botox workshop2003.pdf
TRANSCRIPT
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Botox WorkshopBy:
Moustafa AbouzaidProf. Dermatology & Andrology
Faculty of medicineAzhar University
Cairo Egypt2011
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Clostridium Botulinium
A gram positive,
Spore-forming,
Obligate anaerobic bacillus
Produces the most potent neurotoxins ,causing Botulism.Latin name: Botulus (black sausage)
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There are seven distinct antigenic toxins.:
1. BTX A,2. B , C ( C & C ),3. D,4. E,5. F &6. G
BTX-A is the most potent.
All are produced by different strains of clostridiumbotulinum.
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There are three forms of human botulism:
1. Food-borne (improperly preserved food containing
the preformed neurotoxin).
2. Infantile (ingestion of spores and production of thetoxin in infant's intestine).
3. Wound infection
Botulism
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History
1820.
First
collected
data onbotulism
1895.
Theanaerobicbacterium
was isolated
1922.
Theextracellular
toxin (crudeform) wasisolated
1930
Thecrystalline
(purifiedform) wasdeveloped
1946
BTX(clinicalproduct )
1973Animal
experiments
onstrabismus(Published).
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The cosmetic useof botulinium
toxinBy Jean Carruthers
in 1987.
FDA approved use
in adultstrabismus andblepharospasm in
1989.
BTX for blockingcholinergic
innervations tosweat glands forhyperhidrosis
1994 .
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2) Ophthalmological use1- Strabismus2- Blepharospasm3- Nystagmus
Clinical uses of Botox:
Hemifacial spasm Facial asymmetry Oromandibular dystonia Spasmodic dystonia Cervical dystonia
BTX-A was found safe and effective for:
Spasmodic torticollis Achalasia Gustatory sweating Hyperlacrimation Synkinesia
1) Neurologic use and excessive muscle activity
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3) Dermatologic use Hyper functional glabellar frown lines,
crow's feet & f orehead lines Brow ptosis and brow position Nasal scrunch and flare Upper lip wrinkles Marionette (sad lines ) Platysmal bands Palmar and axillary hyperhidrosis
4)Others uses: Anal fissures Pain management
Headache
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Glabellar frown lines
Crow's feetForehead lines
Marionette (sad lines )
Platysmal bands
Nasal scrunch and flare
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Temporary improvement in
the appearance of moderate to severe Glabellar lines
Fore head line
Crows feet
Adults 65 years
Indications for
Botulinum Toxin Type A
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Administering physicians1. Be well trained
2. Have knowledge of muscles controlling facialexpression
3. Should know the dynamics of aging
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The face and ageing
Ageing
Skin loseselasticity and
becomesthinner
Habitualexpressions &
constantmusclecontraction or
relaxation
Wrinklesand
creases
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Cosmetic Uses of BTX
Basic applications Horizontal
forehead lines Glabellar frown
lines Lateral and
medial brow lifts Crows feet
Advanced and otherapplications
Nasal scrunch and flare
Upper lip wrinkles Marionette (sad) lines Neck lines Platysmal bands Facial asymmetry Hyperhidrosis
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Why Botulinum Toxin?
Botulinum Toxin Type A is a therapeutic agentthat improves dynamic facial lines by targetingthe underlying responsible muscles
Mechanism of Action It works by blocking acetylcholine impulses that
trigger hyperactive muscle contractionsResult: CHEMICAL DENERVATION
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Neurotransmission
Neurons are specialized cells that
receive and transmit nerve impulses.
Dendrite
Soma/cell
Axon terminaland synapse
Axon
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Neurotransmission
Nerve impulses are conducted betweenadjacent cells across synapses, via the release of neurotransmitters.
Acetylcholine
Muscle
Axon
Axon branch
Muscle cell
Motor end plate
Axonterminal
Axon terminal
Axon
Neuro-muscular
junction
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The facial muscles muscle basics
Nerve impulse
Relaxed
Contracted
Body Muscles to
Move
Facial Muscles toGive our Features
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Botulinum Toxin
Type A :Mechanism of Action
Adapted from: dePaiva et al. PNAS 1999, 96:3200
1 2 3
4 5
Binding Internalisation Blocking
formation of thecollateral nerve sprouts
The sprouts retract andthe original nerve end
starts to work normally
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Diffusion Description
Particles of greater molecularweight diffuse more slowlythrough an aqueous mediumthan do smaller molecules so
long as charge and temperatureis the same
(Ficks first law, Fick 1855)
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Why is diffusion important?
Desired (larger molecule size) Needed for maximum local effect Access motor nerve terminal (NMJ)
Distribution within target muscle to reach nerve
terminal Not desired (smaller molecular size)
Excess local weakness Pharmacological effect on adjacent muscle
Distal weakness / dry mouth etc. Leakage from target muscle leads to spread via
blood stream
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BOTOX: Vial Dilutions
Saline diluentvolume
U/mL U/0.1 mL
1.0 mL 100.0 10.0
1.5 mL 66.7 6.72.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5
5.0 mL 20.0 2.0Only in axillary hyperhidrosis
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Dosage and Administration
Reconstitution Reconstitute with 0.9% sterile , non-preserved saline
Use 2.5 cc 5 cc syringe to draw saline solution
Insert at 45 angle and inject saline into Botulinum ToxinType A vial
Discard vial if vacuum doesnt pull diluent into vial Record date of reconstitution
Store reconstituted Botulinum Toxin Type A in a refrigeratorand use within 2 hours in room temperature
All details above refer to BOTOX
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Administration
Remove syringe used for reconstitution and useinsulin syringe with built-in 30-gauge needle.
Draw 0.5 mL into syringe and expel air bubbles
NOTE: In practice, it has been reported that:
Refrigerated vial without diluent remainseffective indefinitely
Efficacy maintained following reconstitution
Refrigerated and use it
for up to 4 weeks
Dosage and Administration (cont)
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Considerations for Treatment Botulinum Toxin Type A is contraindicated for the
following patients: Patients with infection at proposed injection site
Patients with known hypersensitivity to any ingredient in Botulinum Toxin A
Administration of Botulinum Toxin Type A is
not recommended during pregnancy
Co-administration with aminoglycosides or other agents interferingwith neuromuscular transmission should be performed with caution
The most common side effect s are injection-related andare transient are localized pain, tenderness &/or bruising
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Injection Considerations
Photograph the patient before injection. Instruct patient to animate to show
muscle activity Mark injection sites Use 30-gauge needle for comfort Inject into relaxed muscle Instruct patient to animate repeatedly
post-injection to maximise toxin absorption(2 - 4 hours) Provide patient with post treatment
instructions
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Follow-up
Pre-injection photos
Inform patients to return in 1-2 weeks forevaluation Compare results with Pre-injection photos
Correct any asymmetries / complains Set re-injection schedule
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Anatomy of the face
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Frontalis
Depressor supercilii Corrugatorsupercili
Procerus
Orbicularis oculi
Depressor labii inferiorus
Depressoranguli oris
Orbicularis oris
Zygomaticus minor
MentalisPlatysma
BuccinatorRisorius
Zygomaticus major
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CorrugatorSupercilii
Procerus
Frontalis
Orbicularis
Oculi
Key Muscles of the Upper Face
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Glabellar Aesthetics
Depression of the central
brow appears angry, sad,
Brow elevation appearsserene and calm
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Sites for Glabellar Injection
X
X X
X X XX
Saline diluent U/mL U/0 1 mL
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5 injection sites: 1 in procerus 2 in each corrugator
Total dose: 20 U (4 U/injection
site) 0.1 mL/injection
site (in case of 2.5mL dilution)
Carruthers A, Lowe NJ
CorrugatorSupercilii
Procerus
volumeU/mL U/0.1 mL
1.0 mL 100.0 10.01.5 mL 66.7 6.72.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5
Dosing
T i l B t li T i T A (BOTOX )
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Typical Botulinum Toxin Type A (BOTOX )Doses for the Female Glabellar
4
444 4
Corrugator
Supercilii
Procerus
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Procerus injection - massage
Firm upward pressure is used to move the BotulinumToxin Type A upward & outward toward depressor
supercillii
Flynn 2001
Gl b ll I j i T h i
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Glabellar Injection Techniques
Thumb of non-injectinghand protects orbital rim
Hand rests on patients faceto control the injection
Injections must be 1 cmaway from orbital rim
Flynn 2001
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Decrease in Glabellar Lines after Treatmentwith Botulinum Toxin Type A
Baseline Day 30
Unretouched clinical trial photos taken while frowning beforeBotulinum Toxin Type A and after Botulinum Toxin Type A . Individual
results may vary .
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The frontalis muscle ends
midway between thelateral and mid-brow.The orbicularis - oculi
depresses the portion of
the brow lateral to this.Injection of 2- 4 Mu of
Botox just below thelateral brow and lateralto the temporal fusionline can raise the lateralbrow, giving the patient a"chemical" brow-lift of
up to 2mm.
Lateral Brow Lifting
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Complications of glabellar injections
Brow ptosis, occurs when toxin affects the frontalis, asthe toxin spread 1-1.5cm (2-3cm in diameter)
Avoid injecting the glabella and whole forehead in one sessionespecially in patients with low-set brows, mild brow ptosis andpatients over 50 years (preinject the brow depressors).
Patient is advised to remain upright for 2 hours .To exercise muscles for the first 2 hours.Avoid rubbing or massaging for 2 hours.Responds to apraclonidine ( -adrenergic agonist) ophthalmiceye drops (2 drops / hour).
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Eyelid ptosis, when toxin migrates to
upper eyelid levator muscle, producing aweak paralytic effect as early as 48 hours oras late as 14 days and persisting for 2-12
weeks.
Avoid injection no closer than 1cm above thecentral eyebrow .Bothersome ptosis is treated byapraclonidine.
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Crows Feet
Superficial rhytides radiatingfrom the region of the lateralcanthus
Represents dynamichypertrophy of the orbicularisoculi coupled with static skinchanges
Coordinates with the smi le
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BOTOX: Crows Feet (cont)
xx
xx
Optimum dose 10 to 12 units per side
Saline diluentvolume
U/mL U/0.1 mL
1.0 mL 100.0 10.01.5 mL 66.7 6.7
2.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5
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BOTOX: Crows Feet
Optimum dose 10 to 12 units per side
Second treatment gave greater improvementand longer duration
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BTX: Crows Feet
After BOTOX
Before BOTOX
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BOTOX : Infraorbital Creases
Test skin laxity with asnap test
1-2 U of BOTOX
Lid margin in linewith the pupil
Lid margin slightlylateral to themidpoint betweenpupil and lateralcanthus
xx
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A more wide-eyed look can be obtained by injecting thelower eyelid at the lash margin by 2MU at mid pupil and2MU midway between pupil and outer canthus, some use
the first injection only.
This also helps smooth out fine lines under eyes.Do not do if patient exhibits a significant degree of scleralshow pretreatment, or had significant surgery under the eye,or if has a great deal of redundant skin under eye asexhibited by the snap test of the lower eyelid
X X
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Infraorbital Creases
Before BOTOX After BOTOX
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Reported complications of this area are :
Diplopia (cover eye) and send to ophthalmologist
Ectropion or a drooping lateral lower eyelid
Strabismus (send to ophthalmologist)Bruising
An asymmetric smile caused by the toxin diffusingto the zygomaticus major
Transient lymph edema
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Horizontal Forehead Lines
Horizontal lines andwrinkles across theforehead
Produced by excessive
contractions of thefrontalis
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BOTOX: Horizontal Forehead Lines
x x x x
For forehead 4-6 injections (a total of 10-20MU ) are placedacross the forehead in a uniform grid, visible blebs are temporarilyproduced. The lateral most injection should be vertically above themid-pupil, although with a wider forehead this can be extendedbeyond the pupil to the iris.
Saline diluentvolume
U/mL U/0.1 mL
1 0 L 100 0 10 0
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x x
xxx
xxx x
4-6 injections (A total of 10-20MU)
1.0 mL 100.0 10.01.5 mL 66.7 6.72.0 mL 50.0 5.02.5 mL 40.0 4.03.0 mL 33.3 3.34.0 mL 25.0 2.5
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x
x x
x
x
xx
x
4-6 injections (A total of 10-20MU)
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BTX: Horizontal Forehead Lines
Before BOTOX
After BOTOX
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Botox (Botulinum toxin Type -A),Myobloc ( Botulinum toxin Type- B),
Dysport (Abobotulinumtoxin-A)
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Follow-up
New patients to return in 1-2 weeks for evaluation Compare results with pre-injection photos Correct any asymmetries / complains Set re-injection schedule
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- Regardless of botulinum toxin is chosen;- Follow the following tips to reducethe risk of both pain and bruising
Injection Pearls
American Society of Dermatologic Surgery in Orlando, Florida,
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THE MORE NEUTRAL PHAND THE BENZYL ALCOHOLDECREASE THE LESS THE STING OF
INJECTION.
1-Dilute with saline containing preservative
By pulling the skin toward the needle and pinchingthe skin lightly between the thumb and first finger(because the pressure sensation of the pull
overrides the sensation of pain).
2-Reduce the pain of the needle stick
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4-PLACE A WARM TOWELON THE FACE BEFORE
APPLYING TOPICAL ANESTHETIC
TO INCREASE THE ABSORPTION AND EFFICACY OF THEANESTHETIC.
3-Limit injections tono more that 4 per needle, after which the needle
starts to dull.
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5-TO MINIMIZE BRUISING,
Request that patients stop all Aspirin or Nonsteroidal anti-inflammatory drugs, Vitamin E, Ginkgo biloba, And garlic
14 days before botulinum injections .
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6- For periocular areas, Consider precooling to help vasoconstrict vesselsand thus reduce the chance of bruising.
In addition, use a specialized vein light to helpvisualize vasculature and thus avoid disturbing it.
7-To tamponade any oozing Use cotton-tipped applicators ; Apply ice
packs afterward to minimize bruising risk .
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Combination Therapy
BOTOX can be combined with manycosmetic procedures:
Fillers Ablative laser resurfacing Non-Ablative laser remodeling
IPL Peels Facial Surgery
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BOTOX + Ablative laser
BOTOX decrease mechanical disruption of healingprocess post laser treatment, improving collagenremodeling.
BOTOX
will prolong the smoothing wrinklereduction effect of laser. Combination useful in crows feet, forehead and
peri-oral areas. Inject BOTOX two weeks before ablative laser
treatment.
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BOTOX + Non-Ablative laser
Specific lasers (1320nm, 1450nm & 1540nm). Existing lasers (erbium-YAG, ND-YAG, Q-switched,
pulse-dye lasers) Radiofrequency technology (e.g. Thermage) BOTOX will improve and prolong the cosmetic
smoothing results.
Use BOTOX
few days prior or post laser to preventincreasing diffusion due to thermal inflamation.
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BOTOX + IPL
IPL is used to stimulate collagen and elastinsynthesis, resulting in softening the facial finelines.
Multiple sessions is needed to achieve this effect,usually 4-6 sessions. BOTOX will improve and prolong the cosmetic
smoothing results. Use BOTOX few days after the first IPL session.
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BOTOX + Peels
Chemical peels produce controlled injury followedby the wound healing process which producessmoother skin.
Selection of the right peel. Use BOTOX 2 weeks before peeling to prevent
increasing diffusion due to inflammation. Microdermabrasion usually doesnt produce
inflammation, so BOTOX can be injected rightafter this procedure.
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BOTOX + Facial Surgery
BOTOX and facial surgery have complementary effecton the aging face.
Recent reports suggested that BOTOX can reduce thetension exerted on the skin by the healing process,
resulting in reduced scarring. With blepharoplasty, relaxation of the local muscles
can allow for accurate resection of the skin and betterplacement of the incision during the surgicalprocedure.
Use BOTOX one week after surgery or at least threemonths before surgery.
Botox and Hyperhydrosis
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Procedure:1) Documentation of the problem :
1- Gravimetric measurement or.
2- The minor starch iodine test.First wiping the skin with a colored iodine tincture (must be brown-orange).
Several seconds are given to allow the iodine solution to dry (fan).The area is then lightly dusted with ordinary baking cornstarchpowder.
Botox and Hyperhydrosis
Th l i f h i i i
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The exact location of the active sweating isthen mapped and outlined with a marking
pen before beginning injections.
N.B. perform the test before applying any regional nerve blocks ortopical anesthetics like eutectic mixture of lidocaine (EMLA)(cause a hyperemic and a vasoconstrictive responserespectively interfering with the amount of sweating and can givemisleading results).
Take a photo.
B t d H h d i
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2) Anesthesia:The axillary, forehead and facial sweating can be treatedwithout anesthetic or by topical anesthesia.
Palmar and plantar with topical anesthesia , but mostpatients require regional nerve block anesthesia, such aswrist or ankle block.
Disadvantages of nerve blocks ------ causes reactivehyperemia thus increasing the tendency to bleed from
each small injection site, which may increase the loss of material from injection site and decrease the relativeeffectiveness of each injection.
Botox and Hyperhydrosis
Botox and Hyperhydrosis
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3) Injection technique:
Dilution
5 ml saline + 1 vial BTXUse 10 syringes ( 5 for each axillae i.e. 2.5 ml for Rt.
Axillae and 2.5 ml for Lt. Axillae).
Withdraw 0.5 ml for each syringe.
Inject 20 25 injections to every axillae i.e. 2 units for
each injection
Botox and Hyperhydrosis
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For axilla, usually involves placement of 10-20
individual intradermal injections (raising tinywheals) about 2.5cm apart , beginning at the periphery
of the hair-bearing skin and circling into the centre of
the axillary vault, keeping the needle bevel up andmore parallel to the skin surface.
Approximately 50U/axilla ,
duration of effect is
approximately 4-10 months .
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Focal Axillary Hyperhidrosis
Before BTX-A After BTX-A
Naumann Arch Dermatol 134 1998
Botox and Hyperhydrosis of Palm & Sole
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Palmar injections are placed approximately every1.5cm across the palmar surface. On the fingers the volarpad of each phalanx receives its individual dose. The fingertips usually receive two: one in mid pad and another at thevery tip. The dominant hand receives an extra row of injection along the ulnar side.
The palmar skin is comparatively stiffer and a wheal cannot
be raised, it is desirable to produce a small zone
of visible blanching , indicating that the material isin the deep dermis . Allow a second or two beforewithdrawing the needle or else the fluid flows back out of injection tract directly.
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C t & F f t t t
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Patients with large shoe size have correspondinglylarger hands and require more injections, e.g. aman with a size 43-45 shoe requires up to150U/palm whereas a woman with a size 36 shoerequires as little as 75U to cover the palm .
Inject approximately 120U/palm , duration of effectis 3-12 months (approximately 6 months).
Treatment is approximately twice a year.
Costs & Frequency of treatment
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. 37 shoes size requires 1.5 vials for both palmsi.e., 150 Us( 75U/ each palm).
. 38- 42 shoes size requires up to 2 vials for bothpalms i.e., 200 Us (100/ each palm).
. 43- 45 shoes size requires up to 3 vials for bothpalms i.e., 300 Us (150/ each palm)
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Injection of the soles follows the same technique and
pattern as the palms.
N.B. it may take several treatments before patient recognize
less than total response as successful.
Almost every patient develops a transient period of weakness and instability of the lumbrical muscles of the
hand, which is predictably spontaneously reversible, patient
can write, type and eat without difficulty, but opening up a
tight jar lid for example poses problems for a few weeks (3-
5). So, ma ybe treat one hand first then the second.
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Thank you