Justinus Kerner described botulinum toxin as a
"sausage poison" because the bacterium that
produces the toxin grew in improperly handled or
prepared meat products.
In the early 1970’s, Alan Scott, an opthalmologist
used botulinum toxin injections to treat
strabismus and blepharospasm.
Alistair and Jean Carruthers were the first to
use botulinum toxin for the treatment of glabellar
lines in 1992.
On April 12 2002, the FDA approved the use of
botulinum toxin type A (Botox Cosmetic) to
temporarily improve the appearance of glabellar
Since then, botulinum toxin has been approved for
a number of cosmetic indications in over 20
Botulinum toxin is a neuroexotoxin which
specifically targets the release of acetylcholine.
It is produced by the anaerobic bacterium
There are harvested by centrifugation and
7 antigenically distinct serotypes (A - G)
They are immunologically distinct.
Incapable of cross neutralization.
Vary in potency and duration of effect.
Type A is used for cosmetic purposes.
Botulinum toxin type A is produced by
fermentation of Hall strain of Clostridium
It is grown in a medium containing casein
hydrolysate, glucose, and yeast extract.
It is purified from the culture solution by dialysis
and a series of acid precipitations to a complex
consisting of the neurotoxin, and several accessory
Botulinum neurotoxins are polypeptides.
Botulinum toxin comprises a protein molecule
(150kd) which can be cleaved into a heavy (100kd)
and a light (50kd) chain.
These chains are normally held together by a
disulphide bond, which is heat labile.
Disruption of this bond inactivates the neurotoxin.
Mechanism of action
Motor nerve fibre is stimulated.
Release of Ach from pre-junctional membrane.
Reaches the junctional membrane.
Attaches to end plate receptors.
Local current initiates muscle contraction.
BTX – A attaches to the cholinergic receptor sites
on the cell membrane of a presynaptic motor
nerve end plate.
Plasma membrane of nerve cell invaginates around
the toxin – receptor complex forming a toxin
Translocation of the neurotoxin into the
Blocks fusion of Ach vesicles onto nerve terminal
This inhibition occurs as the neurotoxin cleaves
SNAP-25, a protein integral to the successful
docking and release of acetylcholine from vesicles
situated within nerve endings.
Thus, impeding exocytosis of Ach and its release
into the synaptic cleft.
There is no neuromuscular transmission and
there’s paralysis of the affected muscle.
Therapeutic effect of the BTX-A is seen within 24
– 72 hrs and lasts for 3-6 months.
Botulinum toxin is not detected in the peripheral
blood following intramuscular injection at the
Pregnancy Category C
Not recommended in children, patients >65
yrs, pregnant and lactating mothers.
2 commercially available botulinum toxins:
Botulinum toxin A : Botox (USA)
Dysport ( UK)
Botulinum toxin B : Myobloc (USA)
Botulinum toxin A
Vaccum dried lyophilized form
Type A serotype
pH - 7
Diluted with 1.0 or 2.5 ml NS
providing conc. of 40 units/ml
or 100 units/ml
Comes with sterile saline with
preservative (benzyl alcohol)-
lessens the sting
Type B serotype
pH - 5.6
5000 units /ml aqueous
Lambert – Eaton syndrome
Absence of tendon reflexes
Hypersensitivity to any ingredient
Pregnancy and lactation
Treatment with aminoglycoside in the past 3
Effect of the toxin may be potentiated with other
agents interfering with neuromuscular transmission
Dosage and Dilution
BTX-A is available as 100 units of freeze dried
powder in a glass vial under vacuum.
Stored in a freezer at -5˚ C.
After reconstitution , stored at 2˚-8˚ C.
Diluents used are normal saline with or without
preservatives (0.9% benzyl alcohol) and equal parts
of saline and lidocaine.
Diluent added Dose in UNITS per 0.1 ml
• 2.5 ml per vial for the upper face.
• 1 - 2 ml for smaller muscles in the lower face.
Pre - procedure care
Pre treatment consultation.
Counsel the patients regarding limitations of the
Pre procedure photographs.
Support head with head rest.
Avoid alcohol and anticoagulants few days before
Oral antibiotics can be given 2 days prior & 3
days after the procedure.
Glabellar frown lines
Corrugator supercilii draws the eyebrow medially
Orbicularis oculi pulls it medially.
Procerus and depressor supercilii draw the eyebrow
6 U injected into the procerus midway just below a
line joining the medial end of both eyebrows.
4 U into each corrugator on a point above the
vertical line joining the inner canthus and superior
margin of bony orbit.
2-4 U injected 1 cm superior to the above point.
Horizontal forehead lines
Occipitofrontalis raises eyebrows and is resposible
for horizontal forehead lines.
2 U is injected at a distance of 1.5cm into the
frontalis, staying 2 finger widths above the
supraorbital rim to avoid ptosis.
Orbicularis oculi has 3 parts.
Orbital part: protrusion of the eyebrows and
voluntary eyelid closure.
Palpebral part: closes lids during blinking.
Lacrimal part: draws lids and lacrimal papillae
medially, compresses the lacrimal sac.
Palpate the orbital rim 1 - 1.5 cm from the lateral
Inject 4 U at this site and 1 cm above and below
Dose for 1 platysmal band is 15 U.
5 U in the top of the muscle band.
5 U injected 2 cm below this site.
5 U injected 2 cm further down.
For horizontal necklace lines, 1-2 U injected every 2
cm along the line as an intradermal bleb.
Post procedure instructions
To sit upright for 4 hours.
To exercise the treated muscle during the first 2
Not to manipulate the treated area for 4 hours.
Patients is followed up after 2-4 weeks.
Photographs should be taken to assess the results.
Pain / edema / erythema at injection site
Impaired blink reflex
Asymmetry of face
Botulinum toxin products may spread from the
area of injection to produce symptoms consistent
with botulinum toxin effects.
These may include asthenia, generalized muscle
weakness, diplopia, blurred vision, ptosis,
dysphagia, dysphonia, dysarthria, urinary
incontinence and breathing difficulties.
These symptoms have been reported hours to
weeks after injection.
Swallowing and breathing difficulties can be life
threatening and there have been reports of death.
Intradermal injections of BTX - A are effective in
the treatment of palmar hyperhidrosis.
50 – 100 U are injected into each palm.
Inject in a grid-type pattern with 2 cm distance
After injection, keep palms down as much as
possible for 1 – 2 hours to minimize penetration to
intrinsic muscles of hand.
Complications - Sensory deficits in injected area
and intrinsic hand muscle weakness.