Chapter 3
Contents
3.1 Introduction . . . 21
3.2 Documentation . . . 21
3.2.1 Chart . . . 21
3.2.2 Photograph . . . 22
3.2.3 Consent . . . 22
3.2.4 Treatment Plan . . . 22
3.3 Staff . . . 22
3.4 Technical Requirements . . . 22
3.4.1 Room . . . 22
3.4.2 Chair . . . 22
3.4.3 Mirror . . . 22
3.4.4 Cosmetic Marker . . . 22
3.4.5 Standard Setting . . . 22
3.4.6 The Toxin . . . 23
3.4.7 Tips and Tricks . . . 24
3.4.8 References . . . 24
3.1 Introduction
The requirements and rules are basically the same for every aesthetic procedure. The follow- ing list is not intended to give a complete over- view but to give some hopefully helpful advice when treating aesthetic indications with botuli- num toxin (BNT).
3.2 Documentation
A thorough documentation of all treatment-re- lated data is highly recommended. Besides be- ing useful for legal and billing reasons, thorough documentation will help to improve one’s own performance and thus patients’ satisfaction, too.
3.2.1 Chart
The patient’s identification data, age, the history of relevant concomitant diseases, present rele- vant drug intake (e.g. the intake of acetylsalicylic acid!) and previous aesthetic procedures should be documented.
Furthermore, the procedure itself has to be documented. This can be either done as text or as text supported by figures of the areas to be treated. Here, the injection points, the injected U and/or volume should be stated.
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Requirements and Rules
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3.2.2 Photograph
It is advisable to document the status of the patient before treatment. If possible, the photo- graphs should be standardized. Standardization requires some effort, such as using a fixed set- ting or following standard procedures. Patients tend to forget their pre-treatment features and might assume that nothing has changed. In such a case, a photograph prior to the treatment session might help avoid unpleasant misunder- standings.
3.2.3 Consent
The consent of each patient should be thorough- ly documented. Patients should date and sign the consent for each new indication. The consent form should be accompanied by a patient infor- mation brochure that includes all necessary in- formation on the estimated efficacy and possible adverse events.
3.2.4 Treatment Plan
A treatment plan is highly recommended for every aesthetic procedure. Patients should be aware of the fact that BNT has a limited durabil- ity and three to four treatments per year might be necessary.
3.3 Staff
The staff have to be trained in several areas: mar- keting, quality control and assistance. Market- ing: the staff should be aware of the aesthetic procedures offered and should be able to give some information about the use of botulinum toxin. Staff are responsible for monitoring the chart as well as ensuring that all necessary docu- ments are available and signed by the patient if applicable.
3.4 Technical Requirements
3.4.1 Room
The room should be brightly lit. No shadows should decrease the visibility of the area to be treated.
3.4.2 Chair
Although all indications can be treated in an upright position, a reclining position is recom- mended, especially for anxious patients. For the treatment of platsymal bands patients should be in an upright position; otherwise the bands would not be visible.
3.4.3 Mirror
A mirror should accompany patient-doctor communication from the start. Using the mir- ror the doctor can ensure that both are speaking about exactly the same areas to be treated. At the end of the treatment the doctor might show the patient the injection points and explain the procedure again.
3.4.4 Cosmetic Marker
A cosmetic pen to mark the injection points can be quite helpful in reducing asymmetry. E.g.
asymmetry might easily occur when treating the forehead. Here, the use of a cosmetic pen such as a lip liner will greatly reduce the risk of asymmetry.
3.4.5 Standard Setting
All tools required should be within reach
(Table 3.1). A standard setting for treatment with
BNT might prove to be helpful.
Chapter 3 23 Requirements and Rules
3.4.6 The Toxin Storage of Undiluted Toxin
BNT has to be stored either in the refrigerator (Botox, Dysport) or under normal room condi- tions (Xeomin).
Dilution
All BNTs-A preparations have to be diluted with saline. Usually 2.5 ml saline is used to dilute the BNT-A when used in aesthetic indications.
Some colleagues prefer lower or higher dilutions (Tables 3.2 and 3.3). The effect of a higher dilution is not clear. Based on a small study investigating one dose in two different volumes, it appears that a greater volume means greater diffusion into the adjacent muscles, giving greater efficacy, but also greater risk of adverse events. There was no fol- low-up on the duration of the effect in this study (Hsu et al. 2004).
The standard dilution for Botox and Dys- port is 2.5 ml.
Storage of Diluted Toxin
All manufacturers recommend the BNT-A to be only used for several hours after dilution. How- ever, in clinical practice, BNT-A is often stored in the refrigerator for several days up to a couple of weeks. With increased storage time, a decrease in efficacy and increased risk of contamination is likely. However, Doris Hexsel reported not such a
Table 3.1. Necessary tools to be arranged before treat- ment
Patient information and consent form
Documentation material for source data (electronic or conventional charts)
Hand mirror
Camera (conventional or digital) for photographic documentation
Topical local anesthetic (usually not needed) Topical disinfectant (preferably without dye and non-alcoholic)
Non-sterile dressings
Cosmetic pen, for example a lip liner (marking the injection points may be quite helpful to ensure harmonious and symmetric results)
Vial with botulinum toxin, saline for dilution (if necessary), appropriate syringes and needles (30-gauge needles are a must, 32-gauge needles are great)
Cool packs or pre-cooled saline to soak compresses Emergency kit (in case of the extremely unlikely event of an anaphylactic reaction)
Table 3.2. Botox: U per ml for different dilutions
0.9% saline Botox
100 U in 0.01 ml 0.02 ml 0.05 ml 0.1 ml 0.15 ml 0.2 ml
2.0 ml 0.52 1 2.52 7
2.5 ml 0.4 0.8 2 4
3.0 ml 0.34 0.66 0.13 3.34 5
4.0 ml 0.26 0.5 1.26 3.5 3.76 5
4.5 ml 0.22 0.44 1.12 2.22 3.34 4.44
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decrease while using BNT-A reconstituted up to six consecutive weeks before application (Hexsel et al. 2003).
3.4.7 Tips and Tricks
■ Most complaints from dissatisfied patients might be traced to insufficient communi- cation between the doctor and the patient.
This also applies to the cost related to these procedures! Patients should know from the start what they can expect and how much they have to pay.
