The rational combination of botulinum toxin injections and physiotherapy allows solving a number of problems that are relevant for the practitioner: to enhance and prolong the effect of BTA without increasing the dose, to help resolve adverse events after the procedure, to weaken the effect of the toxin in case of hypercorrection and to achieve high therapeutic results.
J.A. Yutskovskaya, dermatovenereologist, cosmetologist, doctor of medical sciences, professor,
General Director of LLC "Professor's Clinic of Yutskovskih"
In modern cosmetology, hardware procedures are very popular due to their high efficiency, non-invasiveness and safety, as well as minimally invasive manipulations (injection methods, chemical peels), which allow to successfully and quickly correct involutional skin changes. Of course, when compiling complex programs, it is rational to consider procedures using hardware methods as the first stage, followed by minimally invasive correction.
However, patients, due to their high social demand, often put before us a certain time frame. Seasonal restrictions on certain procedures also introduce their own adjustments. There is a need to change the intervals between procedures and their standard sequence. To what extent is this acceptable and justified?
Combination Therapy
Within each individual medical specialty, quite a lot of practical recommendations and algorithms have been developed regarding the effective and safe combination of techniques. At the same time, against the backdrop of the emergence of a large number of innovative means, devices and technologies for skin rejuvenation, there is a shortage of recommendations on the interaction of modern physiotherapy and injection methods.
In 2005–2008 and in the first half of 2009, 96 new technologies were registered in the field of dermatovenereology and cosmetology, and in general — 18,682 medical devices, among them — more than 1100 new instruments and devices, some of which are intended for use in aesthetic medicine.
The first data on the systematization of methods of hardware cosmetology, depending on the factors of physical nature used and the dominant therapeutic effect, were presented in the works of G.N. Ponomarenko. The proposed syndromic-pathogenetic principle of the classification of therapeutic methods was supported in the works of E.A. Arabian, and he formed the basis of the concept of adaptive integral cosmetological correction. The process of choosing methods, including hardware ones, was optimized to effectively solve the problems of treating and preventing aging, depending on the complex of age-related changes in the phenotype of a particular patient.
Later, the concept of systemic cosmetology (CSC) was developed, which provides for the algorithmization of the main stages of the diagnostic and treatment process in order to more effectively and systematically use the capabilities of modern cosmetology technologies.
In our practice, we also use the syndromic-pathogenetic principle when considering algorithms for combining procedures in integrated treatment circuits. At the same time, we consider it necessary to take into account several key points:
• mechanisms for the development of certain effects when using specific hardware and injection methods. This is necessary to identify common points of application and analyze the nature of the impact;
• the level and nature of direct and indirect therapeutic effects, the potential for their positive or negative interaction when using a complex of methods.
Quite often, in the clinical picture of various types of facial aging, hyperfunctional mimic wrinkles are encountered, for the correction of which injections of botulinum toxin type A (BTA) preparations are widely used.
An extremely important problem in practical botulinum therapy is the development of methods to enhance and prolong the effect of botulinum toxin, since frequent repeated injections significantly increase the cost of treatment, in addition, they can lead to the formation of antibodies and, theoretically, to the development of partial or complete insensitivity to therapy.
For a cosmetologist, this fact will not be critical, but it will deprive a person of the opportunity to use one of the most effective methods of treating serious neurological diseases in the future.
It has been established that a more pronounced and persistent muscle relaxant effect from the introduction of BTA develops with maximum muscle contraction, with a sufficient intracellular concentration of calcium ions (and, possibly, potassium), under the influence of low temperatures. Calcium deficiency in the body is detected using a simple neurological test (based on the Chvostek symptom). However, some experts during the preparation for BTA injections recommend that the patient take calcium supplements with vitamin D for prophylactic purposes (2 weeks before the procedure).
Immediately before and immediately after the injection, the injection site is cooled, and the patient is instructed to actively tighten the muscles into which the botulinum toxin has been injected for 15-30 minutes after the procedure and throughout the day. Similar effects can be achieved using some physiotherapy methods.
On the other side of the scale is the diametrically opposite problem — search for ways to neutralize the muscle relaxant effect in case of excessive relaxation of the target muscle or diffusion of the toxin and relaxation of non-target muscles. This is a rather difficult task, since the process of presynaptic cleavage of transport proteins by botulinum toxin is irreversible and takes an average of 30-60 minutes (in vitro studies). The restoration of synaptic transmission occurs due to the formation of collateral branches of the axon, and physiotherapy procedures in this process can play an important role. Thus, the combination of physiotherapeutic procedures and botulinum therapy in integral treatment programs is not a mechanical summation of the effects of individual exposures, and provides for a relationship of synergy or antagonism. Both types of relationships may be desirable or undesirable depending on the specific situation. Therefore, this issue deserves detailed consideration and analysis.
Mechanism of action of BTA
The action of BTA is based on the principle of inhibition of acetylcholine exocytosis in the neuromuscular synapse and autonomic cholinergic ganglia. After binding of botulinum toxin to receptors on the membrane of the nerve terminal, endocytosis of the toxin molecule into the cytosol occurs (the process of internalization). Already in the cell, the toxin breaks down into heavy and light chains. The toxin light chain is a zinc-dependent protease that selectively cleaves the SNAP-25 transport protein, resulting in blockade of acetylcholine release into the synaptic cleft and interrupting neuromuscular communication. Chemodenervation of the muscle sets in and, as a result, its persistent relaxation.
Despite the fact that the cellular effects develop very quickly and irreversibly, the clinical muscle relaxant effect of the drug begins to manifest itself a few days after the injection: in the small muscles of the face, larynx, hand — after 2-7 days, in the large muscles of the neck, limbs and trunk — after 7-14 days, in the exocrine glands — in 1–5 days. There are descriptions of cases of both instant onset of effect, and delayed for 3-4 weeks. BTA does not affect the anatomical integrity of the axon terminals of the motor nerve, but its introduction leads to the same changes as when crossing the nerve: a rapid growth of compensatory endings — terminal branches (sprouting process).
Approximately 12 weeks later, transport of acetylcholine through the blocked terminal resumes, with the terminals of compensatory innervation gradually disappearing. Regeneration ends with the formation of cholinergic receptors on the postsynaptic membrane and the restoration of the release and acceptance of acetylcholine. After acetylcholine activates cholinergic receptors on the postsynaptic membrane of the muscle fiber, protein channels in the membrane open, through which Na + ions enter the muscle cell. The depolarization of the muscle cell membrane and the generation of the action potential of the muscle fiber develop [7].
Modulation of the muscle relaxant effect of BTA using physiotherapy
Analyzing the process of chemical muscle denervation, it is possible to single out several mechanisms of physiotherapeutic effects that allow accelerating the processes of sprouting or, conversely, enhancing the muscle relaxant effect of BTA. The formation of these diametrically opposite effects will depend on the sequence of the appointment of procedures in the course of treatment and is implemented through the following mechanisms: facilitating synaptic impulse transmission (neuromyostimulation), accelerating neuron regeneration and stimulating metabolic processes against the background of the development and activation of the capillary network (regenerative, trophostimulating, vasoactive action ).
The most commonly used hardware methods in modern cosmetology, depending on the dominant mechanism of action, can be divided into several main groups:
- neuromyostimulating methods: low-frequency magnetotherapy, microcurrent therapy (MTT), electrical myostimulation (EMS);
- reparative-regenerative methods: ultrasound therapy (UZT), infrared / red laser therapy;
- vasodilating, trophostimulating methods: cosmechanics (mechanical stimulation of tissues in combination with cyclic vacuum exposure), microcurrent therapy, galvanization and drug electrophoresis with vasodilator drugs, infrared/red laser therapy, low-frequency magnetotherapy.
Types of physiotherapy combined with BTA injections
The most pronounced and at the same time sparing neurostimulating effect is exerted by a low-frequency pulsed magnetic field (PMF). Unfortunately, procedures with the impact of UTIs have not found wide application in cosmetology, but they are used in recovery programs after plastic surgery. Under the influence of a UTI, the speed of impulse conduction along intact nerve fibers increases, their excitability increases, and rhythmic contraction of skeletal muscle myofibrils occurs (magnetic stimulation), as well as perineural edema decreases, local blood flow is activated, metabolism and regeneration are stimulated.
Myelination processes, increased conduction of nerve trunks, normalization of lymph and blood circulation, axonal transport and synaptic transmission contribute to the restoration of the function of the neuromuscular apparatus. Along with a pronounced neurostimulating effect, IMP also has a significant anti-edematous and trophic effect.
An important advantage of the method is the unlimited propagation of the magnetic field in space: as you move away from the radiation source, the field weakens significantly, but has no finite boundaries. For the clinician, this means the possibility of influencing deep muscles, for example, the eyes, which are involved in the development of such serious complications of botulinum toxin therapy as diplopia, strabismus, etc.
Electrical myostimulation (EMS) involves the application of electrical current to increase the contraction of skeletal and smooth muscles. For electrical stimulation, a pulsed, low-frequency modulated current is used, the strength of which, as a rule, does not exceed 100 mA (for facial muscles - no more than 50 mA). In the literature, you can find several synonyms for electromyostimulation: myostimulation, neurostimulation, physiostimulation, myolifting, electrical stimulation.
The modes of EMS of the muscles of the face and neck differ from the modes used for electrical stimulation of the skeletal muscles of the body, which is associated with the peculiarities of the structure and physiology of the muscles. Conducting EMS of the facial muscles requires increased caution due to the high dynamism of facial muscles. With an incorrect mode of exposure, excessive and prolonged excitatory stimulation of thin muscle fibers can cause a functional overstrain of the neuron: “fatigue” muscle is clinically manifested by increased hypo- or hypertonicity.
The optimal parameters for exposure in the maxillofacial region are as follows: frequency 50–300 Hz, pulse duration 0.01–1.0 ms, stimulating pulse filling frequency 10–11 kHz, duration of exposure to each muscle group from 1–3 up to 10 minutes. Conducted in the optimal mode, EMS contributes to an increase in the number of actively functioning motor units in the muscle, has a pronounced effect on the regeneration of nerve fibers, their myelination. Apparently, periodic exposure to electric current in a certain mode plays a significant role both in the growth of axons and in the restoration of their contacts.
Thus, the appointment of electromyostimulation after botulinum therapy (after 2 weeks or more) will stimulate the processes of sprouting, help restore neuromuscular transmission and muscle contractility. Depending on the state of the neuromuscular apparatus (NMA), the modes of conducting electromyostimulation differ significantly. Chemical denervation of the muscle is accompanied by impaired excitability.
Special electrodiagnostics is recommended to determine the qualitative and quantitative changes in the electrical excitability of the NMA and the subsequent selection of the physiological parameters of the EMS according to the identified changes. But even this manipulation should be carried out with great care, given the possibility of persistent muscle contraction — contractures. So, for example, with changes in the electrical excitability of the NMA of the maxillofacial region, an impact is performed with a pulse duration of up to 0.8 ms (upper limit of the norm) with a simultaneous decrease in the threshold current strength, while the time of onset of fatigue of the NMA decreases. The latter must be clearly recorded, since the subsequent procedure of electromyostimulation with “fatigue” muscle is not allowed. With an increase in the degree of damage to the NMA, the ratio of the time for the supply of impulses (sends) and pauses also increases. For a healthy NMA, this ratio is 1:1 & ndash; 1: 1.5, with quantitative changes in excitability — 1:1.5–1:2 and more. The frequency and duration of the impulse should be such that the muscle contraction is optimal and as complete as possible for a given degree of change: from pronounced to varying degrees of sluggish. On the other hand, the internalization of botulinum toxin is enhanced by nerve stimulation. This is why patients are asked to tense their muscles before the injection.
so that muscle contraction is optimal and as complete as possible for a given degree of change: from pronounced to varying degrees of sluggish. On the other hand, the internalization of botulinum toxin is enhanced by nerve stimulation. This is why patients are asked to tense their muscles before the injection.so that muscle contraction is optimal and as complete as possible for a given degree of change: from pronounced to varying degrees of sluggish. On the other hand, the internalization of botulinum toxin is enhanced by nerve stimulation. This is why patients are asked to tense their muscles before the injection.
The impulse current during synaptic transmission causes an increase in the release of the transport protein. By prescribing electromyostimulation immediately before botulinum therapy and / or in the first 20 & ndash; 30 minutes after it, you can get an aggravation of the blocking effect of the toxin in relation to neuromuscular conduction and increase muscle relaxation.
Another area of use of pulsed electric current — the so-called process (procedure) of aquaporation. Aquaporation involves the creation of short-lived pores in lipid cell membranes (and the lipid barrier layer of the epidermis) by high frequency, low intensity electromagnetic waves. In general biology, the introduction into the cell (transfection) of various macromolecular compounds — proteins, nucleic acids, genes.
In cosmetology, aquaporation provides transdermal delivery of active drugs into the deep layers of the skin and, theoretically, into the muscle fibers woven into the skin. Currently, the possibility of introducing BoNta 568, which is a botomimetic, by means of electroporation, is being actively discussed. The mechanism of action of the drug containing three active oligopeptides is associated with the competitive substitution of the SNAP 25 protein in the SNARE transport complex, resulting in a decrease in the release of acetylcholine into the synaptic cleft and a weakening of neuromuscular transmission. Abrasion followed by application of the drug under the occlusive film and/or electroporation procedure, as well as intradermal and intramuscular administration of BoNta 568, can achieve limitation of muscle contractility and prolong the effect of botulinum therapy.
Botomimetic treatments should be considered when the effect of botulinum toxin begins to wane. Thus, it is possible to increase the interval between injections, as well as to achieve the effect of limited muscle relaxation in patients with immunoresistance to botulinum toxin or in the presence of contraindications to botulinum therapy. Moreover, with the help of botomimetics, it is possible to achieve controlled muscle relaxation in the so-called “difficult zones” persons, which include the lower third of the forehead, lateral areas of the forehead during the formation of paradoxical wrinkles after eyebrow lifting with BTA, vertical wrinkles of the cheeks, long wrinkles around the eyes (in the projection of the zygomatic muscle), neck wrinkles.At present, microcurrent therapy (MTT) is actively used in the practice of a cosmetologist due to its pronounced stimulating effects on fibroblasts, melanocytes, keratinocytes, which are so necessary in skin rejuvenation programs. Microcurrent therapy also refers to neuromyostimulating methods, however, unlike EMS, it involves the use of a pulsed electric current of the microampere range (from 10 to 800 μA), which determines other mechanisms of action on the muscle fiber. Such a current acquires a unique property of being tuned to the bioelectric potential of the cell membrane, normalizing, but not increasing it. Accordingly, MTT does not cause muscle fiber contraction, but contributes to the normalization of muscle tone with hypo- or hypertonicity.
Microcurrent therapy performed before BTA injections will not lead to an increase in the muscle relaxant effect of the toxin, however, prescribed after botulinum therapy will have a pronounced regenerating effect, including due to the activation of energy metabolism and the functioning of calcium channels. Cheng's studies have shown that under the influence of MTT there is an increase in ATP synthesis in the cell by 500%, the synthesis of nucleic acids — by 30–40%. All this leads to increased sprouting and restoration of neuromuscular transmission.
Ultrasound therapy and galvanization have a pronounced regenerative effect on the nerve fiber.
Ultrasound therapy (the use of ultra-high frequency mechanical vibrations for therapeutic and prophylactic purposes) optimizes blood circulation and microcirculation, improves regeneration processes by increasing ATP synthesis and tissue oxygenation, increases the speed of impulse conduction along the nerve, accelerates the development and maturation of neurons, their differentiation , increases synaptic activity, activates neurovegetative processes.
Galvanization — therapeutic use of direct electric current. Under the action of a constant electromagnetic field, a conduction current arises in the tissues, ions move, the permeability of membranes changes, and the passive transport of large protein molecules increases. Therapeutic effects of galvanization — vasodilator, muscle relaxant, detoxifying. The predominance of calcium ions at the anode (positive electrode) activates the enzyme cholinesterase, which destroys acetylcholine, resulting in a local decrease in the excitability of neuromuscular structures.
Due to the accumulation of potassium ions on the cathode (negative electrode), a decrease in cholinesterase activity is observed, followed by activation of excitation processes. Direct current increases the processes of regeneration of peripheral nerves, when the current passes along the nerve trunks, the conduction of nervous excitation improves, and the regeneration of damaged nerves is accelerated. The use of galvanic current during electrophoresis allows you to create in the focus a high concentration of drugs involved in the regeneration of the nerve fiber: vitamins of group B, vasodilators.
Low-energy infrared laser (LILI) has a wide range of therapeutic effects on the body, is actively used in the rehabilitation period after plastic surgery. The infrared laser helps to increase the adaptive resistance of the body, provides an immunomodulatory effect, stabilizes the endocrine balance, and normalizes blood pressure. As a result of exposure, tissue metabolism increases, the regeneration process is activated, blood and lymph microcirculation improves. As a result of the selective absorption of infrared radiation quanta by oxygen and nucleic acid molecules, proliferative and reparative processes in the fibers of the affected nerves are activated, and the functional lability of the nerve trunks is normalized. The red laser radiation is absorbed by the NO synthase molecules and causes local formation of the vasoactive compound — nitric oxide, which induces the expansion of blood vessels at a depth of up to 3-4 cm. Selectively absorbed by cytochrome oxidase molecules, red spectrum radiation stimulates cellular respiration and metabolism in neurons.
Cosmechanics method, which is in demand in clinical practice (a combination of three-dimensional mechanical stimulation of the skin and soft tissues with cyclic vacuum aspiration), restores microcirculation, contributing both to a more active work of existing vessels, an increase in blood flow velocity in them by 4-5 times, and the appearance of new capillary loops in the dermis. All this can significantly improve tissue nutrition and activate metabolic processes.
Procedures combined with botulinum toxin injections
Carrying out such procedures on the face can theoretically lead to an acceleration of the recovery of the contractility of muscles relaxed after botulinum therapy, but the effect will not be significant. Cosmechanics and manual lymphatic drainage procedures can contribute to a faster resolution of edema after botulinum therapy in the periorbital area.
It is quite difficult to classify the procedures of photorejuvenation, radiofrequency lifting, fractional photothermolysis to one or another group of physiotherapeutic methods due to the predominance of the damaging factor in the mechanism of their action. Taking into account the thermolability of botulinum toxin and its high rate of binding in tissues, direct thermal exposure can cause BTA inactivation only if the procedure is prescribed in the area of intradermal and subcutaneous injections of BTA within the first 30-60 minutes. In practice, when carrying out photorejuvenation, radiofrequency lifting, we get a controlled, limited in depth and short-term thermal effect. The depth of penetration of high-intensity light in photorejuvenation is in most cases limited to the level of the dermis.
The combination of frequency and current strength in radiofrequency lifting devices is calculated in such a way that the generated thermal effect affects the dermis and hypodermis, causing reversible denaturation and contraction of collagen, and then neocollagenesis processes. Accordingly, radiofrequency exposure, as well as light exposure, does not penetrate to the level of muscle structures and, therefore, does not have a neuromyostimulating or thermal effect that inactivates the neurotoxin injected into the muscles.
Some increase in collateral blood flow as a result of the procedures performed can have a trophostimulating effect not only at the level of the dermis and hypodermis, but also in nearby anatomical structures, indirectly accelerating the processes of sprouting. However, given the frequency of appointment of procedures once every 10-14, and sometimes even 21 days, and the short duration of hyperemia, it can be assumed that such an impact is minimal and clinically insignificant.
Considering thermal procedures as a whole, we can say that their “interaction” with the effects of botulinum toxin is mediated solely by the activation of the microvasculature and trophic processes. These phenomena are most pronounced during deep heating of tissues during a visit to the sauna, including infrared. However, such effects do not occur often, and therefore a pronounced weakening of the effect of botulinum therapy cannot be expected.
Such methods of hardware cosmetology as oxymesotherapy, microdermabrasion, gas-liquid peeling, which work mainly at the level of the epidermis, cause rather weak indirect trophic effects in the superficial musculoaponeurotic system (SMAS). The multi-level effect determines the absence of antagonistic effects on the muscle relaxant effect of botulinum therapy. In the scheme of complex treatment programs, these methods, as well as photorejuvenation, radiofrequency lifting, can be recommended for safe use in the area of muscle chemodenervation.
Conclusions and recommendations
Therapy of involutional changes in the face is one of the key tasks of cosmetology. Given the multifactorial nature of the aging process, the involvement of various anatomical structures in it, the most effective is complex therapy using various techniques, both hardware and injection. Botulinum therapy occupies a special place among injection methods.
The rational combination of botulinum toxin injections and physiotherapy allows solving a number of problems that are relevant for the practitioner:
• to potentiate the muscle relaxant effect of BTA without increasing the dose by summing up the therapeutic effects of calcium electrophoresis performed before the procedure and electromyostimulation performed immediately before and/or in the first 20-30 minutes after the administration of BTA;
• to prolong the muscle relaxant effect of BTA (up to 6–8 months) due to the additional prescription of aquaporation procedures using botomimetics. And also to expand the areas of therapeutic muscle relaxation into areas of increased risk of developing adverse events during botulinum therapy;
•
Accordingly, when compiling complex treatment regimens for involutional skin changes, along with botulinum therapy, it is permissible to prescribe lifting methods (photorejuvenation, radiofrequency lifting), as well as oxymesotherapy, microdermabrasion, gas-liquid peeling. When prescribing such methods as cosmechanics, low-intensity laser therapy, the patient should be informed about a possible slight reduction in the effect of BTA. It is advisable to prescribe microcurrent therapy, ultrasound therapy exclusively in neighboring anatomical zones. And such methods as electromyostimulation, magnetostimulation and galvanization — in cases of special expediency or in other topographical zones.
Understanding the mechanisms of action of the methods used, an objective assessment of the skin condition, its constitutional and age characteristics, a reasonable combination and alternation of methods allow obtaining high therapeutic results and not deceiving the patient's expectations.
The article is printed in abbreviated form.
According to botulin.ru
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