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BOTULINUM TOXIN

BOTULINUM TOXIN. BY: MAICA GALVEZ-VERGARA M.D. Botulinum toxin type A. neurotoxin protein Clostridium botulinum Gram-positive rod shaped anaerobic spore-former bacterium Botulism Latin botulus = "sausage shape” food poisoning. Common Indications for Bt-A. Spasmodic Torticollis

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BOTULINUM TOXIN

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  1. BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D.

  2. Botulinum toxin type A • neurotoxinprotein • Clostridium botulinum Gram-positive rod shaped anaerobic spore-former bacterium • BotulismLatinbotulus = "sausage shape” • food poisoning

  3. Common Indications for Bt-A • Spasmodic Torticollis • Blepharospasm • Hemifacial Spasm • Post-Stroke Spasticity • Cerebral Palsy • Dystonia • Various movement disorders • Aesthetics (Wrinkles) • Hyperhidrosis • Square face and other remodelling indications • Spasmodic dysphonia • Myofascial and other Pain • Headache, migraine • Drooling • Etc., etc., etc.

  4. Structure of Botulinum Toxin Disulfide bond Light chain: the molecule’s toxic fraction Heavy chain: responsible for specificity of each serotype Botulinum Toxin is inactivated by heat

  5. Mechanism of Action • Botulinum Toxins block the exocytosis of acetylcholine at the motor endplate, thereby making neuromuscular transmission impossible

  6. The mechanism includes 3 stages

  7. Binding to the Presynaptic Membrane

  8. Internalization of the Toxin

  9. Inhibition of Exocytosis of ACTH • SNARE (SNAP receptor proteins) • SNAP-25 (SyNaptosomal Associated Protein 25 kDa • syntaxin • Synaptobrevin or VAMP • (Vesicular Associated Membrane • Protein)

  10. Recovery by Neuronal Plasticity

  11. ADVANTAGES: • Safe and rapidly administered • Effects are profound • 99% successful • Painless • No recovery time • Technically straightforward to use • Effects are reversible w/in an acceptable limit of time • Complications are rare and self-limiting

  12. DISADVANTAGES: Irreversibility or length of therapeutic effect.

  13. CONTRAINDICATIONS • Hypersensitivity to ingredients ( albumin, sodium chloride botulinum toxin ) • Neuromuscular dx. (myasthenia gravis, motor neuron disease) • Patients treated with other drugs that may interfere with neuromuscular transmission; aminoglycosides, polymixins, penicillamine, quinine, calcium channel blockers neuromuscular blocking agents. • Pregnancy and lactation • Patients in anti-coagulation therapy • Inappropriate anatomy ( skin laxity photo damage ) • Poor psychological adjustment

  14. Bt-A Indications in Aesthetics • Dynamic wrinkles of the glabella • Dynamic wrinkles in the forehead • Dynamic wrinkles around the eyes (« crow’s feet ») • Slight facial asymmetry • Wrinkles in the area around the platysmal muscle and the neck

  15. Other Indications for Bt-A in Aesthetics. • Hyperhidrosis underarms palms

  16. Square face and other remodelling indications • Gummy smiles • Calf contouring • Meso Botox

  17. Different BTXA’s • Botox - Allergan Irvine, CA • BTXA - Lanzhou, China • Refinex - China • Dysport - Wrexam, Wales UK • Korea – Neurotox, Zentox, Botulax • Xeomin (incobotulinumtoxinA) Merz Pharmaceuticals, North Carolina

  18. BTXA – 2-4 units per injection site. Allergan China and Neurotox Dysport – 5-10 units per injection site. 100 units/vial Dilute to 2.5cc of NSS to make 2units of .05ml tuberculin syringe. 500 units/vial Dilute to 2.5cc of NSS to make 5units of .05ml tuberculin syringe. Dose

  19. Pharmacokinetics • Time to action: 24 to 72 hours • Time to peak: 8-15 days after • Duration of action: 3 - 6 months (longer in certain indications • After about the 7th injection, this period is significantly prolonged

  20. TOXICITY • 2500 TO 3000 units in a 70kg human based on the median lethal dose of 40 units / kg. • Single dose of 500 units may produce acute symptoms and signs of botulism.

  21. Facial Muscles • Frontalis> elevates brows. Forehead lines • Corrugators> pull eyebrows medially Procerus, Depressor supercilli> pulls eyebrow down medially. Frown lines • Orbicularis oculi> depresses brows esp. laterally. Crows feet

  22. Dynamic wrinkles of the forehead

  23. Korean Recommendations

  24. Axillary hyperhydrosis • Positive starch-iodine test. 50 units to 100 units/ axilla. • Palmar hyperhydrosis 50 units to 100 units/ hand.

  25. COMPLICATIONS

  26. Areas To Avoid • Around the orbit (lessthan 1 cm) • Lateral area of the browlessthan 1 fingerbreath • Lowereyelid – Neg. Snap test • Lower face (nasolabial) • Around the mouth

  27. Rare Secondary Effects • Pain, burning sensation • Hematoma, edema • Ptosis, drooping of eyelid- naphcon A or apraclonidine 0.5% eye drops. • Always REVERSIBLE and related to dose and • individual sensitivity of each patient

  28. MEPHISTO LOOK…. SPOCK • Usually resolves in weeks • May consider injection at the arch, lateral side to bring down the brow.

  29. FROZEN EXPESSIONS

  30. LOCAL • PAIN • SWELLING • EDEMA • ERYTHEMA • HEMATOMA • RASH • BRUISING • ECCHYMOSIS • TENDERNESS • HEADACHE • SHORT TERM PARESTHESIA

  31. REGIONAL • ASSYMETRY • LOSS OF FACIAL EXPRESSION • INCOMPLETE MUSCLE PARALYSIS

  32. SYSTEMIC • NAUSEA • FATIGUE • SEVERE GENERALIZED WEAKNESS • MALAISE • FLULIKE SYMPTOMS • ALLERGY 2NDARY TO ALBUMIN

  33. POINTS TO PONDER • KNOW YOUR ANATOMY WELL. • KNOW YOUR PRODUCTS WELL. • KNOW YOUR PATIENTS WELL IF POSSIBLE. • USE MINIMUM DOSAGING. • FOLLOW UP IN 2 WEEKS. • ALWAYS TAKE BEFORE AND AFTER PICTURES.

  34. THANK YOU VERY MUCH !!!

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