Botox injections

Because I am a successful professional, I have the means to afford elective surgery. And like Pandora s Box, once I opened the door to (20) anti-aging surgical possibilities, it seems almost impossible to close it again. In 2002, more than 1.1 million Americans had Botox injections—a procedure that erases wrinkles by paralyzing facial muscles. I find myself asking Why not me Is it time to jump on the bandwagon In a competitive culture where looks count, is it almost (25) impractical not to ... 

There are at least two relatively common variants of TD tardive dystonia and tardive akathisia. According to Burke et al. (1982), tardive dystonia involves sustained involuntary twisting movements, generally slow, which may affect the limbs, trunk, neck, or face (p. 1335). The face and neck are by far the most frequently affected areas of the body. Severe deformities of the neck (torticollis) can cause extreme pain and disability. I have seen several cases affecting the orbital muscles of the eyes (blepharospasm) to the degree that the individual s vision was impaired, requiring botulinum (Botox) injections to paralyze the muscles. I have also seen respiratory and abdominal muscles affected in a painful and debilitating manner. 

The nurse in a plastic surgeon s office is discharging a client who had Botox injections. Which discharge instructions should the nurse provide ... 

In addition to mild edema, there can be more side effects to Botox injections. Excessive dosing can cause facial paralysis, and clients can lose the ability to smile, frown, raise the eyebrows, or squint. 

Seven patients with hngual movement disorders were treated with intrahngual Botox injections via a novel superior approach into the genioglossus over 3—72 months [63 ]. All had marked improvement in their abnormal tongue movements with no substantial bleeding or dysphagia. 

Medications. Spasmodic dysphonia negatively affects movement of the vocal folds. Routine botu-linum toxin (Botox) injections are a common treatment for this disorder. These injections temporarily and partially relieve the problems by weakening the laryngeal muscles so that they have partial movement. The injections make it easier for the person to use verbal expression, although the voice may not sound normal. On the negative side, the person has to receive an injection every few months. 

This investigation was sponsored by Sawbones, which is a subsidiary of Pacific Research Laboratories. Sawbones manufactures a product comprised of synthetic facial muscles that mimics the human facial anatomy. This product helps medical students learn how to correctly administer Botox injections to patients faces [1]. This product is made from thermoset polyurethane foam with a sheet of carbon fiber veil imbedded across its axis. Each synthetic muscle has its own carbon fiber layer, and these layers are individually connected to a display. When a specialized probe comes into contact widi the specific muscles, the probe will complete the circuit. The display can detect the completed circuit and can indicate whieh muscle group has been contacted. 

Botox is a toxin produced by the bacterium Clostridium botulinum.When Botox is injected into facial tissues, it is absorbed by the nerve endings of muscle fibers. Nerve transmissions are interrupted and consequently the muscle relaxes. The relaxed muscle is then no longer effective to pull the facial lines to show the wrinkles. 

Glabellar lines (Botox Cosmetic only) Inject IM only. 

Primary axillary hyperhidrosis (Botox only) The recommended dose is 50 units per axilla. Define the hyperhidrotic area to be injected using standard staining techniques (eg. Minor s Iodine-Starch Test). Botulinum toxin type A is reconstituted with 0.9% nonpreserved sterile saline (100 units/4 mL). Using a 30-gauge needle, 50 units of botulinum toxin type A (2 mL) is injected intradermally in 0.1 to 0.2 mL aliquots to each axilla evenly distributed in multiple sites (10 to 15) approximately 1 to 2 cm apart. 

Blepharospasm (Botox only) For blepharospasm, reconstituted botulinum toxin type A is injected using a sterile, 27- to 30-gauge needle without electromyographic guidance. The initial recommended dose is 1.25 to 2.5 units (0.05 to 0.1 mL volume at... 

Strabismus (Botox only) The volume of botulinum toxin type A injected for treatment of strabismus should be between 0.05 to 0.15 mL per muscle. 

Botulinum toxin is used clinically in the treatment of blepharospasm, writer s cramp, spasticities of various origins, and rigidity due to extrapyramidal disorders. It is also used to treat gustatory sweating and cosmetically to decrease facial wrinkles. Botulinum toxin A Botox, Oculinum) injected intramuscularly produces functional denervation that lasts about 3 months. Clinical benefit is seen within 1 to 3 days. Adverse effects range from diplopia and irritation with blepharospasm to muscle weakness with dystonias. 

Surprisingly perhaps, given its extreme toxicity, botulinum toxin was introduced into medical practice in 1983 to treat patients with squint. Since then, its use has been expanded to include other disorders of muscle control suffered by patients with cerebral palsy or after a severe stroke where the brain cannot control the muscles, which may remain permanently contracted. Tiny amounts of the toxin are injected into the affected muscle, which then becomes paralyzed and, so, relaxed. There are several forms of the toxin that are now marketed as "Botox 7 (type A toxin) and Myobloc (type B toxin). More recently, Botox has been used in "cosmetic77 medicine as a way of reducing lines and wrinkles in the face due to aging. 

However, the toxin must be used with great care, and there have been cases of unwanted and long-term effects after its repeated cosmetic use and evidence that botox can move away from the injection site. 

This chapter deals with botulinum toxin type A (BOTOX) in the treatment of strabismus, blepharospasm, and related disorders. Botulinum toxin type A (BOTOX) has been used to treat strabismus, blepharospasm, Meige s syndrome, and spasmodic torticollis. By preventing acetylcholine release at me neuromuscular junction, botulinum toxin A usually causes a temporary paralysis of the locally injected muscles. The variability in duration of paralysis may be related to me rate of developing antibodies to me toxin, upregulation of nicotinic cholinergic postsynaptic receptors, and aberrant regeneration of motor nerve fibers at me neuromuscular junction. Complications related to this toxin include double vision (diplopia) and lid droop (ptosis). 

Figure 4.1 At top, Clostridium botulinum is seen under a microscope, and at bottom is a vial of BoTox for intramuscular injection. BoTox has become a popular alternative to cosmetic surgery for removing wrinkles.

Recently, the extreme potency of botulinum toxin has led to multiple medical uses of this substance, including the treatment of cervical torticollis, strabismus, and other musculoskeletal disorders, as well as in cosmetic plastic surgery as Botox for the elimination of facial lines or wrinkles (Lemonick, 2002). The irreversible action of botulinum toxin on nerve transmission when used in minute amounts leads to prolonged therapeutic effects of greater than 3 months in duration. An iatrogenic form is also reported secondary to adverse effects of local injection of the toxin in cosmetic procedures or in patients with spasticity (Ihgnoli, 2002). 

The diluent of sterile normal saline is drawn up in a syringe and gently injected into the vial containing the Botox. Rapid forceful injection that causes frothing or other mechanical stress is discouraged because this can inactivate the toxin. Table 22-7 gives the recommended dilutions calculated for an injection volume of 0.1 ml. 

Without previous anesthesia and avoiding penetration of the orbital septum, the diluted Botox typically is injected subcutaneously or intramuscularly, using a 27- or 30-gauge needle. The most commonly used dilution is 2.5 units per 0.1 ml of volume at each injection site. In patients with blepharospasm, the initial injection sites should include the medial and lateral pretarsal orbicularis oculi of the upper eyelid and the lateral pretarsal orbicularis oculi of the lower eyelid (Figure 22-16). Patients with hemifecial spasm should receive similar injections to any affected muscles of the lower fece (Figure 22-17). The cumulative dose of Botox in a 30-day period should not exceed 200 units. 

The initial effect of the injections usually occurs within 3 days and is maximal 1 to 2 weeks after treatment. The therapeutic effectiveness of Botox in patients with blepharospasm lasts 6 to 28 weeks, with most patients becoming symptomatic again in approximately 3 months. The average interval between injections is longer in patients with hemifecial spasm, sometimes up to 6 months. With repeated injections the therapeutic interval decreases in some patients but appears to stabilize in most after the fourth or fifth injection. This reduction in efficacy may result from the toxin s binding to the nonactive large protein chain, a resprouting of motor end plates, or the development of an antitoxin. 

Myobloc is available premixed in a clear colorless to light yellow sterile solution. It is available in three dosing volumes 2,500 units/0.5 ml, 5,000 units/1 ml, and 10,000 units/2 ml. It can remain stable under refrigeration for up to 21 months. Myobloc exists at pH 5.6 when in aqueous solution. This relatively acidic pH can cause increased discomfort in patients during injection. Myobloc has been found to have a less complete or shorter duration of muscle paralysis compared with Botox. 

Botulimun toxin is derived from the gram-negative bacterium Clostridium botulinum, an anaerobic rod that is commonly known as the source of an extremely harm-fiil food-borne toxin. Although a number of different serotypes of toxin have been identified, serotype A is used in the commercially available drug Botox, or Oculinum. It is a high-molecular-weight protein that is supplied in a freeze-dried form requiring reconstitution with saline before injection. 

Exhibit 4.8). Botulinum toxin (Botox) is being injected as an anti-wrinkle treatment (Exhibit 11.11), and a vitamin A derivative (Retin-A gel, Tretinoin) is prescribed for the treatment of facial wrinkles. Drugs such as tacrine and donepezil, which work by attacking enzymes that breakdown acetylcholine, have been approved for boosting memory. Sildenafil (Viagra, Pfizer) is used to treat sexual dysfunction (Exhibit 3.15). 

BOTULINUM TOXIN TYPE A (Botox powder for injection)... 

Botulinum toxin (Botox) Human, oral, injection, breathing 1 ng/kg of bw (est.)... 

One of the most popular nonsurgical cosmetic procedures is injections of botulinum toxin (Botox). 

Fortima R, Aiuelio Vaz M, Rehan Youssef A et al. (2011) Changes in contractile properties of muscles receiving repeat injections of botuUnum toxin (Botox). J Biomech 44(l) 39-44... 

There is a growing literature on the use of botu-linum toxin injections for the management of achalasia (Mikaeli et al. 2004) and clearly this needs to be administered under endoscopic control. There is some evidence that balloon dilatation together with Botox improves the symptom free period between procedures. Surgery nowadays should be reserved for patients with failed dilatation or injection therapy. 

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