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Neil Bulstrode has a wide experience using Botulinum toxins, such as Botox®, Azzalure® and Dysport®, Fillers such as Juvederm® and Profhilo® Skin Booster. He has published papers regarding Botulins in both cosmetic and reconstructive patients in leading Plastic Surgery Journals.Patients will be seen and assessed for the most appropriate treatment for them.


Topics to be considered and discussed

  • Clostridium botulinum toxin type A has been used in clinical medicine since the late 1940’s and for the successful cosmetic treatment of wrinkles since the early 1990’s

  • Botulinum toxin works by blocking the signal between the nerves and the muscles (neuromuscular junction) and therefore stops the muscle contracting

  • Botulinum toxin is not only used for treating unwanted wrinkles, it is also used for:
    - Treating facial asymmetry
    - Unwanted facial muscle activity, blepharospasm and hemifacial spasm
    - Migraine
    - Spasticity
    - Ceribral Palsy
    - Hyperhydrosis (sweaty armpits)

  • Careful assessment of the face is required and therefore for maximum benefit no makeup should be worn

  • Careful placement of the Botulinum toxin is used to paralyse the muscles that cause wrinkles and also rebalance the muscle actions resulting in the elevation of specific areas of the face such as the brow

  • Botulinum toxin starts to work 6-36 hours after injection and maximum effect will be achieved after 7-14 days

  • The effect will last between 2 to 4 months before you will start to notice the muscles working and the wrinkles reappearing

  • If the patient likes the effect you will require injections around 4 times a year

  • If the patient does not like the effect it will wear off between 2 to 4 months

  • We aim to achieve the desired effect after the first treatment but it may require one or two treatments to decide exactly what the patient prefers in order to gain the optimal effect

  • Repeated treatments may give a quicker result that lasts longer and therefore increases the time interval between appointments

  • Areas that can be treated using Botulinum toxin
    - Horizontal forehead lines (lifting the eye brows)
    - Glabellar complex, vertical or transverse frown lines between the eye brows and above the nose
    -Bunny lines (side of the nose)
    - Crows feet (to the side of the eyes especially when smiling)
    - Upper third of the nasolabial fold
    - Upper lip
    - Marionette groove
    - Chin
    - Neck webs and chords


Details of the procedure and follow up

  • Careful assessment and planning by a Consultant Plastic and Reconstructive Surgeon

  • A calm and relaxed patient laying comfortably

  • Targeted areas are injected when the face is relaxed

  • Combination treatment may be required eg Cosmetic Fillers

  • Gentle pressure may be required and the application of arnica cream


Advice for before and after the procedure

  • Patients encouraged to move the muscles that are injected

  • Avoid lifting bending or staining for 3-4 hours

  • Unrestricted activities after 4 hours

  • Flying and heat is not thought to have an adverse impact

  • The first effect may be as early as 6 hours and maximal effect is at 14 days


Whilst the chance of risk is very low, it must be discussed and understood

  • Local (Normally these are temporary)
    - Pain
    - Tenderness
    - Swelling/oedema
    - Erythema (redness)
    - Bruising (this can usually be covered up by makeup)
    - Headache (do not take aspirin)

  • Regional complications due to the unwanted effect of Botulinum toxin on adjacent muscles. These are self-limiting and wear off in 2-4 months

  • Systemic effects are rare in cosmetic usage

  • Anaphylaxis to Botulinum toxin, albumin or normal saline is very rare.

  • Therapeutic failure or non response can only be truly assessed after 14 days and before 4-6 weeks and may be due to
    - Persistent muscle activity
    - Surrounding muscle action
    - Static lines will not be affected
    - Persistent wrinkle due to dermal atrophy (thinning of the deep layers of the skin)


Conditions or factors that serves as a reason to withhold a certain medical treatment

  • Pregnancy

  • Breast Feeding

  • Patients trying to get pregnant

  • Previous anaphylaxis (allergic reaction) to Botulinum toxin and other ingredients (albumin, sodium chloride)

  • Neuromuscular disease (myasthenia gravis, Eaton-Lambert syndrome, motor neurone disease)

  • Tendency to excessive bleeding

  • Thrombocytopaenia (low platelets)

  • Haemophilia

  • Anticoagulation therapy

  • Aspirin


Additional advice provided by the British Association of Aesthetic Plastic Surgeons

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