Botox: Injecting people with deadly neurotoxin (for money)
1) Botox basics
A) Pathophysiology/practical concerns:
-Mechanism: Gets into neuron vesicle, breaks down snare proteins, nerve can’t release
acetylcholine vessels to muscle. Snare proteins grow back in about 3 months, so effect is
always temporary.
-Generally takes 3-7 days to “kick in”, peak effect in 2-4 weeks, and lasts for around 3 months.
Despite this, many patients will say that they notice difference in minutes, hours, or a few days.
-ALWAYS need prior authorization before giving Botox, given high cost; generally can’t be
done acutely or as inpatient. Must be performed by certified provider in Botox Clinic. Patient
Assistance programs through the companies can help with some of the co-pay if needed.
-Botulinum toxin names: Ona= Botox, Abo= Dysport, Inco = Xeomin, rima=Myobloc (is the
only TYPE B one). UNITS ARE NOT INTERCHANGABLE between brands.
-FDA approvals:
-Botox: Chronic migraine, upper limb spasticity, cervical dystonia, blephrospasm
-Dysport: Cervical dystonia
-Xeomin: Cervical dystonia, blephrospasm
-Myobloc: Cervical dystonia.
B) Materials needed:
-Bottle of NS (for dilution)
-1 cc syringe (for injection) and 3cc syringe (for dilution)
-27 gauge (deep muscles) and 30 gauge (face muscles) needles
-Alcohol swab, tissues
-Botox
-Gloves
-EMG/special EMG needle/grounding pads (unless injecting facial muscles)
C) Diluting/preparing the botox:
-KEY first step is knowing ahead of time what you will inject, and in what amounts, so you can
measure out appropriate amounts in syringe to minimize pokes and wasted Botox.
-Procedure for dilutions:
1) Get a 21 gauge needle on a 3cc syringe and inject air into bottle of NS.
2) Inject 1.1 cc (for 1:1 dilution) or 2.1 cc (for 2:1 dilution) of NS per 100 unit NEW Botox
bottle. The extra 0.1cc is because you can’t get every last drop out. No need to
swirl/shake the bottle.
3) Take a 1cc syringe with a 21 gauge needle and “Burp” the Botox bottle with open
syringe to offset vacuum. Using that same syringe, slide the needle along the inside
corner of the bottle and draw up what you need. Tip the syringe to 45 degree and flick
syringe to get rid of air bubbles gently.
4) If botoxing the face, replace the 21 gauge needle on the 1cc syringe with a 30 cc
needle, after you’ve drawn up the Botox.
Protip: You can tell if a Botox bottle has been used, as unused bottles have the dry
white residue visible on the bottom.
D) Explaining Botox to a new patient:
-Botox works by temporarily weakening specific overactive muscles.
-When to use: When have involuntary muscle movements that are bothersome/limiting.
-How it works: Use tiny needle (smaller than blood draw needle) with EMG attached to locate
problem muscles, and inject Botox into them. Find muscles by combination of knowledge of
anatomy + EMG.
-Starts working in 1-7 days, effect peaks after about 1 month, wears off in 8-14 weeks. Not a
permanent fix, you need to re-inject every 3 months (not sooner, as your immune system could
make it stop working if use too often; possibly can wait longer). Often the early injections don’t
achieve best possible effect, and we need to adjust the dose amount or location in subsequent
visits for optimal results.
-Risks: Pain, infection, bleeding, not work, local weakness/dysphagia. Side effects sually last
1-2 weeks. Black box warning of remote possibility of distal spread of toxin (small number of
kids getting large doses in their legs got breathing/swallowing problems and died; never seen
this complication ourselves, but good to have family know Heimlich maneuver).
-NOT a mandatory thing, you can say no at any time. This is symptomatic benefit only.
E) Record-keeping and chart documentation: ______
-Sample note: _____
F) Billing:
-Under visit type, use code “99999”.
-Click charge capture  click injection Then click Botox A, needle EMG (if used), and
procedure type within procedure type, chose the correct diagnosis, under “quantity” type the
total number of units of Botox used (used + wasted), and under “modifier” type “50” if injected
anything bilaterally (excluding migraine injections).
-Make sure to store extra botox appropriately in the fridge; used bottles of Botox are usually
good for a couple weeks. Label their dilution (1:1, 2:1, etc) and date opened.
G) Trouble-shooting/notables
-Dose increase needed: As general rule of thumb, if dose increase is needed, increase by
about 50% of prior dose; if more dangerous/vulnerable area (SCM, hands, etc) increase by
30%.
-Reasons injections not working: Wrong muscle, inadequate dose, unrealistic expectations,
stress-induced exacerbation, fixed posture, “bad batch”, post-traumatic dystonia, tremor;
MUCH LESS LIKELY changing of dystonia or immune resistance (1-2%).
-Possible immune resistance: Inject 20 units into unilateral brow; if no resistance, will lose
grimace on one side. If immune resistance develops, try different serotype of toxin. If VERY
resistant, may need to consider alternative options (peripheral denervation, DBS, oral meds,
etc)
-Dysphagia: usually resolves in a few weeks. Advise patients to avoid meats, nuts, and (if
difficult) thin liquids. Eat well-cooked foods with small pieces/small bites, and chew well without
talking or getting distracted while eating. Make sure people around you know the Heimlich, and
when to perform it. At next injection, alter where you inject/amount to reduce chance of
recurrent dysphagia.
-If injecting >50 units in one muscle, usually split up dose into a few locations along muscle.
H) What to ask patients when they come back as RV:
-Adequate symptom relief from last injection? If not, what was insufficient?
-What pattern/amount has worked best before? Anything NOT work well before (may need to
review records)?
-How long before it kicked in? Before it reached max? Before it started wearing off? Before it
wore off completely?
-Change in the characteristics of the abnormal movement in interim?
-Side effects (dysphagia, SOB, weakness, ptosis, vision changes, cosmetic concerns, etc)?
2) Conditions potentially warranting Botox
A) Cervical Dystonia
Background:
-DDx: Cervical spine abnormality, tardive dystonia, parkinson’s plus syndrome
Characteristics/exam:
-Muscle hypertrophy, direction of tilt/torticollis/anterocollis/retrocollis, compensatory muscle activity, sensory trick,
psychogenic aspects, symptoms beyond isolated cervical dystonia.
Workup:
-MRI C-spine; consider ceruloplasmin in young patient.
Treatment:
-Botox is gold standard
Muscles involved:
1) Torticollis/head turn:
-Contralateral SCM
-Ipsilateral spenius capitus
2) Laterocollis/Tilt:
Ipsilateral Levator scapulae
Scalene
Trapezius
Longissimus
3) Anterocollis/head forward:
-Platysma
-Bilateral SCM.
Generally avoid injecting for this issue, given the risks of dysphagia.
4) Retrocollis/head back:
-Bilateral cervical paraspinals
-Bilateral spenius capitus
5) Shoulder elevation:
-Ipsilateral trap: As above
-Ipsilateral Levator scapulae: As above.
B) Oromandibular dystonia:
Background:
-Female: male 2:1.
Characteristics/exam:
-Can be classified as jaw opening (lateral pterygoids,digastric, suprahyoid), jaw closing (masseter, temporalis,
medial pterygoids), jaw deviation, or mixed
Workup:
-MRI, cerumoplasmin
Treatment:
-Sinemet, anticholinergics, benzos, baclofen, gabapentin, botox, DBS
Botox:
-Muscles vary based on specific presentation.
-1:1 dilution for tongue, 2:1 dilution for other facial muscles.
-Genioglossal: Tongue protrusion.
-Mentalis: Pulls chin down.
-Masseter: Biting.
-Temporalis: Biting.
-Oris: Puckering. Watch out for trouble with water leaking out of mouth as side effect.
-Depressor angulara oris: Frowns/pulls down face.
-Lateral ptyerygoid: attaches to TMJ. Opens jaw, deviates jaw to OPPOSITE side.
-Side effects: Depends on muscles injected. Can include trouble chewing/moving food in mouth, sucking straw,
water leaking out mouth. Make sure people know to take small bites, have relatives know Heimlich, etc.
C) Blephrospasm:
Background:
-Focal dystonia.
-Mid 50’s, female predominance.
-Idiopathic (most common) vs. symptomatic (PD, PSP, tardive, midbrain lesion) vs. apraxia of eyelid opening.
Characteristics/exam:
-May begin with increased blinking, can result in persistent eyelid closure.
-Can involve blinking, photosensitivity, dry eyes, involuntary eye closure.
-Can often elicit by having patient squeeze eyes shut and then open rapidly, repeatedly
Workup:
-None required if isolated presentation without other signs.
Treatment:
-Botox is treatment of choice
-Oral med effectiveness is limited (anticholinergics, neuroleptics, benzos) vs. surgical (last resort is myectomy or
DBS via GPi).
Botox:
-Inject in the below pattern (bilaterally), 2.5 units each at 2:1 dilution with 30 gauge needle. Avoid levator
palpeprae (center of upper eyelid) to avoid ptosis; 2.5 units per site, 12.5 units per eye total. Can also consider
adding additional sites over each brow (total of 3 sites per brow) at 5 units each, and if not work then increase to
10 units at each brow site.
-93% success rate.
-Adverse effects: ptosis (20%), dry eyes (6%).
D) Hemifacial spasm:
Background:
-Segmental myoclonus, NOT dystonia.
-Involuntary contraction of unilateral 7th CN muscles.
-Usually idiopathic vs. vascular loop compressing unilateral CN VII or structural lesion
-Female predominance.
-DDx post-Bell’s synkinesias (treated the same way), tics, tardive spasms, myokymia
Characteristics/exam:
-
Often see tonically raised eyebrow; specific sign is eyebrow raise when eye shuts.
Often mistaken for facial tic; difference is no urge to perform movement, and obviously involuntary.
Often starts around eye, and eventually (and unpredictably) involves muscle of lower face too.
Workup:
-CN 7 protocol MRI brain w/ and w/o contrast looking for structural lesion (ie, tumor) abutting nerve; no need for
MRA, as vascular decompression is last resort and almost never needed.
Treatment:
-Botox; consider vascular loop decompression only as absolute last resort.
Botox:
-2:1 dilution, 2.5 units per injection (0.05ml per injection), total 17.5 units of Botox. If inadequate, can escalate to
3 or 3.5 units per injection (0.06 ml, total 21 units). May also need to add injections to muscles in lower face over
time.
-First time, inject upper face only; if lower face twitches, next time add SMALL amounts to lower face
muscles mentalis/platysma > risorius/depressor anguli; anything higher than the lip is more liable to
cause weakness/symmetry issues.
-Injecting Eye: Inject glabella, medial above eyebrow, lateral upper lid (superficial), lateral canthus, inferolateral
lower lid (between cheek and eye, superficial), centro-lateral lower lid (between cheek and eye), medial upper lid
(superficial).
-Injecting Lower face (dependent on pattern): lower twitching is mentalis, platysma >risorius and depressor anguli
(2 units each); upper twitching is zygomaticus.
-Avoid central upper lid or medial lower lid, to avoid ptosis and eye movement abnormalities (respectively)
-Side effects: facial weakness, vision changes, ptosis.
E) Migraines:
Background:
-To get insurance approval, document chronic medically refractory migraine that has failed/couldn’t tolerate
reasonable trials of 3 good headache prophylactics (beta blocker, Topamax, and a TCA are good first choices),
and with headaches present at least 15 days per month.
Characteristics/exam:
-Migrainous headaches; rule out neurologic abnormalities or specific headache syndromes that may respond
better to other therapies (hemicranias, cervicogenic, occipital neuralgia, trigeminal neuralgia, pseudotumor, GCA,
etc)
-Need to document that they tried and failed adequate trials of 3 first-line oral meds (TCAs, beta-blockers, calcium
channel blockers, anti-epileptics), and that they have >= 15 days of migrainous headache per month.
Workup:
-None needed if typical migraines
Botox:
-Initial requirements for approval: Failed reasonable trials of three first-line classes of headache prophylactics
(TCAs, beta blockers, calcium channel blockers, SNRIs, anti-epileptics), 15 or more headache days per month.
-After 4 treatments, need to have at least 7 additional headache-free days per month, OR at least 100 additional
headache-free hours a month to get additional treatments approved.
-155 units of 1:1 dilution in STANDARD distribution (see diagram below) using 30cc needle, 5 units (0.05cc) per
location directly subcutaneously; if not respond after first trial, increase to max of 200 units “following the pain”
with 7.5 units in half the spots, and 5 units in the other half.
-Have them bite to bring out temporalis, and trace as a line a couple finger breadths above line a pair of glasses
would take; do occipitalis directly below where bone slopes off, in a triangle pattern or line. Don’t go too low with cervical
paraspinals.
-If fails 2 trials of 200 units, likely Botox non-responder and should no longer receive Botox
-Bill with diagnosis code 346.71
-20% get no response on first dose. ->50% of patients responded after 3 cycles. By cycle 2, 50% had >50%
decrease in # of headache days. By Cycle 5, 2/3 of patients were responders and had >50% decrease in headache days,
cumulative headache hours, and and severity)
-4% get mild head heaviness 2/2 neck injection portion.
F) Limb Dystonias:
1) Arm
-As a rule, flexors/pronators are “safer” to inject than extensors/supinators; side effects include trouble opening
jars, writing, opening doors, throwing ball, using utensils.
-Flexors live in medial anterior forearm, extensors in lateral anterior forearm.
-For Writer’s Cramp, watch them write, and ALSO have them write with off-hand to bring out the dystonia (“mirror
sign”).
G) Sialorrhea:
Background:
-DDx neuromuscular/sensory dysfunction, hypersecretion, anatomic.
Workup:
-None
Treatment:
-Trial glycopyyrolate, scoplamine, atropine drops, botox.
Botox:
-Parotid gland (2 finger breadths anterior to ear, and 2 finger breadths down from bottom of ear line)
-submandibular gland (1/3 of way from angle of jaw to chin, and directly below mandible, angling up)
-Dosing: Myoblock: 1000 units parotids, 250 units submandibular gland; Botox: 30 units parotids, 10 units
submandibular
H) Spasmodic dysphonia:
Background:
-Described in 1871, initially felt to be psychiatric
-1/100,000 mainly females age 40-50’s
-Voice disorder that is task induced with spasms of laryngeal musculature
Characteristics/exam:
-Strained, strangled, breathiness, pitch breaks.
Workup:
-ENT referral for diagnosis.
Treatment:
-Referral to otolaryngologist with botox experience, voice therapy, or surgery. Botox usually handled by ENT.
Botox:
-Adductor: Inject 5mm left or right of space between two thyroid cartilages. Dose 2-2.5 units
-Abductor: Push it in DEEP to same area. 3 units.
3) Summary of muscles and their injection sites:
Muscle
Action
Location to inject
Facial muscles
Starting Botox
dose
Side effects
Genioglossus
Protrude tongue
Depressor Anguli
Mentalis
Risorias
Zygomaticus
Masseter
Frown
Pulls chin down
Fake smile
Real smile
Bite down
Temporalis
Bite down
Oris
Lateral Pterygoid
Puckers lips
Opens jaw, deviates to
opposite side
Neck muscles
Turn head contralateral;
Side of neck; place hand on opposite
anterocollis
cheek and turn into it to bring out
Turn/tilt head
Behind and below ear, a divot at hair
ipsilaterally, retrocollis
line
(bilateral)
Tilt head ipsilaterally,
Neck: Directly below splenius capitus,
shoulder elevation
at neck line, anterior to trap. Back: Find
medial border of scapula, and go 1/3 of
way medial and up from there to C1.
Tilt head ipsilaterally
Behind and inferior to SCM, in “soft
triangle”
Retrocollis
Lateral to spine
Shrug shoulder
Where shoulder meets neck; shrug
shoulder to elicit.
Find trap in neck, pull it back and inject
just anterior to it.
SCM
Spenius capitis
Levator Scapulae
Scalene
Cervical paraspinals
Trapezius
Longissmus
Flexior Digitorum
Profundus (FDP)
Flexor Digitorum
Superficialis (FDS)
Flexor Pollicis
Longus (FPL)
Flexor Carpi Radialis
(FCR)
Pronator Teres (PT)
Flexor Carpi Ulnaris
(FCU)
Opponens Pollicis
Pronator Quadratus
Extensor carpi
radialis
Extensor Carpi
Tilt head back, inject 1 cm lateral from
midline and 1 cm below chin, straight
up; protrude tongue to confirm location
on EMG
Follow nasolabial fold down to jaw
Anterior chin
Lateral to mouth
Inferior to cheek.
Between ear and cheek.
6 each side
3
3
2
2
15 divided in 3
spots
At temples, start at hairline and work
posteriorly
Hand/arm muscles
Flexes distal finger joint
Bend arm; find ulna on medial edge of
arm roughly 1/3 of way from elbow;
inject directly anterior to ulna, and deep
Flexes proximal finger
Arm flat on table. 1/3 of way from
joints
elbow, just medial of midline. Flex
fingers against resistance to locate.
Superficial.
Flex thumb
Inject dead center of anterior arm,
aiming radially. Go deep until hit radius,
then pull back slightly and inject.
Flex wrist radially
On anterior arm near elbow crease, find
anterior (triangle) fossa, just medial and
distal to it
Pronate wrist
On anterior arm near elbow crease, find
anterior (triangle) fossa, and inject just
medial to it
Flex wrist radially
Bend arm; find ulna on medial edge of
arm roughly 1/3 of way from elbow;
inject directly anterior to ulna, superficial
Thumb to pinky
Posterior thumb, mid-metatarsal, just
lateral to bone
Pronate forearm
Flex wrist, come in dead on into medial
wrist from the side just anterior to ulnar
bone, angle straight on
Extend wrist radially
1/3 down dorsal arm, medial side of
moveaable muscle there
Extend wrist ulnar
Bend arm, 1/3 up arm, find ulna, just
30-40
30-50
30
20
30-50
30-45
12
20 divided in 2
sites
10-20
10-20
Ulnaris
Extensor Digiti
communis
Extend fingers
Adductor Pollicis
Adduct thumb
dorsal to that and superficial
1/3 of the way down the dorsal arm,
lateral side, medial to the movable
muscle mass there
On posterior side, inject directly into
web space between thumb and index
finger, angling underneath index finger