Botox - Medical Uses Dr. Heidi LaForge Via Christi Family Medicine

Where does Botox Come From? Botox is derived from a bacteria that is found in the soil—Clostridium Botulinum

Botox Botulism toxin (BOTOX®) is a material that has been known for over a century and used for medical purposes for more than 50 years. In 2002, it was approved for improving and relaxing frown lines in the area between the eyes on the forehead. Since 2002, BOTOX has been used successfully in more than half a million patients.

How Does It Work? Botox works by blocking a chemical that aids in muscle contraction called acetylcholine When the nerve sends a signal to the muscle to contract, acetylcholine is released as before, but it can't bind anywhere on the muscle due to the Botox The muscle has no idea it is supposed to contract. It is essentially paralyzed, but not because the muscle or the nerve have been damaged.

“Red” molecules Botox

Does it Work Right Away? Botox takes 72 hours to reach maximum effect in most patients (some patients it can be as long as 5-7 days)….be patient because beauty takes time. Often After a Botox treatment I have patients periodically exercise the muscles that have been treated to create the desired affect of blocking all of the neuromuscular junctions faster

Can A Patient Build Antibodies to Botox? At large doses this can happen resulting in a loss of therapeutic effect over time. Neutralizing antibodies have been reported in 3-5% of patients with cervical dystonia (torticollis) Resistance to Botox in individuals treated for cosmesis and hyperhydrosis has not been reported.

What Does Botox Look Like When Botox comes in the mail from the manufacturer Allergan it is a fine dry gray powder packed on dry ice. (it looks like there is nothing in the bottle) Botox must be refrigerated Once a patient is selected, it is mixed with a sterile saline preservative and should appear colorless and free of particulate matter.

How Long Does Botox last in the Bottle? Botox will last you 6 months in the refrigerator as long as it is not mixed and is still in powder form. Once mixed with sterile saline it lasts 6 weeks If non-sterile saline is used you must use the Botox within 24 hrs or waste it. Bottom Line----always mix it with sterile saline !!! Sterile saline is inexpensive but Botox is not

How Much is BOTOX for my office? You can order Botox from Allergan and it comes in several sized vials. You can get a 50 units or about $250 or a 100 unit vial for $500 Most places that inject Botox have a 50 percent mark up for patients It is a good idea to order small amounts at first as once it is mixed you need to find a patient to use it on or it cuts into your profit quickly

Botox Approved Applications Strabismus Blepharospasm---in patients greater than 12 years of age Cervical Dystonia (Tortacollis) Glabellar lines Chronic Headaches (Migraines) Hyperhidrosis (this application typically lasts 9 months)

Strabismus—Crossed eyes is a condition in which the eyes are not properly aligned with each other. It typically involves a lack of coordination between the extra ocular muscles, which prevents bringing the gaze of each eye to the same point in space Strabismus can be either a disorder of the brain in coordinating the eyes or a disorder of the strength of eye muscles. Botulinum Toxin (Botox) may also be used in the treatment of strabismus by improving vision and to improve cosmetic appearance. To perform treatment Botox is injected into the stronger muscle, causing temporary paralysis and causing a more symmetric appearance and allowing convergence of gaze. Usual amount 15 units

Blepharospasm benign essential blepharospasm is a neurological movement disorder involving involuntary and sustained contractions of the muscles around the eyes. The cause is unknown, but fatigue, stress, or an irritant are possible contributing factors. Botox injections have been used to induce localized, partial paralysis. Among most sufferers, botolinum toxin injection is the preferred treatment method Usual amount is around units

Cervical Dystonia Spasmodic torticollis is a chronic neurological movement disorder causing the neck to involuntarily turn to the left, right, upwards, and/or downwards. The condition is also referred to as "cervical dystonia". There are several treatments for spasmodic torticollis, the most commonly used being botulinum toxin injections in the dystonic muscle of the neck I have not seen a patient treated for this with Botox and would only consider it if NSAIDs, muscle relaxers, OMT and PT are unsuccessful as BOTOX would be an expensive approach. There is also risk in treated a patient with Botox in the neck (many important things here)

Glabellar lines on April 12, 2002, the FDA announced regulatory approval of botulinum toxin type A (Botox Cosmetic) to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows (glabellar lines). Subsequently, cosmetic use of botulinum toxin type A has become widespread with many celebrities viewing it as less intrusive and/or artificial than other types of plastic surgery Injection into the Glabella is not difficult. There is little subcutaneous tissue here and the muscle is easy to find. Usual dose is units

Glabella Continued While injecting the muscle is not difficult it is important to remember to stay out of the orbital rim. You do not want to create ptosis Also stay one finger widths above the eyebrow so that you do not make them droop. (real eyebrows not pencil eyebrows).

Headaches FDA approval for treatment of chronic migraines on October 15, The toxin is injected into the head and neck to treat these chronic headaches. Approval followed evidence presented to the agency from two studies funded by Botox maker Allergan, showing a slight improvement in incidence of chronic migraines for migraine sufferers undergoing the Botox treatment.

Who Should get Botox for Headaches? A patient who is refractory to Triptans, and other conventional methods. Most insurance companies will not pay for BOTOX unless many other avenues have been explored (and even then some just flat don’t pay) The forehead is traditionally injected first to see if this aids in preventing headaches as the approach is easier and less costly than injecting near the posterior occiput.

Hyperhidrosis While treating patients with hemifacial spasm at Southend Hospital in England in 1993, Khalaf Bushara and David Park were the first to show that botulinum toxin injections inhibit sweating. This was the first demonstration of non-muscular use of BTX-A. Due to this research, Botox was later approved for the treatment of excessive underarm sweating. (hyperhidrosis) If we all remember back from Medical School sweat glands are the only sympathetic cholinergic glands in the body. Usually our fight or flight response is thought of as being related to Eppi and Norepi

Hyperhydrosis continued Hyperhydrosis is the only application of Botox where we are not injecting the muscle. We are now aiming for sweat glands with our injections. The most common place to inject for hyperhydrosis is the axilla It usually takes around units per axilla to make a significant difference and this application does cause more pain with injections as there is more swelling of the skin (more sensitive). It is important to use many needles and syringes with small amounts of BOTOX to avoid dulling the needles. I pinch or tent the skin between my fingers for two reasons……to keep my needle from going deep (near brachial plexus and other important vessels) and to decrease the sensation of pain with the needle stick.

How do I know where the sweat glands are? More Chemistry…….Fun!!! Use Betadyne thickly over the axilla and place corn starch over the entire area. Allow this to sit for 1-2 minutes. The sweat glands will produce a black reaction to the skin. Have the patient shake off the excess powder and you are ready to inject (this is messy so put down towels first) I like to inject with sterile gloves in a grid pattern about one to two units of Botox every square cm. The patient will notice results in 72 hrs. Make sure they are not planning to wear white for a few days as the yellow betadyne and dark corn starch can seep out of pores for a while. ( I would say 2 weeks before a wedding)

Sweat Glands

Off Label Uses of Botox—For the adventuresome Other facial lines Platysma Bands Bruxism Back and Neck Spasms Other spastic conditions---esophagus, bladder, vascular, anal fissure, clubfoot.

Facial Lines Forehead--- Usually units. You need to remember to stay one finger above the eyebrow and to inject between the lines. Remember we are injecting muscles….not chasing lines. I like to inject more medial for women as it creates a nice brow lift (make it and even spread for men as a brow lift looks less than manly). Crows Feet —Stay out of the orbital rim and be realistic. You are only smoothing muscle not getting rid of fine lines. These are sometimes better injected with dermal fillers (whole new talk). Use technique to point the needle away from the eye.

Platysma Bands The Platysma is a muscle that is a broad sheet arising from the fascia covering the upper parts of the pectoralis major and deltoid; its fibers cross the clavicle, and proceed upward and medially along the side of the neck. By injecting Botox into this thin muscle you can reduce the fine lines often noted in the neck as we age. RESERVE THIS ONE FOR HOUDINI……YOU PROBABLY REMEMBER THIS MUSCLE FROM CADAVER LAB (OR LACK OF THIS MUSCLE) WHEN IT COMES TO THE NECK I LIKE DERMAL FILLERS ALL THE WAY!!

Bruxism-- grinding teeth is characterized by the grinding of the teeth and typically includes the clenching of the jaw. It is an oral activity that occurs in most humans at some time in their lives and can be worsened by stress or fatigue In most people, bruxism is mild enough not to be a health problem but is one of the most common sleep disorders In the treatment of bruxism, Botox weakens the muscle enough to reduce the effects of grinding and clenching, but not so much as to prevent proper use of the muscle (not sure how much Botox is used as I have not seen this application)

Back and Neck Spasms Botox is often used by orthopedic and neurology specialists to decrease spasm in paraspinal muscles that boarder our vertebrae. These specialized injections are targeted at relieving pain in small joint segments. This can truly help patients with post-operative pain or scoliosis. (I have not seen this used)

Other spastic conditions Botulinum toxin A can also be injected into muscles that are either spastic or have contractures, the aim being to relieve the disability and pain produced by the inappropriately contracting muscle. This can help treat: cerebral palsy, spastic quadriplegia or any movement disorder with spastic or stiff muscles I do have a patient with severe CP who was so spastic he could not walk with braces or crutches and now can use a walker instead of a wheelchair due to the greatness of Botox

Who is not a candidate for Botox? People who have: – Myasthenia Gravis, Lambert-Eaton Syndrome, ALS – Pregnant or breast feeding – Allergy or sensitivity to Botox – Marked facial asymmetry, ptosis or other anatomic defects – Infection of the skin – History of facial nerve palsy (Bells Palsy)

Botox Rules In general the use of BOTOX poses few risks. BOTOX may cause temporary headaches, bruising or temporary drooping of the eyelid. Certain antibiotics—Levaquin, Cipro or Clindamycin—shorten the therapeutic effect of BOTOX…..it is unclear as to why but the theory is that these antibiotics decrease the affinity of the Botox to stay bound to the muscular junction.

Most Common Complications Most are largely aesthetic (Patients like pre-treatment appearance better) Asymmetry Flattened brow or brow elevation Upper eye lid ptosis

Can Cosmetic side effects be “fixed” If you happen to have drooping eyes (ptosis) following an eye treatment eye drops known as Iopidine can be used to help elevate the upper eyelid by 1-3 mm Additional Botox can be used on one side of the face to aid in fixing any asymmetry that may result

Cosmetic Botox and Patient $$ We all age differently and have different attitudes about what we're willing to do about it. Let's start out with one thing from the start. There are "needs" and "wants" when it comes to our personal health. Cosmetic enhancement is a "want.“ What do I tell patients……………..

Broken on the Inside I'd never want to fly a plane that looked nice on the outside but was mechanically unsound on the inside—and neither should you.

Katie Holmes Age Progression

Look Good for You There are good reasons and bad reasons for wanting to look good. Good reasons include, wanting to look good for "your self." It's not reasonable to think that these products will improve your love life or your marriage. They may help give you more self confidence—and that can be a good thing as long as your self-confidence doesn't rest entirely on an enhanced appearance. Remember that cosmetic enhancement can't reverse aging—it can only reverse some of the outward appearances of aging.

Botox or Bust Anyone who considers any type of cosmetic procedure needs to balance the potential benefits, risks and costs. It's nice to look our best but not at the risk of our overall health, financial ruin and our children's college education.

Why I Love Botox Cosmetic With all of that being said……..I love Botox and all things girly…..make-up, shoes, and nails I think of Botox as yet another way to enhance natural beauty

Judge for Yourself

How is Botox administered? Botox is given by fine needle injection. The number of injections will depend on the number of areas you wish to have treated. Most women say that the pain is minimal. A typical treatment takes minutes—again, depending on the number of areas you wish to have treated.

Proper Injection Sites

What Can I Expect If I am a Patient? There may be some temporary swelling and occasional bruising. The swelling typically lasts a few hours so you don't want to have this done just before an evening out on the town. After treatment you should squint or use the muscles treated but don't massage the injection sites. It's important that you don't lie down or bend over for 4 hours after injection. I generally ask women to not exercise for 4 hours afterwards as well. (other than use of treated muscles)

How long does it last? For most women BOTOX seems to last 3-4 months. The effects wear off gradually and you'll be the best judge of when to come in for your next appointment. About 9 Months for Axillary injections.

Is There anything else I should know? Avoid aspirin and non-steroidal anti-inflammatory drugs (Ibuprofen, Advil, and Aleve) for at least one week prior to your planned treatment. This will reduce the possibility of bruising afterwards. Also, avoid Ginkgo and ginseng, Vitamin E, Fish Oil supplements and red wine for two days prior to treatment—again to avoid bruising. (our office advises to avoid alcohol, aspirin and NSAIDS which is usually sufficient)

Botox Before and After

I am ready for Botox…now what? Finally, in closing, be realistic and establish a budget! Botox can improve your Patient’s lives and your pocketbook but do it because you love it.