introductory botulinum presentation

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New Technologies for Facial Enhancement s i m p l e y o u n g e r r e j u v e n a t e d r e f r e s h e d Introductory course to Vistabel

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Page 1: Introductory Botulinum Presentation

New Technologies for Facial Enhancement

s i m p l e

y o u n g e r

r e j u v e n a t e d

r e f r e s h e d

Introductory course to Vistabel

Page 2: Introductory Botulinum Presentation

• Starting off with Botox• Neurotoxin Pharmacology

• Contraindications and Cautions• Patient selection and treatment options

• Dilution and storage

Course AgendaCourse Agenda

Page 3: Introductory Botulinum Presentation

• Technique tips• Cosmetic indications1. Glabellar frown lines

2. Forehead lines3. Crows feet

Cont’Cont’

Page 4: Introductory Botulinum Presentation

• Live demonstration• Hands-on workshop

• Advanced techniques• Strategies for success

Cont’Cont’

Page 5: Introductory Botulinum Presentation

UK APPROVAL 2006

For Glabellar frown lines

BOTOX (100 Units)

Now launched as VISTABEL (50 Units)

Single patient use

Page 6: Introductory Botulinum Presentation

Developing A Botulinum Toxin Practice

Why develop an injection practice?

- Cosmetic surgery trends favour minimally invasive techniques

- No down time considered lunchtime procedure

- Nonsurgical procedures growing at a faster pace than surgical

- Want as opposed to need!!!!!!!

Personal Communication © Tim Flynn

Page 7: Introductory Botulinum Presentation

Top 5 nonsurgical cosmetic procedures in 2005 Top 5 nonsurgical cosmetic procedures in 2005

American Society for Aesthetic Plastic Surgery

Surgical & Non-surgical Cosmetic Procedures 9 Year - Comparison

1997-2005 1997

2005

154,153

481,227

65,157

159,232

101,176

176,863

485,690

556,172

3,294,782

231,467

364,610

455,489

Laser Skin Resurfacing

Chemical Peel

BOTOX®

Eyelid Surgery

Breast Augmentation

Liposuction (lipoplasty)

556,172

1,023,931

1,194,222

1,566,909

BOTOX®

Laser Hair Removal

Injectable Fillers

Microdermabrasion

Chemical Peels

3,294,782

Page 8: Introductory Botulinum Presentation

What Has Made Botulinum Toxin Type A a Popular Treatment?

Patient satisfaction

- Happy patients return more regularly for treatment

Physician satisfaction

- VISTABEL® provides the cornerstone of rejuvenation treatments of the ageing face

Personal Communication © Ph LEVY

Page 9: Introductory Botulinum Presentation

Cosmetic Maintenance

Patients perceive a “hierarchy” in cosmetic maintenance

Alteration Visible Changes Altering appearance ; major interventions, eg.

Face-Lift

Renovation Subtle, natural changes

Improving appearance viaNON-surgical treatments, eg. VISTABEL®, FILLERS

Prophylaxis Containment Preserving appearance as a part of everyday care,

eg. Anti-wrinkle creams

“Context” Research 2004 Paris, France

Page 10: Introductory Botulinum Presentation

Impact Of Wrinkles On Client’s Life

Just under 50% of the clients considered that wrinkles had a considerable impact on their life

Patients’ level of agreement with the following statements Score *

Wrinkles are a constant reminder of growing old 4.0

Having wrinkles depresses me 3.5

Having wrinkles reduces my self esteem 3.5

Having wrinkles impacts on my personal relationships 3.4

Having wrinkles impacts on my social life 3.3

Having wrinkles impacts on my career / work opportunities and success 3.0

Having wrinkles is just part of growing older and nothing to be too worried about 2.5

*Mean score on a scale from 1 (strongly disagree) to 5 (strongly agree)

“Genactis” Research 2004 France

Page 11: Introductory Botulinum Presentation

Patients Feeling Towards Recommending Treatment To A Friend

More than 90% of patients would recommend treatment to a friend concerned about wrinkles

Neither Recommend

for nor against10%

Recommend52%

Strongly Recomment

38%

Strongly Recommend

Against0%

Recommend Against

0%

“Genactis” Research 2004 France

Page 12: Introductory Botulinum Presentation

Age

1%

7%

17%

23%

32%

0.16

0.05

0% 5% 10% 15% 20% 25% 30% 35%

65 +

55 - 64

45 - 54

35 - 44

25 - 34

18 - 24

Under 18

N=1335Vivid Interface Ltd. Market Research Body Beautiful 2005

Page 13: Introductory Botulinum Presentation

Art and Science combined

It is very importantIt is very important

to learn that BOTOXto learn that BOTOX®® is both an is both an

artart and a and a science science before you become a userbefore you become a user

Page 14: Introductory Botulinum Presentation

Starting BOTOXStarting BOTOX®®

How can you introduce it into

your practice?

Starting BOTOX®

Page 15: Introductory Botulinum Presentation

Starting BOTOX®

Starting BOTOXStarting BOTOX®®

Getting started with BOTOX® can be the

hardest part…

collecting patients,promoting it in the practice,consent forms…

Page 16: Introductory Botulinum Presentation

Before offering BOTOXBefore offering BOTOX®® to patients to patients

• Attend a training course

• Review literature

• Develop a consent form(provided)

• Practice on partner, mother, close friend

• Share data with staff.

• Obtain suitable insurance cover

Starting BOTOX®

Page 17: Introductory Botulinum Presentation

Launching it in your Practice Launching it in your Practice – consider the following:– consider the following:

• Train reception staff to discuss the procedure

• Do some initial free treatments on staff and best patients for word of mouth advertising

• Build a before and after photo library to show prospective patients

Starting BOTOX®

Page 18: Introductory Botulinum Presentation

Launching it in your Practice – Launching it in your Practice – consider the following:consider the following:

• Schedule “BOTOX® days”

• Get local media exposure

• Inform patients with practice newsletter

Starting BOTOX®

Page 19: Introductory Botulinum Presentation

NeurotoxinNeurotoxin

PharmacologyPharmacology

Page 20: Introductory Botulinum Presentation

BOTOX®

Indicated for*;

-Blepharospasm

-Strabismus (USA)

-Hemifacial spasm

-Cervical dystonia

-Cerebral Palsy

-Axillary hyperhidrosis

-Glabellar lines

Photos © J Jankovic

*Approvals and product names vary from country to country – consult specific prescribing information

Page 21: Introductory Botulinum Presentation

Other Clinical Conditions Treated with Other Clinical Conditions Treated with

BOTOXBOTOX® (Un-licensed)® (Un-licensed)

Neurotoxin Pharmacology

•Migraine

•Tension Type Head-Ache

•Back Ache

•Hypersalivation

•Myofacial Pain Syndrome

Page 22: Introductory Botulinum Presentation

Botulinum Neurotoxin SerotypesBotulinum Neurotoxin Serotypes

Neurotoxin Pharmacology

• 1982 Jean Carruthers to San Francisco to work with Alan Scott – one of early co- investigators in FDA study

• 1982 Jean Carruthers brings “Oculinum” into Canada

• 1987 Jean Carruthers Blepharospasm patient comments on improvement in her wrinkles

Page 23: Introductory Botulinum Presentation

• Seven serotypes

- A, B, C1, D, E, F, G

- Type A has longest duration

of action

• Intracellular target varies

- SNAP-25

• Does not penetrate the skin

• No topical application COOH

NH2

NH2

COOH

S-S

SS

HeavyChain

LightChain

Botulinum Neurotoxin SerotypesBotulinum Neurotoxin Serotypes

Neurotoxin Pharmacology

Page 24: Introductory Botulinum Presentation

BOTOXBOTOX® - Mode of Action® - Mode of Action

Neurotoxin Pharmacology

1 Before BOTOX®:

Endplate sits upon muscle fibre

2 Binding:

Neurotoxin binds to nerve terminal

3 Internalization:

Neurotoxin internalized via receptor-mediated endocytosis.

Page 25: Introductory Botulinum Presentation

BOTOXBOTOX® - Mode of Action® - Mode of Action

Neurotoxin Pharmacology

4 Blocking:

Light chain blocks fusion of neurotransmitter vesicle with nerve membrane by cleaving SNAP-25.

5 Sprouting and re-establishment of sprouts:

Endplate expands and collateral axonal sprouts emerge. Sprouts subsequently retract and are eliminated; parent terminal is re-established.

Page 26: Introductory Botulinum Presentation

PRODUCT SAFETY• Botox has long clinical history

• Maximum dose per treatment session for Dystonia 400U

• Cosmetic doses range between 24 to 70U

• LD50 estimated to be 3000U

• Wide margin of safety.

• No relevant systemic effects observed

Page 27: Introductory Botulinum Presentation

How Toxic Is Botulinum Toxin?Look at the Ratio of Therapeutic dose to Life Threatening

dose

- Digitalis 1:2

- Insulin 1:3

- Lidocaine (s.c.) 1:5

- Botulinum toxin-A 1:50

Heckmann M Hauzart 2000

Page 28: Introductory Botulinum Presentation

Contraindications and Contraindications and cautionscautions

Page 29: Introductory Botulinum Presentation

ContraindicationsContraindications

Contraindications & cautions

• Pregnancy and Lactation •Neuromuscular transmission disorders.(Myasthenia Gravis)

• Co-administration with aminoglycoside antibiotics

• Bleeding disorders or anticoagulant therapy

•Patients with known hypersensitivity to any ingredient in BOTOX®

Page 30: Introductory Botulinum Presentation

CautionsCautions

Contraindications & cautions

• Lack of patient co operation

•Unrealistic expectations

•Local infection at injection site (active acne)

•Dysmorphophobia

•Unrealistic fear of systemic botulism

Page 31: Introductory Botulinum Presentation

Patient Selection and Patient Selection and treatment options treatment options

Page 32: Introductory Botulinum Presentation

Patient Selection and Treatment Options

Glogau wrinkle scaleGlogau wrinkle scale

Page 33: Introductory Botulinum Presentation

Patient Selection and Treatment Options

Glogau wrinkle scaleGlogau wrinkle scale

Type I (No Wrinkles) Topical therapyHowever, check

dynamic movementMay treat as

preventive therapy

Page 34: Introductory Botulinum Presentation

Patient Selection and Treatment Options

Glogau wrinkle scaleGlogau wrinkle scale

Type II (Wrinkles in Motion)

BOTOX® plus topicals

Page 35: Introductory Botulinum Presentation

Patient Selection and Treatment Options

Glogau wrinkle scaleGlogau wrinkle scale

Type III (Wrinkles at Rest) BOTOX® plus fillers

•Treat with Botox first•Botox and filler have

synergistic action

Page 36: Introductory Botulinum Presentation

Patient Selection and Treatment Options

Glogau wrinkle scaleGlogau wrinkle scale

Type IV (Nothing but Wrinkles)

Consider surgery

Page 37: Introductory Botulinum Presentation

KEY ELEMENTS• Assess patient’s desires. Are they realistic?

• Assess facial expression at rest and during animation

• Evaluate tonicity of muscles

1. Kinetic

2. Hyperkinetic

3. Hypertonic

Page 38: Introductory Botulinum Presentation

KEY ELEMENTS• Palpate muscles to assess mass

• Assess brow position

• Evaluate any asymmetries

• Begin with recommended starting dosages add more units in 2 week intervals

Page 39: Introductory Botulinum Presentation

Dilution &Dilution &

StorageStorage

Page 40: Introductory Botulinum Presentation

Dilution & Storage

Dilution of VialDilution of Vial• Wipe bung of Botox and saline with alcohol and allow to evaporate

• Vacuum should draw down saline

• Volumes of 1ml to 2.5mls recommended

• Use only Bacteriostatic saline

Page 41: Introductory Botulinum Presentation

Dilution & Storage

Dilution of VialDilution of Vial

• Volumes of 1ml to 2.5mls recommended

• US FDA trial protocol uses 2.5cc

• 1ml dilution allows greater control by reducing diffusion however more difficult to handle leading to increased wastage of expensive product.

• Also minor injection errors with 1ml dilution may lead to unpleasant consequences for patient

Page 42: Introductory Botulinum Presentation

StorageStorage• Unreconstituted can store in fridge or freezer

• DO NOT FREEZE BOTOX® ONCE RECONSTITUTED

- Ice crystals may form which damage the toxin and reduce potency

• Store in the refrigerator at 2 – 4 °C

• As a general rule store in fridge at all times

Dilution & Storage

Page 43: Introductory Botulinum Presentation

DILUTION

100 units botox in 2.5mls

20 units of botox in 0.5mls

2 units of botox in 0.05 mls

4 units of botox in 0.1mls

Each major gradation is 2 units

Page 44: Introductory Botulinum Presentation

DILUTION

50 units Vistabel in 1.25mls

20 units of Vistabel in 0.5mls

2 units of Vistabel in 0.05 mls

4 units of Vistabel in 0.1mls

Each major gradation is 2 units

Page 45: Introductory Botulinum Presentation

Some general Some general technique tips for:technique tips for:

• optimal treatment success

• satisfied, repeat patients

Page 46: Introductory Botulinum Presentation

General Injection Technique TipsGeneral Injection Technique Tips

• Patient should be seated or slightly reclining to best observe facial expressions

• The treatment should be pleasant or, at least, comfortable to encourage repeat visits. Relax the patient & talk soothingly to lessen perceived pain

• Thoroughly cleanse areas prior to injection, avoid alcohol as drying to skin and may interfere with Botox.

Technique Tips

Page 47: Introductory Botulinum Presentation

• Try to change 30 gauge needle after every 4 - 5 injections. A sharp needle is less painful!

• Gloves should be worn at all times, check for latex allergy

• Mark injection sites prior to injection – remember to use a non tattooing pen

• Record technique thoroughly on a patient worksheet so you can duplicate successful treatment and modify over- or under treatment.

Technique Tips

General Injection Technique TipsGeneral Injection Technique Tips

Page 48: Introductory Botulinum Presentation

• Have patients discontinue aspirin,Vit E and NSAIDS, 7 days prior to treatment, to decrease bruising

• Or at least warn patients of increased risk of bruising

• Hold a gauze pad in the non-injecting hand so you can apply gentle pressure to any site that bleeds to minimise chances of bruising

Technique Tips

General Injection Technique TipsGeneral Injection Technique Tips

Page 49: Introductory Botulinum Presentation

• Have the patient contract the muscles

• Mark (when learning) the injection sites

• Inject selected dose with 30 gauge needle

• Inject with patient’s muscle relaxed for comfort

Preparing to InjectPreparing to Inject

Technique Tips

Page 50: Introductory Botulinum Presentation

CHECK LIST• Med history

• Assess expectations

• Explain 2 to 3 days before visible signs, 14 days for maximum effect

• History,Skin status

Page 51: Introductory Botulinum Presentation

Cont’• Explain likely results discuss alternatives

• Peels,microdermabrasion,Laser resurfacing

• Sign consent form

• Photograph, Inject, Record

• Follow up instructions recall

Page 52: Introductory Botulinum Presentation

• Glabellar Frown Lines• Forehead Lines

• Crow’s Feet

• Eyebrow lift

Cosmetic IndicationsCosmetic Indications

Page 53: Introductory Botulinum Presentation
Page 54: Introductory Botulinum Presentation

GlabellarGlabellar

Frown LinesFrown Lines

Page 55: Introductory Botulinum Presentation

• Convey negative emotions such as anger, depression,fatigue,biterness,disappointment and envy

• Consider utilising in younger individuals as habit breaker.Muscle group may atrophy in time allowing longer duration of action

• Women require 20 to 30U, Men 30 to 40U assess individually

Page 56: Introductory Botulinum Presentation

Procerus

Corrugators

Target Muscles for Frown LinesTarget Muscles for Frown Lines

Cosmetic Indications

Page 57: Introductory Botulinum Presentation

Muscles of the Glabellar Complex

Muscles Function

Corrugator Brow adductor (depressor)

• Moves eyebrow downward and medially

Procerus Brow depressor

• Depresses medial head of eyebrow; can produce transverse lines on nasal dorsum

Orbicularis oculi (medial); also known as depressor supercilii

Brow depressor

Carruthers J Fagien S et al Plast Reconstr Surg 2004

Page 58: Introductory Botulinum Presentation

Treating Glabellar Lines: Consensus Recommendations

Higher starting doses may be used depending on individual patient variables

Target Muscles

Usual Number ofInjection Points

(Range)

Total Starting Dose*

(Usual Range)

Corrugator, procerus, depressor supercilii, orbicularis oculi, frontalis

5 to 7; men may require more sites

Women: 20 to 30 UMen: 30 to 40 U

Carruthers J Fagien S et al Plast Reconstr Surg 2004

Page 59: Introductory Botulinum Presentation

Frown lines – Injection sitesFrown lines – Injection sites

Cosmetic Indications - Glabellar Frown Lines

Page 60: Introductory Botulinum Presentation

Post-injection: Advise patient to frown

as much as possible for 1 hour

Glabellar Frown LinesGlabellar Frown Lines

Cosmetic Indications - Glabellar Frown Lines

Page 61: Introductory Botulinum Presentation

Injection Technique (2)

Pinching stabilizes the patient

Pinching the facial skin with the non-dominant hand is helpful to control injection

Allows subtle feeling of needle entering muscle

Helps identify an intramuscular injection

Photo © Tim Flynn

Page 62: Introductory Botulinum Presentation

Cosmetic Indications - Glabellar Frown Lines

Glabellar Frown Lines – How Glabellar Frown Lines – How not to inject!not to inject!

Injecting down toward the globe

Patient supine

No gloves!

Page 63: Introductory Botulinum Presentation

Results (1)

Photos © Hervé Raspaldo

Page 64: Introductory Botulinum Presentation

Clinical ExamplesFemale in her Thirties

Before

30 Days

120 Days

Page 65: Introductory Botulinum Presentation

• Patients to return in 2 weeks to:

- assess results/technique

- photograph patient

- touch up (if necessary)

• Re-injection schedule

- Patient dependent

- 3 - 4 month intervals for first year

- Less frequent after repeated treatments

Glabellar Frown Lines - Follow UpGlabellar Frown Lines - Follow Up

Cosmetic Indications - Glabellar Frown Lines

Page 66: Introductory Botulinum Presentation

HorizontalHorizontal

Forehead LinesForehead Lines

Page 67: Introductory Botulinum Presentation

Anatomy - Frontalis MuscleAnatomy - Frontalis Muscle

Action: elevate brows, draw scalp posteriorly

Frontalis muscle

Cosmetic Indications - Horizontal Forehead Lines

Page 68: Introductory Botulinum Presentation

Horizontal Forehead Lines:Anatomy and Physiology

Muscle Function

Frontalis

(interacts with procerus, corrugators, and orbicularis oris)

Brow elevation

Carruthers J Fagien S et al Plast Reconstr Surg 2004

Page 69: Introductory Botulinum Presentation

Horizontal Forehead LinesHorizontal Forehead Lines

Cosmetic Indications - Horizontal Forehead Lines

• Leave some facial expression do not paralyze

• Use minimal dose to produce desired effect

• Males have more muscle mass

• Assess pre-existing brow position prior to deciding on frontalis doseage and injection sites

• Look for any brow asymmetry

Page 70: Introductory Botulinum Presentation

• Approach should be conservative- 10-20 Units BOTOX® in several divided doses

• In the lateral to mid-pupillary line, stay at least 1 finger width above the supra-orbital rim

Avoid ptosis bynot injecting shaded area

Horizontal Forehead LinesHorizontal Forehead Lines

Cosmetic Indications - Horizontal Forehead Lines

Page 71: Introductory Botulinum Presentation

Clinical ExamplesFemale in her Thirties

Before

30 Days

120 Days

Page 72: Introductory Botulinum Presentation

Cosmetic Indications - Horizontal Forehead Lines

Horizontal Forehead LinesHorizontal Forehead Lines

Standard technique: 2-4 units in 5 injection sites

Page 73: Introductory Botulinum Presentation

Cosmetic Indications - Horizontal Forehead Lines

Horizontal Forehead LinesHorizontal Forehead Lines

Additional sites to consider for males

Page 74: Introductory Botulinum Presentation

Before After

Horizontal Forehead LinesHorizontal Forehead Lines

Cosmetic Indications - Horizontal Forehead Lines

Page 75: Introductory Botulinum Presentation

Note enhancement of brow shape to soft flare

Before After

Horizontal Forehead LinesHorizontal Forehead Lines

Cosmetic Indications - Horizontal Forehead Lines

Page 76: Introductory Botulinum Presentation

Crow’s FeetCrow’s Feet

Page 77: Introductory Botulinum Presentation

Orbicularis oculi

Target Muscles for Crow’s FeetTarget Muscles for Crow’s Feet

Cosmetic Indications - Crow’s Feet

Page 78: Introductory Botulinum Presentation

• Caution in patients with eyebags may make worse

• Assess skin laxity and dlfferentiate between dynamic movement and skin ageing

• Be guarded with prognosis in individuals with laxity and aged skin

• Look closely for blood vessels and avoid

• The orbicularis oculi is a superficial muscle – there is no need to inject deeply

Crow’s FeetCrow’s Feet

Cosmetic Indications - Crow’s Feet

Page 79: Introductory Botulinum Presentation

• Patient at full smile

• Note upper and lower borders of the crow’s feet

Crow’s FeetCrow’s Feet

Cosmetic Indications - Crow’s Feet

Page 80: Introductory Botulinum Presentation

x

x

• Inject 1cm outside the orbital rim

• At least 3 injection sites 1cm apart suffice due to diffusion effect

• Inject 3 - 4 units of BOTOX® per injection site

OPTIONAL- IF PATIENT HAS LINES

REQUIRED

Crow’s FeetCrow’s Feet

Cosmetic Indications - Crow’s Feet

x

Page 81: Introductory Botulinum Presentation

Clinical ExamplesFemale in her Thirties

Before

30 Days

120 Days

Page 82: Introductory Botulinum Presentation

Crow’s FeetCrow’s Feet

Before After

Cosmetic Indications - Crow’s Feet

Page 83: Introductory Botulinum Presentation

Managing complications Managing complications

of BOTOXof BOTOX® treatment® treatment

Page 84: Introductory Botulinum Presentation

• Bruising is the most common side effect

• Avoid obvious blood vessels

• Apply gentle pressure to bleeding area

• Drooping of eyebrow

• Transient headache

• Nausea

• Diplopia

Potential Side EffectsPotential Side Effects

Managing complications

Page 85: Introductory Botulinum Presentation

Potential complicationsPotential complications

Managing complications

BruisingHeadacheEyelid ptosisBrow ptosisBrow repositioningDiplopia

Page 86: Introductory Botulinum Presentation

Treating ptosisTreating ptosis

Managing complications

Alpha-2 agent with weak alpha-1 activity [eg, apraclonidine 0.5% (Iopidine®]

Alpha-1 adrenergic stimulation of Müller’s muscle

Page 87: Introductory Botulinum Presentation

Treating ptosisTreating ptosis

Managing complicationsPtosis left lid 20 minutes after Iopidine®

Usually resolves in 1-6 weeksIopidine (Alcon) eyedrops 1 drop q.i.d. will temporarily resolve

Page 88: Introductory Botulinum Presentation

Brow ptosisBrow ptosis

Managing complications

Wait for natural resolution

Consider infrabrow injection at arch and laterally to raise brow

After BOTOX® to glabellar and brow

Page 89: Introductory Botulinum Presentation

Excessive brow elevation

• “Quizzical” or “Mr Spock” brows

• Correct with 1 to 2units of BOTOX® injected into the frontalis above the lateral brow

Brow repositioningBrow repositioning

Managing complications

Page 90: Introductory Botulinum Presentation

‘Mephisto’

If after glabella treatment “cruella” / mephisto inject 0.5-1.5U only

Photo © Ph LEVY

Page 91: Introductory Botulinum Presentation

Advanced techniques require a degree Advanced techniques require a degree

of judgement gained from of judgement gained from

approximately 3-6 months BOTOXapproximately 3-6 months BOTOX®®

cosmetic experiencecosmetic experience

Page 92: Introductory Botulinum Presentation

• Suborbital region

• Upper lip wrinkles

• Nasal scrunch (“bunny lines”)

• Nasolabial folds & marionette lines

• Platysmal bands

Advanced techniques and combination treatment

Advanced Cosmetic TechniquesAdvanced Cosmetic Techniques

Page 93: Introductory Botulinum Presentation

Infra Orbital Crinkle LinesPhotos© Ph LEVY

Before After

Page 94: Introductory Botulinum Presentation

Bunny Lines ResultsPhotos © K De Boulle

Before After

Page 95: Introductory Botulinum Presentation

Perioral Rhytides

Before After

Photos © K De Boulle

Page 96: Introductory Botulinum Presentation

Chin: Peau D’orange, Mental Crease

Before After

Photos © NJ Lowe

Page 97: Introductory Botulinum Presentation

Marionnette Lines Or Sad Corners Of The Mouth

Uplifts corners of the mouth

Technique: 1.5–3U into each depressor anguli oris muscle

Injection site

-7mm lateral , 8mm caudal OR mandib. border

© Ph LEVY

Page 98: Introductory Botulinum Presentation

Neck - Anterior bands 35-55 y.o.

Maximum dose per session: 60U

Rather tight skin

Before After

Photos © Ph LEVY

Page 99: Introductory Botulinum Presentation

Strategies for Strategies for successsuccess

Page 100: Introductory Botulinum Presentation

Choice of LanguageMedical Phrases Patient Positive Phrases

Frozen Smooth

Toxin Purified or natural protein

Paralyse Relax or soften muscle activity

Pain Minimal discomfort

Weaken Relax

Page 101: Introductory Botulinum Presentation

Strategies for success

Customer serviceCustomer service

• Prompt service availability is essential

•Offer free consultation

• The wait time for BOTOX® is best kept short

• Try and arrange BOTOX® days for efficient use of material

• Always have material available!!!!!!!!

Page 102: Introductory Botulinum Presentation

Strategies for success

Pricing PolicyPricing Policy

• In the UK pricing tends to be by facial areas

• Be consistent in your pricing policy with

single versus 3 areas

• Provide top up treatment free of chargeProvide top up treatment free of charge

Page 103: Introductory Botulinum Presentation

Strategies for success

MarketingMarketing

Don’t advertise BOTOX® or “Botulinum toxin”- it contravenes Advertising Standard Authority guidelines regarding the promotion of Prescription Only Medicines.

Page 104: Introductory Botulinum Presentation

Tips to avoid DisappointmentTips to avoid Disappointment

• Offer free consultation prior to treatment for first time treatment

• Make sure that you and the patient have realistic outcome objectives

• When treatment results are not up to expectations, assess situation and top up if appropriate

• Consider non responder(rare)

Strategies for success

Page 105: Introductory Botulinum Presentation

Cont’Cont’

Strategies for success

• If results are minimised because of additional muscle recruitment, explain with a mirror

• Some movement may return after only 28 days

• Refer patients back to initial photographs

• Make no guarantees concerning duration. Ranges are from 2 – 6 months

Page 106: Introductory Botulinum Presentation

BOTOX®/VISTABEL considered by

many cosmetic practitioners to be

the most successful cosmetic

procedure available due to patient

demand, level of satisfaction and

relative ease of placement.

Optimizing SuccessOptimizing Success

Strategies for sucess

Page 107: Introductory Botulinum Presentation

Conclusion

Long-term treatment with boNTA can prevent the development of imprinted facial lines that are visible at rest

Such treatment is well tolerated, with no adverse events reported during 13 years of regular treatment in this study

Binder WJ AAD 2006

Page 108: Introductory Botulinum Presentation

What Makes A Clinician Confident Using VISTABEL®?

Reproducible efficacy and safety with his/her patients

Satisfied patients

Increasing demand for treatment

Demonstrated long term safety profile

Number and quality of supporting publications

Ongoing basic and clinical research

Active support and training

Page 109: Introductory Botulinum Presentation

Reconstitution

BOTOX

100 units per vial

Reconstitute 2.5 mls Bacteriostatic saline

100 units in 2.5mls

20units in 0.5 mls

2 units in 0.05 mls (marked 5)

4 units in 0.1 mls (marked 10)

VISTABEL

50 units per vial(half of Botox vial)

dilute with1.25mls Bacteriostatic saline and use unit measurements as above.

Page 110: Introductory Botulinum Presentation

CONSENT FORM

Contraindications:You cannot receive Botox/Dysport if you are in the following categories :

Pregnant or Breast Feeding

Neuromuscular disorders/Myasthenia Gravis/Eaton Lambert Syndrome

Blood Coagulation Disorders or taking anticoagulants.

Currently taking Aminoglycoside antibiotics,Spectinomycin or Muscle relaxants.

Potential Side Effects(temporary)

Bruising /Swelling/Redness at injection site

Nausea/Headache

Occasional numbness

Drooping of the Eyebrow or upper Eyelid

Allergic reactions

Brief visual disturbances

Consent for Botox/Dysport Treatment

All foreseeable risks of Botulinum toxin therapy listed above have been thoroughly explained to me.My questions regarding the treatment procedure,its potential side effects and contraindications were answered to my full satisfaction. I also had adequate time to consider my decision.

I understand that I am free to revoke my consent at any time.

I consent to the administration of Botox/Dysport and have been given after care instructions.This consent form is also signed for future administration of Botox/Dysport.

Patient’s Name…………………………… Date………………..

Signature of Patient………………………

Witnessed by (Signature of Physician)………………………………..

Page 111: Introductory Botulinum Presentation

POST TREATMENT INSTRUCTIONS

1) Exercise muscles treated for 1 hour

2) Remain Upright for 3-4 hours

3) No chemical peels, sun beds or laser treatment for 7 days

4) Muscle weakening may not be evident for 3 days and may take as long as 10 days.

Page 112: Introductory Botulinum Presentation

Useful Numbers

Wigmore Pharmacy

23 Wigmore Street

London

W1U 1PL

Tel: 0207 4910111

Botox,0.5ml diabetic syringes

30ml 0.9% Bacteriostatic saline

Iopidine 5mg/ml eye drops

Hamilton Fraser Insurance Solutions(HFIS)

Tel: 0845 3106319(Jeanette Turner)

Steven Kaldor

[email protected]

07801428702

Allergan Ltd(Vistabel)

08003767965

Richard Crawford 0773358145(Rep)

Page 113: Introductory Botulinum Presentation

Thank youThank you