PRESENTS: Botulinum Toxin Injection Techniques (a hands-on workshop) - Eye Face Institute

PRESENTS:

Botulinum Toxin Injection Techniques
       (a hands-on workshop)

COS 2018 Toronto
      Skills Transfer Couse: Oculoplastic Surgery
          Sunday June 3, 2018 — 1045-1215

Botulinum toxin injection techniques:
        a hands-on workshop
Course Director: Dr. Harmeet S. Gill MD FACS FRCSC
Ophthalmologist/Oculofacial Plastic Surgeon
Assistant Professor, University of Toronto, DOVS
Medical Director, Eye Face Institute

No financial disclosures
Email: info@eyefaceinstitute.com

Thank you!

•   STC supplies Sponsors: Allergan, Merz

•   STC Chair: Dr. Delan Jinapriya MD

•   COS: Maxine Colvey

•   Instructors: Drs. Patrick Boulos, Dena Hammoudi, Ahsen
    Hussain, Norman Mainville, Babak Maleki, Quynh Nguyen,
    Navjeep Nijhawan, Nancy Tucker, Jaime Wong, Vivian Yin

•   Patient volunteers

Outcomes
•   Become a comfortable injector of botulinum
    toxin, which you will use in your practice for
    aesthetic patients.

•   Botulinum toxin —must knows:
    - what it is {perceived expert}
    - how to prepare it
    - where to inject it

•   {perfect} practice makes perfect

Botulinum toxin

      An acetylcholine release inhibitor
       (neuromuscular blocking agent)

* indicated for blepharospasm associated with
 dystonia in patients 12 years of age or older

- produced by Clostridium botulinum
 - obligate anaerobic gram-positive bacterium
    - polypeptide endocytosed and prevents
           acetylcholine (ACh) release
- interferes with nerve impulses causing flaccid
              paralysis of muscles

A. Contraindications to neurotoxin
     - known or suspected hypersensitivity
          - infection at injection site
 B. Patient-specific factors (age, philosophy,
 meds – muscle relaxants, aminoglycosides)
      - best avoided during pregnancy)
           C. Medical considerations
      – blepharospasm, hemifacial spasm
            * frequency and severity
           *co-morbidities (dry eyes,
       corneal disease, lagophthalmos,
eyelid disorders – laxity, ectropion, retraction)

Risks
= under-treatment, over-treatment, ecchymosis,
   pain, upper eyelid ptosis, facial asymmetry,
difficulty with speech, allergic reaction, infection

Post-injection considerations
                      - adverse effects
 (ptosis Rx with iopidine, dry eyes Rx with artificial tears)
                 - peak effect within 7-10d
                 - mean duration 3 months
                - long-term efficacy is good

Gill HS, Kraft SP. Can J Neurol Sci. 2010 Sep;37(5):631-6.
Long-term efficacy of botulinum a toxin for blepharospasm and hemifacial spasm.

Product Name              BOTOX                       XEOMIN                    DYSPORT

  Company                 Allergan                        Merz                   Galderma
                                                 No carrier protein; “naked”     fastest-acting;
Main advantages Gold standard, most researched    ? less resistance/allergy    ? wider distribution

Price per unit              $3.57                        $3.30                      $2.67

Unit equivalence             1U                             1U                       2.5U

Onset of action              3d                           3-5 d                      1-3 d
Storage before
reconstitution         -5degC or less            No refrigeration              -5degC or less

  Duration               3-4 months                  3-4 months                 3-5 months

           * All products must be refrigerated 2-5degC after reconstitution

Reconstitution

•   Botox & Xeomin (50, 100, 200U vials)
    Dysport (300, 500 U vials)

•   prior to injection, reconstitute with sterile,
    preservative-free 0.9% Sodium Chloride Injection,
    USP

•   Use 20-27 gauge short-bevel needle

Reconstitution
   Step 1: Clean the exposed portion of the rubber
stopper of the vial with alcohol (70%) prior to insertion
                     of the needle.

   Step 2: After vertical insertion of the needle through
 the rubber stopper, the vacuum will draw the saline into
   the vial. * Pull back on the vial for slow injection and
           angle it towards the side of the bottle.

  Step 3: Remove the syringe from the vial and mix the
     product with the saline by carefully swirling and
   inverting/flipping the vial—do not shake vigorously.

                                                              Source: www.xeomin.com

Dilution

•   Botox and Xeomin (100 U vial):
    For 5 U/0.1cc add 2 mL saline to vial
    For 10U/0.1cc add 1mL saline to vial

•   Dysport (300 U vial):
    *recall that 1 U Botox = 2.5 U Dysport
    For 25U/0.1cc add 1.2mL saline to vial

Injection
TB 1.0cc syringe; 30G needle     Insulin 0.3cc syringe; 31G

       Supplies: gloves, alcohol/disinfectant wipes,
                 ice pack, gauze, mirror

Forehead 15 U

 Brow Lift 5 U x 2                                  Laugh
Glabella 25 U                                       Lines
          Bunny lines 5 U x 2                      10 U x 2

               gummy smiles     soften vertical lip lines
                                         square jaw softening
Marionette lines (smile lift)              dimpled Chin
                                   platysmal (neck) bands &
                                           creases

Glabellar Rhytids

                = 5U (2.5-10U)

Laugh lines
 & Brow lift

               = 5U (2.5-10U)

Forehead Rhytids

                   = 2.5 U

= 5U (2.5-10U)

 = 2.5 U

Functional uses
•   blepharospasm (Meige syndrome)

•   hemifacial spasm

•   hyperlacrimation

•   scar management

Thank you for viewing our presentation.

    For more information, you can
   contact us through our website at:

       www.eyefaceinstitute.com