tox Flashcards
what is the action of botox when injected into the muscle
neurotoxin purified protein derivative of clostridium botulinum bacteria that blocks the release of acetylcholine at the neuromuscular junction. This results temporary reduces muscle contractions and smooths skin wrinkles in the treatment area.
what causes wrinkling to be a prominent feature of skin aging
the skin naturally thins and loses volume over time as collagen, hyaluronic acid, and elastin gradually diminish. this process of dermal atrophy is accelerated and compounded by sun exposure and other extrinsic factors such as smoking, and excessive movement of facial muscles.
what contributes to skin folds and facial contour changes
skin laxity, redistribution of facial fat, and biometric changes such as bone resorption
when was botox first used
in the 80s indicated for blepharospasm and strabismus
when was botox approved for upper face muscles
2002
what are the basic tox treatment areas
the upper third of the face.
frown lines, crows feet, and horizontal forehead lines
what are considered advanced tox treatments
the lower face because this is a highly functioning region and must retain partial functionality and essential function for eating, drinking, speaking, breathing
who will see the most dramatic improvements with tox treatments
patients with dynamic wrinkles that have minimal to no static component
what will the results look like of patients with static wrinkles
slower and cumulative, and may require two to three consecutive treatments for significant improvements
who may not fully respond to tox treatments and need a combination treatment of dermal fillers or resurfacing procedures
people with deep static lines
at what age may require surgical intervention instead of tox treatments
age 65, because they may have severe static wrinkles and laxity
what are the alternative therapies other than botox
for static wrinkles include chemical peels, microdermabrasion, topical retinoids, non ablative lasers, ablative and fractional lasers
what are the contraindications of botox
pregnant or nursing
active infection in treatment area
keloidal scarring
bleeding abnormality
immunocompromised
skin atrophy
active psoriasis/eczema in area
allergy to albumin, lactose, sodium succinate
milk allergy with dysport
gross motor weakness in treatment area
neuromuscular disorder
inability to actively contract muscles in treatment area
periocular or ocular surgery within 6 months
medications such as ahminoglycosides, penicillamine, quinine, calcium channel blockers
how is botox stored
how is botox stored
unopened vials must stay refrigerated as well as when opened. once reconstituted it should be used within 6 weeks
patient friendly terms for
toxin
paralyzes
pain
natural purified protein
relaxes
discomfort
aftercare of tox treatment
avoid lying flat for 4 hrs
no facial massaging or pressure and no activities that will cause facial flushing like heat to face, exercise, alcohol consumption, and tanning
what are the 20 muscles of the face
frontalis
temporalis
procerus
corrugator supercilli
depressor supercilli
orbicularis occuli
nasalis
levator labi superioris alaque nasi
levator labi superioris
zygomaticus minor
zygomaticus major
orbicular oris
modeolus
risorius
platysma
depressor anguli oris
depressor labi inferioris
mentalis
buccinator
masseter
what are the 14 superficial muscles of the face
frontalis
temporalis
procerus
depressor supercilli
orbicularis oculi
nasalis
levator labii superioris alaque nasi
zygomaticus minor
zygomaticus major
orbicularis oris
modeolis
risorius
platysma
depressor anguli oris
what are the 7 deep muscles of the face
corrugator supercilli
levator labii superioris
buccinator
levator anguli oris
masseter
depressor labi inferioris
mentalis
what muscle form horizontal forehead lines
frontalis
what muscle forms frown lines
glabellar complex (procerus, corrugator supercilli, depressor supercilli)
what muscle forms crows feet
orbicular oculi
what muscle forms bunny lines
nasalis
what muscle forms nasolabial folds
levator labii superioris alaque nasi
what muscle forms radial lip lines
orbicularis oris
what muscle forms marionette lines
depressor anguli oris
what muscle forms chin line/orange peel
mentalis
what is the surface anatomy of the face
glabella
nasion
nasal ala
philtral columns
cupids bow
vermillion border
what is the action of the corrugator supercilli
draws eyebrows medially
what is the action of procerus and depressor supercilli
medial eyebrow depressors
what is the action of the frontalis
eyebrow levator
what is the action of the orbicularis oculi
lateral eyebrow depressor
what is the action of the superior orbicularis oculi
superior lateral eyebrow depressor
what is the action of the nasalis
draws nasal sidewalls medially
what is the action of the orbicularis oris
lip puckering
what is the action of the depressor anguli oris
corner of mouth depressor
what is the action of the levator labii superiors alaque nasi
central lip levator
what is the action of the mentalis
chin puckering and lower lip levator
as we get older why do our eyebrows change
the height of our eyebrows can change do to change in frontal fat pads (lowering)
when injecting corrugator supercilli how should we inject
inject deeper medially, getting more superficially as you get to the lateral part of brow
why should you always treat the glabella when treating the frontalis
because if not the frontalis is relaxed when injected and it will give the look of an angry face when brows are not treated
why is the depressor supercilli not directly treated
it is not usually a powerful muscle, but when treating the corrugator supercilli you are also treating the DS.
if the patient is still pulling down with the medial brows even if you think you treated well before, what should you try next
try treating more superficially because the depressor supercilli is above the corrugator supercilli
medial muscle at bridge of nose that pulls the glabella down
procerus
why wouldn’t you treat the procerus with same amount of units on everyone
this muscle is variable because some people have a very meaty procerus and others don’t
what type of dose would someone get with a meaty procerus and downward pull is seen
higher units in procerus than someone who doesn’t seem they pull down from procerus, but instead the corrugators
what muscle runs very close to the surface of the skin around eyes
obicularis oculi
when treating only the lateral canthal lines what may you see
a medial pull under the eye because the outside portion has been relaxed
since the face is like a tug of war, frontalis muscle is pulling up and orbicularis oculi is pulling down, if you relax the OO what do you get
you can get a lift in the brow, can even be a brow treatment for a brow ptoosis
why would you not want to over treat and inject deeply in the orbicularis oculi
the orbicularis oculi is an accessory muscle for cheek elevation, if over treated you could look less genuine. improve technique by injecting more superficially and this will remove the risk of hitting zygomaticus and also do not inject too inferiorly
when injecting the frontalis of a male why would we not treat them like we would a female
men seem to have a taller forehead and they could get “horns” at the top right and left from no treatment higher up
recommended dose for frontalis
12-20 units women
20-25 units for men because muscle strength
recommended dose for glabellar complex
10-24 units women
20-25 units men
recommended dose for crows feet
10 units per side women
10-12 units per side men
recommended dose for lower eyelid
2.5 units total bilateral
typically 0.5 unit each injection
recommended dose for eyebrow lift
5-7 units total bilateral (women)
7-10 units total bilateral (men)
recommended dose for bunny lines
5-10 units total bilateral
recommended dose for lip lines
3.75-5 units total bilateral
recommended dose for gummy smile
2.5 units total bilateral
recommended dose for marionette lines (DAOs)
5 units total bilateral
recommended dose for mentalist (chin)
5 units total
what is the supraorbital ridge
the brow ridge, bony ridge located above the eye socket
what is the lateral limbus line
boundary between the lateral iris and the sclera
what is the orbital rim
outer edges of your eye socket
what is the midpupil line
line directly below pupil when looking straight
what is the lateral canthal line
lateral (outside) corner of eye
what is the nasion
where top of nose starts
what is the nasion-ala line
line on side of nose from nasion to nasion ala
what is the lateral canthal line
invisible line from outside corner of eye directly inferior to jaw
what is the nasolabial fold line
invisible line from nasal ala diagonal to jaw (follows formation of nasolabial fold)
what is the chin circumference
round area of chin with the highest point at the mental crease reaching to the mandibular margin
what is the mandibular margin
chin/ front jaw line
what is the oral commissure lines
invisible line from outside corners of mouth that go inferior to clavicle
safety zone of frown line (11s)
at least 1cm above supraorbital ridge at the lateral limbus line, and extends inferiorly to a point approximately 1cm below glabellar prominence
safety zone of horizontal forehead line
bounded by vertical lines at the lateral limbus line and includes 2cm above supraorbital ridge to the hairline, and small area lateral to vertical lines approximately 2cm inferior to hairline
safety zone of crows feet
1cm outside orbital rim, above the superior margin of zygoma and extends under the eyebrow to the lateral limbus line
safety zone of lower eyelid
medial lower eyelid injection is located mid pupillary line, 0.5cm inferior to eyelid margin
lateral lower eyelid injection is located midway between the first injection and the lateral canthal line 1cm inferior to eyelid margin
safety zone of eyebrow lift
at least 1cm outside the orbital rim, below the supraorbital ridge and lateral to the lateral limbus line
first injection is located 1.5cm lateral to lateral limbus line (near tail) angling injection toward forehead
and second injection is 1cm medial to first injection
safety zone for bunny lines
diamond shaped region with superior point of diamond located at nasion and inferior point located halfway through nasion and nasion tip
the lateral points lie along the nasion ala line
safety zone for lip lines
upper lip= at least 1cm from the lateral corners of the mouth, 0.5cm or less from the vermillion border, and extends to the lateral edge of the philtral column
lower lip= at least 2cm from lateral corners of mouth and is 0.5cm or less from vermillion border
safety zone for gummy smile
while muscle is contracted (big smile) insert needle in the muscle bulge at the uppermost part of the nasolabial fold. angle needle medially and insert half needle length
safety zone for DAOs
at least 1cm anterior to the border of the master muscle, posterior to the marionette line and within 2cm of the mandibular margin
while muscle is contracted, insert needle into muscle, at least 1cm inferior to the corners of the lip, angle needle towards corners of mouth
safety zone for chin
at least 1cm medial to chin circumference and is within 2cm of mandibular margin
inject while muscle is contracted and angle needle towards the lip to tip ends at the chin protuberance
how many injections for mentalis
one for a narrow/ rounded/ pointed chin
two for broad/ square/ cleft chin
where is the mentalist injection located for a narrow/ rounded/ pointed chin
one medial injection
where is the mentalist injection located for a broad/ square/ cleft chin
one point on EACH side of midline
how should bunny lines be injected
while nasals is contracted inject medial to nasal ala line located on side wall. angle needle towards nasal sidewall and insert subdermally, repeat on both sides
the third injection is on dorsal of nose while contracted approach inferiorly angling needle towards dorm of nose and inject
how do you elicit contraction of muscle to be treated for an eyebrow lift (superioris orbicularis oculi)
first check to make sure pt has enough muscle to inject by placing finger beneath this portion of muscle and have patient contract, if visible roll is evident, proceed
have patient blink really hard and hold it and mark spots
insert needle while relaxed
what test should be performed prior to lower eyelid injection
snaptest
pinch skin under eye and let go, if skin recoils immediately the test is normal. if skin recoils longer than 3 seconds the lower lid has insufficient elasticity and should not be performed
how should you inject lower eyelid
two injections usually performed for each eye. one medially and laterally.
medial muscle is placed with muscle at rest and located mid pupillary line 0.5cm inferior to eyelid margin
second injection is placed during muscle contraction between first injection and lateral canthal line 1cm inferiorly to eyelid margin
how should you inject crows feet
instruct pt to smile and mark points, inject middle point first, directly above first injection, and then last injection located below first injection
how should you inject frown lines
inject while pinching muscles, for corrugator muscles inject towards procerus, for procerus inject 90degrees if thick muscle, if not inject inferiorly
