What every Allergan employee should know. Gives an overview of what should be known and touches on Botox.

1. Botox Cosmetic:Botox Cosmetic:
WhatWhat everyevery AllerganAllergan
employee should knowemployee should know
Richard A. Weiss, M.D.Richard A. Weiss, M.D.
Newport Beach, CANewport Beach, CA

2. Allergan employees should:Allergan employees should:
• Know the basics about Botox CosmeticKnow the basics about Botox Cosmetic
• Understand unit pricing versus areaUnderstand unit pricing versus area
pricing for Botox Cosmeticpricing for Botox Cosmetic
• Be aware of theBe aware of the correctcorrect methods of Botoxmethods of Botox
Cosmetic useCosmetic use
• Act as Allergan public relations peopleAct as Allergan public relations people

4. Other 2001 Botox statisticsOther 2001 Botox statistics
• Average price: $358-503Average price: $358-503
• 86% women86% women
• 80% of patients were over 35 y.o.80% of patients were over 35 y.o.

5. The first published reportThe first published report ofof
Botox A in treatingBotox A in treating
hyperkinetic facial lines washyperkinetic facial lines was
published by Carrutherspublished by Carruthers inin
19921992

6. Ten years later…Ten years later…

7. No more frown lines!No more frown lines!
My kids are more relaxed!My kids are more relaxed!

8. When I look in the mirror,When I look in the mirror,
I like what I see now!I like what I see now!

9. What exactly is Botox?What exactly is Botox?
• Botox is a natural, purified proteinBotox is a natural, purified protein
produced by the Clostridium botulinumproduced by the Clostridium botulinum
bacteriumbacterium
• Very low doses of Botox are administeredVery low doses of Botox are administered
via a few tiny injections directly into thevia a few tiny injections directly into the
overactive muscles that cause lines tooveractive muscles that cause lines to
form.form.

10. How does Botox work?How does Botox work?
• Botox blocks the transmission of nerveBotox blocks the transmission of nerve
impulses at the neuromuscular junction byimpulses at the neuromuscular junction by
binding to acceptor sites on motor nervebinding to acceptor sites on motor nerve
terminals, entering the nerve terminal, andterminals, entering the nerve terminal, and
inhibiting the release of acetylcholine.inhibiting the release of acetylcholine.
• This produces a local weakness or flaccidThis produces a local weakness or flaccid
paralysis of the injected muscleparalysis of the injected muscle

14. What is Botox used for?What is Botox used for?
• FDA approval as a safe and effectiveFDA approval as a safe and effective
therapy for blepharospasm, strabismus,therapy for blepharospasm, strabismus,
and hemi facial spasm in December 1989and hemi facial spasm in December 1989
• Botox Cosmetic was approved for use inBotox Cosmetic was approved for use in
the glabella on April 15, 2002the glabella on April 15, 2002

15. Off label usesOff label uses
• CosmeticCosmetic – forehead, crow’s feet– forehead, crow’s feet
• FunctionalFunctional
– MigraineMigraine affects 18% of women and 6%affects 18% of women and 6%
of men in USof men in US
– Axillary hyperhidrosisAxillary hyperhidrosis - ~1% of- ~1% of
populationpopulation

16. Off label usesOff label uses
Many other medical uses includingMany other medical uses including
adductor spasmodic dysphonia,adductor spasmodic dysphonia,
oromandibular dystonia, torticollis,oromandibular dystonia, torticollis,
cerebral palsy, back spasms, newcerebral palsy, back spasms, new
uses every dayuses every day

17. Clinical Use of Botox CosmeticClinical Use of Botox Cosmetic

18. Facial wrinkles and contributoryFacial wrinkles and contributory
underlying musclesunderlying muscles

20. Forehead wrinklesForehead wrinkles

21. Glabellar wrinklesGlabellar wrinkles

23. Orbicularis muscleOrbicularis muscle

24. Nasalis muscleNasalis muscle

25. People are different,People are different,
so results can varyso results can vary

26. Botox dilution: 100U=100UBotox dilution: 100U=100U

27. Complete Botox trayComplete Botox tray

28. How to injectHow to inject
• Glabella and forehead – more perpendicularGlabella and forehead – more perpendicular
• Crow’s feet – more parallel to skin surfaceCrow’s feet – more parallel to skin surface
• Axilla – intradermal, hair bearing skinAxilla – intradermal, hair bearing skin

29. Botox injection techniqueBotox injection technique

30. MarkingMarking

31. Typical glabella distributionTypical glabella distribution

32. RelaxRelax

33. Now smileNow smile

34. Ice pack aids anesthesiaIce pack aids anesthesia

35. More parallel to skin surfaceMore parallel to skin surface

36. More perpendicularMore perpendicular

37. Rotate syringe toward youRotate syringe toward you

38. Grid pattern in hair bearing skinGrid pattern in hair bearing skin

39. Intradermal injectionIntradermal injection

40. How much to injectHow much to inject
• Forehead ~ 20-40UForehead ~ 20-40U
• Glabella ~ 15-30U, 40U lasts longer thanGlabella ~ 15-30U, 40U lasts longer than
20U!20U!
• Crow’s feet ~30-50UCrow’s feet ~30-50U
• Axilla 35-100U per sideAxilla 35-100U per side

41. Risks and complicationsRisks and complications
• Precautions:Precautions: Pregnant or lactatingPregnant or lactating
womenwomen
• Preexisting disorders affecting thePreexisting disorders affecting the
neuromuscular junction function, such as Eaton-neuromuscular junction function, such as Eaton-
Lambert syndrome, myasthenia gravis,Lambert syndrome, myasthenia gravis,
amyotrophic lateral sclerosis and motor neuronamyotrophic lateral sclerosis and motor neuron
disease.disease.
• Aminoglycosides (e.g., gentamicin) interfere withAminoglycosides (e.g., gentamicin) interfere with
neuromuscular transmission and may potentiateneuromuscular transmission and may potentiate
the effect of a given dose of Botox.the effect of a given dose of Botox.

42. General risksGeneral risks
• Swelling or bruisingSwelling or bruising
• Headache (15.7% Botox group, 15%Headache (15.7% Botox group, 15%
placebo),placebo),
• Flu syndrome (Botox group 4.9%, 8.3%Flu syndrome (Botox group 4.9%, 8.3%
placebo),placebo),

43. Specific risksSpecific risks
• ForeheadForehead –– droopy eyebrows and eyelidsdroopy eyebrows and eyelids
especially in patients with preexistingespecially in patients with preexisting
secondary frontalis contraction and significantsecondary frontalis contraction and significant
dermatochalasis, noticeable asymmetry,dermatochalasis, noticeable asymmetry,
spotty coverage, inability to raise the eyebrowspotty coverage, inability to raise the eyebrow
• GlabellaGlabella –– few complications, veryfew complications, very
infrequent bruisinginfrequent bruising

44. Specific risksSpecific risks
• Crow’s feetCrow’s feet
– more chance of bruisingmore chance of bruising
– rarely, a weakened orbicularis can causerarely, a weakened orbicularis can cause
a sagging appearance over the inferiora sagging appearance over the inferior
orbital rim (this may be transient swellingorbital rim (this may be transient swelling
possibly due to lymphatic blockage)possibly due to lymphatic blockage)
– focal facial paralysisfocal facial paralysis

45. Swelling one day post injectionSwelling one day post injection

46. Proper Documentation of BotoxProper Documentation of Botox
Cosmetic treatmentCosmetic treatment
• Detailed Botox treatment maps, withDetailed Botox treatment maps, with
dosages and locations, to refer to atdosages and locations, to refer to at
subsequent visitssubsequent visits
• Still photos and video clipsStill photos and video clips

47. Be a scientist!Be a scientist!
Document each injection siteDocument each injection site

48. Dr. Weiss before botoxDr. Weiss before botox

49. Dr. Weiss after BotoxDr. Weiss after Botox

50. Before Botox to glabellaBefore Botox to glabella

51. After Botox to Glabella (7d)After Botox to Glabella (7d)

52. Before Botox to smile linesBefore Botox to smile lines

53. After Botox to smile lines (7d)After Botox to smile lines (7d)

54. Before Botox to foreheadBefore Botox to forehead

55. After Botox to Forehead (9d)After Botox to Forehead (9d)

56. Before Botox to smile linesBefore Botox to smile lines

57. After Botox to smile lines (9d)After Botox to smile lines (9d)

58. Think units (U)!Think units (U)!
• The only way to evaluate or compareThe only way to evaluate or compare
the efficacy and value betweenthe efficacy and value between
treatments and also between doctorstreatments and also between doctors
• Don’t think in terms of areas orDon’t think in terms of areas or
syringes.syringes.

59. What’s the difference betweenWhat’s the difference between
Botox and Collagen?Botox and Collagen?
• Botox stops muscle motion that causesBotox stops muscle motion that causes
wrinkles to occurwrinkles to occur
• Collagen fills in fine or deep wrinkles thatCollagen fills in fine or deep wrinkles that
are already thereare already there

60. Collagen science (1 of 1)Collagen science (1 of 1)

61. Collagen before and aftersCollagen before and afters

62. Collagen before and aftersCollagen before and afters

63. Collagen before and aftersCollagen before and afters

64. Laser skin resurfacingLaser skin resurfacing

65. Eyelid surgeryEyelid surgery

66. Eyelid surgeryEyelid surgery

67. Endoscopic Brow LiftEndoscopic Brow Lift

68. Brow lift, eyelids, and laserBrow lift, eyelids, and laser

69. • EyeEye – Occuflox, Refresh Plus tears– Occuflox, Refresh Plus tears
– Alphagan, Lumigan, AlocrilAlphagan, Lumigan, Alocril
• BotoxBotox
• SkinSkin – MD Forte skin care products– MD Forte skin care products

70. Botox Cosmetic:Botox Cosmetic:
WhatWhat everyevery AllerganAllergan
employee should knowemployee should know
Richard A. Weiss, M.D.Richard A. Weiss, M.D.
Newport Beach, CANewport Beach, CA