Botox pearls, perils, and pitfalls. Patient comfort. Patient comfort. Higher doses give longer results. Botox (onabotulinumtoxina) starting doses

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1 Botox pearls, perils, and pitfalls Ronald L. Moy, M.D, Beverly Hills, CA No financial conflicts of interests. Botox before Botox after Risks, rewards, happy, unhappy- higher doses, fewer injection sites, better value Patient comfort Chill skin with ice pack before treatment or Zimmer cold air Relaxed environment, spa like Reconstituted Botox or Dysport with preserved saline Topical anesthetic, 32 guage needle Distraction- Fewer injection sites Patient comfort Extra measure for sensitive patients The glabella often can have large follicular orifices Building on the idea of injecting lidocaine for local anesthesia into Follicular orifices which can often reduce pain, why not BoNTA? Single physician injector, 12U per patient to the glabellar complex, 20 patients Significantly reduced pain scores (p=.046) for right corrugator and trend toward significance in procerus and left corrugator Intrafollicular orifice injection technique for botulinum toxin type A. Lewis T, Jacobsen G, Ozog D. Arch Dermatol Dec;144(12): Botox (onabotulinumtoxina) starting doses Forehead Glabella Crow s feet Botox (BTX-A) 20 U 20 U (males may require more) 12 U per side Carruthers JD, Lowe NJ, Menter MA, Gibson J, Eadie N. Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines.plast Reconstr Surg Sep 15;112(4): Yamauchi P, Lowe N. Botulinum toxin types a and b: comparison of efficacy,duration, and doseranging studies for the treatement of facial rhytides and hyperhidrosis. Clinics in Dermatology 2004;22: Lowe N, Ascher B, Heckmann M, et al. Double-blind,randomized,placebo-controlled, dose-response study of the safety and efficacy of botulinum toxin type a in subjects with crow s feet. Dermatol Surg 2005; 31(3): Higher doses give longer results Carruthers A, Carruthers J, Cohen J. A prospective, double-blinded, randomized, parallel-group, doseranging study of botulinum toxin type A in female subjects with horizontal forehead rhytides. Dermatol Surg 2003; 29(5): Comparing efficacy and safety of three doses of BTX-A in females with horizontal forehead rhytides. Improvements at all dosages (16U, 32U, 48U) Higher dosage gave longer duration Highest dose 48U (24U to forehead) greater efficacy and longer duration of effect. 1

2 Dosing BTX-A vs Dysport Botox Dysport Onabotulinum-toxinA Abobotulinum-toxinA 1 U 2-4 U Karsai S, Raulin C. Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology. Dermatol. Surg. Jan 2009; 35(1):1-8. Complications Avoid ASA, NSAIDs if possible. Compression > ice after injecting Intradermal injections to avoid venous plexus at lateral orbital rim Niamtu J. Complications in fillers and botox. Oral Maxillofac Surg Clin North Am. Feb 2009;21(1): Management of Crow s feet Three Traditional injection sites Crow s feet Mang W. Manual of aesthetic surgery-1. Springer Sadick N. The cosmetic use of botulinum toxin type B in the upper face. Clinics in Dermatology 2004;22:29-33 Crow s feet Our technique Survey for Prominent Veins Single intradermal injection 12 U Botox per side Superficial bleb 2

3 Superficial Injections Careful placement of single superficial injection in the middle of the crow s feet Single intradermal injection 36U each side Dysport abobotulinum toxina for Crows Feet Crow s feet pre-treatment VIDEO Carruthers A, Carruthers J. Use of botulinum toxin type A in facial rejuvenation. Surgery of the Skin- Procedural Deramtology. Elsevier 2005; 506. Crow s feet post-treatment-requires higher doses Complications Treatment of orbicularis oculi can lead to migration to zygomaticus major and minor muscles. Inability to raise ipsilateral lip Carruthers A, Carruthers J. Use of botulinum toxin type A in facial rejuvenation. Surgery of the Skin-Procedural Deramtology. Elsevier 2005;

4 Anatomy Avoiding Purpura Counsel patient about the potential risk of bruising. Reminder at time of appointment Ensure that the patient is not at high-risk No anti-platelet medications ASA, NSAIDs, coumadin, herbal or vitamins No h/o bleeding disorder Periocular venous plexus Apply immediate pressure to injection site Have patient or assistant hold pressure for several minutes Consider ice-packs Hemostasis Forehead Mang W. Manual of aesthetic surgery-1. Springer Forehead Sadick N. The cosmetic use of botulinum toxin type B in the upper face. Clinics in Dermatology 2004;22:

5 Forehead Treat 1-2 cm above orbital rim to minimize risk brow ptosis Less toxin to lateral forehead 16 U onabotulinumtoxina (Botox ) Bassichis B, Thomas R. The use of botox to treat glabellar rhytids. Facial Plast Surg Clin N Am 2003;11: VIDEO Forehead Treat 1-2 cm above orbital rim to minimize risk brow ptosis Less toxin to lateral forehead 48 U abobotulinumtoxina (Dysport ) Forehead - Before Forehead - After Carruthers A, Carruthers J. Use of botulinum toxin type A in facial rejuvenation. Surgery of the Skin-Procedural Deramtology. Elsevier 2005; 506. Carruthers A, Carruthers J. Use of botulinum toxin type A in facial rejuvenation. Surgery of the Skin-Procedural Deramtology. Elsevier 2005; 506. Forehead Elderly may compensate for blepharocholasis with frontalis muscle. Caution with botox near brow Less like to use in elderly 5

6 Complications Nicholson/Spock Vartanian J, Dayan S. Complications of botulinum toxin A use in facial rejuvenation. Facial Plast Surg Clin N Am 2003;11: Leonard Nimoy as Spock Star Trek 1966 Complications Complications Insufficient placement toxin lateral forehead allows unopposed elevation lateral brow. Correction: 3-4U Botox or 9-12U Dysport at lateral brow. Niamtu J. Complications in fillers and botox. Oral Maxillofac Surg Clin North Am. Feb 2009;21(1):

7 BoTxA: Brow Lift BoTxA: Brow Lift If lateral eyebrow lift added Hexsel D, Dal Forno T. Type A botulinum toxin In the upper aspect of the face. Clinics in Dermatology 2003;21: Glabella Traditional injection sites Mang W. Manual of aesthetic surgery-1. Springer Botox dosing glabella Carruthers A, Carruthers J, Said S. Dose-ranging of botulinum toxin type A in the treatment of glabellar rhytids in females. Dermatol Surg April 2005;31(4): Comparison of efficacy, safety and duration of effect of four doses BTX-A in glabellar rhytids in females U of BTX-A is significantly more effective than 10U for reducing glabellar lines. Glabella Our Technique Single injection into each corrugator Glabella Our Technique Single injection into each corrugator 20U Botox 60U Dysport average dose in females Pena M, Alam M, Yoo S. Complications with the use of botulinum toxin type A for cosmetic applications and hyperhidrosis. Semin Cutan Med Surg 2007;26: VIDEO 20U Botox or 60U Dysport starting doses in females 7

8 Glabella Before 20U onabotulinum toxina Glabella After 20U onabotulinum toxina Glabella Before 24U onabotulinum toxina Glabella After 24U onabotulinum toxina Glabella Males may require more toxin due to larger corrugator muscle Mang W. Manual of aesthetic surgery-1. Springer

9 Glabella-post treatment Complications Eyelid ptosis Prevention-inject 1 cm above orbital rim Niamtu J. Complications in fillers and botox. Oral Maxillofac Surg Clin North Am. Feb 2009;21(1): Mang W. Manual of aesthetic surgery-1. Springer Glabella needle direction 30 patients total (15 placebo), 10U to each corrugator 15 placebo patients crossed over to receive BTX. Injection delivered upward & lateral-(1/10) 10% ptosis, Injection delivered downward & medial-(2/5) 40% ptosis Blepharoptosis Carruthers A, Lowe N, Menter A, et al. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. JAAD 2002 June 46 ( 6): Blepharoptosis in 5.4% (11/203) of patients. 4 cases of moderate blepharoptosis with average duration 40 days. No cases of complete ptosis. Lowe N, Maxwell A, Harper H. Botulinum A exotoxin for glabellar folds: a double-blind, placebo-controlled study with an electromyographic injection technique. JAAD October 1996;35(4): Blepharoptosis Moy R, Maas C, Monheit G et al. Long-term Safety and Efficacy of a new Botulinum Toxin Type A in Treating Glabellar Lines: Results from a Phase 3, Open-label Extension Clinical Trial. Arch Facial Plast Surgery Open label phase 3 clinical trial of 1200 subjects receiving new BTX-A (Reloxin) over 13 months. 45 subjects had a total of 55 events of ptosis during the study after 4,214 treatments with BTX-A (1.3%.) Treatment lid + brow ptosis Apraclonidine 0.5% or phenylephrine 2.5% ophthalmic solution, 1-2 drops to affected eye TID. (Apraclonidine 1% also available; may consider increased dose and/or frequency.) Alpha-adrenergic receptor agonist Müller muscle: upper eyelid smooth muscle innervated by sympathetic nerves producing 1-2 mm eyelid elevation Omoigui S,IreneS. Treatment of ptosis as a complication of botulinum toxin injection. Pain Medicine. 2005;6(2):

10 Treatment of eyelid ptosis 48y/o female with eyelid ptosis after Botox-A. h/o allergic reaction to alpha-adrenergic eyedrops. 60 mg oral pyridostigmine with 4-8 hours of relief of ptosis Slows breakdown of acetylcholine in neuromuscular junct Caution with S.E. of hypersalivation, N/V, diarrhea. Karami M, Taheri A, Mansoori P. Treatment of botulinum toxin-induced eyelid ptosis with anticholinesterases. Dermatol Surg Nov. 2007;33(11): Botulinum toxin and the facial feedback hypothesis: can looking better make you feel happier? Given: BoNTA treatments of the face can dampen negative expressions Facial feedback hypothesis: facial expressions can themselves create the internal and biologic experience of emotions Therefore: alterations that lead to more positive facial expressions may induce certain positive emotional states Also given: Emotional contagion is when one person s emotions can be transmitted to another person Conclusion: positive facial expressions aided by BoNTA lead to more positive internal emotions + happiness in those around the patient, and may result in improved mood and quality of life Alam M, Barrett KC, Hodapp RM and Arndt KA JAAD 2008; 58: 1061 review Conclusions Botox or Dysport work equally well Patient satisfaction hinges on results and comfort, perception, listening Avoid complications by preventing bruising, less injections and knowing the anatomy Dosage can affect how long it lasts and complications rmoy@ucla.edu Advances in facial rejuvenation: botulinum toxin type A, hyaluronic acid, dermal fillers, and combination therapies--consensus recommendations. Group of 20 experts, in review article format, examined : new treatment paradigms effect of combination HA and BoNTA on different facial zones examined rejuvenation in different ethnic groups Pearls: 80% of the consensus group now use HA fillers (malar augmentation) in combination with BoNTA in the peri-occular region group recommend using filler in the temporal hollow with BoNTA in the tail of the brow to enhance nonsurg. Browlifting skin over chin implants can dimple and 8U BoNTA can flatten mentalis and HA can smooth transitions Carruthers JD Glogau RG Blitzer A Plast Reconstr Surg 2008; 121:5s Treatment of crow s feet Counsel patients on the potential risk of bruising at the time of appointment Survey for prominent veins Place injections superficially and use one injection site Immediate pressure post-injection Ice packs Botulinum toxin A can positively impact first impressions. Photos of botox patients were taken in smiling and relaxed Poses both before and after BoTnA treatment Significant increases in first impression scores were seen In the BoTNA treated group for dating success, attractiveness and athletic success, but not occupational success Conclusion - Without BoNTA, I can still look ugly and be successful at in my practice? Dayan SH et al. Dermatol Surg 2008; 34:s

11 The effect of botulinum toxin type A on fullface intense pulsed light treatment: a randomized, double-blind, split-face study. Randomized, double blind, split face study of 8U in 8 injections of BoToA to one cheek and saline to the other side after full face IPL(560nm) Wrinkles and fine lines improved in cheeks treated with both modalities. Trend (not reached significance) toward improvement in erythema in Side treated with both modalities. Vasoactive neuropeptides? Carruthers J & A similar study on crow s feet treated with Btx and full face IPL in Derm Surg 2004 show better response to treatment when both modalities used Khoury JG, Saluja R, GoldmanMP Dermatol Surg 2008; 34:1062 Improvement in both Raynaud disease and hyperhidrosis in response to botulinum toxin type A treatment. Patient with Raynauds & hyperhidrosis requested palmar hyperhidrosis treatment. 100 units of BoNTA to one hand with the other being a negative control After the injection of one palm, an 85% reduction in hyperhidrosis seen and a significant improvement in Raynaud symptoms. BoNTA-treated hand had reduced swelling, color change, and pain versus control hand. Crossover to other hand then had same results. BoNTA mechanism in Raynaud disease? Possibly. acetylcholine Noradrenaline substance P calcitonin gene-related peptide glutamate release from nerve terminals. Kossintseva and Barankin. J Cutan Med Surg 2008; 12: