article | TreATIng The lIps |
Figure 4 Botulinum toxin A was injected with a 0.3 ml syringe and a 30 G needle
■ (Bocouture 50 U (Merz pharma), a third botulinum toxin A is now available on the Italian market, but was not used in this study). In all cases, the author injected botulinum toxin A with a 0.3 ml syringe with a pre-inserted 30 g needle (Figure 4).
Figure 5 Patients are marked prior to treatment
Session one All 180 patients were treated with botulinum toxin A. As mentioned previously, 74 patients received botulinum toxin A alone, while 106 patients received botulinum toxin A and hyaluronic acid in combination. Analysis of perioral movement and infiltration of the toxin is always carried out in the first session. patients are marked prior to treatment (Figure 5), and an anaesthetic cream (prilocaine and xilocaine as eMlA cream) is locally applied for at least 30 minutes. Injection points are decided in a standardised mode — four points in the superior lip and two points at the inferior. One hundred and sixty-five patients were treated with
and three patients warfarin, for which there were no
problems in either situation. Before and after photographs were taken. patients were evaluated at day 0, after 15 days, and then
after 30 days. After this last session, patients were asked to quantify their satisfaction on a scale of 1–5 (1=no result; 5= best result), and the physician also quantified the result by patient examination, with particular attention to muscle power reduction, evaluating photographs, and quantifying any side-effects.
Personal technique All patients signed an informed consent form before treatment (mandatory by law), where it is clearly stated that the botulinum toxin A treatment is an off-label indication. The only ‘on-label’ indication in Italy is the treatment of glabellar wrinkles1–3, 7, 8
. The treatment is
performed in three sessions, the first two with botulinum toxin A, and the third with hyaluronic acid when needed. In the first session, botulinum toxin A is injected, while the second session evaluates the outcome and corrects if necessary. Two different types of botulinum toxin were used (those
allowed in Italy for aesthetic indications in glabella treatment): ■ Vistabex 50 U (Allergan) in 165 patients ■ Azzalure 125 U (Ibsen, galderma) in only 15 patients, as it has only recently been introduced to the Italian market
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Vistabex, always diluted with 1 ml of saline solution so that one Vistabex unit is in 0.02 ml. In these patients the author injected — in the first session and prudentially — 0.5 U Vistabex (0.01 ml = one step of the syringe) for each point. In the 15 patients injected with Azzalure, the technique is rather different: the vial of 125 U Azzalure was diluted with 0.25 ml of saline solution with adrenalin 1 : 100 000. To make this solution the author diluted 0.1 ml of adrenalin (1 mg/1 ml) in 10 ml sodium chloride, and then 0.25 ml of this solution is used to dilute the vial. In total, five Azzalure units are in 0.01 ml (one step of the 0.3 ml syringe). The author injects only one Azzalure unit in each point.
To be able to inject such a little amount, after the dilution described above, 0.01 ml that contains exactly five Azzalure units is diluted up to 0.6 ml with normal saline solution. This results in five Azzalure units in 0.6 ml. Then 0.01 ml (a little bit less then one unit of Azzalure) is injected in each point. The use of the 0.3 ml syringe is mandatory to be able to clearly see all these little amounts. In no case did the author inject at any other point than the standard ones. The injections are always carried out at a superficial intradermal level, just on the vermilion border. patients are advised that the results will begin to appear after 3–10 days, after which they will feel a slight reduction in movement. In approximately 30 days this feeling will completely disappear.
Session two Fifteen days after the initial treatment patients undergo an evaluation to assess the effect of the first toxin infiltration. It is usually possible to see the reduction of the contraction ability of the orbicularis, which helps to correct the thinner wrinkles and reduce the deepest. A light extroflexion of the vermilion edge, owing to the
Fifteen days after the initial treatment patients undergo
an evaluation to assess the effect of the first toxin infiltration [and] it is usually possible to see the reduction of the contraction ability of the orbicularis.
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