Injection of botulinum toxin preparations

Botulinum toxin - a biological exotoxin, produced by the bacterium Clostridium botulinum, causative agent of botulism.

Botulinum toxin has become a powerful tool in the therapy of a variety of neurological, ophthalmic and other disorders manifested by abnormal or excessive muscle contractions.

The mechanism of action is a local muscle relaxant that blocks neuromuscular transmission due to the cleavage of transport proteins responsible for the release of acetylcholine into the presynaptic cleft. The resulting blockade of the synapses is irreversible. Restoration of contractility of muscle fibers occurs due to the formation of new collaterals of motor axons. The effect after a single injection of the drug develops within 3-14 days, after which it persists for 3 to 10 months (depending on the zone of administration and dosage of the drug). After administration of botulinum toxin, there is no disturbance of microcirculation or sensitivity in the area of drug exposure.

Currently, botulinum toxin type A is used in the form of pharmacological preparations Dysport (lpsen, UK), Botox (Allergan, USA, BTXa Estetox, China), as well as botulinum toxin type B-Myoblok / Neurobloc (Pharmaceutical) . The recommended dosages for these drugs are based on their biological strength and are expressed in units of action (ED).

Some tenderness in palpation can also bother the patient 2-4 days after the procedure. In case of improper administration, hypercorrection, with thrombosis of the vessel, non-observance of aseptic and antiseptic measures, it is possible to form fibrosis and even tissue necrosis. Careful adherence to all principles and rules will avoid such undesirable consequences.

The activity of ED of all preparations is significantly different. One botox unit corresponds to approximately 3-5 units of Dysport.

The preparations of botulinum toxin are thermolabile and sensitive to illumination. Store Dysport at 2-8 ° C, and Botox -1 -5 ° C. After dilution, do not shake or freeze. It is advisable to administer the drug within 6-12 hours after dilution, although there is evidence to confirm the effectiveness of these drugs for up to 7 days.

Indications for injection of botulinum toxin preparations

The results of this procedure are comparable to the effect of plastic surgery. Horizontal wrinkles on the forehead, interbrowal folds are smoothed. The forehead becomes perfectly smooth, "infantile". In addition, you can create the effect of "lifting" the lateral part of the eyebrows, resulting in the eye "open", and the eyebrows acquire a beautiful bend. However, do not forget that the muscles relax and the skin is straightened out due to this. Do not pull up the skin. The effect of lifting the lateral parts of the eyebrows is a natural consequence of the preservation of the tone and some contractile force of the lateral parts of the frontal muscle when the central part is relaxed. The same effect is obtained when the drug is introduced into the lateral upper part of the circular muscle of the eye due to the realization of antagonism between it and the frontal muscle. Very effective is Botox also for the correction of wrinkles located in the corners of the eyes, the so-called "crow's feet". The above refers to the "basic" indications for the administration of botulinum toxin. There are a number of "additional" points of drug administration. They differ in that, with a lower severity of the effect, you significantly increase the risk of side effects. These are perioral folds, chin, neck, decollete and lower eyelid zone.

The choice of dosage and the area of administration of the drug depends on the severity of the muscles, the structure of the eyelids, the shape of the eyebrows, the ptosis of the tissues and the presence of excess skin, the age of the patient. It is important to consider the desired degree of correction (paresis or paralysis of the muscle).

The degree of "smoothing" of wrinkles depends on the dose of the drug, the severity of the "crease", the elasticity of the skin. Better results with the use of botulinum toxin can be obtained in patients of middle and young age without a significant excess of skin. In patients of the older age group, it is optimal to combine the administration of botulinum toxin with drug-fillers. For the safe use of this drug should clearly represent the localization of facial muscles, the effects of their contractile activity and relaxation.

The most often corrected the mimic activity of such muscles as m. Frontalis, m. Corrugator supercilii, m. Procerus (correction of horizontal brow creases on forehead and nose), m. Orbicularis oculi (wrinkles in the corners of the eyes, so-called "crow's feet"), m. Nasalis (wrinkles on the nose). Do not correct frontal wrinkles on the forehead in individuals with excess skin in this area, as this will cause the brow to dislocate downward and cause them to overhang. Also, caution should be exercised when using Botox in the forehead and bridge of the nose in persons with constitutional or acquired overhanging of the upper eyelids.

The method of injecting botulinum toxin preparations

Before the procedure, Botox preparation, which is released in lyophilized form, is diluted with physiological solution at the rate of 1 or 2.0 ml per bottle, and disportation - at the rate of 1.25 or 2.5 ml physiological solution of the vial. You can add a small amount of adrenaline to the solution, since adrenaline reduces the diffusion of the drug into the surrounding tissues, makes it possible to maximize the exact effect of the drug and reduces the risk of various complications. The skin in the area of drug administration is treated with non-alcohol-containing solutions of antiseptics, since contact with alcohol can inactivate the drug. The drug is administered intramuscularly (in the projection of a muscle that has hyperactivity) or intradermally (in the lower eyelids, around the lips, on the neck and in the decollete, in the treatment of hyperhidrosis). After injection, the injection site should not be massaged to avoid diffusion of the drug into the surrounding tissue. You can attach ice.

The field of application of "Botox"	Women	Men's
M. Frontalis	15-20	20-24
M. Corrugator, m. Procerus	15-25	20-30
M. Orbicularis oculi	10-15	15-20
M. Depressor anguli oris	5-10	10-20
M. Platysma	25-40	30-50
M. Nasalis	2.5-5	5-10
M. Rnentalis	2.5	5

The patient is not recommended to occupy a horizontal position for 3-4 hours after the procedure, at least 48 hours - sunbathing, going to the sauna, doing a massage. Also, 2 weeks after the procedure should not take antibiotics (especially aminoglycosides and tetracyclines) and do any myostimulating procedures, microcurrents, ultrasound on the zone of drug administration. It is not recommended to re-administer the drug earlier than 3 months, and also to administer large doses of the drug, as this can lead to the synthesis of neutralizing antibodies and the ineffectiveness of further procedures.

Principles of the choice of this or that injection technique

It is very important to choose the right method, suitable for each individual patient, taking into account age, features of facial expressions, constitutional features of the facial structure, allergic anamnesis. The first step on the road to success is to find out what the patient's wishes are and how much his expectations correspond to the real possibilities of the method, whether there are any contraindications to using any of the proposed techniques, and also the period of time through which it is necessary to obtain an apparent and significant effect.

The optimal treatment is the following. First - a course of chemical peelings and hardware techniques for indications (for example, a combination of microcurrent therapy, endermology and peelings of fruit acids), then - mesotherapy, then - botox (if necessary), then - philling. With this sequence of procedures, we primarily affect "Qualitative" characteristics of the skin, stimulating the metabolism, we activate the activity of fibroblasts, stimulating the production of collagen and elastin, we supply the necessary nutritional components, ie, we really "rejuvenate" to Ms. Botox and phyllings are, first of all, variants of mainly optical "rejuvenation". These procedures allow you to quickly get rid of such signs of wilting as wrinkles and wrinkles, but they practically do not affect the turgor and elasticity of the skin.

Scheme of clinical algorithm for cosmetic correction of age-related changes in facial tissues using botulinum toxin type A

Classes of changes in soft tissues of the face	Type of treatment
IA	Botulinum toxin; conservative cosmetology procedures
IB	Conservative cosmetology procedures; botulinum toxin: hyaluronic acid preparations for administration to the superficial and middle layers of the dermis
IIA	Conservative cosmetology procedures; botulinum toxin; preparations of hyaluronic acid for introduction into the middle and deep layers of the dermis; surface and median chemical peels or dermabrasion by erbium laser
IIB	Conservative cosmetology procedures; transconjunctival blepharoplasty of lower eyelids; botulinum toxin; preparations of hyaluronic acid for insertion into middle and deep dermis of the dermis; surface and median chemical peels or dermabrasion by erbium laser
IIB	Conservative cosmetology procedures; transconjunctival blepharoplasty of the lower eyelids, injectable implants; preparations of botulinum toxin; surface and median chemical peels or (erbium laser dermabrasion, CO2 laser dermabrasion
IIIA	Conservative cosmetology procedures; classical blepharoplasty of the upper and lower eyelids: injectable implants; preparations of botulinum toxin; mechanical dermabrasion; middle and deep dermabrasion with CO2 or erbium laser
IIIB	Conservative cosmetic procedures; classical plastic surgery to eliminate excess skin of the eyelids, face and neck; deep (dermabrasion with CO2 laser or mechanical dermabrasion; injectable preparations of botulinum toxin.

Botox is preferred if the main problem is excessive mimic activity and occurrence of facial wrinkles in the forehead, nose and eyes corners. In this case, the ideal options and the only right choice is botox. Mesotherapy, philling and all other possibilities of cosmetology will not give a comparable effect. In some situations (predominantly in young patients), only the administration of botulinum toxin already produces excellent results. If we do not get a full extension of the facial wrinkles due to a too pronounced crease in the skin or the impossibility of administering a full dose of botulinum toxin, then in this situation, the philling will help to obtain a more perfect effect.

Preference for contour plastics is given if the aim is to correct perioral wrinkles, nasolabial folds, to fill the soft tissue of the face (cheeks, cheekbones, chin). To do this, it is desirable to use filler preparations first and only in some cases to correct perioral folds - botox, since the introduction of botulinum toxin into this zone can lead to a violation of articulation, and the introduction of fillers is safe and gives an excellent effect. The "folds of sorrow" (going from the corners of the lips to the chin), changes in the face relief, the contours of the face, the lowering of the corners of the lips - an advantage over contour plasty, although in some cases the introduction of fillers can be supplemented with the introduction of botulinum toxin. For example, if the introduction of Botox is proposed to correct interbrowal folds or horizontal wrinkles on the forehead, it is worth paying attention to the degree of primordial overhang of the eyelids (can be expressed due to a certain structure of the eyelids or due to age-related changes). If the overhang is already expressed before the procedure, by introducing a large amount of the drug, we have every chance to strengthen it, which can happen even if there is an excess of tissues in the forehead. The way out is to decrease the amount of botulinum toxin injected or to abandon this technique by changing the scheme of its administration (as high as possible) with additional correction by the drug-fillers.

In conclusion, it should be emphasized that when performing injections, the following rules for interaction with the patient should also be adhered to:

1. Prior to the application of injection techniques, the patient should be told about all the advantages and disadvantages of the method, possible complications. It is necessary to provide him with complete and reliable information about alternative methods of treatment.
2. It is strongly recommended that you sign an informed consent to a procedure in which it is important to reflect the immediate subject of correction and the mechanism of action of the drug, as well as potential risks.
3. A pledge of mutual understanding between the doctor and the patient is the documentation of each observation with the help of photography (you need to photograph before and after the procedure in the same patient position and under the same illumination).
4. Each doctor chooses the most comfortable position of the patient during the procedure, but remember that in the sitting position, all wrinkles and wrinkles are better seen and the procedure can be performed more accurately.

All of the above injection methods used in cosmetology are very effective, but they require the doctor who uses them, full knowledge and maximum attention to the patient. The optimal option is a combination of specialization in dermatology, therapeutic cosmetology and training for each of the described techniques.

Complications after the procedure

Complications of intradermal injections include allergic dermatitis, localized urticaria, acute surface and deep pyoderma, activation of herpetic infection, foci of necrosis at the site of injection. Local necrosis is associated with a hyperergic reaction to the injected agent (s) according to the type of Arthus phenomenon. Extremely rare are systemic complications associated with ingestion of the drug into the systemic circulation (common urticaria and Quincke's edema, toxicodermia, exacerbation of atopic dermatitis, bronchial asthma, etc.).

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