Download BOTOX THERAPY Murali Mohan A, Asst. Lecturer HISTORICAL

BOTOX THERAPY
Murali Mohan A, Asst. Lecturer
HISTORICAL ASPECT
A German poet, doctor and scientist , Dr. Justinus Kerner of Wurttemberg, first explained the
disease called botulism (1817 to 1822) caused by ‘sausage poison’.
Dr Emile Pierre van Ermengem (belgium) in 1895 successfully isolated this bacterium, named it
Bacillus botulinus..Botulinum toxin was first used to treat human disease (1980) by Drs Alan Scott
(opthalmologist) and Edward Schantz, in treating strabismus. Manufactured for medical use in 1989
under name “Oculinum”;Licensed for treatment of strabismus and blepharospasm (eye conditions
characterized by excessive muscle contraction)In 1996, they published the first paper on the use of
Botox for cosmetic purposes. In 2002, the FDA announced the approval of BOTOX® Cosmetic to
temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows
(glabellar lines). In July 2004, the FDA approved BOTOX® to treat severe underarm sweating,
known as primary axillary hyperhidrosis, that cannot be managed by topical agents.
MICROBIOLOGY OF BOTULINUM
Botulinum toxin (BTX or BoNT) is produced by Clostridium botulinum, a gram-positive
anaerobic, spore forming bacillus.
BoNT is broken into 7 neurotoxins (labeled as types A, B, C [C1, C2], D, E, F, and G), which
are antigenically and serologically distinct but structurally similar.
Type A is the most potent toxin, followed by types B and F toxin.
Human botulism is caused mainly by types A, B, E, and (rarely) F. Types C and D cause
toxicity only in animals.
PREPARATION BOTOX
The products and their approved indications include the following:
Onabotulinum toxinA (Botox, Botox Cosmetic)
Botox - Cervical dystonia, severe primary axillary hyperhidrosis, strabismus,
blepharospasm, neurogenic detrusor overactivity, chronic migraine, upper limb
spasticity
Botox Cosmetic - Moderate-to-severe glabellar lines
Abobotulinum toxin-A (Dysport) - Cervical dystonia, moderate-to-severe glabellar lines
Incobotulinum toxin-A (Xeomin) - Cervical dystonia, blepharospasm
Rimabotulinum toxin- B (Myobloc) - Cervical dystonia
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BOTOX – HOW DOES IT WORK?
Botox is a muscle relaxant
Botox PREVENTS wrinkle progression
Botox can be used with all other types of anti-aging treatments
Relaxes the muscles which cause the wrinkles formed by movement.
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Botox is both preventative in future wrinkle development and active in treating
current wrinkles
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Fillers can be used in conjunction with Botox for additional reduction of the wrinkles
at rest (crush damage)
BOTOX blocks the transmission of overactive nerve impulses to the targeted muscle by
selectively preventing the release of the neurotransmitter acetylcholine (ACh) at the neuromuscular
junction, temporarily preventing muscle contraction.
This is primarily a local effect. In cervical dystonia, BOTOX may also prevent the release of
pain‐stimulating neuropeptides in peripheral nerves.
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Botox is absorbed by the nerve root that supplies the overactive muscle.
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Signal is blocked from nerve to muscle
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Once inside cell, botox release of a substance called acetylcholine
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This is what stops the nerve from activating the muscle
What happens as the Botox ‘wears off?’
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Botox needs to be repeated every several months - the nerves ‘regrow’ and the muscles
resume activity.
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Results tend to last longer with subsequent treatments (as a result of muscle weakening)
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It will take up to 7-10 days to see the results after the first treatment
How Botox ‘wears off’
The nerve begins to grow a new contact point with the muscle
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The new nerve muscle junction begins to work and the wrinkles return .It is now time for
retreatment
How long do the effects last?
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First treatments wear off the fasts- Avg. 3 months
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Subsequent treatments last longer- Avg. 4-6 months
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Results vary, some people experience results for longer or shorter periods
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Longevity can be improved by increasing the dose of Botox in subsequent sessions
DERMATOLOGICAL INDICATIONS
AESTHETIC INDICATIONS
Botox® is indicated for all wrinkles produced due to persistent muscular contractions. These
include
Horizontal forehead lines
Glabellar lines and vertical frown lines
Crow's feet
Bunny lines
Dimpled chin
BOTOX is a prescription medicine that is injected into muscles and used:
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To treat increased muscle stiffness in elbow, wrist, and finger muscles with upper limb.
• To treat the abnormal head position and neck pain that happens with cervical dystonia (CD).
• To treat certain types of eye muscle problems (strabismus) or abnormal spasm of the eyelids
(blepharospasm).
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THERAPEUTIC USES
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Chronic pain and disorders of localized muscle spasms
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Chronic low back pain
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Tension headache
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Chronic migrane headache
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Medication overuse headache
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Lateral epicondylitis
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Knee, Shoulder,Neuropathic pain
ABSOLUTE CONTRAINDICATIONS
1. Patients afflicted with a pre-existing motor neuron disease, myasthenia gravis, Eaton-Lambert
syndrome, neuropathies, psychological unstability.
2. History of reaction to toxin or albumin.
3. Pregnancy and lactating females.
RELATIVE CONTRAINDICATIONS
Some medications decrease neuromuscular transmission, generally should be avoided in
patients treated with botulinum toxin. Includes :
Aminoglycosides
Penicillamine, quinine, chloroquine and hydroxychloroquine (may reduce effect)
Calcium channel blockers, and blood thining agents eg. warfarin or aspirin (may
result in bruising).
Preoperative Counselling and Informed Consent
Detailed counseling with respect to the treatment, desired effects, and longevity of the results
should be discussed .
A detailed consent form needs to be completed by the patient. Should include the type of
botulinum toxin, longevity expected, need for repeated treatments and possible postoperative
complications.
Preoperative photography is mandatory.
The Glabellar Complex and Vertical Frown Lines
Glabella lines are created by the action of 3 muscles:
Before initiating the treatment,
Assess facial expression at rest and during animation.
Evaluate the range of motion of involved muscles.
Palpate muscles during repose and contraction.
Assess eye brow position
Injections given into the corrugator (red and blue circles) and procerus (green circle) muscles.
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The 52-year-old female patient, frowning in both photos, as she looked before and 32 days
after treatment
Horizontal Forehead Lines
Muscle : Frontalis
The treatment goal is to achieve a balance between eye brow elevation with forehead
smoothing.
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The patient is seen rest before and 33 days after treatment. forehead lines are fairly effaced
and
she
now
has
decent
brow
position.
The same patient is shown with raised eyebrows before and 33 days after treatment.
The patient has relatively normal brow position, and softening of rhytids without dropping of
the brows.
Crow's Feet
Contraction of orbicularis oculi muscle.
The treatment goal is reducing dynamic rhytides and softening static rhytides.
Before initiating the treatment,
Determine the source of the wrinkles - the orbicularis oculi vs zygomaticus major.
Assess while the patient animates and while he is at rest.
"snap test" to measure skin laxity along the lower lid margin.
Patient depicted 17 days after treatment for crow's feet. Smiling without crow's feet
wrinkles.
Bunny Lines
Contraction in the transverse portion of the nasalis.
The treatment goal is to soften the bunny lines on smiling.
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The patient shown 17 days after treatment for bunny lines, with good result. Patient
expression alternates from rest to "scrunching."
Dimpled Chin
Contraction of the mentalis : causes a "cobblestone" appearance of the skin and possible
deepening of the mentolabial crease.
Treatment goal is to reduce the chin dimpling which adds to the rejuvination of lower face.
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The patient is shown alternating from rest to full expression 17 days after treatment of the
chin.
After treatment she is seen unable to flex her mentalis and cause a dimpled chin as she could
before treatment.
Platysmal bands
Occur due to diastasis of the midline platysmal muscle and loss of submental fat, give the
appearance of turkey neck.
The treatment aim is to Reducing vertical bands that appear when the patient contracts the
platysma.
Treated via a series of superficial/intradermal injections directly into the contracted muscular
band. The number of injection points depends on length of each band.
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The patient shown in full expression before and 17 days after treatment. Anterior vertical
bands have disappeared.
INJECTION TECHNIQUE
The bevel should face upwards as the needle penetrates the skin almost parallel to it, and is
then advanced for about 2 mm before injecting intradermally.
The thumb is taken off the syringe plunger for a second or two before withdrawal.
These measures help prevent backflow of botulinum toxin and its wastage.
Avoid subcutaneous injections to prevent diffusion into intrinsic muscles of the palms and
soles or beyond the targeted glands in the axillae.
Precautions after botulinum toxin injection
Pt. should be instructed to contract the injected area for approximately 90 minutes to two
hours, which will help in the uptake of the toxin.
Avoid bending for a few hours after treatment to avoid potential diffusion.
One should go home immediately and rest after Botox®.
Do nothing strenuous for one or two days.
Refrain from laser/IPL treatments, facials and facial massage for one to two weeks after
injections. This is to minimize toxins dislodging and traveling (due to increased blood
circulation or direct pressure) to the surrounding muscles.
Any side effects?
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Most individuals do not experience any side effects.
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If there is a side effect, the most common are related to the fact that an injection has been
given and include:
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Slight tenderness at the injection site
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Pin point bleeding – very brief
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Transient swelling – very brief, like an insect bite
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Temporary bruising – can be concealed if desired
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Unlikely chance of local infection
Botulinum toxin therapy
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The ideal treatment for spasmodic dysphonia (SD) has not been identified. Currently, the
American Academy of Oto-laryngology- Head and Neck Surgery endorses the injection of
minute quantities of botulinum toxin into laryngeal muscles as the primary treatment
modality.
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Botulinum toxin causes a chemical denervation of muscle fibers by blocking the release of
acetylcholine at neuromuscular junctions.
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The clinical effect of botulinum toxin is classically thought to result from its peripheral effect,
but some research suggests otherwise. The toxin is found to not only affect extrafusal muscle
fibers but also the afferent muscle spindle output.
Dosage
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Percutaneous injection of botulinum toxin into the thyroarytenoid (TA) muscle in adductor
spasmodic dysphonia (SD) is usually performed with a starting dose of 1.25 U into each TA
muscle.
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For patients with abductor spasmodic dysphonia (SD), the dose is 5 U for unilateral posterior
cricoarytenoid (PCA) injection.
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In adductor spasmodic dysphonia (SD), the needle is passed through the skin that lies over the
superior edge of the cricoid, just lateral to midline. The needle is then advanced through the
CT membrane and superiorly and laterally directed into the right or left vocal fold to reach the
TA muscle