Cosmetic Uses Of
Botulinum Toxin
(BOTOX)
By Mustafa Z. Hasan
DEFINITION
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Botulinum toxin, is a protein and neurotoxin produced
by bacterium Clostridium Botulinum. It’s the most
acutely toxic substance known. It can cause botulism
a serious life threatening illness in humans and
animals, it is used for various cosmetic and medical
procedures.
MECHANISM OF ACTION
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The toxin is a fully sequenced, 1,295 amino acid chain.
It consists of a heavy chain of 97 kilodaltons (kDa)
connected by a disulfide bond to a light chain of 52
kDa.
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The heavy chain binds to the neuronal cell membrane,
allowing passage of the light chain into the cytoplasm
of the nerve. The light chain is a metalloprotease that
cleaves the protein known as SNAP-25
(synaptosomalassociated protein 25).
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SNAP-25 is necessary for the transmitter vesicle
containing acetylcholine with the cell membrane.
Without fusion of the vesicle with the cell membrane,
the neurotransmitter cannot be released into the
synapse and a presynaptic neural blockade is created.
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Clinically, the beneficial effects of the toxin are
apparent for 3 to 6 months.
it typically takes 6 to 7 months for all of the clinical
effects to fade.
there are more than 200 different conditions reported
in the scientific literature that can be treated with the
toxin, including blepharospasm, strabismus, cervical
dystonia, torticollis, achalasia, spasmodic dysphonia,
anal fissure,….
APPLIED MECHANISM OF
ACTION
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As long as a wrinkle is caused or partially caused by
muscular action, it can be treated with botulinum
toxin A.
a glabellar rhytid is nearly completely caused by the
actions of the corrugator and procerus muscles and
can be completely eradicated in a young patient.
Vertical lip rhytides in an elderly woman with thin skin,
sun damage, a history of smoking, and loss of lip
volume can only be partially improved by injection of
the toxin
PREPARATIONS
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The Clostridium botulinum bacteria secretes eight
distinguishable exotoxins.
The most potent of these serotypes is A (botox)
Myobloc (toxin B) is not approved for cosmetic
purposes, Although the onset of action is faster than
that of Botox, the increased pain on injection
(relatively low pH of 5.6) and decreased duration of
action limit its cosmetic usefulness.
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Botox is supplied as a freeze-dried crystalline complex
in a vial containing 100 units.
According to the labeling of the product, it should be
mixed with 2.5 mL of nonpreserved saline.
Botox injection is
contraindicated in:
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disorders of neuromuscular transmission, such as
myasthenia gravis and Lambert-Eaton syndrome.
in patients taking aminoglycoside antibiotics,
potentiate the effects of the toxin.
pregnant women, breast-feeding women..??
DOSAGE
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Just as dilution of Botox is a personal choice, so is
dosage in most circumstances.
Every patient is different and requires a different
dose placed differently across the muscle being
treated.
For example, most practitioners inject about 25
units, on average, per glabella. Some
dermatologists advocate as much as 80 units, but
some patients have excellent results with as little as
7.5 units and some require as much as 27.5 units.
Men typically require higher doses as the muscle
mass tends to be greater.
Posttreatment
Instructions
Don’t massage the treatment area.
 Contract and relax the treated muscles for 90 minutes
to 2 hours.
 No need to limit physical activity, but avoid bending,
flying, or exposure to heat for 2 hours after treatment.
 These practices may help reduce unwanted diffusion,
but no controlled studies have been conducted .
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GLABELLA
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The glabella was the first area
to be treated cosmetically with
Botox.
The median dose for treating
the corrugator and procerus
muscles is 17.5 units for
women and 20 units for men.
Horizontal frowners are not
injected in the procerus
muscle. Vertical frowners are
injected in the medial portion
of the corrugator and procerus
muscles.
FOREHEAD
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The dosage range for the frontalis is 3.75 to 35.0
units.
Care must be taken to not overly denervate the
frontalis because it can lead to an overly smooth,
artificial appearance, brow ptosis, and eyelid
ptosis in the patient who has been using his
frontalis as an accessory eyelid elevator.
The strongest portions of this muscle are
targeted, not the rhytides.
No standard pattern of injection is used.
CROW’S FEET AND
LOWER EYELID
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The lateral and inferior orbicularis oculi is weakened to
diminish crow’s feet and lower eyelid rhytides in
selected patients.
overzealous injection can yield an unpleasant deer-inthe-headlights appearance and even cheek ptosis.
Excessive chemodenervation of the orbicularis oculi
across the lower lid can cause ectropion or lower-lid
retraction.
most patients receive between 3.75 and 5.0 units per
side.
Treating Bunny Lines
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Target muscles are nasalis and procerus.
The usual number of injection, 1 per side for nasalis
and 1 in midline for procerus.
Usual dose is 2-5 u divided evenly for nasalis and 1 u for
procerus.
BROW ELEVATION
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Botox can easily and reliably lift the brows in excess
of 6 mm.
When portions of the frontalis are weakened, the
other portions of the frontalis lift more strongly.
The muscle segments that can depress the medial
brow: the procerus, transverse heads of the
corrugator, oblique heads of the corrugator,
depressor supercilii, medial orbicularis oculi, and in
some patients, the nasalis muscles.
The lateral brow is depressed by the cephalic portion
of the lateral orbicularis oculi.
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There is no standard pattern of injection for brow
elevation.
For a more medial brow elevation, the medial
depressors are eliminated and the lateral frontalis is
weakened, leaving the medial frontalis strong.
For a more lateral elevation, the lateral depressor and
the medial frontalis are injected.
For a peaked and arched brow, the lateral depressor is
weakened and the frontalis over the junction of the
middle and lateral third of the brow is left strong.
THE NECK
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Botox injections in
platysmal bands can yield
excellent results.
The best patients have
minimal skin excess and
relatively strong bands.
current dose range is 15 to
35 units for the neck.
NASOLABIAL FOLD
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The levator labii superioris alaeque nasi muscle is the
muscle mainly responsible for the medial nasolabial
fold and the final 3 to 4 mm of central upper lip
elevation.
Weakening of this muscle results in smoothing of the
medial nasolabial fold and a change in the smile
pattern of the patient.
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Rubin described the
three major smiling
patterns in 1974.
The most common, or
“Mona Lisa,” smile
pattern.
The canine smile
pattern.
The gummy smile
pattern
Canine smile
Gummy smile
PERIORAL LINES
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1)
2)
3)
The most common rejuvenative procedure for this area is the injection
of filler materials.
Botox indicated in:
patient that is already having Botox injected into other areas of the
face
not increasing the size of their lips at all, for fear of looking “done.”
receives concomitant Botox and filler injection.
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current dosing range is only 2 to 7 units per lip.
Overly weakening the upper lip leads to problems
with plosive sounds, then general speech, and, finally,
oral competence. Overinjection of the lower lip more
readily leads to drooling and competence problems.
MENTALIS
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Patients who have difficulty with oral competence
tend to form an unattractive, dimpled pattern on the
chin during active speech or when closing the lips. This
appearance results from contraction of the underlying
mentalis muscle.
Dosing range for the mentalis is 2.5 to 12.5 units.
Care is taken to inject the superficial mentalis only,
leaving the deep mentalis fully functional.
DEPRESSOR ANGULI
ORIS
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depresses the oral commissures. This action
contributes to the marionette lines and often creates
a distinct horizontal rhytid below the commissure.
TOO MUCH BOTOX…
THANKS