Foundation Pre-Course Theory

This is a timed quiz. You will be given 3600 seconds to answer all questions. Are you ready?

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What kind of molecule is botulinum toxin?

Correct! Wrong!

Botox is a protein.

Where in the body does the Botox molecule do its work?

Correct! Wrong!

The molecule is taken up by the nerve and it trims off the SNAP2 receptor at the Neuromuscular Junction. The result is smoothing of lines on the dermis. It does not actually work on the muscle.

How does the Botox molecule alter the neuromuscular complex?

Correct! Wrong!

The molecule cleaves off the SNAP2 receptors which resides on the inside of the neuromuscular junction.

What are the 2 mechanisms by which botox can lift eyebrows?

Please select 2 correct answers

Correct! Wrong!

The strongest way to lift the brow in most people is to inject the medial frontalis, which increases the resting tone of the lateral frontalis causing a lateral brow lift. It also helps a lot to inject the brow depressors- orbicularis ocult especially, but to some degree also the glabellar complex.

Which one option best describes the mechanisms which improves & helps smoothing of wrinkles after a botulinum toxin treatment? ​

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Lifting and relaxing are the only ways botox improves skin quality.

What three ingredients are in the un reconstituted vial you receive?

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What does the manufacturer recommend reconstituting their product with?

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It is industry practice to use bacteriostatic saline because in theory your product lasts longer. Many say it also stings less, but the manufacturer advises normal saline and to discard the product after 24 hours. Lidocaine is definitely not recommended as it stings more when being injected than saline alone, and adds additional risk of complications. Risk with no benefit.

What is the recommended dilution in medical aesthetics treatments in the upper face?

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Most data is is based on the 2.5ml per 100 units, but it is also acceptable to use more concentrated forms to decrease spread of product. Be aware that this also makes injecting a little more difficult because with more concentrated solutions the accuracy of your injections decreases – it is easier to accidentally add a little more or less than you intended.

Why is it helpful to neutralise the vacuum in the container before adding saline?

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Assuming the standard 100 Botox units per 2.5mls saline dilution, how many units would fit in this space on the syringe (to the 10 insulin unit mark)?

4-units-syringe
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Crunching or crackling noises as resistance as you inject a patient is caused by:

Correct! Wrong!

The needle has often been damaged by touching the glass vial during needle preparation - be extremely careful not to touch the glass while loading the syringes.

What should you do at the start of a consultation to put your client at ease?

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It puts people at ease when you are warm and caring, far more than any training or qualification will. When they feel relaxed, they will find the experience much easier.

Once someone has told you their concerns, what should you do next and why?

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Put yourselves in the position perhaps of going for a haircut- doesn’t it make you feel safe and understood when they clarify what you are hoping to get from the haircut before starting to cut? It also gives both parties chance to double check their understanding.

Which of the following prevent clients having unrealistic expectations?

Please select 2 correct answers

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Why do we tell patients about the side effects and risks?

Please select 2 correct answers

Correct! Wrong!

If you don’t explain a risk that does occur, you are liable to be sued successfully because the client was not in possession of the facts they need to make the decision they did. A good consent process will prevent the anger and sense of injustice clients might feel if they didn’t realise a bad outcome that occurs was actually possible. The process makes them feel in control of what happened, rather than victims of what happened.

What are the ‘4 D’ side effects we must warn patients about prior to treatment?

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These are the most unwanted side effects – the droopy brow or brow ptosis is the most common but should only occur from frontalis treatment.

If a patient is taking blood thinners like aspirin, clopidogrel, warfarin etc, what should you do?

Correct! Wrong!

The only risk is short term bruising, and this still won’t happen every time even if they are talking blood thinners.  Make sure they know the extra risk and have considered the impact a large bruise would have on them socially and psychologically. Since bruising is self limiting, being patient centred is key in making this decision – it really comes down to the patient deciding whether the benefits to them are likely to outweigh the risks. It is not possible for the clinician to decide this as the impact of the benefit and risks is very subjective.

What is the most common side effect people get after Botox injections?

Correct! Wrong!

Why should you go through the consent process every time?

Please select 2 correct answers

Correct! Wrong!

People do forget the side effects and risks even after a few months, and every time you see them their life will have moved on. The impact of a bruise may be totally different if for example, they have a new partner who they do not wish to know that they have Botox treatments. They may be close to a major event like a wedding which may change their attitude to risk.

What is the minimum distance you should leave between the orbital rim and your injection point?

safety margins
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Toxin is considered clinically active up to 1 cm from the injection site with the standard dilution. The licence dose recommends a 1.5cm space from the orbital rim.

With respect to point A, what is the most likely side effect?

side effects
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The levator palpebrae superioris muscle has its middle portion near the edge of the orbital rim.  When injections are at the correct depth it is shielded by orbicularis oculi, but inject too deep and the toxin trickles down behind orbicularis oculi into a space over this middle section of the levator palpebrae superioris. Ptosis lasts 6 weeks on average and can be treated with iopidine/Apraclonidine drops.

With respect to point B, What is the vulnerable structure most likely to cause a side effect?

side effects
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The nearest structure with acetylcholine receptors that we don’t want to treat is the lacrimal gland which sits just within the orbit. Deep injections are much more risky than superficial injections over the same area.

Injecting around point D is a higher risk for relaxing zygomaticus major – the muscle we smile with. Which of the following options would INCREASE the risk of hitting this muscle?

side effects

Please select 2 correct answers

Correct! Wrong!

Depth is dangerous here- it is far safer to stay superficial. The muscle is shielded with fat if you stay in the top level where orbicularis oculi resides. It is also distal to the orbicularis oculi so injecting too low is also a risk.

What is the licensed dose for the crows feet/ lateral canthal lines?

Correct! Wrong!

24 units is the licensed dose.

What is the licence dose per injection site (not the total dose) of the glabella complex?

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5 injections each of 4 units per site, making a total of 20 units.

What should people avoid for 48 hours after the procedure?

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The goal with aftercare is to reduce the chance of toxin molecules being washed away or damaged before they have had a chance to enter the neuron and to work. Heat and blood flow through the face are the main concerns. Though we want to avoid excessive blood flow to the face, it is unreasonable to stop someone sleeping lying down for two days, so we usually say 2 hours.

What can be done to draw the Botox into the nerve quicker and reduce the risk of dispersion?

Correct! Wrong!

Option 2 is correct, because nerve depolarisation increased the rate of absorption of the molecule through the nerve membrane. The other options are not helpful.

Which artery might be affected if a patient develops a very painful nostril a few hours after having their nasolabial fold injected?

Correct! Wrong!

The lateral nasal artery is very close to the nasolabial fold, and is vulnerable during hypodermic injections in the alar fossa, as it tends run in the fat rather than on the bone in this region.   It is therefore safer using deep injections onto the bone.

Why is it thought to be better to treat the shadow of the nasolabial fold with a deep injection on the periosteum?

Correct! Wrong!

The main reason for this technique is to avoid the facial artery, which runs lateral and in the hypodermis.  In effect the filler is as far away as it can be while still getting a result, increasing safety. It happens to be quicker than the fan technique too, as only one injection per side is required.

Which level in the skin would you inject to treat a fine line?

layers of skin
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The upper dermis is ideal. Anything above the upper dermis will cause visible filler - white areas of blanching or visible filler. Anything below the dermis is totally ineffective at treating a crease with a fine line filler.

Which levels of the skin would generally be preferred to treat volume loss?

layers of skin
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Generally, these injections are deep, and either in the fat of the hypodermis or placed on the periosteum for maximum projection. More superficial injections are a problem with the volumising fillers as lumps and irregularities on the surface of the skin are much more likely.

What is number 5 in the diagram below?

arterial anatomy face
Correct! Wrong!

Number 5 is Lateral Nasal Artery.

What is number 7 in the diagram below?

arterial anatomy face
Correct! Wrong!

Number 7 is Inferior Labial Artery.

What is number 3 in the diagram below?

arterial anatomy face
Correct! Wrong!

Number 3 is Angular Artery.

Which of the following side effects needs the most urgent review?

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Pain and discolouration that is getting progressively worse can be a sign of a blocked artery needing immediate review and treatment. All of the other side effects are likely caused by self limiting short term side effects.

Which is the best description of the purpose of the consultation?

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Many medical people put the majority of the emphasis on medical history and consent as those are the ‘hard’ medical aspects we all are indoctrinated to focus on in hospital medicine. In aesthetics the most important part of the process is to understand what your client is really looking for from the procedure. They are never looking for Botox or filler, they are looking for the feeling that they anticipate the treatment they ask for will generate. Feeling confident, attractive, younger or more certain about the future. The treatment they often come in asking for may not actually provide this feeling if it is the wrong treatment. They need your expert advice.

True or False: To obtain a dermal filler you must prescribe it first at a face to face consultation

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Fillers are not prescription only medication, and you can therefore buy them without a prescription.

What is the correct depth to deposit filler in the nasolabial shadow (blue circle)?

filler position
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What is the most important way to avoid injuring the Supratrochlear artery when injecting frown lines?

arterial anatomy frown alert
Correct! Wrong!

Staying superficial is the key, as superficial as you can without being above the papillary dermis. Aspirating prior to injections is vital, but as you will know if you have taken blood before, it is possible to be in a vessel and not get blood out, and the arteries are very small and could be occluded by the needle giving false reassurance. It is reassuring to check capillary refill after an injection, but this is not a proactive measure and it’s obviously better to have avoided the problem rather than just picked it up early, so getting depth correct is still more important. Thought lighter products are safer, all dermal fillers could cause injury if injected into an artery.  It would be safer to inject the wrong filler at the right depth than it would be to inject the right filler at the wrong depth.

Which of the following items must you have in stock & available in your emergency kit, when providing filler treatments?

Please select 3 correct answers

Correct! Wrong!

Adrenalin, Aspirin & Hyalase

Foundation Pre-Course Theory
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