botulinum toxin botulinum toxin by: maica galvez-vergara m.d

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

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

BOTULINUM TOXINBOTULINUM TOXIN

BY: BY: MAICA GALVEZ-VERGARA M.D.MAICA GALVEZ-VERGARA M.D.

Page 2: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Botulinum toxin type A Botulinum toxin type A

neurotoxin protein Clostridium botulinumClostridium botulinumGram-positive rod shaped rod shaped anaerobic spore- spore-

former former bacterium

Botulism Latin botulusbotulus = "sausage shape” = "sausage shape”

food poisoningfood poisoning

Page 3: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Common Indications for Bt-ACommon Indications for Bt-A

Spasmodic Spasmodic TorticollisTorticollis

BlepharospasmBlepharospasm Hemifacial SpasmHemifacial Spasm Post-Stroke Post-Stroke

SpasticitySpasticity Cerebral PalsyCerebral Palsy Dystonia Dystonia Various movement Various movement

disordersdisorders Aesthetics (Wrinkles)Aesthetics (Wrinkles)

Hyperhidrosis Square face and other

remodelling indications Spasmodic dysphonia Myofascial and other

Pain Headache, migraine Drooling Etc., etc., etc.

Page 4: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Structure of Botulinum ToxinStructure of Botulinum Toxin

Disulfide bond

Light chain:the molecule’s toxic fraction Heavy chain:

responsible for specificityof each serotype

Botulinum Toxin is inactivated by heat

Page 5: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Mechanism of ActionMechanism of Action

Botulinum Toxins block the exocytosis of acetylcholine at the motor endplate, thereby making neuromuscular transmission impossible

Page 6: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

THE MECHANISM INCLUDES 3 STAGES

Page 7: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Binding to the Presynaptic Binding to the Presynaptic MembraneMembrane

Page 8: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Internalization of the ToxinInternalization of the Toxin

Page 9: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Inhibition of Exocytosis of ACTHInhibition of Exocytosis of ACTH

SNARE (SNAP receptor proteins)• SNAP-25 (SyNaptosomal Associated Protein 25 kDa• syntaxin• Synaptobrevin or VAMP (Vesicular Associated Membrane Protein)

Page 10: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Recovery by Neuronal PlasticityRecovery by Neuronal Plasticity

Page 11: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

ADVANTAGES:ADVANTAGES:

Safe and rapidly administeredSafe and rapidly administered Effects are profoundEffects are profound 99% successful99% successful Painless Painless No recovery timeNo recovery time Technically straightforward to useTechnically straightforward to use Effects are reversible w/in an acceptable limit of Effects are reversible w/in an acceptable limit of

timetime Complications are rare and self-limiting Complications are rare and self-limiting

Page 12: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

DISADVANTAGES:DISADVANTAGES:

Irreversibility or length of Irreversibility or length of therapeutic effect.therapeutic effect.

Page 13: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

CONTRAINDICATIONSCONTRAINDICATIONS Hypersensitivity to ingredients ( albumin, sodium chloride Hypersensitivity to ingredients ( albumin, sodium chloride

botulinum toxin ) botulinum toxin ) Neuromuscular dx. (myasthenia gravis, motor neuron Neuromuscular dx. (myasthenia gravis, motor neuron

disease)disease) Patients treated with other drugs that may interfere withPatients treated with other drugs that may interfere with neuromuscular transmission; aminoglycosides, neuromuscular transmission; aminoglycosides,

polymixins, penicillamine, quinine, calcium channel polymixins, penicillamine, quinine, calcium channel blockers neuromuscular blocking agents. blockers neuromuscular blocking agents.

Pregnancy and lactationPregnancy and lactation Patients in anti-coagulation therapyPatients in anti-coagulation therapy Inappropriate anatomy ( skin laxity photo damage )Inappropriate anatomy ( skin laxity photo damage ) Poor psychological adjustmentPoor psychological adjustment

Page 14: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Bt-A Indications in AestheticsBt-A Indications in Aesthetics

DynamicDynamic wrinkles of the wrinkles of the glabellaglabella

DynamicDynamic wrinkles in the wrinkles in the foreheadforehead

DynamicDynamic wrinkles wrinkles around the eyes around the eyes (« crow’s feet »)(« crow’s feet »)

Slight facial asymmetrySlight facial asymmetry Wrinkles in the area Wrinkles in the area

around the platysmal around the platysmal muscle and the neckmuscle and the neck

Page 15: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Other Indications for Bt-A in Other Indications for Bt-A in Aesthetics.Aesthetics.

Hyperhidrosis

underarms

palms

Page 16: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Square face and other remodelling indications

Gummy smiles

Calf contouring

Meso Botox

Page 17: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Different BTXA’sDifferent BTXA’s

Botox - Allergan Irvine, CABotox - Allergan Irvine, CA BTXA - Lanzhou, ChinaBTXA - Lanzhou, China Refinex - ChinaRefinex - China Dysport - Wrexam, Wales UKDysport - Wrexam, Wales UK Korea – Neurotox, Zentox, BotulaxKorea – Neurotox, Zentox, Botulax Xeomin (incobotulinumtoxinA) Merz Xeomin (incobotulinumtoxinA) Merz

Pharmaceuticals, North CarolinaPharmaceuticals, North Carolina

Page 18: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

DoseDose

BTXA – 2-4 units per BTXA – 2-4 units per injection site.injection site.

Allergan China and Allergan China and NeurotoxNeurotox

Dysport – 5-10 units per Dysport – 5-10 units per injection site.injection site.

100 units/vial100 units/vial Dilute to 2.5cc of NSS to Dilute to 2.5cc of NSS to

make 2units of .05ml make 2units of .05ml tuberculin syringe.tuberculin syringe.

500 units/vial500 units/vial Dilute to 2.5cc of NSS to Dilute to 2.5cc of NSS to

make 5units of .05ml make 5units of .05ml tuberculin syringe.tuberculin syringe.

Page 19: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

PharmacokineticsPharmacokinetics

Time to action: 24 to 72 hoursTime to action: 24 to 72 hours

Time to peak: 8-15 days afterTime to peak: 8-15 days after

Duration of action: 3 - 6 months (longer in Duration of action: 3 - 6 months (longer in certain indicationscertain indications

After about the 7After about the 7thth injection, this period is injection, this period is significantly prolongedsignificantly prolonged

Page 20: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

TOXICITYTOXICITY

2500 TO 3000 units in a 70kg human 2500 TO 3000 units in a 70kg human based on the median lethal dose of 40 based on the median lethal dose of 40 units / kg.units / kg.

Single dose of 500 units may produce Single dose of 500 units may produce acute symptoms and signs of botulism.acute symptoms and signs of botulism.

Page 21: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Facial MusclesFacial Muscles

Frontalis> elevates Frontalis> elevates brows. brows. Forehead linesForehead lines

Corrugators> pull Corrugators> pull eyebrows medially eyebrows medially Procerus, Depressor Procerus, Depressor supercilli> pulls eyebrow supercilli> pulls eyebrow down medially. down medially. Frown Frown lineslines

Orbicularis oculi> Orbicularis oculi> depresses brows esp. depresses brows esp. laterally. laterally. Crows feetCrows feet

Page 22: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Dynamic wrinkles of the foreheadDynamic wrinkles of the forehead

Page 23: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Korean RecommendationsKorean Recommendations

Page 24: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D
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Page 27: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D
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Page 29: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Axillary hyperhydrosisAxillary hyperhydrosis Positive starch-iodine Positive starch-iodine

test.test.

50 units to 100 units/ 50 units to 100 units/ axilla.axilla.

Palmar hyperhydrosisPalmar hyperhydrosis

50 units to 100 units/50 units to 100 units/

hand. hand.

Page 30: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

COMPLICATIONSCOMPLICATIONS

Page 31: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Areas To AvoidAreas To Avoid Around the orbit (less than 1 Around the orbit (less than 1

cm)cm)

Lateral area of the brow less Lateral area of the brow less than 1 finger breaththan 1 finger breath

Lower eyelid – Neg. Snap testLower eyelid – Neg. Snap test

Lower face (nasolabial)Lower face (nasolabial)

Around the mouthAround the mouth

Page 32: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

Rare Secondary EffectsRare Secondary Effects

Pain, burning sensationPain, burning sensation Hematoma, edemaHematoma, edema Ptosis, drooping of eyelid- naphcon A or apraclonidine 0.5% Ptosis, drooping of eyelid- naphcon A or apraclonidine 0.5%

eye drops.eye drops.

Always REVERSIBLE and related to dose and individual sensitivity of each patient

Page 33: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

MEPHISTO LOOK…. SPOCKMEPHISTO LOOK…. SPOCK

Usually resolves in weeksUsually resolves in weeks May consider injection at the arch, lateral side to bring May consider injection at the arch, lateral side to bring

down the brow.down the brow.

Page 34: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

FROZEN EXPESSIONSFROZEN EXPESSIONS

Page 35: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

LOCALLOCAL PAINPAIN SWELLINGSWELLING EDEMAEDEMA ERYTHEMAERYTHEMA HEMATOMAHEMATOMA RASHRASH BRUISINGBRUISING ECCHYMOSISECCHYMOSIS TENDERNESSTENDERNESS HEADACHEHEADACHE SHORT TERM PARESTHESIASHORT TERM PARESTHESIA

Page 36: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

REGIONALREGIONAL

ASSYMETRYASSYMETRY

LOSS OF FACIAL EXPRESSIONLOSS OF FACIAL EXPRESSION

INCOMPLETE MUSCLE PARALYSISINCOMPLETE MUSCLE PARALYSIS

Page 37: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

SYSTEMICSYSTEMIC

NAUSEANAUSEA FATIGUEFATIGUE SEVERE GENERALIZED WEAKNESSSEVERE GENERALIZED WEAKNESS MALAISEMALAISE FLULIKE SYMPTOMSFLULIKE SYMPTOMS ALLERGY 2NDARY TO ALBUMINALLERGY 2NDARY TO ALBUMIN

Page 38: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

POINTS TO PONDERPOINTS TO PONDER

KNOW YOUR ANATOMY WELL.KNOW YOUR ANATOMY WELL. KNOW YOUR PRODUCTS WELL.KNOW YOUR PRODUCTS WELL. KNOW YOUR PATIENTS WELL IF KNOW YOUR PATIENTS WELL IF

POSSIBLE.POSSIBLE. USE MINIMUM DOSAGING.USE MINIMUM DOSAGING. FOLLOW UP IN 2 WEEKS.FOLLOW UP IN 2 WEEKS. ALWAYS TAKE BEFORE AND AFTER ALWAYS TAKE BEFORE AND AFTER

PICTURES.PICTURES.

Page 39: BOTULINUM TOXIN BOTULINUM TOXIN BY: MAICA GALVEZ-VERGARA M.D

THANK YOUTHANK YOUVERY MUCH !!!VERY MUCH !!!