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Reference:
Harmony &
Balance
Normal
Relationship
Between Facial
Units
Muscles
Attached To
Skin
Inelastic,
Aging Skin
Skin Subject
To Pull Of
Gravity
Flaccid,
Loose Skin
Face Lift
Wrinkles
perpendicular
To Muscle
Fibers
Repetitive
Movement
BOTOX
Brow Lift
Lasers &
Light, RF,
Meso
Redundant Skin
Hyperdynamic Wrinkles
Toxin:
1920:
1946:
1949:
1950s:
1973:
1977:
1979:
1985:
1987:
Carruthers & Carruthers performed joint dermatologicalophthalmologica research with Dr. Alan B. Scott.
Dr. Jean Carruthers observed significant improvement of
dynamic rhytides in glabellar region while treating
patients for blepharospasm.
1989:
1991-1992:
1993:
1997:
1999:
2003:
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.
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
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 28C for 21 months
May be used when no
response to Type-A
(antibodies to Type-A)
Myobloc
Dysport (Reloxin)
FDA-approved 2009
Puretox (Mentor)
Linurase (Prollenium)
CBTX A (China)
Clinical Trials:
Topical Botulinum Type A
Lifts eyebrows
Draws the scalp
down
Wrinkles two
sides
Not always
bifurcated
Fear, surprise
Superficial
muscle
Not attached to
skull
Attention:
Migration
FRONTALIS
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
PROCERUS
The Frown
Muscle:
-
Compresses
the skin
between the
eyebrows
Frown,
concern,
concentration.
Deep muscle
Deep injection
CORRUGATOR
The Squinting
Muscle:
-
Closes the
eyelids,
compresses
eye opening
Encircles the
eye
Close, wink,
tired
Extends
superior over
eyebrow
Note: injection
of brow lift
ORBICULARIS OCULI
The Smiling
Muscle:
-
Raises the
mouth upward
and outward
Smiling,
laughing
Orbicularis
Oculi also
contracts when
smiling
Note: attention
when injection
below eye; may
cause bunny
cheeks
ZYGOMATICUS MAJOR
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 labii
superior into
levator anguli
oris!
Lifts the
corners of the
mouth
Note: injection
into levator
labii superior
(too low if
treating bunny
lines) can
cause
migration into
levator anguli
oris resulting in
drooping
mouth corners!
The Lip
Tightener
Muscle:
-
Compress and
purses the lips
Circles the
mouth
Disdain,
repulsion
Inject to treat
wrinkles
around mouth
and smoker
lines.
ORBICULARIS ORIS
The Clenching
Muscle:
-
Used to clench
teeth (and lift
lower jaw)
Fear, yawn
MASSETER
Draws the
lower lip down
and outward
Neck muscle
Crying, terrified
Also called:
Risorius
PLATYSMA
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.
Storage:
Keep refrigerated after use (4 hours 30 days)
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
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 inch needle (for drawing larger
gauge).
For skin preparation & sterility: alcohol
(wipes), gloves, cotton balls, 4x4 sterile
gauze.
Syringes:
1ml syringes.
Needles:
30 gauge inch needles to administer.
21-25 gauge (1/2 1 inch) for mixing and drawing up
solution.
Breastfeeding.
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.
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).
Crows feet: superficial injections (avoid bruising).
PROCERUS
ORIGIN
Nasal bone and cartilages
INSERTION
Skin of medial forehead
ACTION
Wrinkles and 'frowns' forehead
NERVE
Temporal branch of facial nerve
(VII)
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.
CORRUGATOR SUPERCILII
ORIGIN
Medial superciliary arch
INSERTION
Skin of medial forehead
ACTION
Wrinkles forehead
NERVE
Temporal branch of facial nerve
(VII)
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.
FRONTALIS
ORIGIN
Occipital : highest nuchal line and
mastoid process. Frontal: superior
fibers of upper facial muscles
INSERTION
Galeal aponeurosis
ACTION
Wrinkles forehead and fixes galeal
aponeurosis
NERVE
Posterior auricular and temporal
branches of facial (VII)
20 40 units.
Injections must be well above the brow to
avoid ptosis as well as loss of expression.
ORBICULARIS OCULI
ORIGIN
Medial orbital margin and lacrimal
sac (orbital, palpebral and lacrimal
parts)
INSERTION
Lateral palpebral raphe
ACTION
Closes eyelids, aids passage and
drainage of tears
NERVE
Temporal and zygomatic branches
of facial nerve (VII)
Note: Orbicularis
Oculi extends
superior over the
eyebrow, and
depresses eyebrow.
Crows feet
Attention: Due to the baggy, loose skin under the eyes, BTX may migrate
into unwanted areas and cause drooping op the mouth (by affecting the
levator labii superior and consequently the levator anguli oris).
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.
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
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.
No effective treatment!
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%.
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
More challenging:
Muscles serve
important
functions
(oration,
expression,
mastication).
Muscles work
synergistically.
Not for novice!
ORBICULARIS ORIS
ORIGIN
Near midline on anterior surface of
maxilla and mandible and modiolus
at angle of mouth
INSERTION
Mucous membrane of margin of lips
and raphe with buccinator at
modiolus
ACTION
Narrows orifice of mouth, purses lips
and puckers lip edges
NERVE
Accessory parts are incisivus labii
superioris and inferioris
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 dont last as long.
ORIGIN
Medial infra-orbital margin
INSERTION
Skin and muscle of upper lip
ACTION
Elevates and everts upper lip
NERVE
Buccal branch of facial nerve (VII)
1 U into levator at
nasofacial complex,
just inferior to
nasomaxillary
groove.
1 injection just
above periosteum.
2-3 week follow-up;
increase gradually up
to 5 U if indicated.
Note: treatment of
depressor labii
inferioris 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.
marionette lines
ORIGIN
Outer surface of mandible
posterior to oblique line
INSERTION
Modiolus at angle of mouth
ACTION
Depresses and draws angle of
mouth laterally
NERVE
Mandibular branch of facial nerve
(VII)
MENTALIS
ORIGIN
Incisive fossa on anterior aspect
of mandible
INSERTION
Skin of chin
ACTION
Elevates and wrinkles skin of
chin and protrudes lower lip
NERVE
Mandibular branch of facial
nerve (VII)
ORIGIN
Outer surface of mandible along
oblique line
INSERTION
Skin of lower lip
ACTION
Depresses and draws lower lip
laterally
NERVE
Mandibular branch of facial
nerve (VII)
Asymmetrical smile:
N
E
C
K
A
N
A
T
O
M
Y
PLATYSMA
ORIGIN
Skin over lower neck and upper lateral
chest
INSERTION
Inferior border of mandible and skin
over lower face and angle of mouth
ACTION
Depresses and wrinkles skin of lower
face and mouth. Aids forced depression
of mandible
NERVE
Cervical branch of facial nerve (VII)