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Botox Botox Presentation Transcript

  • Shumez
  • History  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 lines.  Since then, botulinum toxin has been approved for a number of cosmetic indications in over 20 countries.
  • Introduction  Botulinum toxin is a neuroexotoxin which specifically targets the release of acetylcholine.  It is produced by the anaerobic bacterium Clostridium botulinum.  There are harvested by centrifugation and acidification.
  •  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.
  • Manufacturing process  Botulinum toxin type A is produced by fermentation of Hall strain of Clostridium botulinum.  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 proteins.
  • Structure  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 Normally,  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 containing vesicle.  Translocation of the neurotoxin into the cytoplasm.  Blocks fusion of Ach vesicles onto nerve terminal plasma membrane.
  •  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 recommended doses.  Pregnancy Category C  Not recommended in children, patients >65 yrs, pregnant and lactating mothers.
  • Commercial forms 2 commercially available botulinum toxins:  Botulinum toxin A : Botox (USA) Dysport ( UK)  Botulinum toxin B : Myobloc (USA) Neurobloc (Europe)
  • Botulinum toxin A
  • BOTOX MYOBLOC  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  Aqueous solution  Type B serotype  pH - 5.6  5000 units /ml aqueous solution
  • Cosmetic indications  Chemical brow lifting  Suborbital hypertrophic orbicularis  Infraorbital crow’s feet  Nasal scrunch (Bunny line)  Nasal flare  Nasolabial folds  Perioral lip line
  •  Marionette lines  Mental crease  Popply chin  Hypertrophic mandibular angles  Facial asymmetry
  • Other indications  Cervical dystonia  Blepharospasm  Primary hyperhidrosis  Strabismus  Achalasia  Chronic focal neuropathies  Chronic migraine  Bruxism
  •  Neurogenic detrusor overactivity  Incontinence due to neurogenic bladder  Anal fissure  Vaginismus  Diabetic neuropathy  Vocal cord dysfunction  Excessive salivation  Painful bladder syndrome
  • Contraindications  Myasthenia gravis  Lambert – Eaton syndrome  Muscle weakness  Absence of tendon reflexes  Autonomic dysfunction  Local infection  Hypersensitivity to any ingredient  Pregnancy and lactation  Treatment with aminoglycoside in the past 3 months
  • Drug Interactions Effect of the toxin may be potentiated with other agents interfering with neuromuscular transmission like :  Aminoglycosides  Lincosamides  Polymyxins  Quinidine  Magnesium sulfate  Anticholinesterases  Succinylcholine chloride
  • 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 1.0 ml 2.0 ml 2.5 ml 10.0 U 5.0 U 4.0 U • 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 treatment.  Pre procedure photographs.  Upright position.  Support head with head rest.  Avoid alcohol and anticoagulants few days before the treatment.  Oral antibiotics can be given 2 days prior & 3 days after the procedure.
  • Glabellar frown lines  Corrugator supercilii draws the eyebrow medially and downwards.  Orbicularis oculi pulls it medially.  Procerus and depressor supercilii draw the eyebrow downwards.
  •  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.
  • Response Rates Day Investigator’s assessment 7 74 % 30 80 % 60 70 % 90 48 % 120 25 %
  • 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.
  • Crow’s feet 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 canthus.  Inject 4 U at this site and 1 cm above and below this site.
  • Neck bands Platysma shows vertical bands.  Anterior fibers : assist mandibular depression  Intermediate fibers : depress the lower lip  Posterior fibers : depress the buccal angle
  • 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 hours.  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.
  • Complications  Ecchymosis  Pain / edema / erythema at injection site  Lid ptosis  Brow ptosis  Lip ptosis  Impaired blink reflex  Mephisto sign  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.
  • Hyperhidrosis  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 between sites.  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.