Chemodenervation and Fillers - Board Review

Question 1

From what organism is Botox made?

Answer 1

Purified neurotoxin type A complex produced by fermentation of bacterium Clostridium botulinum type A, Hall strain

Question 2

What is the mechanism of action of Botox?

Answer 2

Inhibits Acetylcholine release at the neuromuscular junction and may inhibit neuropeptide transmitter release. This blocks nerve stimulation of muscular activity and causes muscle paralysis.

Question 3

How long does Botox take to work?

Answer 3

Some reduced muscular activity at 24-48 hours, full effect at 14 days. Clinical effect for rhytids lasts 3-4 months, for hyperhidrosis can last 8-10 months

Question 4

Describe the depressor muscles of the brow.

Answer 4

Corrugator supercilii (transverse and oblique heads), procerus, orbital portion of the orbicularis oculi and associated depressor supercilii muscle medially

Question 5

Describe the elevator muscles of the brow

Answer 5

Frontalis

Question 6

Describe the elevator muscles of the upper eyelid

Answer 6

Levator palpebrae muscle (parasympathetic innervation) and Mueller’s muscle (sympathetic innervation) Both insert onto the tarsal plate.
Frontalis can also elevate lid with dermatochalasis

Question 7

What is the cause of ptosis after Botox? How is it managed?

Answer 7

1. Paralysis of brow elevation in the presence of brow strain compensating for pre-existing lid ptosis
2. Migration of the toxin to the lid retractors
   Managed with alpha-adrenergic agonist drops (eg phenylephrine or iopidine)

Question 8

What is the Mephisto/Spock brow? How is it treated?

Answer 8

Medial brow depression and paralysis with preserved lateral brow function. Treat with small dose to lateral frontalis muscle. Prevent by uniform treatment of the frontalis and conservative treatment of glabella.

Question 9

What muscles are responsible for bunny lines?

Answer 9

Levator labii superioris alaque nasi and nasalis muscles.

Treatment with botox can cause migration into medial orbicularis muscle.

Question 10

What are absolute contraindications for Botox?

Answer 10

Infection at proposed injection site, known hypersensitivity/allergy, pregnancy, patients with neuromuscular disorders (Lambert-Eaton, MG, ALS)

Question 11

What are the relative contraindications?

Answer 11

1. Diseases of neuromuscular transmission
2. Coagulopathy (including therapeutic anticoagulation)
3. Nursing mothers