Botox technology

After acquaintance with the procedure for introducing Botox, indications for its use and possible complications from the patient, it is necessary to obtain informed consent. He needs to be informed that Botox injections were authorized by the Office of Control and Quality of Food and Drugs (USA) in 1989, as an effective method of correcting blepharospasm, strabismus and hemifacial spasm. In 1990, the Conciliation Conference of the National Health Organizations added to such indications as spastic dysphonia, oromandibular dystonia, facial dystonia, scabies and torticollis. In 1998, the instruction was spastic changes. Indications not indicated in the instructions are tremor, infantile cerebral palsy, excessive sweating, impaired sphincter function and the presence of hyperfunctional facial folds.

After obtaining the patient's consent, evaluation of the functional lines on the scale and photographing on the patient's face, the marker marks areas where the maximum muscle tension causes the formation of hyperfunctional folds. Labels are placed on the site of each injection to affect these muscles. Around the marks draw circles, 1-1.5 cm in diameter - the zone of diffusion of toxin. Their totality should completely cover the area of the excessively functioning muscle, but not touch adjacent, adjacent muscles. The photograph or diagram of injection points and the dose for each point should form part of the patient's outpatient card so that it is possible to evaluate the effectiveness of the correction and create a kind of "geographical map" for future injections. The location of the injection points where the desired result was achieved is recorded in an outpatient card with a dose indication.

When the labeling is completed to reduce the discomfort associated with puncturing the skin with a needle, the injection areas can be treated with ice or an EMLA cream. The toxin is collected in a tuberculin syringe with a monopolar Teflon-coated EMG needle of caliber 27 G. It is connected to the EMG apparatus, grounded, and electrodes are applied to the patient's face. The needle is guided through the skin into the muscle intended for injection. The patient is asked to create a special facial expression, for example frown, squint or raise an eyebrow. If the needle is in the active part of the muscle, a loud signal will be heard in the dynamics of the electromyograph. If the signal is weak, then the needle should be moved until it becomes loudest, and only then a toxin is injected. This procedure is repeated at each site scheduled for injection. Using the EMG technique increases the accuracy of administration and, as a result, reduces the dose necessary to achieve the desired effect. If an increased dose is required for some area, a larger volume of solution or the same volume with a higher concentration can be introduced. An increase in volume can lead to diffusion of the toxin into the adjacent muscles, with the development of undesirable hypotension. To prevent this, the toxin concentration in the same volume of solution is increased, which leads to more relaxation of the desired muscle without increasing the diffusion area of the toxin. Injections around the eye to loosen the circular muscle can be performed with a tuberculin syringe with a needle of size 30 G, having a length of 1.25 cm. Patients with severe muscles or those who have already had injections and muscles are well detected can be injected without the use of EMG. Now we are introducing a needle with a size of 30 G in length of 2.5 cm that can be used with portable EMG, which allows you to inject the toxin accurately and without discomfort, which happens when using a needle with a size larger than 27 G. After the injection, its place can be slightly pressed to prevent the occurrence of ecchymosis. Carruthers introduced a technique of carefully squeezing injected toxin from the eye or from an important adjoining muscle in order to facilitate its penetration into those areas where relaxation is desirable. The patient is asked not to touch the injection site for 6 hours in order to prevent excessive toxin penetration into the adjacent muscles and, thereby, reduce the possibility of their excessive relaxation.

[1]

Botox injections in the area of nadriposition

Injections in the area of the nadpings regulate the excessive activity of the muscle of the proud and the muscle wrinkling the transference, forming the "angry" lines on the forehead. To eliminate them we introduce into this area 7,5-25 ED Botox. We usually start with the introduction of 2.5-5 units in 0.1 ml of solution in each wrinkling muscle, and 2.5 units in 0.1 ml of solution in the muscle of the proud. The dose of Botox depends on the size of the muscle, which is evaluated before the procedure. In men, muscles are usually larger, so they need a large dose. Injections into the muscle wrinkling the eyebrow can be done by several separate needles or the muscle can be "planted" onto the EMG needle and treated with a toxin as it is removed. The toxin as a result of this should spread far enough to the sides to cover the entire muscle within the vertical lines held through the middle of the pupils. Significantly more lateral or closer to the eyebrow injection of the drug can lead to relaxation of the muscles lifting the upper eyelids, and cause ptosis.

When ptosis occurs, apraclonidine is used in the form of 0.5% eye drops (Iopidine). They stimulate the muscle of Mueller (adrenergic muscle), located under the muscle that lifts the upper eyelid. Usually, as a result of treatment, it is possible to achieve an increase in the edge of the eyelid by 1-2 mm.

Botox injections into the frontal muscle

The frontal muscle contracts in a vertical direction, creating horizontal folds on the skin of the forehead. Bo-tox should not be injected close to the eyebrows, as this can cause the lowering of the eyebrows and even lifting muscles. We prefer to gradually raise the injection site above the eyebrow, as we move from the center, to leave the lateral part of the frontal muscle functioning, retaining the function of emotional expressiveness and removing most of the frontal folds. Usually our patients prefer to keep the mobility of the eyebrows. If there are several rows of horizontal lines on the forehead, several rows of injections may be needed to act on them. To do this, labels with a diameter of 1-1.5 cm are drawn again. After that, the forehead is treated with ice or EMLA cream. In order to make sure that the needle is in the excessively functioning part of the frontal muscle, the toxin is injected under the control of EMG. We usually inject 2.5 units per 0.1 ml of solution into each label on the forehead. The total dose of Botox is 10-30 units. If there are especially hyperactive areas above the eyebrows to avoid excessive diffusion into the adjacent muscles, we use a more concentrated solution (5 units of toxin per 0.1 ml of solution).

[2], [3], [4], [5], [6], [7]

Eyebrow Correction

Often, if the lateral part of the frontal muscle is not treated, the relaxation of the frontal muscles and the muscles of the napper causes arched bending of the lateral parts of the eyebrows upward. Relaxation of the lateral part of the frontal muscle often leads to the omission of the eyebrow. If the arcuate bend is large, a small amount of toxin (1 ED of toxin in 0.1 ml of solution) is introduced into the lateral part of the frontal muscle in order to lower the eyebrow somewhat. On the contrary, if a sufficient raising of the eyebrow is not obtained, the administration of Botox at the same dose at the lateral edge of the orbit will weaken the circular muscle of the eye at the site of its attachment and allow the frontal muscle to raise the eyebrow more.

[8], [9], [10]

Botox injections to eliminate "crow's feet"

The lateral orbital lines, or "crow's feet," are the result of the hyperactivity of the lateral part of the circular muscle of the eye. This muscle closes the eye, flashes and closes, but the excess activity of its lateral part wrinkles the skin of the face at the lateral edge of the orbit, forming a "crow's foot". A small amount of botox can weaken the lateral part of this muscle and, thereby, reduce the wrinkling of the skin without disturbing the flashing and closing of the eye. To create the desired attenuation, a label is applied, retreating 1 cm from the lateral angle of the eye gap. The patient is asked to squint, and if the hyperfunctional folds are formed above the first mark, then in this, the top part is put the second mark. The folds appearing below the first mark are marked with the third label. Labels are applied from two sides. Do not inject too close to the eyelids or eyelid, as this can cause retardation of eyelid closure, epiphora, mild ectropion, diplopia, or worsen blinking.

Skin is treated with ice or cream EMLA. Injections around the eyes are usually performed with a 1.25-centimeter needle of size 30 G. If the desired result is difficult to achieve, an electromyograph is used to increase the accuracy of needle insertion. Typically, the initial dose is 2.5 units of toxin per 0.1 ml of solution in each of the previously drawn labels. The usual dose is 7,5-15 units on each side.

[11], [12]

Nasolabial folds

With the help of injections, you can smooth the lines of hyperactivity at the border between the circular muscle of the mouth and the lifting muscles (large and small cheekbones and the muscle that raises the corner of the mouth). However, the weakening of these muscles changes the look of a smile and is unacceptable for most people. The use of fillers and other approaches often yield better results.

Nose trumpet

Some patients express concern over the excessive turn of the wings of the nose. It is the result of excessive contraction of the nasal muscles. We use the technique described by Carruthers, in which botox is injected into the nasal muscles from both sides at a dose of 5 U in 0.1 ml of the solution. This gives excellent results if a small amount of solution is introduced, which excludes diffusion into the muscles that raise the lip.

Injections into the chin area

Patients with excessively pursed lips are characterized by excessive activity of the chin muscle and the circular muscle of the mouth. Especially this effect is manifested after the installation of chin implants or surgical correction of the occlusion. Muscular activity can cause abnormal position of the lips and lead to the fact that the skin in this area will look like an "orange peel". We found that the introduction of small amounts of Botox (2.5-5 units) on either side can prevent excessive activity in this area and improve the appearance of the skin. The injection is performed at a point located midway between the edge of the red border of the lower lip and the edge of the chin, 0.5-1 cm medial than the oral solder. The patient is asked to wrinkle his lips and inject the drug using EMG. Botulinum toxin should not be injected too close to the lip to avoid excessive loosening of the circular muscle of the mouth followed by a change in the smile and drooling.

Botox injections in the cords of the subcutaneous muscle of the neck

Botox injections in patients in whom the hypodermic neck muscle forms unique protruding cords, both before and after the face lift, can give a positive effect without performing a sub-chin and cutting the muscle. When implementing these injections, we first mark the front and back edges of the muscle from both sides. We mark the area of pronounced cords of the subcutaneous muscle of the neck, on which horizontal lines are drawn at an interval of 2 cm. Usually they are three. A monopolar EMG needle is inserted into the muscle towards the medial edge of the strand. It is advanced perpendicularly to the muscle fibers. The patient is asked to strain the subcutaneous muscle, lowering the lower lip. The drug is introduced as the needle moves back in the muscle. The muscle is usually injected with 2.5-5 ED of toxin in 0.1 ml of solution per injection, 2-3 injections on each side. The dose of Botox on one side is 7.5-20 units. To prevent diffusion of the toxin on the front surface of the neck, in the subluxal muscle, the relaxation of which can cause dysphonia or dysphagia, it is necessary to administer the drug in a small volume and with a minimum dose.

[13], [14], [15], [16], [17], [18]

Auxiliary injections of Botox

It has been found that relaxation of the underlying facial muscles greatly improves the results of laser resurfacing or the use of injectable excipients such as collagen. The best results are achieved in stages - Botox injections are initially performed, and a week later the patient comes to perform the following procedure. If it is laser-polished, then relaxing the skin folds around wrinkles helps to properly orient the collagen fibers, which causes better and longer results. In the conditions of long weakening of the underlying muscles, the skin heals without forming wrinkles. The strength of the muscles is restored after 4-5 weeks, and Botox injections can be repeated.

Botox can relax the skin lines and, thereby, minimize the amount of collagen or other injectable filler necessary to improve the cosmetic result. If there is no permanent compressive action of muscles in filling deep wrinkles, the injection material is retained in the tissue much longer. Therefore, if correction is performed in combination with additional administration of Botox, the material is required to be smaller, and it retains its initial location longer.

[19], [20]