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Although bruising may be prevented by certain techniques in dermatologic practice, bruises are considered an inevitable side effect of injectable procedures Therefore, it is incumbent upon the practitioner to inform the patient of this minor side effect Patients need to be aware that bruises may take approximately 7 to 14 days to clear, so they can make appropriate adjustments to their schedules
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TABLE 21-3 Medications and Supplements to Avoid at Least 10 Days Prior to Undergoing Cosmetic Procedures NSAIDs (Aspirin, Advil, Motrin, Ibuprofen) Vitamin E Green tea Garlic Ginkgo Ginseng St John s Wort
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1 Ang-Lee MK, Moss J, Yuan CS Herbal medicines and perioperative care JAMA 2001;286:208
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2 Kang WS, Lim IH, Yuk DY, et al Antithrombotic activities of green tea catechins and ( )-epigallocatechin gallate Thromb Res 1999;96:229 3 Marsh SA, Coombes JS Vitamin E and alpha-lipoic acid supplementation increase bleeding tendency via an intrinsic coagulation pathway Clin Appl Thromb Hemost 2006;12:169 4 Rowan AD, Buttle DJ, Barrett AJ The cysteine proteinases of the pineapple plant Biochem J 1990;266:869 5 Rowan AD, Buttle DJ Pineapple cysteine endopeptidases Methods Enzymol 1994; 244:555 6 Maurer HR Bromelain: biochemistry, pharmacology and medical use Cell Mol Life Sci 2001;58:1234 7 Glaser D, Hilberg T The influence of bromelain on platelet count and platelet activity in vitro Platelets 2006;17:37 8 Pirotta F, De Giuli-Morghen C Bromelain A deeper pharmacological study I Anti-inflammatory and serum fibrinolytic activity after administration of bromelain in the rat Drugs Exptl Clin Res 1978;4:1 9 Kumakura S, Yamashita M, Tsurufuji S Effect of bromelain on kaolin-induced inflammation in rats Eur J Pharmacol 1988;150:295 10 Singer F, Singer C, Oberleitner H Phlyoenzyme versus diclofenac in the treatment of activated osteoarthritis of the knee Int J Immunother 2001;17: 135 11 Singer F, Oberleitner H Drug therapy of activated arthrosis On the effectiveness of an enzyme mixture versus diclofenac Wien Med Wochenschr 1996; 146:55 12 Tilwe GH, Beria S, Turakhia NH, et al Efficacy and tolerability of oral enzyme therapy as compared to diclofenac in active osteoarthritis of knee joint: an open randomized controlled clinical trial J Assoc Physicians India 2001;49: 617 13 Brien S, Lewith G, Walker A, et al Bromelain as a treatment for osteoarthritis: a review of clinical studies Evid Based Complement Alternat Med 2004;1:251 14 Lyss G, Schmidt TJ, Merfort I, et al Helenalin, an anti-inflammatory sesquiterpene lactone from Arnica, selectively inhibits transcription factor NF- B Biol Chem 1997;378:951 15 Baeuerle PA, Henkel T Function and activation of NF- B in the immune system Annu Rev Immunol 1994;12:141 16 Schroder H, Losche W, Strobach H, et al Helenalin and 11 , 13-dihydrohelenalin, two constituents from Arnica montana L, inhibit human platelet function via thioldependent pathways Thromb Res 1990; 57:839 17 McIvor EG Arnica montana: a clinical trial following surgery or trauma J Am Inst Homeopath 1973;66:81 18 Alonso D, Lazarus MC, Baumann L Effects of topical arnica gel on post-laser treatment bruises Dermatol Surg 2002; 28:686 19 Ramelet AA, Buchheim G, Lorenz P, et al Homeopathic arnica in postoperative haematomas: a double-blind study Dermatology 2000;201:347
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CHAPTER 21 PREVENTION AND TREATMENT OF BRUISING
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CHAPTER 22 Botulinum Toxin
Leslie Baumann, MD Mohamed L Elsaie, MD Lisa Grunebaum, MD
Botulinum toxin (BTX), an exotoxin produced by the bacteria Clostridium botulinum, occurs naturally in nature BTX induces a bilaterally symmetric descending neuroparalytic condition called botulism The word botulinum is derived from the Latin word for sausage, botulus Botulism was so named during the Napoleonic Empire in the early 1800s when it was noted to be triggered by the ingestion of spoiled sausages Later, German physician Justinus Kerner described food-borne botulism and its clinical symptoms during the period between 1817 and 1822 In 1946, Schantz reported isolating BTX type A in its crystalline form, and nearly a quarter of a century later, Alan Scott became the first to harness the effects of BTX for medicinal use in monkey strabismus1 The use of C botulinum A exotoxin, commonly known as botulinum toxin type A (BTX-A), has emerged over the last decade as one of the most popular methods of combating cutaneous signs of aging, particularly the dynamic wrinkles of the face The therapeutic application of this potent neurotoxin has carved a comfortable niche in the cosmetic realm of dermatology practice for practical reasons: Results appear within several days of administration, the procedure itself is short in duration and relatively uncomplicated, and side effects are minimal Although medicinal use of BTX by physicians is widespread, professional opinions vary as to the best ways to administer the treatment For instance, the ideal dilution of the toxin, the number of units to inject, and the longevity of prepared and refrigerated BTX remain debated issues (Box 22-1) The methods described in this chapter are those used most frequently by the primary author The novice injector should try the various methods espoused by experienced specialists to determine which yields the best results in his/her own practice BOX 22-1 Units of Botulinum Toxin One unit (U) of BTX is the dose that would be lethal to 50% (LD50) of the speci c mouse species tested For a 70-kg person, the LD50 of Botox is 2500 to 3000 U However, manufacturers use different mouse models, so a unit of one brand is not equivalent to a unit of another brand Because of these variations, it is important to know which type of BTX was used when evaluating dosing information in the literature For cosmetic indications, injection of approximately 20 to 75 U doses of Botox is typical Practitioners have used doses as high as 1000 Botox units to treat cerebral palsy and other neurologic conditions TABLE 22-1 Binding Sites of Various Toxin Serotypes TOXIN SEROTYPE BTX-A BTX-B BTX-C1 BTX-D BTX-E BTX-F BTX-G BINDING SITE SNAP-25 Synaptobrevin SNAP-25 and syntaxin Synaptobrevin SNAP-25 Synaptobrevin Synaptobrevin
cle movement BTX achieves chemical denervation of striated muscles by cleaving one or more of the proteins required for the release of ACh (Fig 22-1) The target protein depends on the serotype of toxin used (Table 22-1) The result is temporary flaccid paralysis of the injected muscles, which persists approximately 3 to 5 months As new neuromuscular junctions form, muscle function returns There are seven BTX serotypes (A G) Serotype A is the most potent and was the first to be made
available in the United States for medical use Botox Cosmetic (Allergan Inc, Irvine, CA) and Dysport (Ipsen Products, Maidenhead, Berkshire, UK) are both formed from serotype A, which functions by cleaving the SNAP-25 protein, a component of the SNARE (Soluble N-ethylmaleamide-sensitive factor Attachment protein Receptor) complex (Box 22-2) The presence of an intact SNARE complex, composed of synaptobrevin, SNAP-25, and syntaxin, is necessary for vesicles containing ACh to fuse with the cell membrane and to release ACh into the neuromuscular junction (Fig 22-1) BTX-B, now available in the United States as Myobloc (known as Neurobloc in Europe), cleaves synaptobrevin, thus preventing the release of ACh
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