Myobloc Clostridium botulinum can be safely and painlessly injected directly in a specific muscle to relax that muscle temporarily.

This treatment has been used for many years for the treatment of nervous tics and strabismus (lazy eyes). The treatment of frown lines, crow s feet, forehead wrin!les, and the nec! folds with "#T#$% (botulinum toxin type &) has been used successfully for these facial wrin!les since '()'. Myobloc is a different type of botulinum toxin (type ") that is also used to treat facial wrin!les. *t was +,& approved for the use of cervical dystonia in ,ecember -... and has been used for facial wrin!les since that time. Myobloc is administered with a tiny needle. &fter the injection, the muscle is temporarily relaxed, thus, stoppin/ the ability of the muscle to shorten and allowin/ the wrin!le lines to /radually disappear. This can help prevent future wrin!lin/ of the s!in. Myobloc can also help /et rid of the an/ry expression that we /et when we wrin!le our brows.. &lthou/h Myobloc is temporary, it can help train you to not use these muscles as often, therefore, 0curin/0 you of the habit of wrin!lin/ the brow. *n most of the patients the effects last several months. The injections are painless in most of people, and anesthesia is not necessary. *f you prefer to use a topical anesthetic, 1M2&, arrive -. minutes prior to your appointment. "ruisin/ can occur but is common around the area of the crow s feet. 3se of topical 4itamin 5 cream to the area ' prior to the injection can lower the incidence of bruisin/. *ce pac!s can be applied after the procedure to decrease the chance of bruisin/. 3se of 4itamin 1, /reen tea, coumadin, ibuprofen (&dvil), Motrin, or aspirin will increase the incidence of bruisin/. *t is best to have the injections performed 6 days prior to an important event in case bruisin/ occurs. "esides bruisin/, the second most common side effect is dry mouth. This is temporary and usually resolves within a few days or wee!s. The most serious side effect of Myobloc is ptosis (droopin/ of the eyelid) which can happen in a small percent of patients. *f this happens, it usually resolves in ' 7- wee!s. *t is often so subtle that the patient doesn t notice it. To diminish the incidence of developin/ ptosis, we avoid treatin/ the area of the forehead just over the eyebrow. #nce the Myobloc has been injected, it ta!es 6) 7 8- hours for the maximum effects to be apparent. 9lease drop by our office in :76 days so that our staff can ma!e sure that you have achieved the maximum results. This ta!es approximately '. minutes and an appointment is not necessary. &fter the injections, you can return to wor! or any social commitment immediately. ;ou should move the muscles as much as possible durin/ the : days followin/ the injection so that the Myobloc can0 discover0 the muscles and it will have a stron/er effect. ;ou should not lower their head below the level of your heart durin/ 6 hours after the injection. *t has been said that this prevents diffusion of the Myobloc to other areas. ;ou can wash your face and it can use your home /lycolic products and <etin & as usual.

"otulinum toxin ("T$) induces chemical denervation of striated muscles by cleavin/ proteins re=uired for the release of acetylcholine. The result is temporary flaccid paralysis of the injected muscles, which lasts approximately three to five months. &s new neuromuscular junctions form, muscle function returns. There are seven serotypes (&7 >) of "T$. #f these, type & was the first to be made available in the 3nited ?tates for medical uses ("#T#$%). "T$7& is +,& approved for the treatment of blepharospasm, strabismus, and cervical dystonia. & common off7

label use is for the treatment of wrin!les. "T$7 ", now available in the 3nited ?tates as Myobloc, provides another option for the treatment of facial wrin!lin/. 1ach of the seven serotypes of "T$ are composed of three domains@ the bindin/ domain, the translocation domain, and the enzymatic domain. The bindin/ domain, located on the heavy chain of the "T$ molecule, is responsible for attachin/ to the acceptor on the presynaptic nerve terminal. The bindin/ domain of Myobloc is distinct from the bindin/ domain of "#T#$%, therefore these a/ents bind to different acceptors. "indin/ of botulinum toxin to its proper acceptor initiates endocytosis and internalization of the toxin heavy chain and li/ht chain. &lthou/h the mechanisms of action of the translocation domain are not completely understood, it is responsible for /ettin/ the toxin into the endosome of the nerve terminal that contains &Ah. #nce inside the endosome, the acidic environment is believed to cause a chan/e in the conformation of the toxin that allows the molecule to cross into the cytosol.i The enzymatic domain of the li/ht chain becomes functional in the cytosol and cleaves a protein in the ?B&<1 complex that incapacitates this complex, preventin/ the fusion of acetylcholine vesicles, thus bloc!in/ extrusion of their contents. The ?B&<1 complex is composed of synaptobrevin, ?B&97-C and syntaxin. (fi/. () Myobloc cleaves a component of the ?B&<1 complex called synaptobrevin, while "#T#$% cleaves a component !nown as ?B&9 7-C. &ntibodies to the critical bindin/ site on the heavy chain of the "T$ molecule will prevent bindin/ of the toxin to its receptor, thereby cripplin/ the actions of the toxin. These 0neutralizin/ antibodies0 have been reported in patients treated with hi/h doses of botulinum toxin for neurolo/ic disorders such as cerebral palsy, but have not been reported in "#T#$% patients treated with cosmetic doses ran/in/ from '- units to '.. units. "ecause Myobloc has a bindin/ domain that is distinct and different than the bindin/ domain of "#T#$%, antibodies that neutralize "T$7& would not neutralize "T$7" and vice versa. Therefore, if patients develop antibodies to "T$7&, then they would still be able to use "T$7".