1. BY: MAICA GALVEZ-VERGARA M.D.
BOTULINUM TOXIN
BY:
MAICA GALVEZ-VERGARA M.D.

2. Botulinum toxin type A neurotoxin protein Clostridium botulinum
Gram-positive rod shaped anaerobic spore-former bacterium
Botulism Latin botulus = "sausage shape”
food poisoning

3. Common Indications for Bt-A
Spasmodic Torticollis
Blepharospasm
Hemifacial Spasm
Post-Stroke Spasticity
Cerebral Palsy
Dystonia
Various movement disorders
Aesthetics (Wrinkles)
Hyperhidrosis
Square face and other remodelling indications
Spasmodic dysphonia
Myofascial and other Pain
Headache, migraine
Drooling
Etc., etc., etc.

4. Structure of Botulinum Toxin
Disulfide bond
Light chain:
the molecule’s toxic fraction
Heavy chain:
responsible for specificity
of each serotype
Botulinum Toxin is inactivated by heat

5. Mechanism of Action
Botulinum Toxins block the exocytosis of acetylcholine at the motor endplate, thereby making neuromuscular transmission impossible

6. The mechanism includes 3 stages

7. Binding to the Presynaptic Membrane

8. Internalization of the Toxin

9. Inhibition of Exocytosis of ACTH
SNARE (SNAP receptor proteins)
SNAP-25 (SyNaptosomal Associated Protein 25 kDa
syntaxin
Synaptobrevin or VAMP
(Vesicular Associated Membrane
Protein)

10. Recovery by Neuronal Plasticity

11. ADVANTAGES: Safe and rapidly administered Effects are profound
99% successful
Painless
No recovery time
Technically straightforward to use
Effects are reversible w/in an acceptable limit of time
Complications are rare and self-limiting

12. Irreversibility or length of therapeutic effect.
DISADVANTAGES:
Irreversibility or length of therapeutic effect.

13. CONTRAINDICATIONS
Hypersensitivity to ingredients ( albumin, sodium chloride botulinum toxin )
Neuromuscular dx. (myasthenia gravis, motor neuron disease)
Patients treated with other drugs that may interfere with
neuromuscular transmission; aminoglycosides, polymixins, penicillamine, quinine, calcium channel blockers neuromuscular blocking agents.
Pregnancy and lactation
Patients in anti-coagulation therapy
Inappropriate anatomy ( skin laxity photo damage )
Poor psychological adjustment

14. Bt-A Indications in Aesthetics
Dynamic wrinkles of the glabella
Dynamic wrinkles in the forehead
Dynamic wrinkles around the eyes (« crow’s feet »)
Slight facial asymmetry
Wrinkles in the area around the platysmal muscle and the neck

15. Other Indications for Bt-A in Aesthetics.
Hyperhidrosis
underarms
palms

16. Square face and other remodelling indications
Gummy smiles
Calf contouring
Meso Botox

17. Different BTXA’s Botox - Allergan Irvine, CA BTXA - Lanzhou, China
Refinex - China
Dysport - Wrexam, Wales UK
Korea – Neurotox, Zentox, Botulax
Xeomin (incobotulinumtoxinA) Merz Pharmaceuticals, North Carolina

18. Dose BTXA – 2-4 units per injection site. Allergan China and Neurotox
Dysport – 5-10 units per injection site.
100 units/vial
Dilute to 2.5cc of NSS to make 2units of .05ml tuberculin syringe.
500 units/vial
Dilute to 2.5cc of NSS to make 5units of .05ml tuberculin syringe.

19. Pharmacokinetics Time to action: 24 to 72 hours
Time to peak: 8-15 days after
Duration of action: months (longer in certain indications
After about the 7th injection, this period is significantly prolonged

20. TOXICITY
2500 TO 3000 units in a 70kg human based on the median lethal dose of 40 units / kg.
Single dose of 500 units may produce acute symptoms and signs of botulism.

21. Facial Muscles Frontalis> elevates brows. Forehead lines
Corrugators> pull eyebrows medially Procerus, Depressor supercilli> pulls eyebrow down medially. Frown lines
Orbicularis oculi> depresses brows esp. laterally. Crows feet

22. Dynamic wrinkles of the forehead

23. Korean Recommendations

29. Axillary hyperhydrosis
Positive starch-iodine test.
50 units to 100 units/ axilla.
Palmar hyperhydrosis
50 units to 100 units/
hand.

30. COMPLICATIONS

31. Areas To Avoid Around the orbit (less than 1 cm)
Lateral area of the brow less than 1 finger breath
Lower eyelid – Neg. Snap test
Lower face (nasolabial)
Around the mouth

32. Rare Secondary Effects
Pain, burning sensation
Hematoma, edema
Ptosis, drooping of eyelid- naphcon A or apraclonidine 0.5% eye drops.
Always REVERSIBLE and related to dose and
individual sensitivity of each patient

33. MEPHISTO LOOK…. SPOCK Usually resolves in weeks
May consider injection at the arch, lateral side to bring down the brow.

34. FROZEN EXPESSIONS

35. LOCAL PAIN SWELLING EDEMA ERYTHEMA HEMATOMA RASH BRUISING ECCHYMOSIS
TENDERNESS
HEADACHE
SHORT TERM PARESTHESIA

36. REGIONAL ASSYMETRY LOSS OF FACIAL EXPRESSION
INCOMPLETE MUSCLE PARALYSIS

37. SYSTEMIC NAUSEA FATIGUE SEVERE GENERALIZED WEAKNESS MALAISE
FLULIKE SYMPTOMS
ALLERGY 2NDARY TO ALBUMIN

38. POINTS TO PONDER KNOW YOUR ANATOMY WELL. KNOW YOUR PRODUCTS WELL.
KNOW YOUR PATIENTS WELL IF POSSIBLE.
USE MINIMUM DOSAGING.
FOLLOW UP IN 2 WEEKS.
ALWAYS TAKE BEFORE AND AFTER PICTURES.

39. THANK YOU
VERY MUCH !!!