Welcome to Medical Aesthetics Courses for Medical Professionals

Welcome to Medical Aesthetics Courses for Medical Professionals Dr Julia Bernardo BDS, BSC (Hons), MFDS RCS (Ed), PGDipl, MSc W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Foundation Botulinum Toxins Cosmetic Use W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Agenda Outline • Starting off with BOTOX® • Neurotoxin Pharmacology • Dilution & Storage • Contraindications • Technique Tips • Patient Selection and Treatment Options • Cosmetic Enhancement of the Upper Face - Glabellar Frown Lines - Crows Feet - Forehead Lines • Dealing with complications of treatment • Advanced techniques and combination treatment • Strategies for success • Workshop demonstrations W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Disclaimer The material presented in this course represents the clinical experience of the BOTOX® trainers’ faculty, as well as current information obtained from the medical literature and includes discussions of un-licensed indications. Certification of this course is on an attendance basis only and is not necessarily a statement of competency. The course tutor does not take any responsibility for your technique or subsequent actions as a result of attending this course. The use of the course tutor’s name as proof of suitability of yourselves as an injector is not allowed. W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum toxins for cosmetic use W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Why learn about Botox®? ® Botox is now the most common aesthetic procedure performed in the US 3, 500, 000 50 -fold increase from 1997 to 2005 Nearly 500, 000 in UK in 2007 3, 000 2, 500, 000 Botox® 2, 000 Laser Hair Removal 1, 500, 000 Dermal Fillers 1, 000 Microdermabrasion Chemical Peels 500, 000 0 W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

2008 ASAPS-USA Non Surgical Procedures Top surgical and non surgical cosmetic procedures among men and women in 2008: • Non-surgical treatments • Botox = 2, 464, 123 • Laser Hair Removal = 1, 280, 964 • Hyaluronic Acid = 1, 262, 848 (including Teosyl, Juvéderm, Perlane/Restylane) • Chemical Peel = 591, 808 • Laser Skin Resurfacing = 570, 880 W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

2009 ASAPS-USA Non Surgical Procedures Top surgical and non surgical cosmetic procedures among men and women in 2009: • Non-surgical treatments • Botox = 4, 795, 357 • Laser Hair Removal = 893, 054 • Hyaluronic Acid = 1, 209, 217 (including Teosyl, Juvéderm, Perlane/Restylane) • Chemical Peel = 1, 142, 949 • Laser Skin Resurfacing = 434, 830 W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

2010 ASAPS-USA Non Surgical Procedures Top surgical and non surgical cosmetic procedures among men and women in 2010: • Non-surgical treatments • Botox = 5, 379, 360 treatment areas • Laser Hair Removal = 937, 602 • Hyaluronic Acid = 1, 201, 368 (including Teosyl, Juvéderm, Perlane/Restylane) • Chemical Peel = 1, 321, 562 • Laser Skin Resurfacing = 426, 695 W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum toxins for Cosmetic Use It is very important ® to learn that BOTOX is both an art and a science before you start W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

• Starting BOTOX ® • How can you introduce it into your practice?

Starting BOTOX® ® Getting started with BOTOX can be the hardest part… e. g. Collecting Patients, Advertising, Equipment, Insurance… Starting BOTOX® W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Before Offering BOTOX® to Patients • Attend a Training Course • Watch a Training Video • Review Allergan / Other Literature • Personalise Consent Form / History Sheet • Practice on partner, family, close friends Starting BOTOX® W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Neurotoxin Pharmacology

Botulinum Neurotoxin Development • 1944 – Toxin isolated from C. Botulinum • 1950 s – Discovery of NMJ Blockade • 1970 s – Monkey Experiments • 1980 – First use of BTX-A in Humans • 1989 – FDA approval for non-cosmetic purposes • 2006 – MHRA approval for Glabellar Lines • 2013 – FDA approval for lateral canthal lines • 2014 – MHRA approval for lateral canthal lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum Neurotoxin Serotypes COOH NH 2 • Seven serotypes - A, B, C 1, D, E, F, G • Intracellular target varies - SNAP-25 S-S Light Chain Heavy Chain - Synaptobrevin - Syntaxin NH 2 • 150 k. D S S • Only intact molecule works • Does not penetrate the skin COOH • No topical application Neurotoxin Pharmacology

Mechanism / Mode of Action W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

BOTOX® - Mode of Action 1. Before BOTOX® 2. Binding 3. Internalisation Endplate sits upon muscle fibre Neurotoxin binds to nerve terminal Neurotoxin internalised via receptor-mediated endocytosis. W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

BOTOX ® - Mode of Action 4. Blocking 5. Sprouting and reestablishment of sprouts Light chain blocks fusion of neurotransmitter vesicle with Endplate expands and collateral axonal sprouts emerge. Sprouts nerve membrane by subsequently retract and are cleaving SNAP-25. eliminated; parent terminal is reestablished. W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum Toxin Products W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Range of Botulinum Toxins Xeomin®=100 units per vial - Merz Pharma Boucouture=50 unit vial – Merz Pharma Dysport®=500 units- Ipsen Azzalure®=125 Speywood units - Ipsen and Galderma BOTOX®= 100 units - Allergan BOTOX®= 50 units – Allergan* NOTES next slide W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

*Product Changes 2012 VISTABEL® = 50 units – Allergan To BOTOX® = 50 units - Allergan BOTOX® is now licensed for cosmetic use for the glabellar and Allergan inc has be rebranding VISTABEL® as BOTOX® in 50 unit vials. W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Warning: Botulinum Toxin Products Are NOT Interchangeable • BOTOX ®(Allergan) - 100 units and 50 units per vial • Dysport (Ipsen) - 500 units per vial • Azzalure (Ipsen – Galderma) - 125 Speywood units per vial • Xeomin / Bocouture (Merz Aesthetics) - 100 units and 50 units per vial Simple Dose Ratios Are Inappropriate 1 unit BOTOX / Xeomin ≠ 1 unit Dysport/Azzalure Neurotoxin Pharmacology W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Warning: Botulinum Toxin Products Are NOT Interchangeable • Product dosing and performances differ • Safety margins and side effects differ • Neurotoxin protein exposures differ - Botox® : 4. 8 ng per vial - Dysport : 12. 4 ng per vial Neurotoxin Pharmacology

Current UK BOTOX® Approvals • Glabellar lines • Horizontal forehead lines • Periorbital lines • Migraine • Blepharospasm • Cervical Dystonia • Cerebral Palsy • Hemifacial spasm • Focal Spasticity Associated with Stroke • Hyperhidrosis of the Axillae Neurotoxin Licensed Use

Current UK BOCOUTURE® Approvals • Glabellar lines • Horizontal forehead lines • Periorbital lines Neurotoxin Licensed Use

Other Clinical Conditions Treated with BOTOX® (off -license) • Migraine • Tension Type Head-Ache • Back Ache • Achalasia • Hypersalivation • Myofascial Pain Syndrome • Anal Fissure Neurotoxin Off License

Dilution and Reconstitution

BOTOX Dilution of Vial • Volumes of 1 to 10 ml have been used with varying results • Consensus of experts is 2. 0 ml dilution, although some use 1 ml with accurate injection technique • Unpreserved 0. 9% Saline recommended on packaging • Bacteriostatic / Preserved Saline 0. 9% often used Dilution & Storage W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

BOTOX®-100 unit vials / Xeomin®-100 units vials Dilution Chart Diluent Added (0. 9% Sodium Chloride Injection) Resulting Dose (units per 0. 1 m. L) 1. 0 ml 10. 0 U 2. 0 ml 5. 0 U 2. 5 ml 4. 0 U 3. 0 ml 3. 3 U 4. 0 ml 2. 5 U W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

BOTOX®-50 unit vial /Bocouture®-50 unit vial Dilution Chart Diluent Added (0. 9% Sodium Chloride Injection) Resulting Dose BOTOX© 50 U (Units per 0. 1 ml) 1. 0 ml 5. 0 U 1. 25 ml 4. 0 U 2. 0 ml 2. 5 U 2. 5 ml 2. 0 U 4. 0 ml 1. 25 U W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Dilution • Use a 2 ml Syringe and 21 g Needle (green) to draw up Bacteriostatic Sodium Chloride 0. 9% for the dilution of BOTOX / VISTABEL W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

BOTOX® (100 units) requires 2 ml BOTOX®(50 units) requires 1 ml W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

BOTOX Reconstitution • Flip off lid, pierce rubber cap with needle and listen for ‘hiss’ • Use 21 G Needle and 2. 0 ml Syringe • Insert at 45 angle and slowly inject 2. 0 mls 0. 9% Bacteriostatic Saline into BOTOX® vial • BOTOX 100 units/ Xeomin 100 units in 2. 0 ml saline = 5 units in 0. 1 ml • BOTOX 50 units / Bocouture 50 units in 1. 0 ml saline = 5 units in 0. 1 ml • Record reconstitution date, expiry date and batch number Dilution & Storage W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Units of BOTOX / VISTABEL in 0. 5 ml Syringe BOTOX 100 unit / Xeomin 100 unit vial reconstituted with 2 ml bacteriostatic 0. 9% sodium chloride. BOTOX 50 unit/Bocouture 50 unit vial reconstituted with 1 ml bacteriostatic 0. 9% sodium chloride. Each 5 unit increment on the syringe = 2. 5 units of BOTOX/VISTABEL BD Microfine 0. 5 ml syringe with 30 g needle 0. 5 ml Syringe marking BOTOX/VISTABEL units 5 2. 5 units 10 5 units 15 7. 5 units 50 25 units W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Factors Which May Affect Potency • Storage time and temperature of diluted toxin • Agitation of the bottle or syringe • Bubbles Dilution & Storage W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Storage W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Storage • Unreconstituted: Store in a fridge at 2 – 8 °C or in a freezer at – 5 °C or below • Reconstituted: Allergan’s approved storage time is 4 hours • Current clinical practice regarding reconstituted storage time varies • Group patients together in early phases of business to prevent wastage Dilution & Storage W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Storage • DO NOT FREEZE BOTOX®ONCE RECONSTITUTED o Ice crystals may form which damage the toxin and reduce potency • Store in the refrigerator at 2 – 8 °C • Any residual Botox® should be inactivated with hypochlorite solution (0. 5%) • Used vials should be autoclaved Dilution & Storage W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Contraindications and Cautions W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Contraindications • Patients with infection at proposed injection site • Patients with known hypersensitivity to any ingredient in BOTOX® • Administration of BOTOX® is not recommended during pregnancy or lactation • Generalised disorders of muscle activity (e. g. myasthenia gravis) • Co-administration with aminoglycosides or other agents interfering with neuromuscular transmission • Bleeding disorders or anticoagulant therapy Contraindications & Cautions W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Cautions • History of Bell’s Palsy • Dysmorphophobia • Clopidogrel, Aspirin and other NSAIDs • Vitamin E, Ginkgo Biloba and St. Johns Wort Contraindications & Cautions W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Some General Technique Tips for: • Optimal Treatment Success • Satisfied, Repeat Patients W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

General Injection Technique Tips • Patient should be seated or slightly reclining to best observe their facial expressions • Try to make the treatment as pleasant as possible • An experienced patient copes better with more than 2 areas injected in one session - new patients may not Technique Tips W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

General Injection Technique Tips • Try to change insulin syringe after every 4 - 5 injections. • Gloves should be worn at all times, non-latex is recommended due to the potential for patient reaction. • Mark injection sites prior to injection – remember to use a non tattooing pen! • Record technique thoroughly on a patient worksheet so you can duplicate successful treatment and modify over- or under treatment. Technique Tips W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

General Injection Technique Tips • Never advise to discontinue aspirin / clopidogrel • Stop other NSAIDs, Vitamin E etc. 7 – 10 days prior to decrease risk of bruising • Hold a gauze pad in the non-injecting hand so you can apply gentle pressure to any site that bleeds to minimise chances of bruising Technique Tips W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Preparing to Inject • Wipe injection sites with alcohol / cleansing wipe and allow to dry • If required for patient comfort, chill the injection sites first • EMLA will relieve sensation of injection into skin but is messy • EMLA cannot stop the mild sting from injecting fluid into the muscle Technique Tips W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Preparing to Inject • Take a photo if allowed • Have the patient pull faces and contract muscles • Mark (when learning) or plan the injection sites • Inject selected dose with 30 Gauge Needle • Inject with patient’s muscle relaxed for comfort W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Patient Selection and Treatment Options W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glogau Wrinkle Scale Type III Type IV Patient Selection and Treatment Options W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Treatment Options Type I (No Lines) - Topical Therapy Type II (Dynamic Lines) - BOTOX® plus Topicals Type III (Static Lines and Folds) - BOTOX® plus Dermal Fillers, Peels, Laser Type IV (Nothing but Lines and Folds) - BOTOX® and then Laser Resurfacing or Deep Phenol / TCA peel. Consider Surgery. Patient Selection and Treatment Options W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Cosmetic Indications • Glabellar Frown Lines • Crow’s Feet • Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Facial Anatomy • BOTOX® is an Intramuscular Injection. • Thorough knowledge of the complex facial musculature is essential for success. • Spend some time reviewing facial anatomy Cosmetic Indications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Target Muscles for BOTOX® Treatment Depressor Supercilii m. Orbicularis oculi

Actions of Facial Muscles Muscle Action Expression Lines Frontalis Brow Elevator Horizontal forehead lines Corrugators Pull Eyebrows Medially Frown lines Brow Depressors Procerus & Depressor supercilli Frown lines & Horizontal nasal lines Orbicularis oculi Crows Feet Brow Depressors especially Laterally Cosmetic Indications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Factors Influencing BOTOX® Dosing • Sex • Ethnicity • Skin Type • Muscle mass • Extent of wrinkles • Previous response to BOTOX® treatment Technique Tips W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Target Muscles for Frown Lines Procerus Corrugators Cosmetic Indications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Target Muscles for Frown Lines Image adapted from Radlanski & Wesker, 2012. The Face, Pictorial Atlas of Clinical Anatomy W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Lines- Injection Sites Normal Dose = 5 units/site Dose Range can be 20 - 80 units Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Lines- Injection Technique Non-dominant thumb protects orbital rim Non-dominant hand rests securely on patient’s face Injecting hand rests on nondominant hand for accuracy and security Syringe rests on non-dominant thumb Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Lines- How Not to Inject! • Injecting down towards the eye • 2. 5 ml syringe • No gloves or gauze! Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Lines Post-injection: you can advise patient to frown as much as possible for 1 hour ? ? ? Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Lines Female 32 years old Before After Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Lines Male 42 years old Before After Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Glabellar Lines- Follow Up • Patient to return in 2 weeks to: - Assess Results / Technique - Photograph Patient - Top up (if necessary) • Re-injection Schedule - Patient Dependent - 3 - 4 month intervals for first year - Less frequent after repeated treatments Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Physician’s Rating of Glabellar Line Severity at REST Responder Rates Over 3 BOTOX® Treatments % Responders 1 st BOTOX® Treatment 100 90 80 70 60 50 40 30 20 10 2 nd BOTOX® Treatment * * 0 30 60 120/0 30 Arrow indicates BTX-A injection 90 60 *Significantly greater than same time point 3 rd BOTOX® Treatment 120/0 90 Study Day * 30 120 after one or both previous treatments W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk * 60 * 90

Most common, treatment related, adverse events following each BOTOX® treatment 1 st BOTOX® Treatment (n=501) 2 nd BOTOX® Treatment (n=362) 3 rd BOTOX® Treatment (n=258) All events 23. 0% 6. 1% 3. 5% Headache 9. 8% 2. 2% 0. 8% Blepharoptosis 3. 0% 2. 2% 0. 8% Adverse Event Carruthers A, Lowe N, Gibson J, et al. For the BOTOX® Glabellar Lines Study Group. (Incidence 2% in any treatment cycle) Cosmetic Indications – Glabellar Frown Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Time for a break! W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Crow’s Feet W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Target Muscles for Crow’s Feet Orbicularis oculi Cosmetic Indications-Crow’s Feet W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Target Muscles for Crow’s Feet Image adapted from Radlanski & Wesker, 2012. The Face, Pictorial Atlas of Clinical Anatomy W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Poor skin tone and wrinkles at rest. - Ask patient not to smile. - Push skin up over zygomatic arch. - Demonstrate to patient the wrinkles that occur at the crow’s feet due to deterioration of skin tone. - These will also occur when the patient smiles and their smile ‘pushes’ the cheek up, even when BTX has paralysed the lateral orbicularis oculis W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Crow’s Feet • Examine individual variation by getting patients to smile & squint fully • Look closely for Blood Vessels and Avoid • The Orbicularis Oculi is a superficial muscle – there is no need to inject deeply Cosmetic Indications-Crow’s Feet W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Intradermal Injections W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Crow’s Feet • Patient at Full Smile • Note- Upper and Lower Borders of the Crow’s Feet Cosmetic Indications-Crow’s Feet W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Crow’s Feet • Inject 1 cm outside the orbital rim • 3 injection sites 1 cm apart • Inject 2 - 5 units of BOTOX® per injection site x x • 12 units total per side • May inject around to the midpupillary line • Extreme caution under eye • Stay above Zygoma REQUIRED x OPTIONAL- IF PATIENT HAS LINES Cosmetic Indications-Crow’s Feets W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Crow’s Feet Female 39 years old Before After Cosmetic Indications-Crow’s Feet W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Crow’s Feet Female 40 years old Before After Cosmetic Indications – Crow’s Feet W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Anatomy - Frontalis Muscle Origin: Occipitofrontalis Insertion: Skin of Eyebrows and Root of Nose Action: Elevate Brows, Draw Scalp Posteriorly Frontalis muscle Cosmetic Indications - Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Anatomy - Frontalis Muscle Image adapted from Radlanski & Wesker, 2012. The Face, Pictorial Atlas of Clinical Anatomy W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines • Very careful evaluation required • Leave some facial expression • Males have more muscle mass than many females • Look for pre-existing brow ptosis which the patient may be elevating their frontalis to compensate for • Look for any brow asymmetry Cosmetic Indications – Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines • Approach should be conservative - 10 -20 Units BOTOX® in 4 -10 divided doses • In the lateral to mid-pupillary line, stay 1 finger width above the supra-orbital rim Avoid ptosis by not injecting shaded area Cosmetic Indications – Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines X Standard technique: 2. 5 units in 5 injection sites Cosmetic Indications – Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines X Optional injection sites Cosmetic Indications – Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines X Additional sites to consider for males Cosmetic Indications – Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines Male 36 years old Before After Cosmetic Indications – Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Horizontal Forehead Lines Female 40 years old Before After Note enhancement of brow shape a to soft flare Cosmetic Indications – Horizontal Forehead Lines W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

General Post-Treatment Advice • Remain upright for 4 hours • Refrain from exercise for 24 hours • Do not rub / massage eyebrows for 24 hours • Avoid Saunas / Hot Tubs / Sunbeds for 24 hours Cosmetic Indications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Managing Complications Botulinum Toxin Treatments W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Potential Complications Bruising Swelling Headache Eyelid Ptosis Brow Repositioning Diplopia Managing Complications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Treating Ptosis Alpha-2 agent with weak alpha-1 activity [eg, apraclonidine 0. 5% (Iopidine®, Alcon Inc)] Alpha-1 adrenergic stimulation of Müller’s muscle (eg, adrenaline) Managing Complications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Treating Ptosis • Usually resolves in 1 -6 weeks • Iopidine eyedrops 1 drop q. d. s. will temporarily resolve Ptosis left lid 20 minutes after Iopidine® Managing complications Managing Complications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Brow Ptosis • Wait for natural resolution • Consider injection of 2 units at tail of eyebrow to lift After BOTOX® to Glabellar and Brow Managing Complications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Brow Repositioning Excessive Brow Elevation • “Quizzical” or “Mr Spock” brows • Correct with 2 - 4 units of BOTOX® injected into the Frontalis 2 cm above the Lateral Brow Managing Complications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Unnatural brow peaking following botulinum toxin to glabella in a patient with overactive lateral frontalis W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Potential Side Effects • Bruising - avoid Aspirin & NSAID’s 10 days prior to BOTOX® treatment - apply gentle pressure immediately, then ice • Local Temporary Swelling • Diplopia - Rare Managing Complications W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Advanced Techniques require a degree of judgement gained from approximately 3 – 6 months BOTOX® cosmetic experience W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Advanced Cosmetic Techniques • Suborbital region • Facial asymmetry • Upper lip wrinkles • Nasal scrunch (“bunny lines”) • Nasal flare • Nasolabial folds • Marionette lines • Correction of downturned mouth corners • “Poppy” chin • Platysmal bands Advanced Techniques and Combination W: www. k-ttraining. com treatment T: 01793 323786 E: info@kttraining. co. uk

Patient Treatment Information and Documents W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum toxins for cosmetic use Patient Medical History W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Medical History Contact Dermatitis Yes No Are you attending or receiving treatment from a doctor or specialist Yes No Psychiatric Illness / Depression Yes No Heart Problems Yes No High or Low Blood Pressure Yes No Epilepsy / Blackouts Yes No Melasma (pigmentary change of the face) Yes No Diabetes Yes No Keloids (hypertrophic scarring) Yes No Blood disorders Yes No Moles Yes No Recent scar tissue (6 months) Yes No Sunburn Yes No Bruises Yes No Cuts / abrasions Yes No Excema Yes No Are you pregnant or are you breast feeding? Yes No Do you suffer from any autoimmune disease? Yes No Are presently engage in IVF treatment? Yes No Do you suffer from cold sores? Yes No Do you suffer from Anaphylactic Shock? Yes No Do you have any known allergies? Yes No Are you taking aspirins on a daily basis? Yes No Do you bruise easily? Yes No Have you been treated with any cosmetic products (Botox, Dermal Fillers, etc) before? Yes No If Yes, please list the name of the treatments and dates Yes No Have you had an allergic reaction to any cosmetic product? Yes No Do you have any other medical problems that we have not identified? Yes No If yes, please give details: Are you taking any medication, herbal remedies or any other drugs (e. g. Aspirin, Antibiotics, Muscle Relaxants, St. Johns Wart, Anticoagulants, Roaccutane) If yes, please give details: Review of the Patient Medical History. Are you allergic to any medicines, antibiotics, foods or other substances? If yes, please give details: Have you suffered from or had any of the following illnesses? To be completed before treatments Must be signed and dated by patients Reviewed by practitioner before any treatment. If yes please list: Signed Patient Dated: W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Reviewing the Medical History Identify Cautions and contraindications Underlying medical conditions. Previous reactions to drugs. Previous treatments surgical/non surgical. Current medication. If in doubt DO NOT Treat. W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum toxins for cosmetic use Informed Consent W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Providing Informed Consent Your patient must be provided with the treatment information. Essential: • Medical legal requirement • Insurance cover requirement W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Informed Consent Review of the Patient Informed Consent. Provide the patient with Information about the product and treatment including any potential side effects and adverse events plus Off license indications you are treating. To be completed before treatments. Must be signed and dated by patients Mild Swelling at the Injection Site Headache Localised Numbness Bruising Rash Temporary loss of function of the near-by muscles (e. g. ptosis / drooping lid) Other POTENTIAL ADVERSE EVENTS DISCUSSED PATIENT CONSENT: I have received information about BOTOX®, which I have read and understood. All aspects of treatment with BOTOX® have been explained to me and I have discussed the treatment fully with my doctor (including reasonably foreseeable risks associated with BOTOX® injections). I understand the importance of medical review at 2 weeks and 4 months (or as advised by my physician). I consent to receiving BOTOX® which I understand is licensed for cosmetic use (specifically for the treatment of glabellar lines – the vertical lines between my eyebrows). If my practitioner is recommending additional areas for treatment with BOTOX®, I understand that BOTOX® is not licensed for these and I have discussed this with my physician. PATIENT’S SIGNATURE : …………………………………. . DATE: ………………………. Clinician SIGNATURE : ………………………………… . DATE: ………………………. W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum toxins for cosmetic use Patient Injection/Treatment Records W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Botulinum toxins for cosmetic use Patient Injection Record A Patient 24/05/2012 • Patients Name • Treatment Dates 2. 5 • Treatment Mapping with Number of Units Injected • Product Batch Numbers 5 5 5 2. 5 EXAMPLE ONLY • Expiry Date • Total Units Injected • To be recorded and retained in the patients file complying with current data protection legislation. Ie: C 2836 C 2 W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk 01/2014 20 units

Examples of Treatment Injection Records W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Strategies for Success W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Customer Service • Prompt service availability is essential • The wait time for BOTOX® is best kept short • More than two weeks is too long • Try and arrange BOTOX® days for efficient use of material • Be flexible in your scheduling – mornings, lunch, evenings and weekends Strategies for Success W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Pricing Policy • Free Consultations • Price Match Promise • Price According to Number of Facial Areas • Try to Avoid Treating Only One Area! • Vouchers / Referral / Loyalty Rewards Strategies for Success W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Marketing • Do not advertise BOTOX® or “Botulinum Toxin” • It contravenes Advertising Standard Authority guidelines regarding the promotion of Prescription Only Medicines. Strategies for Success W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Optimizing Success ® BOTOX is considered by many cosmetic practitioners to be the most successful cosmetic procedure available Strategies for Success W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Ordering BOTOX® and other Aesthetic Products and Supplies W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

BOTOX® Please still use the Guernsey address for all correspondence: Healthxchange Pharmacy Albert House South Esplanade St Peter Port Guernsey GY 1 1 AJ Tel: 01481 736837 Fax: 01481 736677 If you would like to collect goods in person at the new modern pharmacy located at: 79 Great Portland Street, London, W 1 W 7 LS Note: Health Xchange do not distribute Xeomin or Azzalure products W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk Ordering BTN

Church Pharmacy 1 The Old Bleach Yard Wards End Loughborough LE 11 3 HA Tel: 01509 213439 Fax: 01509 230344 Email : enquiries@order-line. co. uk BOTOX, Azzalure, Xeomin, Bocouture W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Wigmore Pharmacy Wigmore Medical provides prompt and personalised pharmaceutical services to hospitals, clinics, doctors and pharmacies throughout the world. Wigmore Medical Ltd. 23 Wigmore Street , London , W 1 U 1 PL Tel: +44(0) 207 491 0150 Fax: +44(0) 207 491 2782 Email: customerservice@wigmoremedical. com Xeomin, Bocouture, Dysport, Azzalure *Wigmore do not distribute Allergans BOTOX / Vistabel products W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk Ordering BTN

Allergan Inc W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk Allergan distributes Botox®/Vistabel® to Doctors and

Questions & Answers W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

KT Medical Aesthetics Training Resources KT Training Forum - http: //www. kttraining. co. uk/forum/ Free membership for KT Training course attendees. You will receive your user name and password please keep these details for access. The Beauty Advice Centre - http: //www. beautyadvicecentre. co. uk/index. php Free 1 year web listing to assist in marketing your cosmetic clinic. KT Solutions - http: //www. k-tsolutions. com/index. htm Marketing and business development for cosmetic clinics. KT Training Blog aesthetics training and business news . http: //www. kttraining. co. uk/blog/? cat=61 W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk

Thank You! KT Medical Aesthetics Training Tel: 01793 323786 Email: info@kttraining. co. uk Web: http: //www. k-ttraining. com W: www. k-ttraining. com T: 01793 323786 E: info@kttraining. co. uk