Botulinum toxin injections

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

Botulinum toxin has become a powerful tool in the treatment of many neurological, ophthalmological and other disorders that involve abnormal or excessive muscle contractions.

According to the mechanism of action, it is a local muscle relaxant that blocks neuromuscular transmission by breaking down transport proteins responsible for the release of acetylcholine into the presynaptic cleft. The resulting blockade of synapses is irreversible. Restoration of the contractile ability 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 lasts from 3 to 10 months (depending on the injection area and dosage of the drug). After the introduction of botulinum toxin, no microcirculation or sensitivity disorders are observed in the area of the drug's action.

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 - Myobloc/Neurobloc (Pharmасеutical). The recommended dosages for these preparations are based on their biological strength and are expressed in units of action (U).

Some pain during palpation may also bother the patient for 2-4 days after the procedure. In case of incorrect administration, hypercorrection, thrombosis of the vessel, failure to comply with aseptic and antiseptic measures, fibrosis and even tissue necrosis may develop. Careful adherence to all principles and rules will help to avoid such undesirable consequences.

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

Botulinum toxin preparations are heat-labile and sensitive to light. Dysport should be stored at a temperature of 2-8° C, and Botox -1 -5° C. After dilution, they should not be shaken or frozen. It is advisable to administer the preparation within 6-12 hours after dilution, although there is data confirming the fact that the effectiveness of these preparations lasts up to 7 days.

Indications for injections of botulinum toxin preparations

The results of this procedure are comparable to the effect of plastic surgery. Horizontal wrinkles on the forehead and brow folds are smoothed out. The forehead becomes perfectly smooth, "baby-like". In addition, it is possible to create the effect of "lifting" the lateral part of the eyebrows, as a result of which the eyes "open" and the eyebrows acquire a beautiful curve. However, do not forget that the muscles relax and the skin is straightened due to this. There is no upward skin tightening. The effect of lifting the lateral parts of the eyebrows is a natural consequence of maintaining the tone and some contractile force of the lateral parts of the frontal muscle when its central part is relaxed. The same effect is obtained when the drug is injected into the lateral upper part of the orbicularis oculi muscle due to the antagonism between it and the frontal muscle. Botox is also very effective for correcting wrinkles located in the corners of the eyes, the so-called "crow's feet". The above refers to the "main" indications for the introduction of botulinum toxin. There are a number of "additional" injection points. They differ in that with a less pronounced effect, you significantly increase the risk of side effects. These are the perioral folds, chin, neck, décolleté and lower eyelid area.

The choice of dosage and area of administration of the drug depends on the expression of muscles, the structure of the eyelids, the shape of the eyebrows, tissue ptosis and the presence of excess skin, the patient's age. It is important to take into account the desired degree of correction (paresis or paralysis of the muscle).

The degree of wrinkle "smoothing" depends on the dose of the drug, the severity of the "fold", and the elasticity of the skin. The best results when using botulinum toxin can be obtained in middle-aged and young patients without significant excess skin. In older patients, it is optimal to combine the introduction of botulinum toxin with filler drugs. For safe use of this drug, you should clearly imagine the localization of the facial muscles, the consequences of their contractile activity and relaxation.

The most frequently corrected muscles are m. frontalis, m. corrugator supercilii, m. procerus (correction of horizontal interbrow folds on the forehead and bridge of the nose), m. orbicularis oculi (wrinkles in the corners of the eyes, the so-called "crow's feet"), m. nasalis (wrinkles on the nose). Correction of frontal wrinkles on the forehead should not be performed in individuals with excess skin in this area, as this will entail downward dislocation of the eyebrows and lead to their overhang. Caution should also be exercised when using Botox in the forehead and bridge of the nose area in individuals with constitutional or acquired overhang of the upper eyelids.

Method of injection of botulinum toxin preparations

Before the procedure, the lyophilized Botox preparation is diluted with saline at a rate of 1 or 2.0 ml per bottle, and Dysport - at a rate of 1.25 or 2.5 ml of saline per bottle. A small amount of adrenaline can be added to the solution, since adrenaline reduces the diffusion of the preparation into the surrounding tissues, makes it possible to achieve the most precise effect of the preparation and reduces the risk of various complications. The skin in the area of injection is treated with non-alcohol-containing antiseptic solutions, since contact with alcohol can inactivate the preparation. The preparation is administered intramuscularly (into the projection of the muscle with hyperactivity) or intradermally (in the lower eyelid area, around the lips, on the neck and in the décolleté area, in the treatment of hyperhidrosis). After administration, the injection site should not be massaged to avoid diffusion of the preparation into the surrounding tissues. Ice can be applied.

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

Principles for choosing one or another injection technique

It is very important to choose the right method suitable for each specific patient, taking into account age, facial expressions, constitutional features of the facial structure, and allergy history. The first step towards success is to find out what the patient's wishes are and how much their expectations correspond to the actual capabilities of the method, whether there are any contraindications for using any of the proposed methods, as well as the period of time after which it is necessary to obtain a visible and significant effect.

The optimal order of therapy is as follows. First, a course of chemical peels and hardware techniques as indicated (for example, a combination of microcurrent therapy, endermology and fruit acid peels), then mesotherapy, then Botox (if necessary), then filling. With this sequence of procedures, we primarily affect the "quality" characteristics of the skin, stimulating metabolism, activate the activity of fibroblasts, stimulating the production of collagen and elastin, supply the necessary nutritional components, i.e. we truly "rejuvenate" the skin. Botox and fillings are, first of all, options for predominantly optical "rejuvenation". These procedures allow you to quickly get rid of such signs of aging as wrinkles and folds, but they have virtually no effect on 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 facial soft tissue changes	Type of treatment
I.A.	Botulinum toxin; conservative cosmetic procedures
IB	Conservative cosmetology procedures; botulinum toxin: hyaluronic acid preparations for injection into the superficial and middle layers of the dermis
IIA	Conservative cosmetic procedures; botulinum toxin; hyaluronic acid preparations for injection into the middle and deep layers of the dermis; superficial and medium chemical peels or dermabrasion with an erbium laser
IIB	Conservative cosmetic procedures; transconjunctival blepharoplasty of the lower eyelids; botulinum toxin; hyaluronic acid preparations for injection into the middle and deep layers of the dermis; superficial and medium chemical peels or dermabrasion with an erbium laser
IIB	Conservative cosmetic procedures; transconjunctival blepharoplasty of the lower eyelids, injection implants; botulinum toxin preparations; superficial and medium chemical peels or (erbium laser dermabrasion; CO2 laser dermabrasion
IIIA	Conservative cosmetic procedures; classical blepharoplasty of the upper and lower eyelids: injection implants; botulinum toxin preparations; mechanical dermabrasion; medium and deep dermabrasion with CO2 or erbium laser
IIIB	Conservative cosmetic procedures; classic plastic surgeries to remove excess skin from the eyelids, face and neck; deep (CO2 laser or mechanical dermabrasion); injectable botulinum toxin preparations.

Preference is given to Botox if the main problem is excessive facial activity and the appearance of expression wrinkles in the forehead, bridge of the nose and corners of the eyes. In this case, the ideal option and the only correct choice will be Botox. Mesotherapy, filling and all other cosmetology options will not give a comparable effect. In some situations (mainly in young patients), only the introduction of botulinum toxin already gives excellent results. If we have not achieved complete smoothing of expression wrinkles due to too pronounced a fold in the skin or the impossibility of introducing a full dose of botulinum toxin, then in such a situation, filling will help to achieve a more perfect effect.

Contour plastic surgery is preferred if the goal is to correct perioral wrinkles, nasolabial folds, and restore the volume of soft tissues of the face (cheeks, cheekbones, chin). For this purpose, it is advisable to use filler preparations first and foremost, and only in some cases to correct perioral folds - Botox, since the introduction of botulinum toxin into this area can lead to articulation disorders, while the introduction of fillers is safe and gives an excellent effect. "Sorrow folds" (running from the corners of the lips to the chin), changes in facial relief, facial contours, drooping corners of the lips - the advantage is for contour plastic surgery, although in some cases the introduction of fillers can be supplemented with the introduction of botulinum toxin. For example, if Botox is supposed to be introduced to correct the glabellar fold or horizontal wrinkles on the forehead, it is worth paying attention to the degree of the initial drooping of the eyelids (it can be expressed due to a certain structure of the eyelids or due to age-related changes). If the overhang is already evident before the procedure, by injecting a large amount of the preparation, we have every chance of increasing it, which can also happen if there is excess tissue in the forehead area. The way out of the situation is to reduce the amount of botulinum toxin injected or to abandon this method, change the scheme of its injection (as high as possible) with additional correction with filler preparations.

In conclusion, it should be emphasized that when performing injection techniques, it is also necessary to adhere to the following rules of interaction with the patient:

1. Before using injection methods, 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 to sign an informed consent for the procedure, in which it is important to reflect the direct subject of the correction and the mechanism of action of the drug, as well as potential risks.
3. The key to mutual understanding between the doctor and the patient is documenting each observation with the help of photography (photographs should be taken before and after the procedure in the same position of the patient and under the same lighting).
4. Each doctor chooses the most comfortable position for the patient during the procedure, but it should be remembered that in a sitting position all folds and wrinkles are better visible 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 to have full knowledge and maximum attention to the patient. The optimal option is a combination of specialization in dermatology, therapeutic cosmetology and training in each of the described methods.

Complications after the procedure

Complications of intradermal injections include allergic dermatitis, localized urticaria, acute superficial and deep pyoderma, activation of herpes infection, foci of necrosis at the injection site. Local necrosis is associated with a hyperergic reaction to the administered agent (agents) according to the Arthus phenomenon. Systemic complications associated with the drug entering the systemic bloodstream (widespread urticaria and Quincke's edema, toxicoderma, exacerbation of atopic dermatitis, bronchial asthma, etc.) are extremely rare.

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