Download pdf - Putting BOTOX Facial Fillers Into Practice

7/27/2019 Putting BOTOX Facial Fillers Into Practice

1/62

Putting Botulinum Toxins and

Sirtaz S. Sibia, D.O., FAOCO

Orlando, Florida May 2013


2/62

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.


3/62

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


4/62

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.


5/62

Aging Face

Glabellar frown lines

or zon a ore ea nes

Periorbital lines (Crows feet) Lateral brow lift


6/62

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.


7/62

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.


8/62

Rare

Generalized weakness

u- e symp oms

Diffuse skin rash

Headache


9/62

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


10/62

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


11/62

None

ce, e y c or e

Emla, ELA-Max,


12/62

Botulinum toxin needs

with sterile,

preservative freesaline

Refer to Botulinum

toxin by units notvolume


13/62

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


14/62

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


15/62

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


16/62

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: ___________________


17/62

Key Muscles of the Upper Face

Superciliiron a s

Procerus Orbicularis

Oculi


18/62

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

.


19/62

Discussing BOTOX Cosmetic, Xeomin,

an yport w t your at ents

Dont

, , , ,

needles

Do

smoo , re ax , re res , nyinjection, soften


20/62

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


21/62

Rhytids (wrinkles)

Produced by

corru ator

procerus

orbicularis oculi

depressor supercilli


22/62


23/62

1 in procerus

2 in each corru ator

Total dose:

Botox/Xeomin: 20 U

(4U/injection site)

Dysport: 50 U

(10 U/injection site)


24/62

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.


25/62

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


26/62

Why use Botulinum in glabella vs. fillers

Occlusion of cutaneous vessels (Zyplast)

n ness o agen, a , r amc no one

Cerebrovascular occlusion (fat)


27/62

Rhytids (wrinkles)

across the forehead

Produced by frontalis muscle


28/62

Before and After:Forehead


29/62

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


30/62

Potential com lications of foreheadtreatments

Bruising

row os s

Eyelid Ptosis


31/62

Rhytids (wrinkles)

radiating from the

lateral canthus,

person smiles

orbicularis oculi


32/62

Before and After: eriorbital lines


33/62

Botox/Xeomin:

Dysport: 8 U per site

rim

To prevent bruising in this area

injections


34/62

Potential com lications of eriorbitaltreatments

Diplopia

era s

Ectropion Epiphora

Weakness of z omaticus muscle


35/62

Lateral Brow Lift

Performed mainly for

Treat the lateral brow

de ressors so the browelevators work

unopposed


36/62

Before and After:lateral brow lift


37/62

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


38/62

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


39/62

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


40/62

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

,


41/62

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


42/62

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


43/62

- -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


44/62

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


45/62

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


46/62

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


47/62

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


48/62

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


49/62

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


50/62

Importance of HA

Hyaluronic acid is a naturally

The most important

y u

acid relevant to its performance

retention, i.e., water binding


51/62

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


52/62

Before and After Fillers


53/62

Before and After Filler


54/62


55/62


56/62


57/62


58/62


59/62


60/62


61/62

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.


62/62

May cause darkening of

the eyelid skin.

brown pigmentation of

the iris.

May cause itchingsensation or redness of

the eyes.

May cause dry eyes.