Botulinum Toxin Injection

Aka: Botulinum Toxin Injection, Onabotulinum Toxin A, Onabotulinumtoxin A, Abobotulinum Toxin A, Botulinum Toxin Type A, Botox

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II. Indications: Cosmetic

  1. Dynamic facial lines and Wrinkles in the upper one third of the face
  2. Frown lines (Glabellar lines, FDA approved as of 2002)
    1. Vertical Wrinkles between the eyebrows
    2. Dynamic Wrinkles are most amenable to treatment (although static Wrinkles will also improve with treatment)
    3. Treatment of the Glabellar complex (Corrugator supercillii, procerus and depressor supercillii Muscles)
  3. Crow's Feet (lateral orbiocularis oculi lines, FDA approved as of 2013)
    1. Wrinkles eminating laterally from lateral canthus region
    2. Treatment of the lateral obicularis oculi Muscle
  4. Horizontal forehead lines (frontalis lines)
    1. Treatment of the frontalis Muscle
  5. Vertical Neck Lines (Platysma bands)

III. Indications: Neurologic

  1. Blepharospasm (first-line treatment, Botox or Xeomin)
  2. Cervical Dystonia (Dysport or Mybloc)
  3. Spasticity in Adults
  4. Chronic Migraine Headache (>15 days/month for at least 3 months)

IV. Contraindications: Botulinum Toxin Injection

  1. Body Dysmorphic Disorder
  2. Unrealistic expectations
  3. Career dependent of facial Muscle use (e.g. performers, vocal artists)
  4. Infection or dermatitis affecting the treatment area
  5. Pre-existing motor deficit in the treatment area (Bell's Palsy)
  6. Immunocompromised state
  7. Keloidal scarring
  8. Neuromuscular condition (e.g. ALS, Myasthenia Gravis)
  9. Pregancy or Lactation
  10. Allergy to components of Botulinum Toxin
    1. Dysport is contraindicated in Cow's Milk Allergy

V. Mechanism

  1. Neurotoxin derived from Clostridium botulinum (cause of Botulism)
  2. Botulinum Toxin acts at Neuromuscular Junction and inhibits release of Acetylcholine
    1. Cleaves SNAP-25 (synaptosomal-associated Protein, 25 kDA) on Neuronal membrane
    2. SNAP-25 destruction prevents Vesicle fusion and Acetylcholine release
    3. SNAP-25 ultimately regenerates, resulting in a waning of effect over time
  3. Injection into overactive facial Muscles results in localized Muscle relaxation
    1. Smooths overlying skin and reduces Wrinkles
    2. Facial Muscles are uniquely attached to skin via superficial muscular aponeurosis
      1. Unlike most Muscles, which typically attach to bone via tendons
      2. Dynamic Wrinkles form perpendicular to the direction of Muscle Contraction
        1. Dynamic Wrinkles are most responsive to Botulinum Toxin
        2. Static Wrinkle treatments yield a slower response (deep static Wrinkles may require fillers)

VI. Preparations

  1. Precautions
    1. All toxin formulations contain the same 150-kDA core toxin
      1. Formulations differ by the Protein complexes that surround the 150-kDA core toxin
    2. Botulinum Toxin preparations have similar clinical effectiveness despite Differing Protein formulations
      1. In vivo, the Protein complexes dissociate from the active 150-kDA core toxin
    3. Botulinum Toxin preparations are NOT interchangeable
      1. Differences in concentration/potency, formulation and effects do not allow for standardized substitution
  2. Botulinum Toxin serotype A (most common serotype used for cosmetic procedures)
    1. Onabotulinum Toxin A (Botox)
    2. Abobotulinum Toxin A (Dysport), which also contains bovine Protein
    3. Incobotulinum Toxin A (Xeomin)
    4. Prabotulinum Toxin A (Jeaveau)
    5. Daxibotulinum Toxin A (Daxxify)
  3. Botulinum Toxin serotype B
    1. Rimabotulinum Toxin B (Mybloc)

VII. Dosing

  1. One treatment every 3-4 months

VIII. Advantages

  1. Brief procedure and highly effective

IX. Disadvantages

  1. Small margin of error for injection site

X. Approach

  1. Precautions
    1. Botulinum Toxin Injection should only be performed by providers trained in this technique
    2. The technique described here is for review only, and not intended to replace proper training
  2. Consultation
    1. Review alternative options (see Skin Cosmetic Procedures)
    2. Obtain "before" photographs (static and dynamic)
    3. Prioritize cosmetic interventions
    4. Set realistic expectations
    5. Identify preexisting asymmetry (e.g. eyebrow height, eye aperture)
    6. Review potential adverse effects and complications
    7. Use a handheld mirror to demonstrate regions of treatment
    8. Review medications that may risk complications (e.g. Aspirin, Anticoagulants)
  3. Preparation
    1. Reconstitute Botulinum Toxin powder in sterile Normal Saline immediately before injection
      1. Botulinum Toxin diluted with 1-4 ml saline per 100 unit vial
      2. Draw solution into a tuberculin syringe or similar (1 ml) and apply a 30 gauge needle (1/2 or 1 inch)
    2. Anesthetic (e.g. Lidocaine) is NOT typically used
      1. Patient should be prepared to expect localized singing and burning in the region of injection
      2. Consider ice or Topical Ointment to sensitive areas of injection
        1. Topical LET gel (Lidocaine, Epinephrine, tetracaine)
        2. BLT ointment (Benzocaine/Lidocaine/Tetracaine)
  4. Technique: Frown Lines (Glabellar Complex Muscle injection)
    1. Frown Line safety zone is marked
      1. Lateral iris to hairline bilaterally
      2. From inferior (below Glabellar prominence by 1 cm) to superior (above supraorbital ridge by 2 cm)
    2. Patient actively frowns
    3. Inject each of five sites
      1. Procerus Muscle (1 injection)
      2. Bilateral corrugator supercillii Muscles (4 injections total, 2 for each Muscle body)
  5. Aftercare
    1. Patient should stay upright (not supine) for at least 4 hours after procedure
    2. Patient should avoid massaging or applying heat to the area on the day of the procedure
    3. Patient should avoid Exercise, Alcohol or other activities that cause Flushing on the day of the procedure
  6. Follow-up (at 2 weeks)
    1. Effects will evident by day 3 following the procedure, maximal by 2 weeks and start to diminish at 3-4 months
    2. Obtain "after" photographs (static and dynamic)
    3. Evaluate effects and adverse effects

XI. Adverse Effects

  1. Injection reaction
    1. Injection site erythema, edema or tenderness (resolve within 24 hours)
    2. Bruising (may persist for up to 2 weeks after injection)
    3. Apply cool packs to the area after procedure to reduce swelling and Bruising
  2. Mild Headaches (15% of patients)
    1. More severe Headaches that last weeks are less common
    2. Treat with NSAIDs
  3. Collateral effects of adjacent Muscles (transient)
    1. Blepharoptosis (upper Eyelid droop)
      1. Consider Naphazoline 0.025%/Pheniramine 0.3% (Naphcon-A or Opcon-A) 1-2 drops four times daily
      2. Intraocular Alpha-2 Adrenergic Agonist (e.g. Apraclonidine) may considered in severe cases
    2. Eyebrow Ptosis (frontalis Muscle effects)
    3. Facial asymmetry (uneven dosing)
  4. Other uncommon to rare adverse effects
    1. Infection (<0.01% Incidence)
    2. Paresthesias or dysesthesia from nerve injury (<1%)
    3. Hypersensitivity Reaction including Anaphylaxis (<0.1%)
    4. Botulism toxicity (large doses in non-cosmetic injection)
      1. See Botulism
      2. Specialty Consultation
      3. Pyridostigmine 60 mg orally three times daily may be considered

XII. References

  1. Carruthers (2004) Plast Reconstr Surg 114(6 suppl): 1s-22s [PubMed]
  2. Neurology (2016) 86(19): 1818-26 [PubMed]
  3. Small (2026) Am Fam Physician 113(5): 449-56 [PubMed]
  4. Small (2014) Am Fam Physician 90(3): 168-75 [PubMed]
  5. Small (2009) Am Fam Physician 80(11): 1231-8 [PubMed]
  6. Wise (2006) Facial Plast Surg 22(2):140-6 [PubMed]

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