"The Beauty of BOTOX" presentation by Heidi LaForge, DO, Via Christi Clinic family medicine physician. Dr. LaForge explains how BOTOX is made and how it can help eliminate wrinkles.

1. Botox - Medical Uses
Dr. Heidi LaForge
Via Christi Family Medicine

2. Where does Botox Come From?
• Botox is derived from a bacteria that is found in the soil—Clostridium
Botulinum

3. Botox
• Botulism toxin (BOTOX®) is a material that has been known for over a
century and used for medical purposes for more than 50 years.
• In 2002, it was approved for improving and relaxing frown lines in the area
between the eyes on the forehead.
• Since 2002, BOTOX has been used successfully in more than two million
patients.

4. How Does It Work?
• Botox works by blocking a chemical that aids in muscle contraction called
acetylcholine
• When the nerve sends a signal to the muscle to contract, acetylcholine is
released as before, but it can't bind anywhere on the muscle due to the
Botox
• The muscle has no idea it is supposed to contract. It is essentially
paralyzed, but not because the muscle or the nerve have been damaged.

5. Molecules Botox

6. Does it Work Right Away?
• Botox takes 72 hours to reach maximum effect in most patients (some
patients it can be as long as 5-7 days)….be patient because beauty takes
time.
• Often After a Botox treatment I have patients periodically exercise the
muscles that have been treated to create the desired affect of blocking all
of the neuromuscular junctions faster

7. Can A Patient Build Antibodies to
Botox?
• At large doses this can happen resulting in a loss of therapeutic effect over
time.
• Neutralizing antibodies have been reported in 3-5% of patients with
cervical dystonia (torticollis)
• Resistance to Botox in individuals treated for cosmesis and hyperhydrosis
has not been reported.

8. What Does Botox Look Like
• When Botox comes in the mail from the manufacturer Allergan it is a fine
dry gray powder packed on dry ice. (it looks like there is nothing in the
bottle)
• Botox must be refrigerated
• Once a patient is selected, it is mixed with a sterile saline preservative
and should appear colorless and free of particulate matter.

9. How Long Does Botox last in the
Bottle?
• Botox will last you 6 months in the refrigerator as long as it is not mixed
and is still in powder form.
• Once mixed with sterile saline it lasts 6 weeks
• If non-sterile saline is used you must use the Botox within 24 hrs or waste
it.
• Bottom Line----always mix it with sterile saline !!! Sterile saline is
inexpensive but Botox is not

10. Botox Approved Applications
• Strabismus
• Blepharospasm---in patients greater than 12 years of age
• Cervical Dystonia (Tortacollis)
• Glabellar lines
• Chronic Headaches (Migraines)
• Hyperhidrosis (this application typically lasts 9 months)

11. Strabismus—Crossed eyes
• is a condition in which the eyes are not properly aligned with each other.
• It typically involves a lack of coordination between the extra ocular
muscles, which prevents bringing the gaze of each eye to the same point
in space
• Strabismus can be either a disorder of the brain in coordinating the eyes
or a disorder of the strength of eye muscles.
• Botulinum Toxin (Botox) may also be used in the treatment of strabismus
by improving vision and to improve cosmetic appearance. To perform
treatment Botox is injected into the stronger muscle, causing temporary
paralysis and causing a more symmetric appearance and allowing
convergence of gaze.
• Usual amount 15 units

12. Blepharospasm
• benign essential blepharospasm is a neurological movement disorder
involving involuntary and sustained contractions of the muscles around
the eyes.
• The cause is unknown, but fatigue, stress, or an irritant are possible
contributing factors.
• Botox injections have been used to induce localized, partial paralysis.
• Among most sufferers, botolinum toxin injection is the preferred
treatment method
• Usual amount is around 10-15 units

13. Cervical Dystonia
• Spasmodic torticollis is a chronic neurological movement disorder causing
the neck to involuntarily turn to the left, right, upwards, and/or
downwards. The condition is also referred to as "cervical dystonia".
• There are several treatments for spasmodic torticollis, the most
commonly used being botulinum toxin injections in the dystonic muscle of
the neck
• I have not seen a patient treated for this with Botox and would only
consider it if NSAIDs, muscle relaxers, OMT and PT are unsuccessful as
BOTOX would be an expensive approach. There is also risk in treated a
patient with Botox in the neck (many important things here)

14. Glabellar lines
• on April 12, 2002, the FDA announced regulatory approval of botulinum
toxin type A (Botox Cosmetic) to temporarily improve the appearance of
moderate-to-severe frown lines between the eyebrows (glabellar lines).
• Subsequently, cosmetic use of botulinum toxin type A has become
widespread with many celebrities viewing it as less intrusive and/or
artificial than other types of plastic surgery
• Injection into the Glabella is not difficult. There is little subcutaneous
tissue here and the muscle is easy to find.
• Usual dose is 10-15 units

15. Glabella Continued
• While injecting the muscle is not difficult it is
important to remember to stay out of the
orbital rim. You do not want to create ptosis
• Also stay one finger widths above the eyebrow
so that you do not make them droop. (real
eyebrows not pencil eyebrows).

16. Headaches
• FDA approval for treatment of chronic migraines on October 15, 2010. The
toxin is injected into the head and neck to treat these chronic headaches.
• Approval followed evidence presented to the agency from two studies
funded by Botox maker Allergan, showing a slight improvement in
incidence of chronic migraines for migraine sufferers undergoing the Botox
treatment.

17. Who Should get Botox for Headaches?
• A patient who is refractory to Triptans, and other
conventional methods.
• Most insurance companies will not pay for BOTOX
unless many other avenues have been explored (and
even then some just flat don’t pay)
• The forehead is traditionally injected first to see if
this aids in preventing headaches as the approach is
easier and less costly than injecting near the
posterior occiput.

18. Hyperhidrosis
• While treating patients with hemifacial spasm at Southend Hospital in
England in 1993, Khalaf Bushara and David Park were the first to show that
botulinum toxin injections inhibit sweating.
• This was the first demonstration of non-muscular use of BTX-A.
• Due to this research, Botox was later approved for the treatment of
excessive underarm sweating. (hyperhidrosis)
• If we all remember back from Medical School sweat glands are the only
sympathetic cholinergic glands in the body. Usually our fight or flight
response is thought of as being related to Eppi and Norepi

19. Hyperhydrosis continued
• Hyperhydrosis is the only application of Botox where we are not injecting
the muscle. We are now aiming for sweat glands with our injections.
• The most common place to inject for hyperhydrosis is the axilla
• It usually takes around 15-20 units per axilla to make a significant
difference and this application does cause more pain with injections as
there is more swelling of the skin (more sensitive).
• It is important to use many needles and syringes with small amounts of
BOTOX to avoid dulling the needles.
• I pinch or tent the skin between my fingers for two reasons……to keep my
needle from going deep (near brachial plexus and other important vessels)
and to decrease the sensation of pain with the needle stick.

20. How do I know where the sweat glands are?
• More Chemistry…….Fun!!!
• Use Betadyne thickly over the axilla and place corn starch over the entire
area. Allow this to sit for 1-2 minutes. The sweat glands will produce a
black reaction to the skin. Have the patient shake off the excess powder
and you are ready to inject (this is messy so put down towels first)
• I like to inject with sterile gloves in a grid pattern about one to two units
of Botox every square cm.
• The patient will notice results in 72 hrs. Make sure they are not planning
to wear white for a few days as the yellow betadyne and dark corn starch
can seep out of pores for a while. ( I would say 2 weeks before a
wedding)

21. Sweat Glands

22. Off Label Uses of Botox—For the
adventuresome
• Other facial lines
• Platysma Bands
• Bruxism
• Back and Neck Spasms
• Other spastic conditions---esophagus, bladder,
vascular, anal fissure, clubfoot.

23. Facial Lines
• Forehead--- Usually 10-20 units. You need to remember to stay one finger
above the eyebrow and to inject between the lines. Remember we are
injecting muscles….not chasing lines. I like to inject more medial for
women as it creates a nice brow lift (make it and even spread for men as a
brow lift looks less than manly).
• Crows Feet —Stay out of the orbital rim and be realistic. You are only
smoothing muscle not getting rid of fine lines. These are sometimes
better injected with dermal fillers (whole new talk). Use technique to
point the needle away from the eye.

24. Platysma Bands
• The Platysma is a muscle that is a broad sheet arising from the fascia
covering the upper parts of the pectoralis major and deltoid; its fibers
cross the clavicle, and proceed upward and medially along the side of the
neck.
• By injecting Botox into this thin muscle you can reduce the fine lines often
noted in the neck as we age.
• RESERVE THIS ONE FOR HOUDINI……YOU PROBABLY REMEMBER THIS
MUSCLE FROM CADAVER LAB (OR LACK OF THIS MUSCLE) WHEN IT
COMES TO THE NECK I LIKE DERMAL FILLERS ALL THE WAY!!

25. Bruxism-- grinding teeth
• is characterized by the grinding of the teeth and typically includes the
clenching of the jaw.
• It is an oral activity that occurs in most humans at some time in their lives
and can be worsened by stress or fatigue
• In most people, bruxism is mild enough not to be a health problem but is
one of the most common sleep disorders
• In the treatment of bruxism, Botox weakens the muscle enough to reduce
the effects of grinding and clenching, but not so much as to prevent
proper use of the muscle
• (not sure how much Botox is used as I have not seen this application)

26. Back and Neck Spasms
• Botox is often used by orthopedic and neurology specialists to decrease
spasm in paraspinal muscles that boarder our vertebrae.
• These specialized injections are targeted at relieving pain in small joint
segments. This can truly help patients with post-operative pain or
scoliosis.
• (I have not seen this used)

27. Other spastic conditions
• Botulinum toxin A can also be injected into muscles that are either spastic
or have contractures, the aim being to relieve the disability and pain
produced by the inappropriately contracting muscle.
• This can help treat: cerebral palsy, spastic quadriplegia or any movement
disorder with spastic or stiff muscles
• I do have a patient with severe CP who was so spastic he could not walk
with braces or crutches and now can use a walker instead of a wheelchair
due to the greatness of Botox

28. Who is not a candidate for Botox?
• People who have:
– Myasthenia Gravis, Lambert-Eaton Syndrome, ALS
– Pregnant or breast feeding
– Allergy or sensitivity to Botox
– Marked facial asymmetry, ptosis or other anatomic defects
– Infection of the skin
– History of facial nerve palsy (Bells Palsy)

29. Botox Rules
• In general the use of BOTOX poses few risks. BOTOX may cause temporary
headaches, bruising or temporary drooping of the eyelid.
• Certain antibiotics—Levaquin, Cipro or Clindamycin—shorten the
therapeutic effect of BOTOX…..it is unclear as to why but the theory is that
these antibiotics decrease the affinity of the Botox to stay bound to the
muscular junction.

30. Most Common Complications
• Most are largely aesthetic (Patients like
pre-treatment appearance better)
• Asymmetry
• Flattened brow or brow elevation
• Upper eye lid ptosis

31. Can Cosmetic side effects be “fixed”
• If you happen to have drooping eyes (ptosis)
following an eye treatment eye drops known
as Iopidine can be used to help elevate the
upper eyelid by 1-3 mm
• Additional Botox can be used on one side of
the face to aid in fixing any asymmetry that
may result

32. Cosmetic Botox and Patient $$
• We all age differently and have different attitudes about what we're
willing to do about it.
• Let's start out with one thing from the start. There are "needs" and
"wants" when it comes to our personal health. Cosmetic enhancement is a
"want.“
• What do I tell patients……………..

33. Broken on the Inside
• I'd never want to fly a plane that looked nice on the outside but was
mechanically unsound on the inside—and neither should you.

34. Katie Holmes Age Progression

35. Look Good for You
• There are good reasons and bad reasons for wanting to look good. Good
reasons include, wanting to look good for "your self."
• It's not reasonable to think that these products will improve your love life
or your marriage.
• They may help give you more self confidence—and that can be a good
thing as long as your self-confidence doesn't rest entirely on an enhanced
appearance.
• Remember that cosmetic enhancement can't reverse aging—it can only
reverse some of the outward appearances of aging.

36. Botox or Bust
• Anyone who considers any type of cosmetic procedure needs to balance
the potential benefits, risks and costs.
• It's nice to look our best but not at the risk of our overall health, financial
ruin and our children's college education.

37. Why I Love Botox Cosmetic
• With all of that being said……..I love Botox and all things girly…..make-up,
shoes, and nails
• I think of Botox as yet another way to enhance natural beauty

38. Judge for Yourself

39. How is Botox administered?
• Botox is given by fine needle injection. The number of injections will
depend on the number of areas you wish to have treated.
• Most women say that the pain is minimal.
• A typical treatment takes 10-15 minutes—again, depending on the
number of areas you wish to have treated.

40. Proper Injection Sites

41. What Can I Expect If I am a Patient?
• There may be some temporary swelling and occasional bruising. The
swelling typically lasts a few hours so you don't want to have this done just
before an evening out on the town.
• After treatment you should squint or use the muscles treated but don't
massage the injection sites.
• It's important that you don't lie down or bend over for 4 hours after
injection. I generally ask women to not exercise for 4 hours afterwards as
well. (other than use of treated muscles)

42. How long does it last?
• For most women BOTOX seems to last 3-4 months. The effects wear off
gradually and you'll be the best judge of when to come in for your next
appointment.
• About 9 Months for Axillary injections.

43. Is There anything else I should know?
• Avoid aspirin and non-steroidal anti-inflammatory drugs (Ibuprofen, Advil,
and Aleve) for at least one week prior to your planned treatment. This will
reduce the possibility of bruising afterwards.
• Also, avoid Ginkgo and ginseng, Vitamin E, Fish Oil supplements and red
wine for two days prior to treatment—again to avoid bruising.
• (our office advises to avoid alcohol, aspirin and NSAIDS which is usually
sufficient)

44. Botox Before and After

45. Botox Before and After

46. I am ready for Botox…now what?
• Finally, in closing, be realistic and establish a budget!
• Botox can improve your Patient’s lives and your pocketbook but do it
because you love it.