Introductory Botulinum Presentation

s i m p l e
younger
rejuvenated
New Technologies for Facial
refreshed Enhancement
Introductory course to Vistabel

Course Agenda
• Starting off with Botox
• Neurotoxin Pharmacology
• Contraindications and Cautions
• Patient selection and treatment options
• Dilution and storage
Cont’
• Technique tips
• Cosmetic indications
6. Glabellar frown lines
7. Forehead lines
8. Crows feet
Cont’
• Live demonstration
• Hands-on workshop
• Advanced techniques
• Strategies for success
UK APPROVAL 2006
For Glabellar frown lines
BOTOX (100 Units)
Now launched as VISTABEL (50 Units)
Single patient use
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

Surgical & Non-surgical Cosmetic
Procedures 9 Year - Comparison
1997-2005 1997
Liposuction (lipoplasty) 176,863 455,489
2005
Breast Augmentation 101,176 364,610
Eyelid Surgery 159,232 231,467
BOTOX® 65,157 3,294,782
Chemical Peel 481,227 556,172
Laser Skin Resurfacing 154,153 485,690
Top 5 nonsurgical cosmetic procedures in 2005

Chemical Peels 556,172
Microdermabrasion 1,023,931
Injectable Fillers 1,194,222
Laser Hair Removal 1,566,909
BOTOX® 3,294,782
American Society for Aesthetic Plastic Surgery

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

Patients perceive a “hierarchy” in cosmetic maintenance
Alteration Visible Changes Altering appearance ;

major interventions, eg.
Face-Lift
Renovation Subtle, natural Improving appearance via
changes NON-surgical treatments,
eg. VISTABEL®, FILLERS
Prophylaxis Containment Preserving appearance as a
part of everyday care,
eg. Anti-wrinkle creams
Cosmetic Maintenance
“Context” Research 2004 Paris, France
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

Patients Feeling Towards Recommending
Treatment To A Friend
More than 90% of patients would recommend treatment to
a friend concerned about wrinkles
Recommend Strongly
Neither Against Recommend
Recommend 0% Against
for nor against 0%
10%
Strongly
Recomment
38%
Recommend
52%
“Genactis” Research 2004 France

Age
Under 18 0.05
18 - 24 0.16
25 - 34 32%
35 - 44 23%
45 - 54 17%
55 - 64 7%
65 + 1%
0% 5% 10% 15% 20% 25% 30% 35%
N=1335
Vivid Interface Ltd. Market Research Body Beautiful 2005
It is very important
®
to learn that BOTOX
is both an
art and a science
before you become a user
Art and Science combined

Starting BOTOX ®
How can you introduce it into
your practice?
Starting BOTOX®
Starting BOTOX®
Getting started with BOTOX can be

®
the hardest part…
collecting patients,
promoting it in the practice,
consent forms…
Starting BOTOX®
Before offering BOTOX® 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®
Launching it in your Practice
– 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®
Launching it in your Practice –
consider the following:
• Schedule “BOTOX® days”
• Get local media exposure
• Inform patients with practice
newsletter
Starting BOTOX®
Neurotoxin
Pharmacology
Indicated for*;
-Blepharospasm
-Strabismus (USA)
-Hemifacial spasm
-Cervical dystonia
-Cerebral Palsy
-Axillary hyperhidrosis
-Glabellar lines
*Approvals and product names vary from country to country – consult specific
prescribing information
BOTOX®
Photos © J Jankovic
Other Clinical Conditions Treated with
BOTOX® (Un-licensed)
•Migraine
•Tension Type Head-Ache
•Back Ache
•Hypersalivation
•Myofacial Pain Syndrome
Neurotoxin Pharmacology
Botulinum Neurotoxin Serotypes
• 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
Botulinum Neurotoxin Serotypes
COOH NH2
• Seven serotypes
S-S
- A, B, C1, D, E, F, G
Light
- Type A has longest duration Chain Heavy
Chain
of action
• Intracellular target varies
NH2 S
- SNAP-25 S
• Does not penetrate the skin

• No topical application COOH
BOTOX® - Mode of Action
1 Before BOTOX®: 2 Binding: 3 Internalization:

Endplate sits upon Neurotoxin binds to Neurotoxin
muscle fibre nerve terminal internalized via
receptor-mediated
endocytosis.
BOTOX® - Mode of Action
4 Blocking: 5 Sprouting and re-

establishment of sprouts:
Light chain blocks
fusion of Endplate expands and
neurotransmitter collateral axonal sprouts
vesicle with nerve emerge. Sprouts subsequently
membrane by cleaving retract and are eliminated;
SNAP-25. Neurotoxin
parent terminal isPharmacology
re-
established.
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
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

Contraindications and
cautions
Contraindications
• Pregnancy and Lactation
•Neuromuscular transmission
disorders.(Myasthenia Gravis)
• Co-administration with aminoglycoside

antibiotics
• Bleeding disorders or anticoagulant therapy
•Patients with known hypersensitivity to any

Contraindications & cautions
ingredient in BOTOX®
Cautions
• Lack of patient co operation
•Unrealistic expectations
•Local infection at injection site (active acne)
•Dysmorphophobia
•Unrealistic fear of systemic botulism
Contraindications & cautions

Patient Selection and
treatment options
Glogau wrinkle scale
Patient Selection and Treatment Options

Type I (No Wrinkles)

Topical therapy
However, check
dynamic movement
May treat as
preventive therapy

Type II (Wrinkles in
Motion)
BOTOX® plus topicals

Type III (Wrinkles at Rest)

BOTOX® plus fillers
•Treat with Botox first
•Botox and filler have
synergistic action

Type IV (Nothing but

Wrinkles)
Consider surgery

KEY ELEMENTS
• Assess patient’s desires. Are they realistic?
• Assess facial expression at rest and during
animation
• Evaluate tonicity of muscles
5. Kinetic
6. Hyperkinetic
7. Hypertonic
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
Dilution &
Storage
Dilution 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
Dilution & Storage

Dilution 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
Dilution & Storage

Storage
• 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

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
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
Some general
technique tips for:
• optimal treatment success
• satisfied, repeat patients
General 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
• 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
• 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
Preparing to Inject
• 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
Technique Tips
CHECK LIST
• Med history
• Assess expectations
• Explain 2 to 3 days before visible signs, 14 days
for maximum effect
• History,Skin status
Cont’
• Explain likely results discuss alternatives
• Peels,microdermabrasion,Laser resurfacing
• Sign consent form
• Photograph, Inject, Record
• Follow up instructions recall
Cosmetic Indications
• Glabellar Frown Lines
• Forehead Lines
• Crow’s Feet
• Eyebrow lift
Glabellar
Frown Lines
• 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
Target Muscles for Frown Lines
Procerus
Corrugators
Cosmetic Indications
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 Brow depressor

depressor supercilii
Carruthers J Fagien S et al Plast Reconstr Surg 2004

Treating Glabellar Lines:
Consensus Recommendations
Higher starting doses may be used depending on individual patient
variables
Usual Number of Total Starting

Injection Points Dose*
Target Muscles (Range) (Usual Range)
Corrugator, 5 to 7; men may Women: 20 to 30 U
procerus, require more sites Men: 30 to 40 U
depressor
supercilii,
orbicularis oculi,
frontalis

Frown lines – Injection sites
Cosmetic Indications - Glabellar Frown Lines

Glabellar Frown Lines
Post-injection: Advise patient to frown
as much as possible for 1 hour

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

Glabellar Frown Lines – How
not to inject!
Injecting down
toward the globe
Patient supine
No gloves!

Results (1)
Photos © Hervé Raspaldo

Clinical Examples
Female in her Thirties
Before
30 Days
120 Days
Glabellar Frown Lines - Follow Up
• 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
Horizontal
Forehead Lines
Anatomy - Frontalis Muscle
Action: elevate brows, draw scalp posteriorly
Frontalis muscle
Cosmetic Indications - Horizontal Forehead Lines

Horizontal Forehead Lines:
Anatomy and Physiology
Muscle Function
Frontalis Brow elevation
(interacts with procerus, corrugators,

and orbicularis oris)

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

• 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 by
not injecting
shaded area

Clinical Examples
Before
30 Days
120 Days
Standard technique: 2-4 units in 5 injection sites

Additional sites to consider for males

Before After

Before After
Note enhancement of brow
shape to soft flare

Crow’s Feet
Target Muscles for Crow’s Feet
Orbicularis oculi
Cosmetic Indications - Crow’s Feet

Crow’s Feet
• 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 Feet
• Patient at full smile
• Note upper and lower

borders of the crow’s
feet

Crow’s Feet
• Inject 1cm outside the
orbital rim
• At least 3 injection sites
x x
1cm apart suffice due to
diffusion effect
• Inject 3 - 4 units of BOTOX®
per injection site REQUIRED
x OPTIONAL- IF PATIENT HAS LINES

Clinical Examples
Before
30 Days
120 Days
Crow’s Feet
Before After

Managing complications
of BOTOX® treatment
Potential Side Effects
• 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 complications
Bruising
Headache
Eyelid ptosis
Brow ptosis
Brow repositioning
Diplopia
Treating ptosis
Alpha-2 agent with

weak alpha-1 activity
[eg, apraclonidine 0.5%
(Iopidine®]
Alpha-1 adrenergic
stimulation of Müller’s
muscle
Treating ptosis
Usually resolves in 1-6 weeks
Iopidine (Alcon) eyedrops 1 drop q.i.d. will
temporarily resolve
Ptosis left lid 20 minutes after Iopidine®

Brow ptosis
Wait for natural resolution
Consider infrabrow injection at arch and laterally
to raise brow
After BOTOX® to glabellar and brow
Brow repositioning
Excessive brow
elevation
• “Quizzical” or “Mr
Spock” brows
• Correct with 1 to
®
2units of BOTOX
injected into the
frontalis above the
lateral brow
If after glabella treatment
“cruella” / mephisto
inject 0.5-1.5U only
‘Mephisto’
Photo © Ph LEVY
Advanced techniques require a
degree of judgement gained from
approximately 3-6 months BOTOX®
cosmetic experience
Advanced Cosmetic Techniques
• Suborbital region
• Upper lip wrinkles
• Nasal scrunch (“bunny lines”)
• Nasolabial folds & marionette
lines
• Platysmal bands
Advanced techniques and combination treatment

Before After
Infra Orbital Crinkle Lines

Photos© Ph LEVY
Before After
Bunny Lines Results

Photos © K De Boulle
Before After
Perioral Rhytides
Photos © K De Boulle
Chin: Peau D’orange, Mental
Crease
Before After
Photos © NJ Lowe
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
Before After
Neck - Anterior bands

35-55 y.o. Photos © Ph LEVY
Strategies for
success
Choice of Language
Medical Phrases Patient Positive Phrases
Frozen Smooth
Toxin Purified or natural protein
Paralyse Relax or soften muscle activity
Pain Minimal discomfort
Weaken Relax
Customer 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!!!!!!!!
Strategies for success

Pricing 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 charge

Marketing
Don’t advertise BOTOX® or “Botulinum toxin”-

it contravenes Advertising Standard Authority
guidelines regarding the promotion of
Prescription Only Medicines.

Tips 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)

Cont’
• 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

Optimizing Success
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.
Strategies for sucess

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

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
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.
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)………………………………..
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.
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
stevenkaldor@hotmail.com
07801428702
Allergan Ltd(Vistabel)
08003767965
Richard Crawford 0773358145(Rep)
Thank you

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Formats disponibles

s i m p l e

Introductory course to Vistabel

Personal Communication © Tim Flynn

Eyelid Surgery 159,232 231,467

BOTOX® 65,157 3,294,782

Chemical Peel 481,227 556,172

Laser Skin Resurfacing 154,153 485,690

Top 5 nonsurgical cosmetic procedures in 2005

Injectable Fillers 1,194,222

Laser Hair Removal 1,566,909

American Society for Aesthetic Plastic Surgery

Personal Communication © Ph LEVY

Alteration Visible Changes Altering appearance ;

Patients’ level of agreement with the following statements Score *

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

“Genactis” Research 2004 France

“Genactis” Research 2004 France

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

Art and Science combined

How can you introduce it into

Getting started with BOTOX can be

the hardest part…

• Attend a training course

• 1982 Jean Carruthers brings “Oculinum”

• 1987 Jean Carruthers Blepharospasm

• Does not penetrate the skin

1 Before BOTOX®: 2 Binding: 3 Internalization:

4 Blocking: 5 Sprouting and re-

- Lidocaine (s.c.) 1:5

- Botulinum toxin-A 1:50

Heckmann M Hauzart 2000

• Co-administration with aminoglycoside

• Bleeding disorders or anticoagulant therapy

•Patients with known hypersensitivity to any

• Lack of patient co operation

•Local infection at injection site (active acne)

•Unrealistic fear of systemic botulism

Contraindications & cautions

Patient Selection and Treatment Options

Type I (No Wrinkles)

Patient Selection and Treatment Options

Patient Selection and Treatment Options

Type III (Wrinkles at Rest)

Patient Selection and Treatment Options

Type IV (Nothing but

Patient Selection and Treatment Options

• Vacuum should draw down saline

• Volumes of 1ml to 2.5mls recommended

• Use only Bacteriostatic saline

Dilution & Storage

• US FDA trial protocol uses 2.5cc

• 1ml dilution allows greater control by reducing

• Also minor injection errors with 1ml dilution may

Dilution & Storage

• DO NOT FREEZE BOTOX® ONCE

• Store in the refrigerator at 2 – 4 °C

Dilution & Storage

• Patient should be seated or slightly reclining to best

• Try to change 30 gauge needle after every 4 - 5

• Have patients discontinue aspirin,Vit E and

• Mark (when learning) the injection sites

• Inject selected dose with 30 gauge needle

• Inject with patient’s muscle relaxed for comfort