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Putting Botulinum Toxins and
Sirtaz S. Sibia, D.O., FAOCO
Orlando, Florida May 2013
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Anatomic areas of concern to the patient
History of previous treatment
ocumen pa en s ana omy
Educate the patient about treatment options
Botox Cosmetic, Dysport, Xeomin, Restylane,
Perlane, Juvederm, Radiesse, etc.
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Basic Physician Knowledge of
Botulinum toxins Indications Administering physicians
Temporary improvementin the appearance of
moderate to severeglabellar lines
Be well trained
Have knowledge of
Corrugator and/orprocerus activity
Adults 65 ears
expression
Understand the dynamicsof a in
Be qualified to evaluateand determine individualtreatment
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Botulinum Toxin Overview
BOTOX Cosmetic, Xeomin and Dysport are,
bacterium Clostridium botulinum.
Botulinum toxins works by blocking
acetylcholine impulses that trigger hyperactive
musc e contract ons.
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Aging Face
Glabellar frown lines
or zon a ore ea nes
Periorbital lines (Crows feet) Lateral brow lift
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Store vacuum-dried product .
Administer within 4 hours
after reconstituting product.
2C to 8C.
BOTOX Cosmetic should beclear, colorless and free of
particulate matter. Supplied in a single patient
use vial.
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Store vacuum-dried product .
Administer within 4 hours
after reconstituting product.
2C to 8C.
Dysport should be clear,colorless and free of
particulate matter. Supplied in a single patient
use vial.
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Rare
Generalized weakness
u- e symp oms
Diffuse skin rash
Headache
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Pregnancy and breast feeding
sor ers o e neuromuscu ar unc on
Myasthenia gravisyopa es
Aminoglycoside therapy
ay mpa r neuromuscu ar ransm ss on an are a eore cacontraindication
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Botox/D s ort Pre aration
1 cc syringes Insulin s rin e with re-
attached 30 guage needle vs.
separate syringe and needle
Digital camera
Postop instructions
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None
ce, e y c or e
Emla, ELA-Max,
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Botulinum toxin needs
with sterile,
preservative freesaline
Refer to Botulinum
toxin by units notvolume
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Botox: Vial Dilutions
Saline U/ml U/0.1 ml
2.0 ml 50 5.0
2.5 ml 40 4.0
4.0 ml 25 2.5
5.0 ml 20 2.0
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D s ort: Vial Dilutions
Saline U/ml U/0.1 ml
1.5 ml 200 20.0
2.0 ml 150 15.0
2.5 ml 120 12.0
3.0 ml 100 10.0
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Documentation of Botox treatments
Botulinum toxin injection worksheet
e ore an a er p o ograp s
Make good notes on how many unitsinjected for each site to help improve results
for future Botox/Dysport / Xeomin
treatments
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BOTOXRInjection Worksheet
Patient Name: _______________________________ DOB: _________ Date: _________
Treatment Areas: glabella forehead periorbital perioral other
BOTOXR: Lot __________ Expiration ___________ Concn ___________
The risks, benefits, and alternatives of Botox injections were discussed with patient.
BotoxRwas administered after alcohol skin prep and topical anesthesia placement.
Patient tolerated procedure well and there were no complications.
Return appointment: ___________________
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Key Muscles of the Upper Face
Superciliiron a s
Procerus Orbicularis
Oculi
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Discussing BOTOX Cosmetic,
Patients
,protein thatrelaxes wrinkle-causing muscles, creating asmoothed and improved appearance.
BOTOX Cosmetic/ Dysport/ Xeomin is administered via afewtiny injections of purified protein into the muscle to block nerveimpulses that trigger wrinkle-causing muscle contractions.
BOTOX Cosmetic/ Dysport/ Xeomin is asimple and quick,minimally invasive treatment that delivers dramatic results with
.
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Discussing BOTOX Cosmetic, Xeomin,
an yport w t your at ents
Dont
, , , ,
needles
Do
smoo , re ax , re res , nyinjection, soften
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Botulinum Toxin Marketin
Internal marketing
Treat office staff with left over Botox/Dysport
External marketin Traditional advertising
Spas, salons, gyms, health clubs
Pricing Botox Days
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Rhytids (wrinkles)
Produced by
corru ator
procerus
orbicularis oculi
depressor supercilli
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1 in procerus
2 in each corru ator
Total dose:
Botox/Xeomin: 20 U
(4U/injection site)
Dysport: 50 U
(10 U/injection site)
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Decrease in Glabellar Lines after
Treatment with BOTOX Cosmetic
Baseline Day 30
Unretouched clinical trial photos taken while frowning before
BOTOX Cosmetic and after BOTOX Cosmetic. Individual
resu s may vary.
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Potential com lications of labellartreatments
Bruising
row os s
Diplopia Eyelid Ptosis Treat with Naphcon A or Iopidine, the alpha agonistic activity
s mu a es ue er s musc e w c s e an compensa es or eloss of the levator
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Why use Botulinum in glabella vs. fillers
Occlusion of cutaneous vessels (Zyplast)
n ness o agen, a , r amc no one
Cerebrovascular occlusion (fat)
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Rhytids (wrinkles)
across the forehead
Produced by frontalis muscle
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Before and After:Forehead
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Forehead line treatment
Botox/Xeomin: 2 U/
site
Dyport: 5U/ site to prevent eyelid ptosis,
injections should be at least 1
cm above the supraorbital rim
and away from the area abovethe lateral eyebrow
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Potential com lications of foreheadtreatments
Bruising
row os s
Eyelid Ptosis
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Rhytids (wrinkles)
radiating from the
lateral canthus,
person smiles
orbicularis oculi
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Before and After: eriorbital lines
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Botox/Xeomin:
Dysport: 8 U per site
rim
To prevent bruising in this area
injections
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Potential com lications of eriorbitaltreatments
Diplopia
era s
Ectropion Epiphora
Weakness of z omaticus muscle
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Lateral Brow Lift
Performed mainly for
Treat the lateral brow
de ressors so the browelevators work
unopposed
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Before and After:lateral brow lift
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Lateral Brow Lift Treatment
4 units Botox/Xeomin
2 units Botox/Xeomin
glabellar lines
add an additional 2 units into
-
lateral to the orbital rim and atthe tip of the eyebrow
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Posto Instructions
Do not lie down for the next 4 hours
o no ean over or e nex ours
Do not touch or massage the treated areas inany fashion for at least 4 hours
Immediately after the injections, frown and
smile repeatedly for the next 15 to 30minutes
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Fillers: Temporary, Semipermanent,
and Permanent
Temporary Fillers1. Less durable and enduring
Semipermanent fillers1. Slowly biodegradable
3. Bovine Collagen: Zyderm and
Zyplast
4. Human dollagen: Cosmoderm
and Cosmoplast
3. Polylactic acid: Sculptra
4. Calcium Hydroxylapatite:
Radiesse
5. Hyaluronic acid: Restylane,
Perlane, Captique, Hylaform,
Juvederm Ultra
6. Fat fillers
Permanent fillers:1. Nonbiodegradable
2. Polymethylmethacrylate:
Artefill, Artecoll
3. Fat fillers
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Collagen Implants:
y erm an yp as
FDA approved in 1981 and 1985,respectively
Bovine collagen implant
Pros: safe, reliable, user-friendly, contains
lidocaine Cons: allergic reaction, redness, swelling,
skin test is required, and a second skin
Recommended use: fine to deep wrinkles,frown lines, smile lines, crows feet, lip
,
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Collagen Replacement:
Cosmoderm and Cosmoplast
FDA approved in 2003 Pros: immediate rsults with no down time
Cons: short-lived correction
Recommended use for Cosmoderm:superficial papillary dermis for correction
of wrinkles and acne scars
deep dermis for correction of wrinkles andacne scars
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Synthetic Calcium:
a esse
FDA approved in 2006 Volume com osition made u of 70%
carboxymethylcellulose and 30% calcium
hydroxylapatite
, ,
longevity once injected
Cons: nodules common es eciall in li s
mistakes no easily forgiven Recommended use: nasolabial folds,
epresse scars, ora comm ssures
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- -Acid: Sculptra
FDA approved in 2004 S nthetic ol -L-lactic acid
Pros: long-lasting, long safety record as an
implant/suture material
Cons: approved for HIV lipodystrophy only;
granulomas have been reported
lipodystrophy-related atrophy; and mildvolume loss
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Polydimethylsiloxane:
on
FDA approved in 1997 Purified ol dimeth lsiloxane
Pros: low biological toxicity potential,
inert material
Cons: approved for retinal tamponade
during vitreoretinal surgery only, requires
multi le treatments
Recommended use to treat faciallipoatrophy in patients with HIV
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PMMA/Bovine Collagen:
r eco an r e
FDA approved in 2006(Artefill) Made up of 20% precision-filtered
polymethylmethacrylate microspheres and80% purified bovine collagen
Pros: lon -lastin must be in ectedcorrectly
Cons: skin testing required,
surgical excisions required for removal,multiple treatments required
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FDA approved in 2004 Bacterial fermentation-derived h aluronic
acid
Pros: safe, reliable, user-friendly,
,
Cons: rare allergic reactions, post-
in ection swellin ain
Recommended use: moderate to severefacial wrinkles
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Hyaluronic Acid:
es y ane
FDA approved in 2003 Bacterial-cultured stabilized h aluronic
acid
Pros: safe, reliable, user-friendly,
,
Cons: rare allergic reactions and particles
ma lead to uneven distribution
Recommended use: superficial defects,lips, lines, contouring for moderate to
severe wr n es
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FDA approved in 2007 Hi h-viscosit bacterial-cultured
hyaluronic acid
Pros: excellent for deeper folds requiring a
,
material than Restylane
Cons: rare aller ic reactions
Recommended use: shaping facialcontours, defining cheeks, eliminating
eep o s an en arg ng ps
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Hyaluronic Acid: Juvederm
ra an ra p us
FDA approved in 2006 Bacterial-cultured stabilized h aluronic
acid
Smooth-consistency gel
Pros: safe, reliable, user-friendly, no
allergy testing
-
and tenderness
Recommended use: lips, lines, contouring
moderate wrikles
Importance of HA
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Importance of HA
Hyaluronic acid is a naturally
The most important
y u
acid relevant to its performance
retention, i.e., water binding
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complications with fillers
Early1. Bruisin
Late Aller ic reaction
2. Swelling
3. Pain
Asymmetry
Scarring
.
5. Overcorrection
6. Undercorrection
Granulomas
Elevations
7. Necrosis
8. Hematoma
Migration
Lumping
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Before and After Fillers
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Before and After Filler
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Latisse is FDA approved
to grow eyelashes,
makin them lon er
thicker and darker.
Applied at night to the
upper eyelid margins atthe base of the lashes.
Patients with a history of
abnormal intraocular
supervised by theirophthalmologist.
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May cause darkening of
the eyelid skin.
brown pigmentation of
the iris.
May cause itchingsensation or redness of
the eyes.
May cause dry eyes.