Procedure
Botulinum Toxin Injection
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Botulinum Toxin Injection
, Onabotulinum Toxin A, Abobotulinum Toxin A, Botulinum Toxin Type A, Botox
See Also
Skin Cosmetic Procedure
Dermal Filler Injection
Indications
Cosmetic
Dynamic facial lines and
Wrinkle
s in the upper one third of the face
Frown lines (FDA approved as of 2002)
Vertical
Wrinkle
s between the eyebrows
Dynamic
Wrinkle
s are most amenable to treatment (although static
Wrinkle
s will also improve with treatment)
Treatment of the
Glabella
r complex (Corrugator supercillii, procerus and depressor supercillii
Muscle
s)
Crow's Feet (FDA approved as of 2013)
Wrinkle
s eminating laterally from lateral canthus region
Treatment of the lateral obicularis oculi
Muscle
Horizontal forehead lines (off label use)
Treatment of the frontalis
Muscle
Indications
Neurologic
Blepharospasm (first-line treatment, Botox or Xeomin)
Cervical Dystonia
(Dysport or Mybloc)
Spasticity in Adults
Chronic
Migraine Headache
(>15 days/month for at least 3 months)
Mechanism
Neurotoxin
derived from
Clostridium botulinum
(cause of
Botulism
)
Botulinum Toxin
act
Neuromuscular Junction
and inhibits release of
Acetylcholine
Injection into overactive facial
Muscle
s results in localized
Muscle
relaxation
Preparations
Precautions
Botulinum Toxin
preparations are not interchangeable due to differences in concentration, formulation and effects
Botulinum Toxin
serotype A (most common serotype used for cosmetic procedures)
Onabotulinum Toxin A (Botox)
Abobotulinum Toxin A (Dysport), which also contains bovine
Protein
Incobotulinum Toxin A (Xeomin)
Botulinum Toxin
serotype B
Rimabotulinum Toxin B (Mybloc)
Dosing
One treatment every 3-4 months
Advantages
Brief procedure and highly effective
Disadvantages
Small margin of error for injection site
Approach
Precautions
Botulinum Toxin Injection should only be performed by providers trained in this technique
The technique described here is for review only, and not intended to replace proper training
Consultation
Review alternative options (see
Skin Cosmetic Procedure
s)
Obtain "before" photographs (static and dynamic)
Prioritize cosmetic interventions
Set realistic expectations
Review potential adverse effects and complications
Preparation
Reconstitute
Botulinum Toxin
powder in sterile
Normal Saline
Draw solution into a tuberculin syringe or similar (1 ml) and apply a 30 gauge needle (1/2 or 1 inch)
Anesthetic
(e.g.
Lidocaine
) is NOT typically used
Patient should be prepared to expect localized singing and burning in the region of injection
Technique: Frown Lines (
Glabella
r Complex
Muscle
injection)
Patient actively frowns
Inject each of five sites
Procerus
Muscle
(1 injection)
Bilateral corrugator supercillii
Muscle
s (4 injections total, 2 for each
Muscle
body)
Aftercare
Patient should stay upright (not supine) for at least 4 hours after procedure
Patient should avoid massaging or applying heat to the area on the day of the procedure
Patient should avoid
Exercise
,
Alcohol
or other activities that cause
Flushing
on the day of the procedure
Follow-up (at 2 weeks)
Effects will evident by day 3 following the procedure, maximal by 2 weeks and start to diminish at 3-4 months
Obtain "after" photographs (static and dynamic)
Evaluate effects and adverse effects
Adverse Effects
Injection reaction
Injection site erythema, edema or tenderness (resolve within 24 hours)
Bruising
(may persist for up to 2 weeks after injection)
Headache
s
Treat with
NSAID
s
Collateral effects of adjacent
Muscle
s (transient)
Blepharoptosis
(upper
Eyelid
droop)
Eyebrow
Ptosis
Facial asymmetry
Contraindications
Botulinum Toxin Injection
Body Dysmorphic Disorder
Career dependent of facial
Muscle
use (e.g. performers, vocal artists)
Infection or dermatitis affecting the treatment area
Pre-existing motor deficit in the treatment area (
Bell's Palsy
)
Immunocompromised
state
Keloid
al scarring
Neuromuscular condition (e.g. ALS,
Myasthenia Gravis
)
Pregancy or
Lactation
Allergy to components of
Botulinum Toxin
Dysport is contraindicated in
Cow's Milk Allergy
References
Carruthers (2004) Plast Reconstr Surg 114(6 suppl): 1s-22s [PubMed]
Neurology (2016) 86(19): 1818-26 [PubMed]
Small (2014) Am Fam Physician 90(3): 168-75 [PubMed]
Small (2009) Am Fam Physician 80(11): 1231-8 [PubMed]
Wise (2006) Facial Plast Surg 22(2):140-6 [PubMed]
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