Units per 0.1 ml)

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.

ORIGINNasal bone and cartilages

INSERTIONSkin of medial forehead

ACTIONWrinkles and 'frowns' forehead

NERVETemporal branch of facial nerve (VII)

PROCERUS

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.

ORIGINMedial superciliary arch

INSERTIONSkin of medial forehead

ACTIONWrinkles forehead

NERVETemporal branch of facial nerve (VII)

CORRUGATOR SUPERCILII

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.

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

INSERTIONGaleal aponeurosis

ACTIONWrinkles forehead and fixes galeal aponeurosis

NERVEPosterior auricular and temporal branches of facial (VII)

FRONTALIS

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.

ORIGINMedial orbital margin and lacrimalsac (orbital, palpebral and lacrimalparts)

INSERTIONLateral palpebral raphe

ACTIONCloses eyelids, aids passage and drainage of tears

NERVETemporal and zygomatic branches of facial nerve (VII)

ORBICULARIS OCULI

“Ideal” male eye brow,

positioned at the supra-orbital

rim with an almost horizontal

shape.

“Ideal” female eye brow, with a

gentle gull-wing 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

Crow‟s feet

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).

Under the eyes

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.

Spasm of lower eyelids

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 irritation (55%), midfacial or lower facial spasm (59%), brow spasm (24%), and eyelid tic (22%) .

Copyright © 1997-2008 EyePlastics.com

http://www.eyeplastics.com/misc/copyright/copyright.html

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.

Upper Face

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!

And „smoker lines‟

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.

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

INSERTIONMucous membrane of margin of lips and raphe with buccinator at modiolus

ACTIONNarrows orifice of mouth, purses lips and puckers lip edges

NERVEAccessory parts are incisivus labiisuperioris and inferioris

ORBICULARIS ORIS

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!).

ORIGINMedial infra-orbital margin

INSERTIONSkin and muscle of upper lip

ACTIONElevates and everts upper lip

NERVEBuccal branch of facial nerve (VII)

LEVATOR LABII SUPERIORIS

1 U into levator at nasofacial complex, just inferior to nasomaxillarygroove.

1 injection just above periosteum.

2-3 week follow-up; increase gradually up to 5 U if indicated.

Note: treatment of depressor labiiinferioris 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.

“marionette lines”

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.

ORIGINOuter surface of mandible posterior to oblique line

INSERTIONModiolus at angle of mouth

ACTIONDepresses and draws angle of mouth laterally

NERVEMandibular branch of facial nerve (VII)

DEPRESSOR ANGULI ORIS

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

ORIGINIncisive fossa on anterior aspect of mandible

INSERTIONSkin of chin

ACTIONElevates and wrinkles skin of chin and protrudes lower lip


MENTALIS

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 & orbicularisoris may affect speech and sphincter function!

ORIGINOuter surface of mandible along oblique line

INSERTIONSkin of lower lip

ACTIONDepresses and draws lower lip laterally


DEPRESSOR LABII INFERIORIS

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

N

E

C

K

A

N

A

T

O

M

Y

ORIGINSkin over lower neck and upper lateral chest

INSERTIONInferior border of mandible and skin over lower face and angle of mouth

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

NERVECervical branch of facial nerve (VII)

PLATYSMA