pre- reading course material foundation botox® and …

PRE- READING COURSE MATERIAL

FOUNDATION BOTOX® AND DERMAL FILLERS

Module 2

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Dear Acquisition Aesthetics delegate,

These pre-reading documents form the lectures you will attend on the day of training.

As a CPD certified course based on theoretical knowledge, we ask that you review all

the material prior to the course date.

Please feel free to print the pre-reading modules to annotate on the day.

You will be provided with an abbreviated practical guide for your review on the

training day.

We look forward to seeing you soon and happy reading!

Yours sincerely,

Acquisition Aesthetics

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Botulinum Toxin

Treatment: Foundation Techniques

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Overview

• Pharmacology

• Indications

• Foundation techniques

• Advanced techniques (introduction)

• Cautions and contra-indications

• Reconstitution

• The treatment process

• Technique

Treatment of the glabella

Treatment of the frontalis

Treatment of crows feet

• Aftercare instructions

• Adverse effects

• The market – key manufacturers and products

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Botulinum Toxin

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Botulinum Toxin

http://www.statista.com/statistics/307411/revenue-of-the-global-cosmetics-industry/

Botulinum Toxin is a neurotoxin

Produced by clostridium botulinum

Used to treat a wide variety of medical and surgical conditions

FDA approval granted in 2002

Over 11 million cosmetic clients treated since

The most popular non-invasive cosmetic procedure worldwide

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Botulinum Toxin - Core principles

http://www.allergan.com/assets/pdf/botox_cosmetic_pi.pdf

Botulinum

Toxin inhibits

cholinergic

transmission

Cleaves the SNAP-

25 protein (needed

for the exocytosis

of Acetylcholine)

The resulting effect

is a temporary

paralysis of the

target muscles

Cholinergic

reinnervation at

the NMJ takes 3-4

months to occur

The pharmacology of botulinum Toxin

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Botulinum Toxin - Core principles

Indications for use in the Aesthetic client:

• Eliminate or reduce dynamic facial wrinkles

• Soften static wrinkles

• Create a ‘lift’

Glabella Complex/

Frown lines

Frontalis/

Forehead lines

Crow’s Feet / lateral canthal lines

The 3 most common treatment zones for Botulinum Toxin

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Learning outcomes

Indications for use / treatment zones

• Glabellar complex (frown lines)

• Frontalis (forehead)

• Lateral canthal lines (crow’s feet)• Neck lift (Nefertiti technique)

• ‘Smoker’s lines’• Gummy smile

• Masseteric hypertrophy

• Chin dimpling

• Hyperhidrosis

• Bunny lines

• Chemical brow lift

• Downturned mouth corners

• Management of complications

Today’s foundation course Advanced course in toxin and

dermal fillers

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Indications for use

• Glabellar complex (frown lines)

• Frontalis (forehead)

• Crows feet

• Bunny lines

• Neck lift (nefertiti technique)

• Smokers lines

• Gummy smiles

• Chin dimpling

• Hyperhidrosis

• Management of complications

Indications for use / treatment zones

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Indications for use

• Glabellar complex (frown lines)

• Frontalis (forehead)

• Crows feet

• Bunny lines

• Neck lift (nefertiti technique)

• Smokers lines

• Gummy smiles

• Chin dimpling

• Hyperhidrosis

• Management of complications

Indications for use / treatment zones

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Indications for use

• Glabellar complex (frown lines)

• Frontalis (forehead)

• Lateral canthal lines

• Bunny lines

• Neck lift (nefertiti technique)

• Smokers lines

• Gummy smiles

• Chin dimpling

• Hyperhidrosis

• Management of complications

Indications for use / treatment zones

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Advanced toxin and dermal fillers course

• Foundation refresher

• Advanced techniques in toxin and dermal fillers

• Supervised hands-on training

• Live models

• Development of the ‘aesthetic eye’• Complications management protocols

• Interactive lecture on the latest developments in the cosmetic

industry (new products, novel techniques and changing

guidelines)

• Business and marketing seminar

• Q+A session with the experts of facial rejuvenation

• CPD certification ceremony

• Post-certification support package with discount on further

courses

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Advanced applications

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Indications for use

• Glabellar complex (frown lines)

• Frontalis (forehead)

• Crows feet

• Bunny lines

• Neck lift (nefertiti technique)

• Smokers lines

• Gummy smiles

• Chin dimpling

• Hyperhidrosis

• Management of complications

Indications for use / treatment zones

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Botulinum Toxin - Core principles

• Aged under 18 years

• Known hypersensitivity to

Botulinum Toxin or any

components within the chosen

formulation

• Neuromuscular disorders

• Soft tissue infection

• Pregnancy

• Breast-feeding

• Contra-indicating medications

• Skin disorders

• Bleeding disorders

• Anti-coagulant / anti-platelet

medication

• Excessive weakness or atrophy

of the target muscles

• Unrealistic expectations

• Concomitant Botulinum Toxin

treatment

• Severe lactose intolerance

(Azzalure)

Contra-indications Cautions

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AbobotulinumtoxinA - Core principles

Product development

• Azzalure contains a purified

botulinum toxin A

• Widely used for over 25 years

• Over 2600 patients involved in

the clinical trails behind

development of the toxin

• High levels of evidence

demonstrating safety and

efficacy profile

Randomised controlled trial

Prospective cohort study

Retrospective cohort study

Case series

Case report / expert opinion / anecdotal evidence

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AbobotulinumtoxinA - Core principles

Product characteristics

✓ Solid clinical evidence

✓ Extensively evaluated safety profile

✓ Predictable results

✓ Fast onset of action

✓ Desirable longevity

✓ High rates of patient satisfaction

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AbobotulinumtoxinA - Core principles

• Unopened vials of Azzalure®

must be stored in a refrigerator

at 2-8°C

• Reconstituted Azzalure® is kept

refrigerated at 2-8°C

• Should be used within 24 hours

• Should not be frozen

• Unused reconstituted toxin

should be deactivated in Dakin

solution (1% hypochlorite)

Storage and shelf life

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Botulinum Toxin - Core principles

Reconstitution

• Azzalure ® should be reconstituted with 0.9% Sodium Chloride (normal saline)

• Reconstituting a 125 U vial of Azzalure ® with 0.63ml NaCl results in a solution

of 10U/0.05ml concentration

• Cleanse the rubber stopper of the vial with alcohol

• Introduce the diluent (NaCl) slowly into the vial. Do not shake or invert the

vial

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Botulinum Toxin - Core principles

Injection technique / hand positioning

tips are in your practical guide!

The treatment process

• Positioning and lighting

• (Pretreatment photographs)

• Cleanse the target areas

• (Apply topical anaesthetic)

• Mark out the injection sites as guided by the client’s activity lines• Deliver the product into the target

areas

• Treat any bleeding points with moist

gauze / cotton pads and light pressure

• Remain receptive and aware of the

client at all times

• Provide all aftercare instructions as

detailed below, including contact

details to arrange follow-up

appointments

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Botulinum Toxin - Core principles

Glabellar zone - Standard injection sites and dosing regimen

1010

10

10 10

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Botulinum Toxin - Technique

1. Procerus (deep, central)

2. Medial aspect of corrugators (deep)

3. Lateral aspect of corrugators

(superficial)

Glabella zone - Injection sites

• Be mindful of avoiding injections near

levator palpebrae superioris

• Use your thumb to prevent spread of

toxin inferior to the supraorbital rim

• Position lateral corrugator injections at

least 1cm above the supraorbital ridge

• Keep the needle bevel upward facing

Glabella zone - Treatment tips:

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Botulinum toxin - technique

4cm5 5 5 5

Forehead region – Standard injection sites and dosing regimen

NOTE: Off-label application of Azzalure

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Botulinum Toxin - Technique

Forehead - Treatment tips

• Tailor the pattern of administration

to suit your client

• Inject into the peaks of the wrinkles

and not the troughs

• Inject superficially

• Angle the needle at 45 degrees to

facilitate superficial administration

• Avoid injecting the aponeurosis

• Ensure you manage to create a ‘bleb’ of product

Pattern A Pattern B

Over-treating frontalis can result in a

brow ptosis (esp. in the older client)

Stay well above >4cm supraorbital rim

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Botulinum Toxin - Technique

Lateral canthal lines - Standard injection sites and dosing regimen

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10

5 5

10

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Botulinum Toxin - Technique

Lateral canthal lines - Injection sites and

treatment tips

• Central site at least 1.5cm temporal

to the lateral canthus

• Ensure the site is temporal to the

orbital rim

• Mark out the upper and lower sites

1.5cm above and below the central

site. Remain lateral to the orbital rim

• Keep all injections lateral to the

lateral canthus

• Keep the needle bevel tip up and the

syringe orientated away from the

eye to avoid injury

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Botulinum Toxin – Technique Summary

4cm

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Botulinum Toxin – Documentation

Sample treatment record forms

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Botulinum Toxin - Aftercare

Aftercare instructions

• Reiterate the potential for slight bruising and discomfort

• Seek medical attention in the event of any major concerns

• Do not lie down, fall asleep or rub / massage the treated areas for at

least 4 hours after treatment

• Gently exercising the muscles that have been treated (i.e. frowning /

smiling) can help to activate the Toxin and expedite results

• Clients should avoid consuming alcohol for 24 hours after treatment

or wearing makeup

• Advise the patient that the effects can take up to a week to become

apparent

• Remember the effects are temporary and treatment is recommended

every 3-6 months

• Contact details for follow up assessment / further treatment provided

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Botulinum Toxin - Complications

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Botulinum Toxin – ComplicationsPlease refer to your starter packs...

Adverse effects

• Haematoma

• Pain at the injection sites

• Headache

• Ptosis (3%)

• Eyelid oedema (1%)

• Diplopia

• Hyperactivity of local antagonist

muscles

Serious risks

• Systemic spread of product

(breathing / swallowing

difficulties)

• Potentially (theoretically) life

threatening

• No reports of death following

cosmetic administration of

Botulinum toxin yet

J Cutan Aesthet Surg. 2008 Jul-Dec; 1(2): 95–97. doi: 10.4103/0974-2077.44169

Rzany B, Zielke H. Mauricio de Maio and Berthold Rzany, Botulinum Toxin in Aesthetic Medicine. Berlin Heidelberg:

Springer-Verlag; 2007. Safety of botulinum Toxin in aesthetic medicine; pp. 119–25

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Botulinum Toxin – Complications

Bruising Headache

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Botulinum Toxin – Complications

Ptosis

Spock eyebrow

Asymmetrical smile

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Botulinum Toxin - The market

Key manufacturers and products

Many products on the market. Read instruction manual and consider

dosing and storage of product

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Botulinum Toxin - The market

A comparison of key products

Product Manufacturer U/Vial Excipients

Storage /

shelf life

Stability of

reconstituted

product Supplier

Azzalure® Galderma 125

(Speywood

units)

HSA, Lactose 2 years at 2-8℃ 24 hours 2-8℃ MedFX

Dysport® Galderma 300 / 500 HSA, Lactose 2 years at 2-8℃ 8 hours 2-8℃ MedFX /

Wigmore

Bocouture® Merz 50 HSA, Sucrose 3 years <25℃ 24 hours 2-8℃ Wigmore

Botox® Allergan 50 / 100 HSA, NaCl 3 years at 2-8℃ 24 hours 2-8℃ Health

Xchange

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Summary

Learning outcomes

• Pharmacology

• Indications for use

• Foundation and advanced techniques applications:

– Glabellar

– Frontalis

– Crow’s feet– Advanced techniques

• Cautions and contra-indications

• Reconstitution

• The treatment process

• Technical tips

• Treatment of the glabella, frontalis and crow’s feet• Aftercare instructions

• Adverse effects

• The market – key manufacturers and products

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