PRE- READING COURSE MATERIAL ADVANCED BOTOX Module 2

Unit Overview Storage and shelf-life Cautions and contra-indications of treatment Reconstitution The treatment process Cosmetic indications for use - Foundation techniques (glabella, frontalis, crows feet) - Advanced techniques (bunny lines, neck lift, smokers lines, gummy smile, chin dimpling, hyperhidrosis) Technique Aftercare

Storage and Shelf-life Storage and Shelf Life: Each product has a different storage and handling profile. Refer to manufacturer instructions Botox should be delivered on dry ice Unopened vials of Botox must be stored in a refrigerator at 2-8 C Reconstituted Botox is kept refrigerated at 2-8 C Should be used within 24 hours (lack of preservative) Do not use if past expiration date / evidence of tampering

Cautions and Contra-indications Contra-indications: Aged under 18 years Known hypersensitivity to Botulinum toxin or any components within the chosen formulation Neuromuscular disorders (Myasthenia gravis, Eaton Lambert syndrome) Soft tissue infection Pregnancy Breast-feeding Contra-indicating medications (muscle relaxants, aminoglycosides, other medications that may interfere with neuromuscular transmission)

Reconstitution Different products need to be reconstituted differently (refer to manufacturer instructions) All products are reconstituted using 0.9% bacteriostatic Saline Examples from leading manufacturers listed in the table below Product type Units Excipients Volume 0.9% Saline (ml) Allergan Botox 50 HSA, NaCl 1 5 Galderma Dysport 300 HSA, Lactose 1.5 20 Merz Xeomin 100 HAS, Sucrose 2 5 Strength (Units / 0.1ml)

Dilution Table Botox (Cosmetic use) Reconstitution

Reconstitution Reconstitution Botox (Cosmetic use) ConFirm the product is appropriate for use (expiration date, hologram, no evidence of tampering) Draw up 1.1ml 0.9% bacteriostatic Saline (non-preserved) into the syringe using the 21G needle. Drawing up 1.1 mls instead of 1ml ensures that you reconstitute correctly and allow for the 0.1ml of the saline that you will lose in the tip of the needle Insert the needle into the vial and slowly inject the Saline Disconnect the syringe only (leaving the needle in the vial) and mix the Botox using gentle rotary movements. Do not invert the vial Attach the syringe and draw up the product Disconnect the syringe only from the drawing up needle, expel any air bubbles and attach the 30 gauge needle used for treatment Aseptic technique is crucial. Clinicians should practice good hand hygiene, wear gloves and ensure a clean clinical environment.

Reconstitution Tips for Reconstitution Botox (Cosmetic use) Check for the presence of the vacuum by piercing the seal of the vial with the needle (without the syringe attached) and listen for the audible hiss of air as the vacuum is released. This reassures you the product has not been tampered with and prevents the uncontrolled pull of Saline into the vial which can create bubbles Avoid vigorous shaking. Gentle rotation of the vial will help prevent bubbles Do not invert the vial to mix the product Allow for losses of Saline in the drawing up needle (i.e. draw up 1.1ml Saline to reconstitute with a 50 unit vial to produce 1ml product with a strength of 5 units/ 0.1ml).

1. Apply topical anaesthetic (e.g. EMLA cream) to the target areas 15 minutes prior to injecting 2. Position the client in a semiupright position on the examination table 3. Ensure you have appropriate lighting 4. Cleanse the target areas of the face using a non-alcoholic cleanser such as witch hazel 5. Mark out the injection sites as guided by the client s activity lines. (e.g. white pencil eyeliner) 6. Deliver the product into the target areas 7. Aftercare instructions The Treatment Process

The Treatment Process General Points: Treat any bleeding points with moist gauze / cotton pads and sustained pressure Remain receptive and aware of the client at all times, provide rest breaks and reassurance where needed Provide all aftercare instructions including contact details to arrange follow-up appointments

Cosmetic Indications for Use Indications for Use in the Aesthetic Client: Eliminate or reduce dynamic facial wrinkles Soften static wrinkles Create a lift The 3 most common treatment zones for Botulinum toxin

Cosmetic Indications for Use SpeciSic Treatment Zones / Indications: Glabellar complex (frown lines) Frontalis (forehead) Crows feet Bunny lines Neck lift (nefertiti technique) Smoker s lines Gummy smiles Chin dimpling Hyperhidrosis

Frontalis Contraction of these key muscles causes wrinkling of the overlying skin. Origin: galea aponeurotica along the coronal suture Insertion: into the dermis at the level of the eyebrows. No bony insertions.

Contraction of Frontalis

Foundation Techniques Forehead Lines ChieFly the result of the frontalis muscle (epicranius, occipitofrontalis and venter frontalis) Acts as a brow elevator

Glabella Complex Frontalis Procerus Depressor supercilii Corrugator supercilii Orbicularis oculi

Contraction of the Glabella complex

Foundation Techniques Glabella frown lines Principally caused by the activity of procerus muscle and the corrugator supercilii muscles Muscles depress the brow and draw the brows medially Minor contribution from frontalis, orbicularis oculi and depressor supercilii

Orbicularis Oris Frontalis Procerus Depressor supercilii Corrugator supercilii Orbicularis oculi

Contraction of Orbicularis Oculi

Foundation Techniques Crows feet The crows feet (or lateral canthal lines) are the product of the lateral aspect of orbicularis oculi Acts to depress the lateral brow

Foundation Techniques Key target areas for Botulinum toxin are dictated by activity lines produced by facial expression These include the glabella (frown) lines, horizontal forehead (frontalis) lines and crows feet (lateral canthal lines)

Foundation Techniques Key Principles Exact administration sites and doses should be tailored to suit the individual client, their unique pattern of dynamic and static activity and their main concerns Treatment regimen must support a balanced result (e.g. frontalis should not be treated in isolation to avoid a brow drop) Be receptive to any pre-existing asymmetry, highlight to the client and document. Aim to improve symmetry and cosmetic balance

Advanced Techniques Bunny Lines Wrinkles on the dorsolateral aspect of the nose which develop due to the activity of nasalis muscle Exaggerated in laughing / squinting Treat with <2.5 units in the body of each nasalis muscle

Advanced Techniques Neck lift (Nefertiti lift) This technique relaxes the muscular bands of platysma which can exaggerate the jowling effect and create the turkey neck appearance Botulinum toxin enhances jawline definition, softens jowls and creates a lift in the lower face Product is injected along the jawline and along the bands of muscle in 2.5 unit doses

Advanced Techniques Smoker s Lines These perioral lines are created by the activity of orbicularis oris that encircles the mouth Early smokers lines can be treated with Botulinum toxin Small doses (1.25 units) can be injected above the upper lip (>4mm superior to the vermillion border) Note deeper / static smokers lines may require dermal Filler treatment.

Advanced Techniques Gummy Smile In full smile, the aesthetic ideal is considered 90% incisor display and minimal gingival display A gummy smile (excessive gingival display) can occur through overactivity of levator labii superioris and zygomaticus minor Botulinum toxin can be injected to relax these elevators and soften a gummy smile Small doses (<2.5 units) are injected at the corners of the nose

Advanced Techniques Chin Dimpling Contraction of the mentalis muscles in the chin can create this dimpling / pebbling effect Exaggerated by pouting./ drawing lower lip in and up Inject <2.5 units into each muscle belly Can also reduce a prominent mental crease

Advanced Techniques Hyperhidrosis Hyperhidrosis (excessive sweating) of the arm pits (axillae) and palms of the hands or soles of the feet can be treated with Botulinum toxin Botulinum toxin temporarily blocks cholinergic stimulation of apocrine sweat glands, giving up to 6 months relief from excessive sweating Can only be used to treat defined areas (not useful in generalised hyperhidrosis) Note treatment of palmar hyperhidrosis can be very painful and therefore a nerve block may be required In the axillae, mark out a grid of 20 injection sites across the main sweat producing zone with 2.5 units injected at each site (total 50 units / axilla)

Hyperhidrosis

Technique Injection Technique: Proceed through the injection sites systematically (avoid over/ undertreating areas) Identify and avoid any visible blood vessels, reducing the chance of significant bruising (crows feet area is notoriously vascular) Use a 30 gauge 1-inch needle Inject in a slow and steady manner to ensure accuracy and avoid discomfort Inject with the bevel of the needle facing upwards to allow for downwards spread of product

Technique Hand Positioning Tips: Use your non-dominant thumb to protect the orbital rim (typically when treating corrugators) Rest your injecting hand against the non-dominant hand or on the client s face for optimal control and accuracy Rest the syringe itself on your non-dominant hand

Technique Forehead Region Standard Injection Sites: Typically 5 injection sites Low dose, superficial injections to treat the broad and Flat frontalis muscle Injections can be administered in a line across the width of the forehead or in a zig-zag pattern depending on client s anatomy Do not inject the Fibrous aponeurosis (black lines)

Technique Forehead Region Standard Dosing Regimen:

Technique Forehead Region Treatment Tips: Straight row or zig-zag pattern Inject into the peaks of the wrinkles and not the troughs Inject superficially Angle the needle at 45 degrees to facilitate superficial administration Avoid injecting the aponeurosis Injection sites can be tailored to suit each individual client

Technique Glabellar Zone Standard Injection Sites: Standard treatment for the Glabella involves 5 injections: Ø Central deep injection targeting procerus Ø 2 injections to target medial aspect of the corrugators Ø 2 injections to target the lateral aspect of the corrugators Note - Injections to the glabellar should stay medial to the midpupillary line which is demonstrated by the 2 vertical axes here

Technique Glabellar Zone Standard Dosing Regimen 2.5 2.5 5 5 7.5

Technique Glabella Zone Injection sites: 1. Procerus (deep, central) 2. Medial aspect of corrugators (deep) 3. Lateral aspect of corrugators (superficial) Glabella Zone Treatment Tips: Be mindful of avoiding injections near levator palpebrae superioris Do not inject Botox within 1cm above the medial aspect of the eyebrow Position lateral corrugator injections at least 1cm above the supraorbital ridge Keep the needle bevel upward facing

Technique Crows Feet Standard Injection Sites: Typically consists of 3 small and superficial injections on each side Mark out the central site at least 1.5cm lateral to the lateral canthus and ensure the site is outside of the orbital rim Mark out the upper and lower sites 1.5cm above and below the central site. These sites may be at an angle of up to 30 degrees to the central site but must remain outside the orbital rim and lateral to the lateral canthus

Technique Crows Feet Standard Dosing Regimen

Technique Crows Feet Treatment Tips: Palpate for the orbital rim to ensure all injections to the crows feet area are outside of this border Keep all injections lateral to the lateral canthus Keep the needle bevel tip up and the syringe orientated away from the eye to avoid injury Ask the client to turn their head to the side to facilitate smooth administration of product and comfortable hand positioning

Technique

Aftercare Aftercare Instructions: Reiterate the potential for slight bruising and discomfort Seek medical attention in the event of any major concerns Do not lie down, fall asleep or rub / massage the treated areas for at least 4 hours after treatment Gently exercising the muscles that have been treated (i.e. frowning / smiling) can help to activate the toxin and expedite results Clients should avoid consuming alcohol for 24 hours after treatment or wearing makeup Advise the patient that the effects can take up to a week to become apparent Remember the effects are temporary and treatment is recommended every 3-6 months Contact details for follow up assessment / further treatment provided

Summary Storage and shelf-life Cautions and contra-indications of treatment Reconstitution The treatment process Cosmetic indications for use - Foundation techniques (glabella, frontalis, crows feet) - Advanced techniques (bunny lines, neck lift, smokers lines, gummy smile, chin dimpling, hyperhidrosis) Technique Aftercare