Botulinum toxins Flashcards
Botulinum toxin is a neurotoxin produced by Clostridium botulinum, a Gram-positive anaerobic bacterium.
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Botulinum toxin binds to the cholinergic receptors, enabling acetylchloline release, which prevents muscular contraction of the affected muscles.
F Blocks acetylcholine release.
Botox and Dysport are type B botulinum toxins.
F Type A.
The duration of botulinum toxin-B is shorter than toxin-A.
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Botulinum toxin binds selectively and reversibly to cholinergic nerve terminals, mediated by its heavy chain.
F Binds irreversibly.
The light chain of botulinium is specific for cholinergic action and promotes the light chain translocation through the endosomal membrane
F Heavy chain
Once inside the cytoplasm, the botulinum toxin light chain blocks the release of Ach.
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Botulinum toxin inhibits sweat production by blocking ACH release in the autonomous cholinergic fibres from sympathetic fibres of the sweat glands.
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Dynamic wrinkles are those caused or aggravated by muscular contraction, whereas static wrinkles are apparent even if facial muscles are relaxed.
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Initially, the dynamic wrinkles on the forehead appear parallel to the direction of the muscle fibres, and become static over time.
F Perpendicular rather than parallel.
Within the mid face, ageing changes are due to remodelling of the osseous and cartilaginous structures, loss of elasticity and of subcutaneous tissues, as well as muscle relaxation.
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In the lower face, muscular hyperactivity and volumetric losses of the mandibular region and adipose tissue contribute to ageing.
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Ageing in the lower face is characterised by vertical lip stretching, upward oral commissures, and increase in the distance between the columella and vermillion border.
F Horizontal lip stretching, downward oral commissures.
With regards to ageing in the lower face, this is characterised by loss of lip thickness, perioral wrinkles, marionette lines and dimpled or peau d’orange chin.
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The main manifestations of neck ageing are horizontal bands of platysma muscle, as well as vertical wrinkles, deposits of subcutaneous fat, and skin alterations related to photodamage.
F Vertical bands of platysma muscle, horizontal wrinkles.
Platysma bands are determined mainly by muscular hyperkinetic activity and are not treatable by BT-A.
F Are treatable by BT-A.
The muscular effects of BT usually appear from 24-72 hours after injection, reaching a maximum around 2 weeks.
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The muscular effects of BT last 6-9 months.
F 4-6 months.
The anhidrotic effects of BT last 4-6 months.
F 6-9 months.
Repeated treatments with BT-A have been proven to be safe and effective.
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Repeated treatments with BT-A produce cumulative changes to the innervation pattern and cumulative histological changes affecting some muscles more than others.
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Nerve regeneration does not always occur after BT-A injections, therefore chronic denervation and muscular atrophy can persist after repeated BT-A injections.
F Some degree of nerve regeneration always occurs. Chronic denervation and muscular atrophy don’t persist.
Muscular tonus recovery can be allowed in the intervals between injections by selecting the correct dose and respecting the recommended intervals between injections.
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Neurological patients using BT-A are not more prone to develop antibodies.
F Are more prone.
In order to avoid antibody formation, you should use the lowest effective dose and avoid repeating injections at less than 12-week intervals.
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The commercially used BT-A products come in a lyophilized state.
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Reconstitution of BT-A should be done 24 hours prior to use with sterile water, with or without preservatives.
F Immediately prior to use with 0.9% sterile saline solution.
Preservatives contained in reconstituted BT-A do not interfere with its results.
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Preservatives may allow less painful injections, longer storage period after reconstitution and reduced risk of bacterial contamination.
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It is recommended that bubble formation is avoided during reconstitution of BT-A.
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According to manufacturers, BT-A should be used within 2 days after reconstitution.
F Within first hours after reconstitution.
Studies conducted with Botox and Dysport have shown that they are effective and safe for use over 2 to 6 weeks after reconstitution.
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Botox and Dysport should be stored in a refrigerator prior to and after their reconstitution.
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It is safe to freeze BT-A after dilution.
F
Treatment with BoNT-A must be repeated every 3-6months in order the maintain results
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Patients are instructed not to lie down, manipulate the treated area or pratice physical activity upto 6 hours after the injections
F 4 hours
A sauna is highly recommended on the day of treatment
F
BT in contraindicated in neuromuscular disease, such as myasthenia gravis, Eaton-Lambert syndrome, Bell’s paralysis and peripheral neuropathy.
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BT is pregnancy category D.
F B3
BT is contraindicated with concomitant usage of medications such as quinine, calcium channel blockers, penicillamine, aminoglycosides and NSAIDs.
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Relative contraindications for BT include blood coagulation disorders and previous infections or trauma in the treatment area.
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Patient with unrealistic/high expectations or questionable reasons for treatment should be treated with BT.
F
Relative contraindications for treatment include psychiatric disorders such as psychosis, mania, severe depression, or body dysmorphic disorder.
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BT improves dynamic wrinkles and offers better results in the lower face.
F Upper face.
Wrinkles may persist after treatment either because they are static and deep and will not fully respond to BT.
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Written informed consent is not necessary for patients being treated with BT.
F
Patients should lie down and manipulate the treated area after BT injections in order to increase their effectiveness.
F Should avoid doing these things.
Patients should not practice physical activity for up to 4 hours after BT injections.
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Make-up does not need to be removed prior to BT injections.
F
Topical anaesthetics, cold air or ice compresses should not be used prior to BT injections.
F
BT injections should be symmetrical not only in relation to the areas treated, but also to the doses applied, except in cases of asymmetry.
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BT injections for the prevention of dynamic wrinkles should be placed deeply.
F Should be superficial.
Reconstitution of low volumes is preferable for BT, allowing a larger concentration of the product and injections of smaller volumes, allowing a more precise technique, decreasing the risk of complications, and increasing the duration of some effects.
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The dilution needed to achieve equivalence between Botox and Dysport is 1:3U.
F I:2U
Wrinkles on the upper third of the face represent the classical indications for BT usage, especially for the glabella.
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Glabellar lines (‘frown lines’) are mainly due to the elevating action of the procerus and corrugator muscles.
F Depressing action of these muscles.
For the treatment of glabellar frown lines, BT-A should be injected approximately 1cm above the orbital rim.
T The needle must be placed perpendicularly and pushed slowly upwards toward the hairline
Two finger palpation should be used for injection of the glabellar muscles since this minimizes the occurance of side-effects, especially eyelid ptosis
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The usual recommended dose for treatment of the glabella is 50U of Botox.
F 20U
At least four central injection sites are essential for the treatment of glabellar wrinkles.
F Three.
The usual recommended dose for treatment of the periorbicular or crow’s feet wrinkles is 24U of Botox.
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The usual recommended dose for treatment of the forehead is 35U.
F 15U.
The usual recommended dose for treatment of nasal tip droop is 10U. .
F 2U
The usual recommended dose for treatment of a gingival smile with Botox is 4U.
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The usual recommended dose for treatment of the neck with Botox is 40U.
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The usual recommended dose for treatment of palmar hyperhidrosis with Botox is 200U.
F 100U.
The usual recommended dose for treatment of axillary hyperhidrosis with Botox is 100U.
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The usual recommended dose for treatment of plantar hyperhidrosis with Botox is 100U.
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Periorbicular wrinkles (‘crow’s feet wrinkles’) are radial lines mainly caused by hyperactivity of the frontalis muscle.
F Hyperactivity of the orbital portion of the orbicularis oculi muscle.
For the treatment of periorbicular wrinkles, BT injections should be a minimum distance of 1cm from the lateral orbital margin.
T To avoid complications, such as dipolpia
The thin wrinkles in the lower eyelid should not be treated with BT.
F They can be treated with intradermal injections of 2U Botox in the midpupillary line, 3mm from the lower ciliary border.
Contraction of the frontalis muscle results in the horizontal forehead lines.
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For BT injection of the forehead, usually 5-10 points are used, depending on whether it is decided to treat the forehead completely or partially.
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The points for BT injection of the forehead should only be distributed in a horizontal line.
F Can also be distributed in a ‘V’.
All injections for the forehead should be made from 3-4cm above the orbital rim, in order to avoid eyebrow ptosis.
F 1-2cm.
Low BT doses should be used in the mid and lower face in order to achieve the desired partial relaxation of the muscles, instead of paralysis.
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Low BT-A doses are used in the transversal areas of the nasal bone in order to treat nasal wrinkles (‘bunny lines’)
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The injection for the treatment of nasal wrinkles should be in the low lateral nasal wall.
F High lateral nasal wall.
The injection for the treatment of nasal wrinkles should be below the angular vein.
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The injection for the treatment of nasal wrinkles should be near the nasofacial groove.
F Should avoid this area in order to prevent relaxation of the levator labii superioris muscle, which may lead to ptosis of the upper lip.
Repeated nasal flare can be treated with BT-A injections on each side in the lower nasal fibres above the lateral nasal ala.
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Nasal tip droop can be treated with BT injections at the base of the columella.
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The depressor septi nasi is a small muscle located in the external inferior base of the nasal septum.
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Gingival smile is characterised by the exposure of more than 5mm of upper gum when the patient smiles.
F More than 2mm.
Gingival smile is caused by the contraction of the levator labii superioris muscle.
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Injections of BT-A on each side of the levator labii superioris alaeque nasi muscle applied in each nasofacial groove will prevent nasal tip drop.
F Prevents gingival smile.
Perioral wrinkles (‘smokers’ lines’) are due to the combined action of the orbicularis muscle with photodamage, intrinsic ageing, and hereditary factors.
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Injections of BT-A for the treatment of perioral wrinkles can be made at the vermillion border or up to 1cm from the border.
F Up to 5mm from the border.
It is recommended that BT-A injections be made at the corner of the mouth in order to completely treat perioral wrinkles.
F This should be avoided – may lead to undesirable relaxation of the depressor anguli oris muscle, zygomaticus major muscle, and risorius muscle.
The corners of the mouth are permanently turned down by the action of the depressor anguli oris muscle.
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BT-A can be injected directly above the mandibular angle, along its rim, and 1cm lateral to the oral commissure bilaterally to treat marionette lines.
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It is not possible to treat a dimpled or ‘cellulitic’ chin (peau d’orange) with BT-A. This should be treated with fillers.
F BT can be injected bilaterally at the most distal point of the mentalis muscle at the prominence of the chin.
A face lift can be performed by treating platysma muscle fibres along the lateral mandibular border with BT-A.
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It is recommended for BT injections to start with small but effective doses, and in subsequent treatments, to increase the dose and points of injection, allowing patients some time to adapt to new muscular movements.
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Fractionated and repeated injections are preferable to over-dosing with BT.
F Should avoid this to prevent antibody production.
Wrinkles of the anterior mid-chest in some patients may result from the action of the medial fibres of the pectoralis major muscle and the tail portion of the platysma muscle.
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Involvement of the pectoralis major muscle in causing wrinkles of the chest can be investigated by palpation while having the patient stand with their arms at the side.
F Patient should cross their arms.
Chest wrinkles can be treated with BT injections in a ‘V’ shape.
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Fillers should not be used in conjunction with BT injections.
F
BT-A should be administered 1 month prior to the injection of fillers.
F 1 week prior or in same session.
Combined use of BT and fillers has no effect on treatment duration.
F Combined use extends the life of fillers.
Hyaluronic acid and collagen are the main fillers used in association with BT-A.
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Non-ablative laser and IPL can be used immediately following BT-A injections, without interfering in the results from BT-A.
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BT-A injections for hyperhidrosis act at the nervous synapse, inhibiting ACh release and cause hypo- or anhidrosis in the treated areas for 6-8 months, or longer.
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A potential side effect of BT injections for hyperhidrosis is compensatory hyperhidrosis.
F
A potential side effect of BT injections for hyperhidrosis is secondary reversible muscular paralysis.
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BT touch ups can be done after 15-30 days to optimise the results.
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The most frequent reported side effects of BT injections are the absence of effect, reaction at the injection site and ptosis.
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The most feared complication of BT injections in the lower eyelids is ptosis, which may occur due to the diffusion of BT into the orbital septum.
F This is true for upper eyelids.
BT injections in the upper eyelids can cause ectropion, entropion, damage to the ciliary ganglion caused by Adie’s pupil, and more evident skin laxity or bulging of the eyes.
F This is true for lower eyelids.
Diplopia or double vision can occur when BT injections are close to the ocular globe, or when there is diffusion of the toxin into the orbit, with consequent paralysis of the superior oblique muscle.
F Paralysis of lateral rectus muscle.
The ‘Botox sign’ refers to the appearance or aggravation of nasal wrinkles seen in patients that receive BT into the glabella and/or periorbital area, as the nasalis muscle is more often recruited when the lateral part of the orbicularis oculi muscle is relaxed.
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Brow ptosis may occur following BT treatment of forehead wrinkles when high doses of BT-A are used, or when the forehead musculature is completely paralysed, leading to a ‘masked face’.
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In the upper face, high doses of BT-A may cause unwanted paralysis of the muscles related to the perioral area, causing difficulty in articulating words and incompetence of mouth functions.
F In mid and lower face.
In the mid and lower face, injections into inappropriate points may compromise the zygomatic major and levator labii superioris muscle, causing ptosis of the upper lip and the corners of the mouth, difficulties in mouth movements, and asymmetry.
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In the neck, high doses of BT-A may result in reduced muscular strength during abduction and medial rotation of the upper limbs.
F This is true for injections in the anterior chest.
In the neck, the most common complications are dysphagia and difficulty in flexing the neck.
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In cases where very high doses are used, BT injections in the anterior chest may result in difficulty in breathing deeply.
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