Clinical indications and use





Abstract


Botulinum toxin is used for cosmetic (45%) and noncosmetic (55%) indications. It is effective as a skeletal muscle relaxant, an antispasticity agent, for essential tremor and for trigeminal neuralgia. Botulinum toxin acts at the autonomic junctions to treat hyperhidrosis and reduce sialorrhoea. It works on involuntary muscle contraction and is effective for internal organ spasticity. It modifies the effect of pain mediators and is effective in chronic migraine.


Cosmetic indications include elimination of wrinkles around the eyes (crow’s feet), forehead lines, vertical glabellar (frown) wrinkles, perioral lines, neck rhytids and lip lines. The concentration of the preparation of botulinum toxin is directly related to the desired degree of diffusion of effect and the desired duration of effect. The different serotypes are assessed with different unit assays, and 100 BOTOX units are equivalent to 400 AZZALURE/Dysport units. Various concentrations may be used to reduce or extend the duration of effect. The author recommends using a constant concentration of botulinum toxin whilst varying the volume injected to develop the intuitive art of choosing the correct degree of diffusion over underlying muscles and glands.


Keywords


Botox, Dysport, Azzalure, Xeomin, diffusion, dose, concentration


The cosmetic indications for botulinum toxin have not changed since the first edition of this book and are listed in Box 3.1 , but the noncosmetic indications now represent 55% of all botulinum toxin use. In the author’s oculofacial practice, botulinum toxin is an essential first-line treatment for hemifacial and blepharospasm, post–facial nerve palsy synkinesis, chronic migraine, frontal ‘trigeminal’ headaches and hyperhidrosis. Table 3.1 provides a list of other uses at the time of press.



BOX 3.1 ■

Cosmetic Indications For Botulinum Toxin





  • Crow’s feet (periocular rhytids)



  • Vertical (glabellar) frown



  • Horizontal (frontalis) frown



  • Wrinkles on nose



  • Upper lip rhytids



  • Vermilion border



  • Angle of mouth



  • Pebbly chin



  • Nasolabial folds



  • Jaw line (platysma)



  • Venus rings (horizontal neck rhytids)



  • Turkey neck (vertical platysma bands)



  • Décolleté



  • Scar management




TABLE 3.1 ■

Noncosmetic Indications for Botulinum Toxin








































Movement Disorders Internal Organs Other
Focal dystonias Detrusor muscle Hyperhidrosis
Essential tremor Bladder spasm pain Chronic migraine
Parkinsonism Urinary retention Tension headaches
Spasticity Hyperactive/overactive Trigeminal neuralgia
Post-stroke spasticity Pelvic floor pain Temporomandibular pain
Traumatic spasticity Anal fissures Spinal muscle pain
Multiple sclerosis Benign prostate hyperplasia Frey’s syndrome
Eye movement disorders Sialorrhoea


Much has been published on the differences between the different products, and the reader is referred to an excellent 2018 review on the same by Dr. Richard Glogau.




USER TIP


DIFFUSION is influenced by concentration, by product and by the concentration of receptors on the muscle being injected. More receptors mean less diffusion per volume injected.



Concentrations


Botulinum toxin is the most potent toxin known to mankind. It functions at very low concentrations and so can be assessed accurately only in terms of lethal dose unit per Swiss-Webster mouse. (Research is ongoing in to cell-based potency assay.) Different serotype A brands are shown in Table 3.2 . One mouse unit (mu) is the median intraperitoneal dose required to kill 50% (LD 50 ) of a batch of 18- to 20-g female Swiss-Webster mice over 3 to 4 days.



TABLE 3.2 ■

Botulinum Toxin Serotype Type A



































Onabotulinumtoxin A Abobotulinumtoxin A Incobotulinumtoxin A
BOTOX/visabel Dysport/Azzalure Xeomin/Bocouture
900-kDa complex <900 kDa 150 kDa
Vacuum-dried powder Freeze-dried powder Freeze-dried powder
2–8° 2–8° Room temperature
HSA 500 μg NaCl (900 μg/vial HSA 125 μg Lactose (2.5 mg/vial) HSA 1000 μg Sucrose (4.7 mg/vial)
BOTOX: 100-U or 200-U vial Vistabel: 50 U Dysport: 300 U or 500 U Azzalure: 125 U Xeomin: 100 U or 200 U Bocouture: 50 U
5 ng/100 U 4.35 ng/500 U 0.44 ng/100 U

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Oct 22, 2019 | Posted by in General Surgery | Comments Off on Clinical indications and use

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