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Botulinum toxin type A is a potent neurotoxin produced by the bacterium clostridium botulinum. The toxin inhibits the release of acethylcholine at the nerve terminal producing a flaccid paralysis. This results in a decrease in the strength of facial muscle contraction and reduction in the wrinkle lines.
In the aging skin, ridges and wrinkles occur in the skin perpendicular to the underlying muscle fibers. Therefore, Botox injections are commonly used for:
- Glabellar folds: are formed by the action of the procerus and corrugator muscle.
- Midforehead wrinkles: are formed by the repeated contraction of the frontalis muscle.
- Crow’s feet lines: are formed by the repeated contraction of the orbicularis oculi muscle.
- Perioral rhytids: formed by the action of the orbicularis oris.
- Drooping of the outer margin of the eyebrow: is one of the earliest signs of aging, the eye appears crowded and smaller with abnormal fullness of the upper eyelid causing fatigue and tired appearance. The condition can be improved by injecting Botox to the forehead in order to increase the action of the lifting muscle.
- Treatment of focal hyperhidrosis: excessive sweating of the palms, axillae, face and soles of the feet.
The Botox injection may be considered on it’s own to reduce wrinkles or as an ancillary technique to compliment skin resurfacing, face and forehead lifting. Botox is very successful in over 70% of cases and the duration of its effects lasts two to eight months, with an average of five months. Most patients usually express the desire to have repeated injections.
The botulinum A toxin was prepared using Botox. Each vial contains 100 units of sterile lyophilized form of purified botulinum toxin type A, 0.5mg human albumin and 0.9mg sodium chloride. We use the technique explained by the Cleveland Clinic (Jill Foster): For the glabellar wrinkles, one cc of sterile saline is added to a vial of Botox to create a solution concentration of 10 units per 0.1ml. For the crow’s feet wrinkles, 2ml of sterile saline was added to a vial of Botox to create a solution of 5 units per 0.1ml. Patients were asked to squint to emphasized the wrinkles, which are marked with a skin marking pen. The location of maximal skin displacement with muscle contraction is marked and used as the location for injection. The injection is given into the muscle adjacent to the crease of the wrinkles, not into the wrinkle valley. The skin was prepared with iodine solution and the injections are given via a tuberculin syringe and a twenty six gauge needle. A volume of 0.1ml is injected into each site in the glabellar region and a volume of 0.05ml is injected into each site in the lateral periocular region. The injection is placed into the subdermal or intramuscular tissue layer. Pressure is applied immediately after injection to prevent bruising. For perioral rhytids the concentration of Botolinum A toxin in this area is decreased to 2.5 units per 0.1ml. A total of 0.2ml is used for both upper and lower lip. The injections are placed in a pericrease fashion.
Dr. Markus Nauman, Germany, was the first to publish on the use of BTX-A in the management of hyperhidrosis. After identifying the hyperdrotic area of the palm, axilla, Face or sole of the foot, the area for treatment is marked and Botox is injected intradermally at multiple sites, using 30-80 U Botox per palm or axilla.
- Discomfort during administration.
- Slight frontal headache: resolve within three days.
- Extra fold in the lid (medial brown ptosis): resolve within a few days.
- Bruising at injection site.
- Eyelid ptosis: It is important in glabellar folds injection to press with the thumb below the injection at the orbital rim for five minutes to prevent the leak of the Botox down to the eye lid.
Fig. 18 – 16. (A,B,C,D,E)Illustrations of the usual sites of Botox Injection (A,B) Glabellar folds. (C) Crow’s lines. (B,E)Mid-forehead wrinlkles