Botox Training Courses, dermal filler, PDO threads courses

1. Foundation Botox training course

2. Your journey  Foundation botox course – gives you the basic knowledge and skills to start up in the new aesthetic industry  Advanced – further training in advanced injectable aesthetic technique  One2one workshops

3. Overview  Signs of facial ageing  Principles of botulinum toxin  Indications  Contraindications  Injection sites and techniques  Complications

4. Signs of Facial Ageing  Active lines  Volume lost  Skin quality  Sagging

5. Skin anatomy During the aging process, there is an ongoing loss of collagen and elasticity in the skin, resulting in the skin becoming lax. Collagen loss causes tissue atrophy and thinning of the skin, with increased rhytid (wrinkle) formation.

6. Skin anatomy The skin is made up broadly of 3 layers: - Epidermis - Dermis - Subcutis

7. The ageing face There are two types of wrinkles: dynamic wrinkles and static wrinkles. The dynamic wrinkle is caused by animation or muscle function. They disappear when the patient relaxes. Static wrinkles are seen at rest, even on relaxation of the muscle.

8. The ageing face Over many years the changes in skin laxity lead to loss of the volume and curves of the cheeks, resulting in bony contours. Tissue descent also causes increased nasolabial and labiomandibular folds

9. The ageing face Loss of the underlying fat causes descent of the overlying structures in the ageing face. This occurs most predominantly in the following areas;

10. Facial map

11. Pharmacology  Neurotoxin produced by bacterium clostridium botulinum  Present in some food and water  Infections cause botulism  Type A – Botox, Dysport or Azzalure, Bocouture or Xeomin  Type B - Myoblock

12. Development of Botox  1970 – first clinical development blepharospasm and strabismus  1989 – Botox FDA approval for the treatment of strabismus and blepharospasm  2002 – Botox FDA approval for the improval of glabellar lines  Botox approved in 75 countries

13. Bot. toxin indications Cosmetic 2000 – Myobloc FDA approval for cervical dystonia 2010 – Botox FDA approval for chronic migraines 2014 – UK MHRA approval for lower limb spasticity associated with stroke Upper motor neuron syndrome (cerebral palsy) Primary hyperhidrosis Overactive bladder A few small trials have found benefits in people with depression        

14. Mode of action 1. Endplate sits upon muscle fibre 2. Neurotoxin binds to nerve terminal 3. Receptor-mediated endocytosis 4. Light chain blocks fusion of neurotransmitter vesicle with nerve membrane by cleaving SNAP-25 5. The resulting effect is a temporary paralysis of the target muscles, which takes effect within 72 hours. 6. Cholinergic re-innervation at the NMJ occurs through new nerves prouting which takes 3-4 months

15. Botulinum toxin-introduction www.statista.com/statistics/307411/revenue-of-the-global-cosmeticsindustry/

16. Onset of Botox up to 2 weeks

17. Immunology  Global incidence varies from 0.6% to 6%  Patients develop IgG with repeated injections  Secondary resistance to Botox has been reported  Related to small doses and increased number of injections  Apply the 12 WEEK RULE

18. Botox indication Eliminate or reduce dynamic facial wrinkles Soften static wrinkles Create a ‘lift’   

19. Botox contra-indications Local skin infection/inflammation Pregnancy ot breast feeding Known allergic reaction to Botox Neuro-muscular disorders (miasthenia gravis, amyotrophic lateral sclerosis) Clients taking muscle relaxants, aminoglycosides and other agents that may interfere with neuromuscular transmission Aged under 18thyears Cautions: skin disorders, bleeding disorders, anti-coagulant / anti-platelet medication, excessive weakness or atrophy of the target muscles, unrealistic expectations, body dysmorphia, concomitant Botulinum toxin treatment       

20. Reconstitution

21. Administration tips Technical Tips: Pre-fill the syringes with air to facilitate drawing up Saline /product Be aware that the vacuum in the vial will draw the saline into the space very quickly, creating bubbles. Pre-empt this effect and control flow of saline into the vial when introducing the needle Avoid vigorous shaking. Gentle rotation of the vial will help prevent bubbles If no vacuum is present in a new vial, do not use the product and contact the supplier directly    

22. Administration tips Position the client in a semi-upright position on the examination table and ensure you have appropriate lighting Cleanse the target areas of the face using a non alcohol cleanser Apply EMLA cream to the target areas as needed 20 minutes prior to treatment Mark out the injection sites as guided by the client’s activity lines Using the hand positioning and administration guides below, deliver the product into the target areas Throughout the procedure, treat any bleeding points with moist gauze / cotton pads and light pressure Remain receptive and aware, allowing the patient any rest breaks they desire and providing any reassurance needed Provide all aftercare instructions as detailed below, including contact details to arrange follow-up appointments        

23. Types of Botulinum Toxin Allergan Galderma Mertz Product BOTOX 50 units per vial AZZALURE 125 units per vial BOCOUTURE 50 units per vial Dilution 1 ml 0.63ml 1 ml Concentration 50 unit/ml 125 unit/0.63ml 50 unit/ml

24. Botox Before and After

25. Botox Treatment area

26. 1starea: Glabella complex Key: 5 units per injection Total dose: 25 units per side Number of injections: 5 Treatment Tips: • 0.5–1 cm from the upper orbital rim and internal to the mid-pupillary lines • Position lateral corrugator injections at least 1cm above the supraorbital ridge • Keep the needle bevel upward facing and away from the orbital rim •Deep intramuscular and perpendicular injections to the last third of a the needle

27. Glabella complex

28. Frontalis muscle contraction

29. 2ndarea: Frontalis muscle Key: 1-2.5 units per injection Total dose: 15 units in total Number of injections: 6-10 Treatment Tips: • Superficial intramuscular and perpendicular injections to the middle third of an 30G needle • Keeping the angulation of the needle at 45 degrees will facilitate superficial administration of the product • Under the hairline, V-shape in women and straight in men, if applicable

30. FRONTALIS? BEFORE? AND? AFTER? Frontalis muscle

31. Forehead Region

32. Glabella and Frontalis muscles

33. Crow’s feet The medial portion of the orbicularis is a medial brow depressor and contributes to the glabella lines. It runs superficial to the depressor supercilii.  The lateral portion of the orbicularis oculi is a lateral brow depressor and creates the wrinkling pattern known as crow’s feet.  The orbicularis oculi muscle interdigitates with the dermis of the skin throughout its course such that botulinium toxin injections need only be intradermal or very superficial to achieve the desired effects. 

34. Crow’s feet Key: 2.5 units per injection Total dose: 7.5 units per side Number of injections: 3 per side, total 6 points Treatment Tips: • Mark out the central site at least 1.5cm lateral to the lateral canthus • Mark out the upper and lower sites 1- 1.5cm below the central site. •Superficial injections with needle pointing away from the eyes (20–30 degree angle to the skin), to the first third of a 30G needle

35. Botox injection technique

36. Botox aftercare instructions: Reiterate the potential for slight bruising and discomfort around the injection sites. The client should seek medical attention in the event of any major concerns Advise the client not lie down, fall asleep or rub / massage the treated areas for at least 4 hours after treatment Gently exercising the muscles that have been treated (i.e. frowning / smiling) can help to activate the toxin and expedite results Clients should avoid consuming alcohol or wearing makeup for at least 24 hours after treatment Advise the patient that the effects can take up to a few days to become apparent Clients should be provided with your contact details in the event of wanting a follow up assessment / further treatment      

37. Adverse side effects: Anaphylaxis (see treatment algorithm on next slide) Haematoma Pain at the injection sites Headache Ptosis (3%) Eyelid oedema (1%) Diplopia Hyperactivity of local antagonist muscles To date there have been no reports of death following cosmetic administration of Botulinum toxin          J Cutan Aesthet Surg. 2008 Jul-Dec; 1(2): 95–97. doi: 10.4103/0974-2077.44169 Rzany B, Zielke H. Mauricio de Maio and Berthold Rzany, Botulinum Toxin in Aesthetic Medicine. Berlin Heidelberg: Springer-Verlag; 2007. Safety of botulinum toxin in aesthetic medicine; pp. 119–25

38. Botulinum Toxin – The Market

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