Diploma Course in Aesthetic Dermatology & Skincare

Course Duration : 2 Days

Course Target : Diploma Course in Aesthetic Dermatology & Skincare

Faculty : Dr. Refazul Alam (refat) , Dr. Jinat Khan, Dr. Nizhum Ahmed, Dr. Syeda Maria Adnin , Dr. Afnan H Tanna,

Open to All MBBS Students undergoing Internship , MBBS & BDS.

CPD certificate in Diploma Aesthetic Dermatology & Skincare will be awarded.

DAY 1: 03^rd July 2025 (Thursday) Skin Development Anatomy & Physiology, Clinical Dermatology & Laser Machine Orientation
09:15 – 09:30	Collection of Lecture Course Notes
09:30 – 11:30	Introduction to Glutathione, Routes of Administration & Dosage Guidelines, Introduction to conclusion on Hair Transplantation with Hands-on Training
11:30 – 11:45	Morning Tea Break
11:45 – 01:30	Introduction to Conclusion on Face & Acne Scar Formation & Types, Advanced Treatment for Hypertrophic & Keloid Scars, Patient Selection & Consultation
01:30 – 02.00	Multiple Choice Question Quiz on Glutathione & Face Scar formation.
02:00 – 02:30	Lunch Break
03:00 – 17:30	Hands on training & Live Demostration on Face & Acne scar
DAY 2: 4^th July 2025 (Friday) PRP (Platilet Rich Plasma), Microneedling
09:15 – 09:30	Collection of Lecture Course Notes
09:30 – 11:30	Introduction to conclusion of Botulinum Toxin, Details (Anatomy & Physiology, Indications & Applications, Injection Techniques & Dosage, Introduction to conclusion of Dermal Filler, Details (Introduction to Dermal Fillers , Facial Anatomy & Injection Safety, Indications & Applications, Injection Techniques & Product Selection, Managing Complications & Side Effects)
11:30 – 11:45	Morning Tea Break
11:45 – 01:30	Introduction to conclusion of Filler & Thread, Details of Advanced Filler & Thread Types & Their Uses, Advance Facial Anatomy & Injection Safety Indications & Applications, Patient Selection & Consultation, Filler & Thread Placement Techniques, Managing Complications & Side Effects & Emergency Protocol. Introduction to conclusion of Laser Technology, Types of Lasers Used in Aesthetic Dermatology
01:30 – 02.00	Multiple Choice Question Quiz on Botox, Filler, Thread & Laser.
02:00 – 02:30	Lunch Break
03:00 – 17:30	Live Demonstrations and Hands-On Training Workshops. Certificate Handover

Diploma Course in Aesthetic Dermatology & Skincare

Day 01

Glutathione
Hair Transplantation
Face & Acne Scar

Introduction of Glutathione

Glutathione (GSH) is a tripeptide composed of:

Glutamic acid
Cysteine
Glycine

It is one of the most abundant intracellular non-enzymatic antioxidants, present in nearly all living cells, and plays critical roles in detoxification, redox balance, immune function, and cellular protection.

2. Structure of Glutathione

Molecular Formula: C₁₀H₁₇N₃O₆S
Structure: γ-L-glutamyl-L-cysteinylglycine
Unique Bond: Gamma peptide linkage between glutamate and cysteine (unusual γ-peptide bond instead of the usual α-peptide bond)

3. Biosynthesis of Glutathione

Occurs intracellularly in two ATP-dependent steps:

Step 1:

γ-glutamylcysteine synthetase

Combines glutamate + cysteine
Rate-limiting step
Regulated by feedback inhibition by GSH

Step 2:

Glutathione synthetase

Adds glycine to form glutathione

Location: Predominantly in the liver, also in kidneys, lungs, and intestines.

4. Forms of Glutathione

Form	Description
GSH	Reduced glutathione (active antioxidant form)
GSSG	Oxidized glutathione (2 GSH molecules joined via disulfide bond)

Healthy GSH:GSSG ratio = >100:1 in cytosol
Decrease in this ratio = oxidative stress marker

ii. Medical & Aesthetic Uses of Glutathione

1. Liver Disorders

Mechanism: Detoxifies hepatotoxic substances; replenishes hepatic GSH stores.
Indications: Alcoholic hepatitis, NAFLD, drug-induced hepatitis (e.g., paracetamol toxicity), viral hepatitis (supportive).
Form: Oral or IV

2. Neurodegenerative Diseases

Mechanism: Protects dopaminergic neurons from oxidative damage.
Indications: Parkinson’s Disease, Alzheimer’s Disease (supportive therapy).
Evidence: Studies suggest slowed disease progression in Parkinson’s.

3. Chronic Kidney Disease (CKD)

Mechanism: Reduces oxidative stress and inflammation in renal tissues.
Adjunct: Used along with other nephroprotective agents.

4. Diabetes Mellitus

Mechanism: Reduces insulin resistance via antioxidant effect.
Application: Supports glucose metabolism and protects pancreatic β-cells.

5. Autoimmune & Inflammatory Disorders

Mechanism: Modulates immune activity through cytokine and T-cell regulation.
Applications: Lupus, rheumatoid arthritis (experimental/supportive).

6. Pulmonary Diseases

Indications: ARDS, cystic fibrosis, and COVID-19 (investigational use).
Route: Nebulized GSH is being studied for direct pulmonary antioxidant effects.

7. Cancer (Supportive Use)

Use: Protects normal tissues from chemotherapy-induced toxicity.
Caution: May protect tumor cells—must be used judiciously and under oncologist supervision.

Aesthetic (Cosmetic) Uses of Glutathione

1. Skin Lightening / Brightening

Mechanism:
- Inhibits tyrosinase (enzyme for melanin synthesis)
- Promotes pheomelanin (light pigment) over eumelanin (dark pigment)
- Antioxidant effect reduces UV-induced melanogenesis
Effect: Gradual skin lightening, more noticeable in Fitzpatrick I–IV
Form: Oral, IV, liposomal, topical (limited absorption)

2. Melasma & Hyperpigmentation

Mechanism: Reduces oxidative stress that exacerbates pigmentation
Effectiveness: Best with combination treatments (e.g., tranexamic acid, laser)

3. Anti-Aging

Mechanism: Slows cellular aging by reducing free radical accumulation
Result: Improved skin elasticity, reduced fine lines (limited clinical data)

4. Acne & Post-Inflammatory Hyperpigmentation (PIH)

Mechanism: Anti-inflammatory and antioxidant effects reduce lesion severity and pigmentation
Benefit: Improved healing and reduced post-acne marks

Limitations & Ethical Considerations

Concern	Notes
Regulatory Approval	IV glutathione for skin lightening is not FDA-approved
Overuse Risks	Long-term high-dose IV use may suppress natural GSH synthesis
Unrealistic Expectations	Skin lightening takes months and varies by skin type
G6PD Deficiency	Risk of hemolysis—screen before IV use
Lack of Standard Protocols	Dosing and duration not standardized in aesthetic practice

Functions of Glutathione

A. Antioxidant Defense

Neutralizes reactive oxygen species (ROS) and free radicals
Regenerates Vitamin C and Vitamin E

B. Detoxification

Conjugates with toxins and xenobiotics (via glutathione-S-transferase) for renal excretion

C. Redox Signaling

Maintains intracellular redox homeostasis
Regulates transcription factors (e.g., NF-κB, AP-1)

D. Immune Modulation

Enhances T-cell proliferation, antigen presentation, and NK cell activity

E. Protein and Enzyme Regulation

Reduces disulfide bonds in proteins (maintaining proper folding)

F. Skin Pigmentation

Inhibits tyrosinase enzyme (blocks melanogenesis)
Converts melanin production from eumelanin (dark) to pheomelanin (light)

Routes of Administration

Route	Pros	Cons
Oral	Convenient, available as tablets	Poor bioavailability due to GI breakdown
IV	Fast action, 100% bioavailability	Risk of allergy, controversial long-term use
Sublingual	Better absorption than oral	Limited data
Liposomal	Enhanced oral bioavailability	More expensive
Nebulized	Used in respiratory support	Limited clinical approval

IV. Indications

Glutathione therapy may be administered in the following medical and aesthetic contexts:

A. Medical Indications

Condition	Rationale
Liver diseases (e.g., alcoholic hepatitis, NAFLD, drug-induced hepatitis)	Protects hepatocytes from oxidative damage, supports detoxification
Chronic kidney disease (CKD)	Reduces oxidative burden in renal tissues
Parkinson’s Disease	Preserves dopaminergic neurons from oxidative degeneration
Diabetes Mellitus	Helps lower oxidative stress, supports insulin sensitivity
Autoimmune disorders	Modulates immune responses via redox control
COVID-19 / ARDS (experimental)	Reduces oxidative inflammation in lung tissues
Cancer (supportive care)	Protects normal cells during chemotherapy (controversial role in tumors)

B. Aesthetic Indications

Concern	Use
Skin brightening/lightening	Inhibits melanin synthesis and tyrosinase activity
Melasma, hyperpigmentation	Reduces oxidative stimulation of melanocytes
Anti-aging	Slows oxidative cellular damage contributing to aging
Detox/Wellness protocols	Popular in wellness and IV drip clinics for “cellular cleansing”

General Safety Profile

Glutathione is endogenously produced in the human body and is generally well tolerated when used in physiological or therapeutic doses. However, adverse effects may arise due to inappropriate dosing, incorrect administration routes, or individual susceptibility (e.g., genetic conditions like G6PD deficiency).

Common Side Effects

Route	Side Effects	Frequency
Oral	Abdominal cramps, bloating, metallic taste	Uncommon
IV	Headache, dizziness, flushing, nausea, mild rash	Occasional
Inhaled	Cough, chest tightness, bronchospasm (especially in asthmatics)	Rare
Topical	Contact dermatitis, allergic rash	Rare

2. Serious Adverse Effects

Although rare, the following complications can occur, particularly with high-dose IV glutathione:

A. Anaphylaxis

Symptoms: Rash, difficulty breathing, hypotension
Onset: Minutes after IV administration
Risk Factors: History of drug allergies, IV bolus injections

B. Bronchospasm

Most common in patients with asthma or COPD
May occur with inhaled or IV forms

C. Renal Stress

High doses may cause osmotic stress on the kidneys
Monitor renal function in patients with pre-existing CKD

D. Hemolysis in G6PD Deficiency

Mechanism: Glutathione recycling impaired, leading to red cell damage
Screening: G6PD testing mandatory before IV therapy

3. Controversial & Unproven Risks

Risk	Evidence Level	Comment
Skin cancer risk	Theoretical	No clinical proof, but altering melanin balance is debated
Tumor progression support	Experimental	GSH protects all cells—may reduce chemotherapy efficacy
Infertility	Minimal	Anecdotal only; no solid clinical correlation

4. Overdose & Toxicity

While no established lethal dose exists for glutathione, excessive or prolonged use can lead to:

Disruption of redox balance
Rebound oxidative stress upon withdrawal
Unknown long-term aesthetic effects

5. Contraindications

Condition	Reason
G6PD deficiency	Risk of hemolytic anemia
Severe asthma	Risk of bronchospasm
Allergy to glutathione/sulfur	Potential for hypersensitivity
Pregnancy & lactation	Insufficient safety data

6. Safety Recommendations for Clinical Use

Screen patients for G6PD deficiency
Perform a patch test for topical application
Use slow infusion for IV administration (avoid bolus)
Avoid unregulated high-dose IV regimens
Always obtain informed consent, especially for aesthetic use
Educate patients about realistic expectations and possible adverse effects

7. Regulatory Status & Ethical Considerations

Aspect	Notes
FDA approval	Approved for liver disease and acetaminophen toxicity
IV skin lightening use	Not FDA-approved; off-label and controversial
Marketing caution	Many cosmetic clinics make unproven health claims
Ethical use	Medical justification must outweigh cosmetic demand

Clinical (Medical) Combinations

A. With N-Acetylcysteine (NAC)

Use: Hepatic protection, detox, oxidative stress
Rationale: NAC is a glutathione precursor that replenishes intracellular stores
Example: Acetaminophen overdose, alcoholic hepatitis

B. With Alpha-Lipoic Acid (ALA)

Use: Diabetes, neuroprotection, detox
Rationale: Both are antioxidants; ALA recycles GSH and reduces oxidative inflammation

C. With Vitamin C & E

Use: Chronic diseases, immune modulation
Rationale: Synergistic antioxidant effect; Vitamin C helps regenerate glutathione from oxidized form (GSSG)

D. With Chemotherapeutic Agents (Cisplatin, Doxorubicin – Supportive)

Use: Cancer (supportive care)
Rationale: Protects healthy cells from chemotherapy-induced oxidative damage
Caution: May protect tumor cells—only under oncologist supervision

Aesthetic (Cosmetic) Combinations

A. Glutathione + Vitamin C (Ascorbic Acid)

Use: Skin lightening, melasma, anti-aging
Rationale:
- Vitamin C stabilizes glutathione in plasma
- Enhances tyrosinase inhibition
Route: IV, oral, or topical

B. Glutathione + Tranexamic Acid

Use: Melasma, PIH (post-inflammatory hyperpigmentation)
Rationale: TXA inhibits melanocyte-stimulating pathways; works well with GSH
Route: Oral or mesotherapy

C. Glutathione + Glutamine + Collagen Peptides

Use: Anti-aging and skin rejuvenation
Rationale: Enhances skin firmness, hydration, and antioxidant defense
Often marketed as “IV beauty drips” or wellness infusions

D. Glutathione + Microneedling (Topical Application Post-Procedure)

Use: Hyperpigmentation, aging, dull skin
Rationale: Microneedling enhances transdermal absorption of topical glutathione
Protocol: Apply GSH serum immediately post-needling

E. Glutathione + Chemical Peels (e.g., Glycolic Acid, Kojic Acid)

Use: Skin brightening, acne scars, melasma
Rationale: Peels remove upper pigmented layers; GSH helps prevent rebound pigmentation

F. Glutathione + Laser Therapy (e.g., Q-Switched Nd:YAG)

Use: Melasma, freckles, uneven skin tone
Rationale: Laser reduces melanin; GSH maintains even skin tone post-treatment

Summary Table: Aesthetic Protocol Examples

Goal	Combination	Route
Skin lightening	Glutathione + Vitamin C + Oral sunblock	Oral/IV
Melasma treatment	Glutathione + Tranexamic Acid + Microneedling	Oral/topical
Anti-aging	Glutathione + Collagen + Vitamin C	IV/Oral
Post-laser recovery	Glutathione + Hyaluronic Acid serum	Topical

Hair Transplantation

Module 1: Introduction to Hair Loss & Transplantation

Definition of alopecia – AGA (androgenetic), alopecia areata, cicatricial, telogen effluvium
Epidemiology: Common age groups, male vs female prevalence
Genetic & hormonal basis – Role of DHT (dihydrotestosterone) in AGA
History of hair transplant – Dr. Norman Orentreich’s work to modern techniques
Medical vs Surgical treatment – Indications for hair transplant (stable hair loss)

Module 2: Anatomy & Physiology of Hair

Structure of hair follicle – Shaft, root, bulb, dermal papilla, sebaceous gland
Hair cycle:
- Anagen (growth): 85-90% of scalp hairs
- Catagen (regression): 1-2%
- Telogen (resting): 10-15%
Hair follicle types – Terminal vs vellus
Scalp anatomy: 5 layers (“SCALP”) – Skin, Connective tissue, Aponeurosis, Loose areolar tissue, Pericranium
Vascular & nerve supply – Important during harvesting

Module 3: Evaluation & Diagnosis

Trichoscopy – Diagnostic tool to visualize scalp and hair
Classification systems:
- Norwood-Hamilton scale (Male AGA)
- Ludwig scale (Female AGA)
- Savin scale, BASP classification
Scalp biopsy indications: To rule out scarring alopecia
Laboratory work-up: Thyroid function, iron profile, hormonal panel in female patients
Contraindications: Active scalp infection, unstable alopecia areata, keloid history

Module 4: Transplant Techniques Overview

FUE (Follicular Unit Extraction)

Principle: Individual extraction of FU with small punch
Tools: Motorized, manual punches (0.8–1.0 mm)
Less scarring, faster healing

FUT (Follicular Unit Transplantation/Strip method)

Excision of scalp strip from donor
Slivering under microscope
Linear scar but more grafts per session

Modified FUE with immediate implantation via Choi pen
No need to pre-make slits

Comparison table: Yield, time, scarring, cost, recovery

Module 5: Donor Area Planning

Safe donor zone (SDZ): Occipital-parietal area, resistant to DHT
Donor density assessment: FU/cm² (Normal: 60–100)
Extraction planning: Avoid overharvesting, maintain natural density
Punch size selection: 0.8 mm for finer hair, 1 mm for coarse

Module 6: Graft Harvesting

Depth of punch: Just beyond isthmus
Follicular transection rate (FTR) – Should be <5%
Handling grafts: Atraumatic, avoid desiccation
Slivering (FUT): Use of stereomicroscope to isolate FU
Storage:
- Mediums: Chilled saline, Ringer’s lactate, HypoThermosol®, PRP
- Temperature: 4°C
- Maximum safe ischemia time: 4–6 hours

Module 7: Recipient Site Creation

Slit design principles: Direction, angle (30–40°), depth
Density planning:
- Hairline: 30–40 FU/cm²
- Mid-scalp: 40–60 FU/cm²
Tools: Slit blades, needles, implanter pens
Zones: Frontal, temporal, crown, vertex — each has unique orientation

Module 8: Graft Implantation Techniques

Implantation tools:
- Forceps method
- Sharp/Blunt Choi implanters
Single vs multiple technician system
Bleeding control: Adrenaline-soaked gauze
Graft dehydration risk: Keep moist with chilled saline every 5–10 mins

Module 9: Aesthetic Planning

Frontal hairline design: “Zig-zag” pattern, avoiding straight line
Temporal angle design: Acute angles for natural look
Gender difference:
- Males: M-shaped hairline
- Females: Rounder, lower
Face proportions: Golden ratio relevance

Module 10: Postoperative Management

First 7 days: Saline spray, antibiotics, avoid head trauma
10–15 days: Scab shedding
1 month: Shock loss
3–4 months: Visible regrowth
9–12 months: Final result
Medications:
- Minoxidil 5%
- Finasteride 1 mg (males only)
- Biotin, multivitamins
- PRP every 30–45 days post-op

Module 11: Complications

Immediate: Bleeding, pain, dizziness
Delayed:
- Folliculitis
- Shock loss
- Cobblestoning
- Donor area necrosis
- Pitting/ridging
Prevention: Proper technique, sterile field, hydration, careful planning

Module 12: PRP & Adjunct Therapies

PRP (Platelet Rich Plasma):
- Autologous, growth factor rich
- Activates dormant follicles
- Procedure: 15–20 ml blood, centrifugation, scalp injection
LLLT (Laser therapy):
- 630–660 nm red light
- Improves mitochondrial activity in follicular cells
Mesotherapy:
- Cocktail of vitamins, minoxidil, peptides
Oral support: Biotin, zinc, omega-3, saw palmetto

Module 13: Special Indications

Beard transplant: Male aesthetics, post-trauma
Eyebrow transplant: Artistic angling
Scalp scar camouflage: Post burn/trauma
Transgender care: Gender-affirming hairline design

Module 14: Ethics & Consent

Consent form components:
- Risks, expectations, number of grafts, anesthesia
Medical photography consent
Marketing ethics: No false claims, realistic before-after photos
Legal considerations: Licensing, trained staff, OT compliance

FACE ACNE SCAR

1. Introduction

Definition:

Acne scars are permanent changes in skin texture or pigmentation following inflammatory acne. Scars result from dermal collagen destruction or excess deposition during healing.

Epidemiology:

Affects up to 95% of acne patients to varying degrees.
More prevalent in Fitzpatrick Skin Types IV-VI due to risk of PIH.

2. Pathophysiology of Acne Scarring

Inflammatory Process:

Inflammatory lesions (papules, pustules, nodules) → dermal injury.
Neutrophils & cytokines (IL-1, TNF-α) stimulate MMPs.
Matrix metalloproteinases (MMPs) → collagen breakdown.

Healing Response:

Insufficient collagen = Atrophic scars
Excess collagen = Hypertrophic or Keloid scars
Melanocyte stimulation = PIH

Classification of Acne Scars

A. Atrophic Scars (80–90%)

Ice Pick Scars
- Deep, narrow, V-shaped (<2 mm)
- Extend into dermis/subcutis
- Most difficult to treat
Boxcar Scars
- Broad, sharp edges
- U-shaped; can be shallow or deep
- Common on temples and cheeks
Rolling Scars
- Wavy, shallow depressions with ill-defined borders
- Caused by dermal tethering

B. Hypertrophic & Keloid Scars

Thick, raised, fibrous tissue
Extend beyond the original acne lesion (keloid)
Common over chest, back, jawline

C. Post-Inflammatory Hyperpigmentation (PIH)

Epidermal PIH – brown color
Dermal PIH – gray-blue color
More visible in skin types IV–VI

4. Clinical Evaluation

Assessment Parameters:

Scar type(s) and extent
Depth (superficial vs deep)
Fitzpatrick skin type
Skin texture and elasticity
Patient’s psychological concern

Grading Systems:

Goodman and Baron Scoring System
ECCA Score (Echelle d’Evaluation Clinique des Cicatrices d’Acné)

5. Treatment Modalities: Overview by Scar Type

Scar Type	Best Treatments
Ice Pick	TCA CROSS, Punch Excision
Boxcar	Subcision, Laser, Microneedling
Rolling	Subcision, Microneedling, RF
Hypertrophic	IL Triamcinolone, Silicone, Laser
PIH	Topicals, Chemical Peels, Non-ablative Laser

6. Advanced Treatment Modalities

A. Laser Resurfacing

Fractional CO₂ Laser
- Ablative, improves texture and collagen remodeling
- Downtime: 5–7 days
Er:YAG Laser
- Precision with lower heat damage

B. Microneedling

Controlled dermal injury via 0.5–2.5 mm needles
Stimulates neocollagenesis
Best for rolling scars
Often combined with PRP (vampire facial)

C. Subcision

Performed using Nokor or blunt-tipped cannula
Used for tethered rolling scars
Combines well with fillers or RF

D. TCA CROSS

High concentration (70–100%) TCA applied focally
Induces dermal remodeling
Best for ice pick scars

E. Punch Excision/Elevation

Surgical removal or elevation of deep boxcar or ice pick scars
Requires good wound healing

7. Adjunct Therapies

Dermal Fillers:

Temporary correction (Hyaluronic Acid)
Restore volume under atrophic scars
Duration: 6–12 months

Chemical Peels:

Superficial: Glycolic, Salicylic, Lactic acids
Medium: TCA (15–35%)
Improve pigmentation and superficial scars

Platelet-Rich Plasma (PRP):

Enhances wound healing
Stimulates fibroblasts and collagen
Used with microneedling/lasers

8. Complications & Risk Management

Complications:

PIH (especially in darker skin)
Erythema, edema, scabbing
Infection (bacterial, viral)
Worsening of scars (over-aggressive treatment)

Prevention:

Priming with hydroquinone + retinoids before procedures
Sunscreen post-treatment
Aseptic technique

9. Case-Based Clinical Discussions

Case 1: Rolling + Boxcar Scars (Type IV Skin)

Treatment: Subcision + Microneedling RF
Follow-up: PRP + TCA 20% Peels
Outcome: 60–70% improvement in texture

Case 2: Ice Pick Scars + PIH (Type V Skin)

Treatment: TCA CROSS + Topical depigmenting agents
Complication: Mild PIH – managed with sunscreen & azelaic acid

Case 3: Hypertrophic Scar on Jawline

Treatment: IL triamcinolone + silicone gel
Alternative: Pulsed dye laser for erythema

10. Summary

Accurate scar classification is key to treatment planning.
Combination therapies yield the best results.
Always consider patient skin type, tolerance for downtime, and psychological impact.
Monitor for complications and counsel patients on realistic expectations.

Diploma Course in Aesthetic Dermatology & Skincare

DAY – 02
Botox
Filler
Thread

BOTULINUM TOXIN

Background Of BOTOX

Botulinum Toxin is a neurotoxin made by the bacteria Clostridium Botulinum; an anaerobic bacteria found in soil. Botulinum Toxin is purified for clinical and cosmetic use.
First used in the late 1960’s.
In patients used for facial spasms and it was then noted that facial wrinkling decreased over time.
First approved in 2002 by the FDA and has since then been used by medical professionals to inject millions of patients each year to successfully treat wrinkles and facial creases.

Medical Indications

Blepharospasm – Involuntary spasms of the eyelid muscles causing excessive blinking.
Idiopathic cervical dystonia (spasmodic torticollis) – Involuntary movements/contractions of the neck muscles.
Severe Hyperhidrosis – excessive sweating of the armpit which does not respond to antiperspirants.
Overactive bladder – Leakage of urine due to bladder problems associated with spinal cord injury or multiple sclerosis, not adequately controlled with anticholinergic

medicines.

Hemifacial spasm, a neuromuscular disorder characterised by unpredictable and involuntary twitching of facial muscles on one side of the face.
Migraine – BOTOX® is licensed specifically for the treatment of chronic migraine but has not been shown to be effective for any other headache type (e.g., episodic migraine, tension type headache, cluster headache) yet.

Cosmetic Uses

Glabellar lines (Corrugator Supercilii, Procerus, & Depressor Supercilii)
Crow’s feet – Orbicularis Oculi
Forehead lines – Frontalis
Downturned corners of the mouth
Excessive sweating
Correct facial asymmetry
Bunny lines
Eyebrow lifting
Wrinkles caused by sun damage and gravity will not respond to Botox

Product Safety

Botox has a long clinical history
Maximum dose per treatment for muscle spasms is 400 units
Cosmetic doses range between 20 – 80 units

Mechanism Of Action

Once injected into the muscle, the mechanism of action of botulinum toxin is to cause temporary muscle paralysis through inhibiting the release of the neurotransmitter acetylcholine from motor nerve terminals. This prevents muscular contraction and hence creates the desired cosmetic effects. With time, synaptic-sprouting and receptor formation leads to the reoccurrence of muscular contractions and hence the ‘wearing off effect’ of botulinum toxin.

Fig. 1. Botox effect on muscle nerve terminals

What To Tell Your Patient

Tiny quantities of the toxin are injected directly into the affected muscles. It takes three to five small injections between the eyebrows to treat frown lines. The injection is almost painless. The treated muscles weaken over the following week or so. Most people do not notice anything. They simply become aware that they are no longer able to contract the frown muscles. They can still lift their eyebrows normally and blink

without problems.

The effects of Botulinum Toxin start wearing off within 3 months. Some areas may return to activity sooner or later depending on the injection area, muscle strength, who did the injection and amount injected.
Many people find after three or four treatments to glabellar lines that they don’t need another one for a long time, the muscles have weakened, or they have broken the bad habit that led to the frowning or squinting originally.

The Consultation

Understand patients desires and preferences
Avoid dissatisfaction by establishing realistic expectations
Botox does not erase lines it relaxes them. Deeper lines will become less deep and superficial lines will nearly disappear
Under inject on the 1st appointment
Photographs
Accurate medical history including allergies
All medication (e.g., blood thinners)
Future & past surgery
Assess for weakness of forehead muscles / drooping eyelids

Side Effects

Mild-temporary headache
Swelling and bruising (can occur even among the most skilled injector. Take precautions to watch out for vessels or aggressive manoeuvring)
Tenderness
Dry eyes / mouth
Muscle weakness / fatigue / heaviness

Headache and injection-site reactions have been reported as the most common adverse effects.

Cautions & Contradictions

Contraindications for Treatment:

Those with a known hypersensitivity to Botulinum Toxin Type A or to any of its’

excipients e.g., human albumin, and sodium chloride.

Neuromuscular disorders such as myasthenia gravis or Eaton Lambert Syndrome.
Pregnancy or breast feeding.
Co-treatment with Aminoglycoside antibiotics, or medicinal products which interfere with neuromuscular transmission (e.g., tubocurarine – type muscle relaxants).
< 18 years old
Concurrent use of Anticoagulants, Aspirin, Vitamin E, Chloroquine, Calcium antagonists Cautions for Treatment:
- Caution should be used in those with coagulation disorders or using anticoagulants due to the increased likelihood of bruising.
- Caution should also be used in patients with Amyotrophic lateral sclerosis or with peripheral neuromuscular disorders.

Different Brands of Botox

Botox® Type A, Dysport®, Azzalure®, Xeomin®, Bocouture®.
2002 – Allergan earned FDA approval for cosmetic use.

Dilutions of Various Botulinum Toxins

There are many different botulinum toxins available commercially. The three main manufacturers are Allergan, Merz and Galderma. All vials come in powder form which must be reconstituted for injection with 0.9% sodium chloride solution. This process should be done slowly to avoid denaturing the product. Once reconstituted it must be used within a period of 2 weeks, after this it loses efficacy.

Botulinum toxin effects start within 2 weeks and will generally last for around 3 – 4 months. Immunogenicity with botulinum toxin is typically reported when large doses are injected for therapeutic rather than cosmetic reasons. Immunogenicity may be avoided by administering treatment no less than 3 monthly and by avoiding top-up treatments.

The table below outlines the 3 main groups and their respective preparations and dilutions: Botox, Azzalure and Bocouture:

There are a number of product brands under the different Botulinum toxin A subtypes listed above:

Type of Botulinum Toxin A	Saline Reconstitution	Units per 0.1ml
Allergan Botox 50 Units	1.25ml	4 units
Allergan Botox 100 Units	2.5ml	4 units
Bocouture 50 Units	1.25ml	4 units
Bocouture 100 Units	2.5ml	4 units
Azzalure 125 SU	0.63ml	20 SU

Practitioners may inject botulinum toxin with differing dilutions, different angles and different injection techniques which is acceptable however each product will have specific manufacturer guidelines regarding dilution, dosing and injection sites. Botox is typically diluted with 2.5ml per 100 units of normal saline. Azzalure 125 SU is typically diluted with 0.63ml saline giving a concentration of 10SU/0.05mls.

Patient Positioning

Positioning the Patient

The most commonly used and ideal position to administer treatment is to have the client sitting upright between 60 and 90 degrees. The reason for this is twofold:

To be on a similar level and dimension to the injector
To identify gravitational effects which may influence treatments.

Equipment

Equipment needed for diluting and administering toxin treatments the following are needed:

1ml syringe
Green 21 gauge needle (1.5 inch) for dilution
Yellow 30 gauge needle (1/2 inch) for injection
Antiseptic/sterile wipes
Gauze pads
Sharps bin

Injection Precautions

Always wash hands and glove-up prior to injecting
Make sure the scale on the syringe is visible to monitor dosage
Be aware of needle depth and angle of injection in certain areas
Always inject away from key structures like the orbit and vessels
Mark out landmarks prior to injection according to your client’s anatomy

Treatment areas

Knowledge of the relevant facial anatomy is pertinent prior to administering treatments:

Preparation

Wash hands.
Disposable gloves/apron.
Sharps Bin.
Headband.
White marking pencil.
Syringes.
Alcohol wipes.
Bacteriostatic saline.
Emergency equipment.

Reconstitution

Key Points: avoid bubbles, avoid forcing saline into vial, draw up slowly.
Botox has to be stored in fridge. (2-8 degrees)
Make sure vial is sealed before opening.
Check expiry date.
Remove lid.
Put the green needle in the middle of vial – listen to the hiss.
Withdraw 1.25mls – get rid of air.
Ensure no bubbles.
Rotate vial gently to mix until clear liquid – do not shake.
Prime needle right to the end.

The Procedure (Cleansing)

Head band to facilitate exposure.
Skin preparation, clean skin with alcohol wipes.
Wipe away from injecting area.
Ensure no oil moisturizers.
Apply Emla topically if needle phobic. (rub off after 15mins)

The Procedure (Marking)

Assess & mark the face even if you are experienced – good practice takes time.
Contract the muscles and note where the wrinkles are forming.
Use the white pencil to mark the intended injection sites.
Procerus – should ideally be in the middle of the eyebrows.
Corrugator – bulge above the eye. Mark out mid pupillary line do not inject lateral to this point! Avoid ptosis & brow drop.
Frontalis – bear in mind the muscle runs vertical so therefore do not mark in the triangle. In females we tend to inject in a V pattern. (Sometimes wrinkle go into the hair line so be mindful and mark). Do not inject within 1cm of the brows.
Periorbital – feel orbital rim in line with the lateral campus of eye. Mark 1cm from it, with superior and inferior boarders.

Muscles

1st Procerus – contracts and creates frown. Pinch muscle for improved accuracy. Inject directly into the muscle.
2nd Corrugator Supercilii – lifts and separates – long muscle requires two injections. Pinch muscle and inject away from eye.
3rd Frontalis – thinner so don’t need to go as far in – requires 5 injections – lifts upwards therefore Botox relaxes. It can cause a big problem if it is not done correctly.
4th Orbicularis Oculi – crow’s feet (3 injections – vascular therefore higher risk of bruising).
5th Depressor Supercilii – bunny lines.

The Most Popular Treatment Areas:

Glabellar / Frown Lines

Treatment of vertical glabellar frown lines is perhaps the most commonly administered BOTOX® treatment. Vertical frown lines form in the glabellar area after repeated frowning caused variously by expressions of disapproval, anxiety, and anger.
Primary muscles: Corrugator Supercilii, Procerus, Depressor Supercilii.

Frontalis / Forehead Lines

This muscle group works to pull the eyebrows up.

Text Box: “Rule of 4’s”
• 4 injections
• 4cm above orbital rim
• Use canthi of eyes as landmarks
• Superficial injections (1/3 of needle)
• May cause heaviness - this is not brow droop

Before & After

Orbicularis Oculi / Crows Feet

This muscle is made up of a dual series of concentric curves. The Palpebral part surrounds the circumference of the orbit and spreads over the temple. The Orbital part blends with Frontalis and Corrugator. Together these curves screw the eye shut and pull down the eyebrow.

Text Box: • Get the client to smile to assess prior
• 3 superficial injections at 20 degrees
(1/3 or tip of needle)
• 2.5 units per site
• Landmarks: 1cm from orbital rim, 1cm between each landmark to create a semicircle
• Inject away from the orbit and watch out for vessels

Before & After

Allergan and Bocouture Dosages

Recommended Botulinum Toxin Dosages

Gender Differences

Gender importance, due to men having larger muscle mass.
Shape of male brow is horizontal, and females is a gentle arch.
In studies most used is 20-30 units in the glabella for women.
Men frequently required larger doses.
Thicker sebaceous skin requires higher doses.

Complications and Management

Brow Ptosis – Often the result of injecting into the wrong muscle group (Frontalis) within the danger zones. Cannot be corrected, must allow natural Resolution.

Eyelid Ptosis – Often results from injecting to close to the palpebral part of the Orbicularis Oculi. Can either allow natural resolution (usually 2-6 weeks), or consider Iopidine (Alcon) eye drops three times a day until resolution

Spock Eyes – ‘SPOCK EYEBROWS’ – often a result too few Lateral frontalis injections. Ask your client to raise eyebrows and inject a small amount (1-2 units), 1.5- 2cm above the frontalis pull.

Forehead Heaviness – often a result of injecting too low. In future maintain injection sites higher.

Post Treatment Advice & Reviews

It is good practice to review all patients 2 weeks after treatment. Firstly, you will learn from your work, and secondly, you will gain an understanding of what works for each patient you treat. Reviews are generally free of charge and enable you to ‘top-up’ if an unsatisfactory outcome is achieved. Should top-up treatments of botulinum toxin be required, often the same dosage or half the original dosage is required. This should be accurately documented for future use.

Aftercare Advice:

Avoid high intensity exercise immediately following treatment for 24hrs
Avoid touching/rubbing areas injected
Avoid heavy alcohol consumption on same day
Remain upright for at least 3hrs afterwards
Exercise injected muscles
Full effect will be at around 2 weeks
Duration of action ~3 months

Causes of Treatment Failure Include:

Incorrectly placed toxin
- Suboptimal dose (offer a top-up either at a lower dose or consider original dose again)
- Inactivated toxin due to poor storage
- Resistance due to blocking antibodies

Advanced Botulinum Toxin Procedures

Hyperhidrosis (Excessive Sweating)

Superficial dermal injections into apocrine sweat glands preventing sweat production. This doesn’t cure hyperhidrosis but provides temporary relief and needs to be repeated every five to six months for maximum effect.

Landmarks: Draw around hair follicles, create 20 injection sites.
Dose: 2 units in each injection site, 40 units per axilla, 80 units per patient.
Onset: With 1 week.
Duration: 4-6 months.

Massater Muscle

Botox is injected into the ‘chewing’ muscles of the jaw (called the massater muscle) to

reduce its size.

Landmarks: Into thickened masseter below the ear (palpate the masseter by asking patient to clench their teeth then relax). Draw 4 compartments, injecting the centre of each – insert 1⁄2 to 2/3rd of needle at 90°
Dose: 4 injections of 4 units, 32 units in total – top up in 4 weeks with half the dose.
Onset: 4-6 weeks
Duration: 4-6 months

Brow Lift

Landmarks: tail of brow, into Orbicularis Oculi (Superficial 20°injection into the upper part of the orbicularis oculi, 1cm from orbital rim)
Dose: 1 injection of 2 units, 4 Units in total – top up in 2 weeks with same dose.
Onset: 2 weeks.
Duration: 3-4 months.

It is important to point the injection needle superiorly to avoid downward dispersement of the Botox.

Bunny Lines

Landmarks: each side of nasal bridge – superficial 90° injection either side of the while the patient is asked to contract the muscle.
Dose: 1 injection of 2 units each side, 4 units in total – top up in 2 weeks with same dose.
Onset: 2 weeks

Gummy Smile

A gummy smile is usually caused by an overactive upper lip muscle that lifts the lip too high when smiling, revealing too much of the gum line

Landmarks: both nasal alar triangles. 90° injection, half the needle in the middle of triangle
Dose: 1 injection of 2 units each side, 4 units in total – top up in 2 weeks with same dose or half the dose
Onset: 2 weeks.
Duration: 3-4 months.
Nicely combined with lip fillers.
Patients should be told that they may feel funny when smiling, whistling, and sometimes eating as the lack of movement can come as quite a surprise to some of them.

Caution must be taken as excessive Botox in the lower face may have very obvious cosmetic and functional impairment. It is very important to start conservatively when treating this area – you can always add more if needed.

Down Turned Mouth

Depressor Anguli Oris (DAO): pulls down corners of mouth (while Zygomaticus pulls up). A

small amount of Botox into the DAO muscle can diminish the downward pull on the corners of the mouth and allow the muscles that elevate the corners to take over hence subtly lifting the corners of the mouth.

Identified by asking patient to show lower teeth or look upset → creates ‘dimple’.

Landmarks: 1 injection site below each oral commissure – draw line from oral

commissure to jawline. Inject halfway between them (into dimple) inserting half the needle at 90° angle.

Dose: 2 injections of 2 units, 4 units in total – top up in 2 weeks with same dose
Onset: 2 weeks
Duration: 3-4 months

Pebble Dimpled Chin / Mentalis

Mentalis: repeated contractions can cause ‘dimpling’ – Botox relaxes and smoothens the chin & mental crease.

Landmarks: 2 injections 1cm apart at the bottom / central of chin.
Dose: 2 injections of 2 units, 4 units in total – top up in 2 weeks with same dose.
Onset: 2 weeks.
Duration: 3-4 months.
To identify this muscle, ask patient to ‘pout’ or lift up the lower lip. Place index finger in

the middle of chin, pinch the muscle and insert half the needle at 90° angle.

Smokers Lines aka Perioral Lines / Orbicularis Oris

Smokers/perioral radial lines are fine wrinkles and lines on the upper and/or lower lip that are caused by the contraction of the Orbicularis Oris muscle that surrounds the mouth.

Perioral radial lines can be treated in a number of ways. If the lines are early in their development and are visible only when the perioral muscles contract and purse the lips, relaxation of the perioral muscles with Botox can be used,

· Landmarks:

Botox: 4 injections 5mm above VB, injected at 90 degrees at a depth of about 2 mm
Filler: superficial, 5mm above VB, linear threads injected parallel to the vermilion border, at a depth of 1-2 mm.

o Don’t inject into philtrum

Dose: 4 injections of 1 unit, 4 units in total – top up in 2 weeks with same dose.
Onset: 2 weeks.
Duration: 3-4 months.

Neck Botox / Platysmal Bands & The Nerfertiti Lift

This is a new technique which involves placing multiple injections of Botox horizontally along the lower jawline and vertically down the side of the neck along the platysmal band muscles.

Landmarks: either side of trachea → trapezius.
Dose: 24 injections of 2 units, 48 units in total.
Onset: 4 weeks.
Duration: 4 months.

Tips

Every action has a reaction.
Professional environment.
Good lighting.
No bubbles.
Beware superficial veins especially for crow’s feet injections.
Always use white pencil for markings.
Practice taking photos.
Be safe – avoid needle stick injury.

Obtaining Botox

Botulinum Toxin is a prescription only medicine (POM) which means that it has to be prescribed by an authorised health care professional (e.g., doctors, dentists, nurse prescribers that have trained in the administration of botulinum toxin) and has to be dispensed from a pharmacy.
If you are a non-prescribing practitioner, you will need to use either a prescribing service or buddy up with a local prescriber in order to obtain a prescription for Botulinum Toxin. Your prescriber will need to complete an initial face to face

consultation with the patient before writing the prescription, but they do not need to be present when you administer it.

After obtained a prescription for Botulinum Toxin, you will need to order the product. Your prescriber might order it on your behalf. Have it sent out to you or order it yourself through an online pharmacy. Your prescriber will have to electronically sign the prescription before the transaction is approved.

Safety & Infection Control

Injectable treatments provide a direct route for infectious pathogens to enter the

circulatory system and puts the practitioner at risk of exposure to the patient’s blood.

Always assume that all “blood and body fluids” are infectious for blood-borne diseases such as HIV, Hepatitis B and Hepatitis C.

The following standard infection control precautions help reduce the risk of healthcare acquired infections.

· Hand hygiene

Good hand hygiene is the single most important way of preventing the spread of infection. Hand hygiene describes processes that reduce the number of micro-organisms and includes hand washing and use of alcohol gel. Effective hand hygiene involves making sure all aspects of the hands have been cleaned
- If hands are visibly soiled or potentially contaminated wash hands with antibacterial soap and water and dry with single use towels

If hands are not visibly contaminated, clean with alcohol rub
- To support compliance with hand hygiene in the workplace, practitioners should meet the following standards while working:
  - keep nails short, clean and polish free
  - avoid wearing wrist watches and jewellery
  - avoid wearing rings with ridges or stones (a plain wedding band is usually acceptable)
  - cover any cuts and abrasions with a waterproof dressing
  - wear short sleeves or roll up sleeves prior to hand hygiene

· Personal Protective Equipment (PPE)

Standard infection control precautions advise that practitioners should wear protective clothing appropriate to the clinical activity.

· Gloves

Practitioners should wear well fitting, non-sterile gloves when taking blood (gloves should be close fitting otherwise dexterity will be impaired). Practitioners should also carry out hand hygiene before and after each patient procedure (use one pair of gloves per procedure or patient).
- Natural latex rubber (NLR) proteins found in latex gloves can cause severe allergic reactions – following a risk assessment, if latex gloves are selected, they must be low protein. Neoprene or nitrile are good alternatives to NLR showing comparable barrier performance.

· Skin cleansing

The use of an appropriate skin disinfectant will reduce the number of micro- organisms at the site of insertion.
- Skin cleansing with 2% chlorhexidine in 70% isopropyl alcohol is recommended. Chlorhexidine is an anti-microbial agent that has been shown to reduce the risk of infection.
- Clean the site for 30 seconds and allow to dry completely (30 seconds).

· Sharps disposal

To minimise the risk of injury, sharps should never be re-sheathed and should be discarded into an appropriate sharps bin immediately after removal from the patient. Place the sharps bin within easy reach, no more than one arms distance away from the client. They should not be filled above two-thirds full (there is a mark on the side indicating the fill line).

Needlestick Injuries

A needlestick injury is an incident in which the needle penetrates the skin. Needles

contaminated with infected patient’s blood can transmit up to 20 types of diseases including hepatitis B, hepatitis C and HIV. Needle stick injuries occur due to poor technique or inappropriate handling of needle. Any accident no matter how minor it may seem should be documented, reported to the manager, and receive medical attention.

If you sustain a needlestick injury, follow this process immediately:

Remove your gloves and dispose of them carefully
Gently squeeze the wound to encourage it to bleed
Wash the wound using running water and plenty of soap
Don’t scrub the wound while you are washing it
Don’t suck the wound
Dry the wound and cover it with a waterproof plaster or dressing

You should then attend the nearest A&E department or contact a local sexual health clinic for a blood test.

The healthcare professional treating you will assess the risks to your health and ask you about your injury. Samples of your blood may be tested for Hepatitis B, Hepatitis C or HIV. Your healthcare professional may also arrange to test samples of the other person’s blood if they give their consent.

If you are deemed to be at low risk, you may not need any treatment. If there’s a higher risk, you may need:

Antibiotic treatment
Further vaccination against Hepatitis B

Avoid a needle stick injury at all cost by good practice when dealing with sharps and remaining vigilant throughout all procedures

Practitioners undertaking injectable treatments should be vaccinated against hepatitis B

Medical Emergencies

Anaphylaxis – a severe and potentially life-threatening reaction. Signs and symptoms:

Feeling light headed or fainting
Constriction of airways – breathing difficulties and wheezing
Fast heartbeat
Low blood pressure
Skin reactions e.g., hives
Nausea or vomiting

See Appendix 1 for the treatment of acute anaphylactic reaction See Appendix 2 for Adult Basic Life Support (BLS)

Necrosis – death of body tissues usually due to a failure of blood supply Signs and symptoms usually occur simultaneously with the injection.

Pain
Prolonged blanching of the skin
Skin discolouration – purple indicates tissue death
Numbness and coolness of the skin.

Accreditation Registers – Save Face and JCCP

Businesses offering cosmetic procedures are subject to a wide range of laws and duties. These primarily relate to public health, occupational health and safety, environmental protection, and in some parts of the UK to public control licensing. Most of this law is administered by local authorities, often through their environmental health departments.

It was suggested in the Keogh review that restrictions should be applied to the types of premises used to deliver treatments where clinical oversight was requested, for example, clinics equipped to deal with medical emergencies. It has been left up to the individual providing clinical oversight to ensure the provision of an appropriate and safe environment. Hygiene measures, sharps disposal, in-date products and safety equipment are a must for all situations regardless of venue choice and will be taught during the practical training days.

Save Face

Save Face Ltd is an independent and impartial accreditation scheme for aesthetic medical professionals and clinics. They offer an optional registration service to regulated health professionals only and audit practitioners against seven core standards. Each practitioner must supply:

Evidence of registration and qualification with the relevant statutory board.
Evidence of insurance and training for each procedure offered
Evidence of mandatory training
Evidence of registration with The Information Commissioners Office
Samples of patient information
Consent forms
Evidence of legitimate supply of medicines

Each clinic premise is inspected by auditors who ensure standards are met with regards to infection control, consent and confidentiality, management and reporting of adverse events, appropriate sharps disposal, record keeping, managing complaints and quality of equipment.

A breach of standards can result in investigation, suspension, or exclusion from the Save Face Ltd register. As this register gains momentum and reputation, clients/patients will increasingly look for such quality standard verification.

Joint Council for Cosmetic Practitioners (JCCP)

The JCCP has been established to assist members of the public who are seeking/considering or undergoing non-surgical and hair restoration treatments (Injections, Fillers, Lasers, Peels and Hair Restoration) with advice on patient safety matters and how to gain access to registers of approved practitioners

The JCCP Practitioner Register has been established to enable practitioners delivering the aesthetic treatments set out in the CPSA Framework of Standards and Competences to be accredited.

In order to be accredited applicants will need to demonstrate evidence of competence and proficiency.
- The JCCP recognizes that different practitioners will have varying levels of experience, qualifications, and status.
- The public will be able to access the JCCP Practitioner Register and see at what level and which areas of treatment a practitioner has been accredited by the JCCP.

The JCCP Practitioner Register is voluntary and remains subject to consideration

for approval by the Professional Standards Authority (PSA) who oversee public registers in the health care sector.

APPENDIX 1. Treatment of acute anaphylactic reaction (Resus council protocol UK)

APPENDIX 2. Adult Basic Life Support (BLS)

APPENDIX 3. Botox Placement

Dermal Filler

THREAD

PART 1: Introduction

Definition:

Thread lifting is a minimally invasive cosmetic procedure where temporary sutures (threads) are used to lift and reposition sagging skin, and stimulate collagen production for rejuvenation.

Historical Evolution:

Early threads: Permanent, non-absorbable (e.g., polypropylene)
Modern threads: Biodegradable, absorbable materials (e.g., PDO, PLLA, PCL)

Types of Threads:

Thread Type	Material	Duration	Example Use
PDO (Polydioxanone)	Absorbable	6–9 months	Common for facial lift
PLLA (Poly-L-lactic acid)	Absorbable	12–18 months	Longer collagen effect
PCL (Polycaprolactone)	Absorbable	Up to 24 months	Longest collagen support

PART 2: Anatomy & Physiology Relevant to Threads

Target Skin Layers:

Threads are typically placed in the subdermal or SMAS layer.
Avoid major blood vessels, nerves, and fat compartments.

Mechanism of Action:

Mechanical lifting by anchoring and pulling sagging tissue.
Collagen stimulation: Threads trigger a wound-healing response → neocollagenesis → improved firmness and elasticity.

Key Facial Danger Zones:

Infraorbital foramen
Facial artery (near nasolabial fold)
Temporal branch of facial nerve

PART 3: Indications & Applications

Aesthetic Indications:

Area	Effect
Midface (cheeks)	Lifting and volume restoration
Jawline (jowls)	Definition and tightening
Neck	Skin tightening
Eyebrow lift	Brow elevation
Nasolabial folds	Softening of deep lines
Marionette lines	Reduction of downward pull
Nose bridge and tip	Non-surgical nose lift

Medical Use:

Facial asymmetry correction (post-stroke or palsy)
Support in skin ptosis from weight loss or aging

PART 4: Patient Selection & Assessment

Ideal Candidate:

Age 30–55 with mild to moderate skin laxity
Not ready for surgical facelift
Good skin thickness and elasticity
Realistic expectations

Contraindications:

Severe skin laxity (surgical candidates)
Active skin infections or inflammation
Autoimmune disease or poor wound healing
Pregnancy or breastfeeding
History of keloid scarring

Pre-Treatment Workup:

Facial analysis: symmetry, skin thickness, laxity zones
Mark key vectors for thread insertion
Obtain informed consent
Photographic documentation

PART 5: Injection Techniques & Dosage

A. Types of Threads by Design:

Thread Design	Action
Mono threads	Collagen stimulation, skin texture
Cog/barbed threads	Lifting effect via mechanical traction
Screw/twin threads	Volume enhancement in hollows

B. Insertion Technique Overview:

Marking: Determine lifting vectors
Antisepsis: Clean face with antiseptic
Anesthesia: Local anesthesia with lidocaine
Cannula/Needle Insertion:
- Threads introduced using cannula (blunt tip) or needle (sharp tip)
- Depth: Subcutaneous or SMAS layer
Position & Anchor:
- Gently pull threads upward
- Anchor barbs in tissue
Cut Excess Thread: At skin entry

Sample Dosage / Thread Count:

Area	Type	Typical Threads
Cheeks	Cog / barbed	2–4 per side
Jawline	Cog	2–4 per side
Eyebrows	Mono/cog	1–2 per brow
Nasolabial folds	Screw / mono	3–5 per side

PART 6: Managing Complications & Side Effects

Common Side Effects:

Issue	Management
Bruising or swelling	Cold compress, resolves in days
Discomfort or tightness	Analgesics
Dimples or puckering	Usually resolves in 1–2 weeks
Mild asymmetry	Observe; minor corrections later

Major Complications:

Complication	Cause	Management
Infection	Poor aseptic technique	Antibiotics, removal if necessary
Thread extrusion	Superficial placement	Trim or remove thread
Nerve injury	Incorrect plane or depth	Observation, refer neurology
Hematoma	Vessel injury	Compression, drainage if needed
Skin necrosis (rare)	Vascular compromise	Immediate care, stop procedure

Post-Procedure Care:

Avoid facial massages, dental work for 2 weeks
Sleep face-up for 3–5 nights
Limit exercise for 48–72 hrs
Avoid alcohol and smoking

Summary for MBBS Students

Thread lifting is a non-surgical option for facial rejuvenation and lifting.
Knowledge of anatomical layers and vascular danger zones is critical.
Technique varies depending on thread type, insertion plane, and desired result.
Requires a safe, sterile environment, and proper patient evaluation.
Emergency preparedness for complications like vascular injury or infection is vital.