PRE-READING COURSE MATERIAL ADVANCED BOTOX AND DERMAL FILLERS - Module 2 - Acquisition Aesthetics
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PRE- READING COURSE MATERIAL
ADVANCED BOTOX® AND
DERMAL FILLERS
Module 2
Dear Acquisition Aesthetics delegate,
These pre-reading documents form the lectures you will attend on the day of training.
As a CPD certified course based on theoretical knowledge, we ask that you review all
the material prior to the course date.
Please feel free to print the pre-reading modules to annotate on the day.
You will be provided with an abbreviated practical guide for your review on the
training day.
We look forward to seeing you soon and happy reading!
Yours sincerely,
Acquisition Aesthetics
2
Botulinum
Toxin:
Advanced
principles
and practice
3
Objectives
• Pharmacology and mechanism of action
• Refresher of foundation principles and techniques
• Advanced techniques:
̶ Bunny lines
̶ Chemical brow lift
̶ Smoker’s lines
̶ Chin dimpling
̶ Gummy smile
̶ Masseteric hypertrophy
̶ Nefertiti neck lift
̶ Hyperhidrosis
̶ Down turned corners of the mouth
• Questions and controversies
• Future development
4
Botulinum Toxin - Pharmacology
• Therapeutic chemodenervation
with Botulinum Toxin type A
pioneered by Alan Scott (1980)
• Blocks transmission across
cholinergic NMJs through
cleavage of SNAP - 25 protein
• Results in a temporary
paralysis of target muscles
• Takes effect within 3 - 7 days
• Cholinergic reinnervation
occurs over 3 - 4 months
through ‘sprouting’
5
http://www.allergan.com/assets/pdf/botox_cosmetic_pi.pdf
Botulinum Toxin
General principles of use in
facial aesthetics:
Eliminate /
reduce dynamic
facial wrinkles
Soften static
Create a ‘lift’
wrinkles
6
Foundation refresher
The 3 foundation treatment zones for botulinum Toxin
Glabella complex / Frontalis / Orbicularis oculi /
frown lines forehead Lines crow’s Feet
7
Foundation refresher
Upper face
toxin standard
regimen
(Azzalure®)
8
Advanced Toxin techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
9
Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
10Advanced techniques
Nasalis treatment: ‘Bunny lines’
• Wrinkles on the dorsolateral
aspect of the nose which
develop due to the activity of
nasalis muscle
• Exaggerated in laughing /
squinting
• Can develop through
compensatory over-activity of
nasalis secondary to treatment
of glabella complex
• Treat with 5 Speywood units
in the body of each nasalis
muscle, injected superficially
11Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
12Advanced techniques
Chemical brow lift
• Botulinum Toxin can be used to
2.5 2.5
perform a chemical brow lift for clients
who present with a heavy over-hanging
look Simple chemical brow lift
• 2.5-5 Speywood units is injected into
upper outer fibres of obicularis
oculi, superficially
• >1.5cm above the supraorbital rim
• Treatment can be expanded to include a Brow reshape
brow reshape (peak of brow)
• Full chemical brow includes glabella
(10 units each site) and crow’s feet Tx
(20 units each side)
Full chemical brow lift
13Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
14Advanced techniques
Obicularis oris treatment:
Smoker’s lines
• These perioral lines are created by
the activity of orbicularis oris
• Early smoker’s lines can be treated
with Botulinum Toxin
• Small doses (2.5 Speywood
units) can be injected above the
upper lip (>4mm superior to the
vermillion border)
• Inject perpendicular to the skin at Before After
approximately 2-3mm depth
Note – deeper / static smoker’s lines
may require dermal filler treatment
15Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
16Advanced techniques
Mentalis treatment: Chin dimpling
• Contraction of the mentalis muscle
in the chin can create this dimpling
/ pebbling effect
• Exaggerated by pouting / drawing
lower lip in and up, allowing you to
hold the contracted muscle belly
• Inject up to 5 Speywood units
into each muscle belly
• Can also reduce a prominent Before After
mental crease
17Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
18Advanced techniques
Levator labii superioris
treatment: ‘Gummy smile’
• A gummy smile (excessive gingival
display) can occur through
overactivity of levator labii
superioris and zygomaticus minor
• Botulinum Toxin can be injected to
relax these elevators and soften a
gummy smile
• Small doses (5 Speywood units)
are injected deeply at the
corners of the nose Before After
N.B. Treat conservatively to avoid
functional impairment
19Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
20Advanced techniques
Masseteric hypertrophy
• Botulinum Toxin can be used to
reduce the strength and bulk of the
masseter (chewing) muscles to
reduce the width of the jaws 20
20
• Functional and aesthetic uses
20
• 60 Speywood units are injected
into each masseter (20 units
each injection site)
21Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
22Advanced techniques
Platysma Treatment - Nefertiti
neck lift
• This technique relaxes platysma
muscle
• Benefits of treatment:
̶ Reduces the appearance of
prominent bands
̶ Enhances definition of the
jawline
̶ Can soften ‘jowls’
̶ ‘Liquid facelift’
23Advanced techniques
Platysma treatment - Nefertiti
neck lift
Product is injected along the bands of
the platysma muscle in 5 Speywood
unit doses
Use a double dilution technique (1.25ml)
Identify bands by drawing corners of
mouth down / saying ‘Eee’
You can pinch the bands lightly and tent
the skin towards you to isolate the
injection sites
Inject in subcutaneous layer
Boundaries: Mandibular border, trapezius,
clavicle
Avoid SCM
24Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
25Advanced techniques
Hyperhidrosis
• Botulinum Toxin temporarily
blocks cholinergic stimulation of
apocrine sweat glands, giving up to
6 months’ relief from excessive
sweating
• Double dilution (1.25ml)
• In the axillae, mark out a grid of
12 injection sites across the
main sweat producing zone with
5 Speywood units injected at
each site (total 62 Speywood
units per axilla)
26Advanced techniques
Bunny lines
Chemical brow lift
Smoker’s lines
Chin dimpling
Gummy smile
Masseteric hypertrophy
Nefertiti neck lift
Hyperhidrosis
Down turned corners of the mouth
27Advanced techniques
Depressor anguli oris treatment:
Down turned corners of the mouth
• Botulinum Toxin can be injected
into depressor anguli oris muscles
(DAO)
• Reduces downwards pull on oral
commissures
• Lifts corners of the mouth
• The muscle is identified by asking
the client to draw their lower lip
downwards Before After
• Inject 5 Speywood units into
each muscle (approx. midway
between the oral commissure
and mandible)
28Questions and controversies
Off label use not an issue provided
Off-label use – the facts
the practitioner
• Granted FDA approval for reduction • Understands evidence behind off
of glabella and lateral canthal lines in label use is limited
2009
• Can explain the rationale for
• Other cosmetic applications are treatment
therefore considered ‘off-label’
• Explains the risks / side effects to the
• This implies a relative lack of client
scientific evidence
• Follows an informed consent
• Greater scope for litigious conflict procedure
from off-label usage
29Questions and controversies
Gender
• Are higher doses required in men?
• Differences in muscle bulk and
metabolism
Assess every client (regardless
• Currently very limited evidence
of gender) as an individual
(glabella only)
• No studies to prove that higher doses
are required in other treatment zones Consider differences in muscle
bulk and metabolism to ensure
• Studies into the non-cosmetic
most appropriate dosing
applications of botulinum Toxin have
regimen
demonstrated no correlation
between dose and gender or a
reverse correlation (adductor
laryngeal dystonia)
30
http://aestheticchannel.modernmedicine.com/cosmetic-surgery-times/news/modernmedicine/modern-medicine-feature-articles/gender-tailored-approach?%0A%09%09%09=&date=&id=&pageID=2&sk=Questions and controversies
Resistance - Fact of fiction?
• Requirement of repeat treatments
introduces the risk of secondary
resistance to botulinum Toxin
• This occurs through the formation of
immunoglobulin G - Neutralizing
antibodies
• Current literature suggests a
prevalence of 0.6 - 3% resistance in
aesthetic treatment
• Risk is generally higher in medical
indications where higher doses are
used
31
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872090/Questions and controversies
Resistance - Fact of fiction?
In cases where resistance is suspected:
1. Establish immunological profile of
product used
2. Consider break period / switching
to low antigenicity product such as
incobotulinum Toxin (Bocouture)
3. Maintain practice that deters against
development of resistance
a) Use lowest dose required to
achieve desired effect
b) Do not retreat within 3 month
period
c) Avoid boosters / top-ups
32
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872090/Lecture summary
• Pharmacology and mechanism of action
• Refresher of foundation principles and
techniques
• Advanced techniques:
̶ Bunny lines
̶ Chemical brow lift
̶ Smoker’s lines
̶ Chin dimpling
̶ Gummy smile
̶ Masseteric hypertrophy
̶ Nefertiti neck lift
̶ Hyperhidrosis
̶ Down turned corners of the mouth
• Questions and controversies
• Future development
33Lecture overview
Historical background
Basic sciences and mechanism of action
Refresher of foundation
principles and techniques
Advanced techniques
Lip augmentation Temporal hollows
Cheek augmentation Perioral lines
Jaw contouring Hand rejuvenation
The market
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