1. Kathleen Connolly Grand Canyon University October 9, 2013

2. The Art & Science Of Botulinum Toxin A & Dermal Filler Implantation Baby Boomers (people born between 1946-1964) are reaching middle age Unlike other populations, they refuse to let the aging process define them Physical appearance is very important to many people in this population People are now more open about cosmetic procedures The stigma associated with cosmetic procedures has decreased greatly People want to look and feel more youthful

3. Treatment Options There are 7 serologically different neurotoxins produced by Clostridium Botulinum bacteria (A, B, C, D, E, F & G). Botulinum Toxin Type A = Most potent. Only Botulinum A & B are available for clinical use FDA Approved on April 15, 2002 for moderate-severe horizontal forehead lines, glabellar, and eye areas (crow’s feet).

4. Top Six Most Popular Cosmetic Non-surgical Procedures, 2008 1.) Botox5,014,446 2.) Dermal Fillers2,703,005 3.) Chemical Peels1,048,577 4.) Laser Hair Removal891,712 5.) Microdermabrasion841,733 6.) Vein Treatments375,328

5. Botulinum Type A A Highly refined purified protein Absolutely no live bacteria The injection can not give you an infection (such as botulism) The toxin blocks the nerve impulse that controls muscle movement Restricts the patient’s ability to contract the facial muscles No contraction= no movement= no wrinkles! Results typically last 3-6 months

6. Mechanism Of Action Creates a paralyzing effect Botulinum Toxin A actually effects the nerves, not the muscles Botulinum Toxin A prevents the release of acetylcholine The muscle itself is not altered Does not alter sensory nerves Therefore, it does not make the skin numb Once the product wears off, wrinkles return, but are not any worse than before the treatment.

7. Common Areas Treated Used in the treatment of facial lines that result form a pull for the muscles from expression Known as dynamic wrinkles (wrinkles in motion) Successful in treating the upper third portion of the face Primary areas: Glabellar (frown lines between the eyebrows), horizontal forehead lines, and the Lateral Canthal areas (crow’s feet /outer eye areas ). Also used for treatment of migraine or tension headaches (relaxes muscle tension)

8. Some Possible Side Effects: Ecchymosis: associated with any type of injection Transient headaches Swelling Pain Edema at injection site Infection Rhinitis Nausea Muscle weakness Hypertension Flu-like symptoms Diplopia, Double vision, and Lip Ptosis

9. Contraindications Dermatitis or infection at site to be treated Marked Facial Asymmetry (i.e. Bells Palsy) Deep Dermal Scarring Severe Anxiety related to needle pain Currently using antibiotics and /or aminoglycosides Natural eyelid Ptosis (present with a non-arched eyebrow) Patients who have undergone facial surgery, recent blepharoplasty or CO2 laser resurfacing Pregnant and /or Lactating women Hypersensitivity to any ingredient in Albumin (human blood product) Neurologic Disorders ( Myasthenia Gravis, Parkinson’s Disease, Multiple Sclerosis) Fever, Flu, or Cold symptoms

10. Soft Tissue Augmentation Dermal Fillers Fillers can be classified into two main categories: 1.) Permanent 2.) Non-permanent Other classifications include: 1.) Biodegradable or non-biogradegradable 2.) Animal or non-animal 3.) autologous or non-autologous

11. Permanent Filler Products Artefill (Artecoll): Approved in 2007, and contains Bovine Collagen Silicone (Silikon 1000) FDA approved for Ophthalmology Biopolymers, Silica based (not available in the US)

12. Common Temporary Filler Products Juvederm Ultra: FDA approved in 2007 Restylane: Approved by the FDA: December, 2003 Perlane: Approved by the FDA: May, 2007 These are all hyaluronic acids: they are degradable and dissipate over time. They are non-animal based, no skin testing required.

13. Precautions Caution should be used with: Patients on immunosuppressive therapy Patients on Nsaids and /or Aspirin Hypersensitive patients Patients who have recently had overexposure to UV rays

14. Contraindications In patients with severe allergies and a history of anaphylaxis Patients who are allergic to gram positive bacterial proteins Should not be injected into a blood vessel Patients with known susceptibility to keloid formation or hypertrophic scarring Pregnant or Lactating women

15. Possible Side Effects Hyaluronic Acid based products (Juvedrem, Resrylane, Perlane) can cause: Erythema Swelling Mild pain /discomfort Itching Discoloration Tenderness Pruritis Nodules

16. The Consultation Individual Facial analysis Listen to what the patient is unhappy about (with their appearance) Obtain a medical history Timing of treatment Assess the patient’s need for pain management Communicate that tough-ups made be needed Cost of treatment Realistic results of the treatment Before and after photos Obtain an Informed Consent

17. What Can Fillers Do? 1.) Fill in lines (smile lines, nasolabial folds, perioral lines, marionette lines. 2.) Fill in scars 3.) Restore the contours of the lips 4.) Add fullness to the face (cheeks, cheekbones, lips. Chin, above the eyebrows, under the eyes)

18. Talk to your health care professional about…… The various options Determine what facial areas you may want to enhance Your health history Risks and benefits of various treatment options Prior treatments and procedures

19. Any Questions?????

20. References Dover, J.S. (2005). Clinical use of Restylane. Skin Therapy Letter. 10 (1): 5-7 Retrieved from: http//www.medscape.com/viewarticle/500823 Parker, S. (2008). The Art and Science of Dermal Filler Implantation. Esthetic Skin Institute. Ft. Lauderdale, FL Parker, S. (2008). The Art and Science of Botulinum Toxin A. Esthetic Skin Institute. Ft. Lauderdale, FL. Vartanian, J., Frankel, A., & Rubin, M. (2008). Injected Hyaluronidase Reduces Restylane-Mediated Cutaneous Augmentation. ARCH Facial Plastic Surgery Vol 7, pgs. 231-237