Chemodenervation
Kenneth R. Neufeld, MD
DISEASE DESCRIPTION
Chemodenervation for cosmetic purposes is used primarily to treat facial wrinkles or rhytides.
Rhytides can be divided into static and dynamic types.
Static rhytides are present even at rest.
Caused by a combination of sun exposure, aging changes to the skin, and repetitive facial muscle movements
Genetics play a large role in the severity of skin rhytides.
Smoking is a risk factor for more severe rhytides.
Static rhytides can be reduced to varying degrees depending on their depth but generally are not eliminated by chemodenervation.
Dynamic rhytides are present with facial movement.
Can be greatly improved or eliminated by chemodenervation
MANAGEMENT OPTIONS
Rhytides may be treated in several ways.
Topical products may improve fine rhytides.
Laser resurfacing or chemical peels can improve rhytides.
Injectable filler can be used selectively to shallow or lessen rhytides.
Chemodenervation (discussed here)
PREPROCEDURE CONSIDERATIONS
Product options
Botox is currently the most commonly used toxin product on the market and is used in this discussion. Other toxins such as Dysport, Xeomin, and Jeuveau are formulated per manufacturers’ guidelines.
Confirm dilution because this may vary among different manufacturers.
Contraindications
Relative contraindications
Pre-existing blepharoptosis with brow compensation
Neuromuscular disease (myasthenia gravis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis)
Neuromuscular-active drugs (cholinesterase inhibitors, magnesium sulfate, succinylcholine, aminoglycosides)
Pregnancy
Breastfeeding
Absolute contraindications
Allergy to egg or albumin
History of hypersensitivity reaction to any botulinum toxin preparation
Infection at injection site
Inappropriate expectations
Reconstitution
Botox is supplied in vacuum freeze-dried vials containing various quantities. The product must be brought back into solution before administration.
Decide the desired injection concentration. Use the following equation to calculate the amount of diluent (y ml) required to reach that concentration. In this example, the vial contains 100 U and desired injection concentration is 5 U/0.1 mL.
Use preservative-free 0.9% sodium chloride as diluent. From this example, draw up 2 mL of diluent and inject this volume into the vial. The vacuum will draw the diluent into the vial. Mix gently.
Draw desired volume of reconstituted product out of vial with 25-gauge needle on a Luer-lock tuberculin syringe. Replace the 25-gauge needle with a 30- or 32-gauge needle.
Preinjection preparation
Document patient’s allergies, experience with previous injections, and date of most recent injection.
Clean the injection sites with alcohol swab.
Administer anesthetic agents if desired. These might include topical ice, topical lidocaine, or a handheld massage device applied to adjacent areas while injecting.
Some providers prefer using bacteriostatic 0.9% sodium chloride injection diluent as this may yield less injection site discomfort.
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