introduction, indication, reconstitution, type, MOA, adverse effects, microbiology

1. BY DR SIDDHI TIWARI
MODERATOR : DR SAROJ PUROHIT

2. HISTORICAL ASPECT
 A German poet, doctor and scientist , Dr. Justinus Kerner
of Wurttemberg, first explained the disease called botulism
(1817 to 1822) caused by ‘sausage poison’.
 Already imagined that the toxin that caused such a serious
disease, could be used to treat diseases like muscular
spasms.
 Dr Emile Pierre van Ermengem (belgium) in 1895
successfully isolated this bacterium, named it Bacillus
botulinus.
 Botulinum toxin was first used to treat human disease
(1980) by Drs Alan Scott (opthalmologist) and Edward
Schantz, in treating strabismus.

3.  In 1987, ophthalmologist Jean Carruthers observed that
frown lines disappeared after the use of botulinum toxin A
for blepharospasm.
 In 1996, they published the first paper on the use of Botox
for cosmetic purposes.
 In 2002, the FDA announced the approval of BOTOX®
Cosmetic to temporarily improve the appearance of
moderate-to-severe frown lines between the eyebrows
(glabellar lines).
 In July 2004, the FDA approved BOTOX® to treat severe
underarm sweating, known as primary axillary
hyperhidrosis, that cannot be managed by topical agents.

4. Microbiology
 Botulinum toxin (BTX or BoNT) is produced by
Clostridium botulinum, a gram-positive anaerobic, spore
forming bacillus.
 BoNT is broken into 7 neurotoxins (labeled as types A, B, C
[C1, C2], D, E, F, and G), which are antigenically and
serologically distinct but structurally similar.
 Type A is the most potent toxin, followed by types B and F
toxin.
 Human botulism is caused mainly by types A, B, E, and
(rarely) F. Types C and D cause toxicity only in animals.

5.  The BoNT molecule is
synthesized as a single
chain (150 kD) and then
cleaved to form the
dichain molecule with a
disulfide bridge.

6.  The light chain (~50 kD) acts as
a zinc (Zn2+) endopeptidase
similar to tetanus toxin with
proteolytic activity located at the
N-terminal end.
 The heavy chain (~100 kD)
provides cholinergic specificity
and is responsible for binding
the toxin to presynaptic
receptors, it also promotes lightchain translocation across the
endosomal membrane.

7. MECHANISM OF ACTION
 Botulinum toxins act at four different sites in the body:
 The neuromuscular junction
 Autonomic ganglia
 Postganglionic parasympathetic nerve endings
 Postganglionic sympathetic nerve endings that release
acetylcholine.

8. 
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Release of acetylcholine at the
neuromuscular junction is
mediated by the assembly of a
synaptic fusion complex.
Allows the membrane of the
synaptic vesicle containing
acetylcholine to fuse with the
neuronal cell membrane.
The synaptic fusion complex is a
set of SNARE proteins, which
include synaptobrevin, SNAP-25,
and syntaxin.
After membrane fusion,
acetylcholine is released into the
synaptic cleft and then bound by
receptors on the muscle cell.

9. 
Botulinum toxin binds to the
neuronal cell membrane at the
nerve terminus and enters the
neuron by endocytosis.
 The light chain of botulinum
toxin cleaves specific sites on the
SNARE proteins, preventing
complete assembly of the
synaptic fusion complex thereby
blocking acetylcholine release.
 Botulinum toxins
- types B, D, F, and G cleave
synaptobrevin
-types A, C, and E cleave SNAP-25
-type C cleaves syntaxin.
 Without acetylcholine release,
the muscle is unable to contract.

10.  Induces weakness of striated muscles by inhibiting
transmission of alpha motor neurones at the
neuromuscular junction. This has led to its use in
conditions with muscular overactivity, such as dystonia.
 Transmission is also inhibited at gamma neurones in
muscle spindles, which may alter reflex overactivity.
 Also inhibits release of acetylcholine in all parasympathetic
and cholinergic postganglionic sympathetic neurons. This
has generated interest in its use as a treatment for
overactive smooth muscles (for eg, achalasia) or abnormal
activity of glands (for eg, hyperhidrosis).

11.  The toxin requires 24-72 hours to take effect, reflecting
the time necessary to disrupt the synaptosomal
process. In very rare circumstances, some individuals
may require as many as five days for the full effect to be
observed. Peaking at about 10 days, the effect of
botulinum toxin lasts nearly 8-12 weeks.

12. PREPARATION
 Serotype A is the only commercially available form of botulinum toxin
for clinical use, although experience is emerging with development of
other serotypes B, C, and F .
 The products and their approved indications include the following:
 OnabotulinumtoxinA (Botox, Botox Cosmetic)
 Botox - Cervical dystonia, severe primary axillary hyperhidrosis,
strabismus, blepharospasm, neurogenic detrusor overactivity, chronic
migraine, upper limb spasticity
 Botox Cosmetic - Moderate-to-severe glabellar lines
 AbobotulinumtoxinA (Dysport) - Cervical dystonia, moderate-to-
severe glabellar lines
 IncobotulinumtoxinA (Xeomin) - Cervical dystonia, blepharospasm
 Rimabotulinumtoxin B (Myobloc) - Cervical dystonia

15.  The potency of BoNT-A is measured in mouse units
(MU). One MU of BoNT-A is equivalent to the amount
of toxin that kills 50% of a group of 20 g Swiss-Webster
mice within 3 days of intraperitoneal injection (LD50).
 According to one report, 1 nanogram of toxin contains
approximately 20 U of BOTOX® (ie, 1 U of BOTOX® is
equal to approximately 0.05 nanogram of the toxin).
 One unit of BOTOX® has a potency that is
approximately equal to 4 unit of Dysport®.
 one unit of Xeomin® is equal to 1 unit of Botox®

16. DERMATOLOGICAL INDICATIONS
AESTHETIC INDICATIONS
 Botox® is indicated for all wrinkles produced due to persistent
muscular contractions. These include
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horizontal forehead lines
glabellar lines and vertical frown lines
crow's feet
bunny lines
marionette lines
dimpled chin
platysmal bands.
 Dynamic wrinkles respond better than fixed wrinkles.
NON AESTHETIC INDICATIONS
 Localized axillary or palmar hyperhidrosis that is nonresponsive
to topical or systemic treatment.

19. THERAPEUTIC USES
 Cosmetic use
 Hyperkinetic facial lines (glabellar
frown lines, crow's feet)
 Hypertrophic platysma muscle
bands
 Sweating, salivary, and allergy disorders
 Axillary and palmar hyperhidrosis
 Frey syndrome, also known as
auriculotemporal syndrome
(gustatory sweating of the cheek
after parotid surgery)
 Drooling in cerebral palsy and other
neurological disorders
 Nasal allergy
 Strabismus and nystagmus
 Smooth muscle hyperactive disorders
 Neurogenic bladder – Detrusor
hyperreflexia, BPH
 Achalasia cardia
 Hemorhoids, Chronic anal fissures
 Focal dystonias - Involuntary, sustained,
or spasmodic patterned muscle activity
 Cervical dystonia (spasmodic
torticollis)[3, 4]
 Blepharospasm (eyelid closure)
 Laryngeal, Limb, Oromandibular,
Orolingual, Truncal dystonia
 Spasticity
 Nondystonic disorders of involuntary
muscle activity
 Hemifacial spasm, trismus
 Tremors, tics, myoclonus.
 Chronic pain and disorders of localized
muscle spasms
 Chronic low back pain
 Tension headache
 Chronic migrane headache
 Medication overuse headache
 Lateral epicondylitis
 Knee, Shoulder,Neuropathic pain

20. CONTRAINDICATIONS
1.
2.
3.
4.
Patients afflicted with a preexisting motor neuron disease,
myasthenia gravis, Eaton-Lambert syndrome, neuropathies,
psychological unstability.
History of reaction to toxin or albumin.
Pregnancy and lactating females.
Infection at the injection site.
RELATIVE CONTRAINDICATIONS
 Some medications decrease neuromuscular transmission, generally
should be avoided in patients treated with botulinum toxin. Includes
 aminoglycosides (may increase effect of botulinum toxin)
 penicillamine, quinine, chloroquine and hydroxychloroquine (may
reduce effect)
 calcium channel blockers, and blood thining agents eg. warfarin or
aspirin (may result in bruising).

21. Preoperative Counseling and Informed Consent
 Detailed counseling with respect to the treatment,
desired effects, and longevity of the results should be
discussed .
 A detailed consent form needs to be completed by the
patient. Should include the type of botulinum toxin,
longevity expected, need for repeated treatments and
possible postoperative complications.
 Preoperative photography is mandatory.

22. Reconstitution and Handling
1.
2.
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5.
Follow all usual precautions of sterility and skin preparation before injection.
Seat the patient with chin down and head slightly lower than the physician's.
Plastic single use insulin syringes with 30-32 gauge needles are recommended, and
toxin is injected into affected muscles or glands
Topical anesthetics are generally reserved for the very sensitive. Ice could be used as a
numbing agent.
Doses are tailored according to the mode of use and individual patients, and the dose
depends on the mass of muscle being injected: The larger the muscle mass the higher
the dose required.

23. Electromyograph monitoring
 Administer injections under the guidance of electromyograph
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(EMG) monitoring.
Technique involves using a 27-gauge (1.5 in) polytef-coated EMG
needle connected to an EMG recorder by an alligator clip on its
shaft.
The patient is asked to contract the muscle in question. The
injection is placed where the maximal EMG recording can be
found within the muscle.
This technique ensures that the injection is at the point of the
muscle that is contributing most to the hyperfunctional facial
line. As these injections have become routine,.
EMG-guided injections remain a useful adjunct in patients who
have residual function after their initial injection.

24. The Glabellar Complex and Vertical Frown Lines
 Glabella lines are created by the action of 3
muscles:
 the corrugator supercilli;
 the procerus;
 and the depressor superciliis.
 Before initiating the treatment,
 Assess facial expression at rest and
during animation.
 Evaluate the range of motion of
involved muscles.
 Palpate muscles during repose and
contraction.
 Assess brow position
 Injections given into the corrugator (red and
blue circles) and procerus (green circle)
muscles.
 Caution :

Avoid injecting too low over the
orbit.

Use caution with lateral brow
injections; stay well above the
superior orbital rim.

Do not completely paralyze the
muscles.

25. The 52-year-old female patient, frowning in both photos, as she looked before and 32 days after
treatment

26. Horizontal Forehead Lines
 Muscle : frontalis
 The treatment goal is to achieve a
balance between brow elevation with
forehead smoothing.
 Before initiating the treatment,
 evaluate the patient's anatomy for
expressivity, muscle mass, symmetry,
lateral v/s medial movement,
compensation for brow ptosis, and a
narrow or wide brow.
 injection given at blue circles and
optional red Xs.
 Caution :
 Less experienced injectors of
botulinum toxin type A should stay at
least 2 cm above the brow.
 Ensure that injection sites are lateral
enough to avoid a quizzical eyebrow
appearance.

27. The patient is seen rest before and 33 days after treatment. forehead lines are fairly effaced and she now has
decent brow position.
The same patient is shown with raised eyebrows before and 33 days after treatment.
The patient has relatively normal brow position, and softening of rhytids without dropping of the brows.

28. Crow's Feet
 Contraction of orbicularis oculi muscle.
 The treatment goal is reducing dynamic rhytides
and softening static rhytides.
 Before initiating the treatment,
 Determine the source of the wrinkles - the
orbicularis oculi vs zygomaticus major.
 Assess while the patient animates and while
he is at rest.
 "snap test" to measure skin laxity along the
lower lid margin.
 Injection given in each of the 3 blue circles
(photo) on each side and the red X’s.
 Caution :
 Treat around the lower third of the canthal
area with caution.
 Avoid the area below the zygomatic arch
and the zygomaticus major muscle.
Injection into this area has the potential to
cause lip and cheek ptosis.
 Avoid veins, and treating patients who have
a history of dry eyes.
 Keep injections superficial; use intradermal
or subdermal blebs with the needle oriented
away from the orbit

29. Patient depicted 17 days after treatment for crow's feet. Smiling without crow's feet wrinkles.

30. Bunny Lines
 Contraction in the transverse portion of the
nasalis.
 The treatment goal is to soften the bunny lines
on smiling.
 Before initiating the treatment,
 Patients should be asked to laugh, sniff, and
to squint intensely, only become evident
when smiling at maximum contraction.
 Injections given into the two blue circles.
Sometimes an additional dorsal injection is
required.
 Caution :
 Avoid injecting in the levator labii alaeque
nasi and the levator labii superioris to
prevent drooping of the upper lip.
 Do not massage vigorously or in a
downward direction, could result in lip
ptosis.
 Keep injections superficial in this
vascularized area to avoid bruising.

31. The patient shown 17 days after treatment for bunny lines, with good result. Patient expression
alternates from rest to "scrunching."

32. Dimpled Chin (Peau D'orange)
 Contraction of the mentalis : causes a
"cobblestone" appearance of the skin and possible
deepening of the mentolabial crease.
 Treatment goal is to reduce the chin dimpling
which adds to the rejuvination of lower face.
 Before initiating treatment,
 Patient asked to animate which brings out the
wrinkles.
 Typical treatment is via 1 central or 2 lateral
injections, about one half to 1 cm above the chin
(blue ovals) Injections should be kept at least 1 cm
from the lower lip.
 Caution:
 Avoid injecting the toxin too high, which can
affect the orbicularis oris and cause lower lip
incompetence and possibly, drooling.
 Avoid injection in the depressor labii, which
can cause the lower lip to depress.
 Do not treat the case of dimpled chin who
have hypertrophied mentalis.

33. The patient is shown alternating from rest to full expression 17 days after treatment of the chin.
After treatment she is seen unable to flex her mentalis and cause a dimpled chin as she could before
treatment.

34. Platysmal bands
 Occur due to diastasis of the midline platysmal
muscle and loss of submental fat, give the
appearance of turkey neck.
 The treatment aim is to Reducing vertical bands
that appear when the patient contracts the
platysma.
 Treated via a series of superficial/intradermal
injections directly into the contracted muscular
band. The number of injection points depends on
length of each band.
 Grasping the band with the non-injecting hand
might be helpful while injecting very superficially
in the contracted muscle.
 Caution :
 Use caution to avoid dysphagia, dysphonia,
and neck weakness; the strap muscles should
be avoided.
 Platysmal band injections do not substitute
for surgical procedures and will not correct
skin laxity and fat deposits. So patients
should be counselled to have realistic
expectations.

35. The patient shown in full expression before and 17 days after treatment. Anterior vertical bands
have disappeared.

36. Marionette Lines/ Depressed anguli oris (DOA)
 Contraction of the depressor anguli oris or
DAO. Deep marionette lines give the
impression of being unhappy.
 The aim of treatment is to reduce the
muscular strength of the DAO and the
fibers of the platysma and thereby induce
a lift of the corners of the mouth while the
patient is at rest.
 Typically treated via 1 injection point into
the posterior aspect of each DAO.
Injections should be at least 1 cm lateral to
the mouth corner to avoid adverse
outcomes. A second injection site may be
added laterally to target the platysma.
 Caution:
 Avoid unintended placement of
neurotoxin in the depressor labii
inferioris.
 Titrating the dose, starting with a low
dose and titrating up, is advised.

37. The patient is shown in the photo, in full expression, 28 days after treatment to her DAO.
Neurotoxin treatment effectively softens marionette lines.

38. Botulinum Toxin in the Treatment of
Hyperhidrosis
 Selective, focal chemodenervation may be achieved by injecting
botulinum toxin intradermally to combat localized, but severe
sweating in areas such as the palms, soles and axillae.
 Unlike sympathectomy, which renders > 20% of the body
surface anhidrotic, thereby triggering compensatory sweating,
treatment with botulinum toxin does not precipitate
hyperhidrosis elsewhere as the total body surface area treated is
< 3%.
 The extent of excessive sweating can be documented by
employing the simple starch-iodine test. This should be carried
out prior to regional nerve blocks or the use of topical
anesthetics. The test can also help determine the approximate
amount of the drug needed.

39. INJECTION TECHNIQUE
 The bevel should face upwards as the needle penetrates the
skin almost parallel to it, and is then advanced for about 2
mm before injecting intradermally.
 The thumb is taken off the syringe plunger for a second or
two before withdrawal.
 These measures help prevent backflow of botulinum toxin
and its wastage.
 Avoid subcutaneous injections to prevent diffusion into
intrinsic muscles of the palms and soles or beyond the
targeted glands in the axillae.

40.  Key considerations
Palms and soles:
 Injections are placed about 1.5 cm apart. The total dose is dependent on the surface area
and may range from 50-150 units per palm. Doses on the soles exceed those on the palms.
 A small zone of visible blanching attests to the deep dermal placement.
 Duration of effect varies from 3-12 months.
Axillae:
 Injections are placed between 1.5 and 2.5 cm apart in 10-20 sites totaling approximately
50 units per axilla.
 Tiny intradermal wheals are raised beginning at the periphery of the hair-bearing skin
and circling into the center of the axillary vault.
 Response times for duration of anhidrosis in the axillae range from 4-10 months.

42. Precautions after botulinum toxin injection
 Pt. should be instructed to contract the injected area for
approximately 90 minutes to two hours, which will help in
the uptake of the toxin.
 Avoid bending for a few hours after treatment to avoid
potential diffusion.
 One should go home immediately and rest after Botox®.Do
nothing strenuous for one or two days.
 Refrain from laser/IPL treatments, facials and facial
massage for one to two weeks after injections. This is to
minimize toxins dislodging and traveling (due to increased
blood circulation or direct pressure) to the surrounding
muscles.

43. Therapeutic failure
 Some patients do not respond to injections and, having
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never previously responded, are designated as primary
nonresponders.
Patients with rhytids that are not dynamic in origin (eg,
photodamage, age-related changes) do not respond.
Improper injection technique or the denatured toxin may
also result into therapeutic failure
Some patients may have neutralizing antibodies from prior
subclinical exposure, or individual variations in docking
proteins may exist
Secondary nonresponders respond initially but lose the
response on subsequent injections. Most of these patients
may have developed neutralizing antibodies.

44. ADVERSE EVENTS

Sequelae that can occur at any site include pain, edema, erythema, ecchymosis, injection site pain,
and short-term hypersthesia.
 Generalised reactions including nausea, malaise, flu-like symptoms and cutaneous eruptions may
result from diffusion of neurotoxin into the systemic circulation, and are treated supportively based
on symptoms. Systemic reactions are considered hypersensitivity to BoNT or one of the components
(i.e. albumin or lactose) in the suspension.
 Headaches were the most frequently reported adverse event in the initial trials of BoNTA-ONA for
the treatment of glabellar lines, it is most likely a result of the injection technique and not the drug
itself.
Glabellar Region
 The most common complication in the treatment of the glabellar complex is ptosis of the upper
eyelid.
 injections placed at or under the middle part between the eyebrows in the region of the midpupillary
line. Caused by diffusion of the toxin through the orbital septum, where it affects the upper eyelid
levator muscle.
 Occur as early as 48 hours or as late as 7-10 days following injection and can persist for 2-4 weeks.
 T/t : alpha-adrenergic agonists, apraclonidine 0.5% and phenylephrine hydrochloride (2.5%)
eyedrops. The treatment is symptomatic and 1-2 drops three times a day must be continued until
ptosis resolves.

45. Forehead
 The most significant complication of treatment of the frontalis is brow ptosis.
 Results from overaggressive treatment with injections being placed too low on the
forehead or from poor patient selection.
 Treatment of the brow depressors (glabellar complex) can elevate the brow from 1-2 mm.
Be conservative while treating forehead expression lines.
Crow's Feet
 Complications in this area are bruising, diplopia, ectropion or a drooping lateral lower
eyelid and an asymmetric smile caused by injection of the zygomaticus major.
Lower face and neck
 An asymmetric smile, lip ptosis, cheek bite or incompetence of the mouth manifesting as
drooling or dribbling, are potential complications resulting from the use of botulinum
toxin in the treatment of the complex musculature of the lower face.
 Platysmal injections in large doses to treat prominent vertical bands and horizontal neck
lines, may cause weakness of the neck flexors and dysphagia.
Palmo-plantar hyperhydrosis
 Temporary hand weakness and reduction in fine motor skills which can last several
weeks; thus, injection sites should be spaced appropriately and injections should be
placed superficially.

46. TOPICAL BTX
BoNTA cream based on commercially viable ionic
nanoparticle technology. ( FDA approved in 2008)
Other formulations are under development.
Advantages over conventional injections :
 eliminate the need for multiple traumatic injections for
better comfort
 self administration
 cause only a mild weakening; therefore, it is potentially
safer for use in the areas where muscles are highly
sensitive to smaller doses of the toxin.

47. 
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Aesthetic Plast Surg. 2008 Sep;32(5):715-22; discussion 723. doi: 10.1007/s00266-008-9151-9. Epub 2008
May 15.
Novel topical BoNTA (CosmeTox, toxin type A) cream used to treat hyperfunctional wrinkles
of the face, mouth, and neck.
Chajchir I, Modi P, Chajchir A.
Abstract
BACKGROUND:
This study aimed to compare the effect of the stabilized novel topical botulinum neurotoxin type A
(BoNTA) cream (CosmeTox) and a placebo cream on subjects, to compare clinician-reported
outcomes, and to assess the safety and utility of the novel topical BoNTA cream for treating the entire
upper face, chin, and neck areas.
METHODS:
This study randomized 40 female subjects to receive either topical BoNTA (CosmeTox) cream (2
U/ml) or an identical placebo cream (without BoNTA) on the face, chin, and neck areas. The subjects
were followed for 12 weeks. The main outcome measures were the Facial Line Outcomes
questionnaire scores and results from the Self-Perception of Age instrument, which assesses age of
appearance relative to actual age.
RESULTS:
The BoNTA topical cream (CosmeTox) treatment produced significant improvements in the Facial
Lines Outcome scores, which were maintained throughout the study period and lasted more than 3
months. The BoNTA topical cream treatment also reduced the age of appearance for a majority of
subjects. The placebo had no effect on any measure. No serious adverse events occurred during the
entire study period.
CONCLUSION:
Topical treatment with the stabilized BoNTA cream (CosmeTox) to the entire upper facial lines
resulted in significantly improved facial features and age appearance, as measured by the subjects and
clinicians. The BoNTA cream (CosmeTox) resulted in a significantly younger, more satisfying, relaxed
appearance.

48. THANKS