In-house staff training 中環的一天~

（診所標誌剛好有個心心、在我頭上好可愛哦。）

上星期日完成了一天的Staff training~

因為藥物的label use 有on有off，

所以公司便因應我們的疑問，請來皮膚科專科醫生作出一天的培訓。

雖然負責Dysport這藥物已接近三年、

....仍然不能自滿啊，隨時ready進修一下!!!

主要藥物的製造方式(我們是法國藥廠/英國製造)，

用法調量及打法我們都懂，

但也有好多新資訊!!!

例如講師給予我們從他醫生角度、對於一般藥廠可以如何支援的意見...

市場上更新動態(醫學美容上肉毒桿菌蛋白素已是不新的產品，有新的只是打法。)...

還有他最拿手的pharmacokinetics(藥理)、

注射進哪哪哪條肌肉的Anatomy解釋....

(背過一輪，

但因為咱們家的肉毒桿菌素只影響肌肉.... 

neuromodulators很少在血管產生副作用

所以我們常忽略了血管層(對不起); 

如果我家是賣透明質酸的一定會狠狠背(抱腿笑)!!!!!!

(HA打進血管若嚴重副作用case、可導致細胞壞死啊))

說著說著，

因為診所只有我們幾位學生，

<右面是他在上月公開教導其他醫生的學堂倩影>

很自然就看一下各位可改善的狀況....

嗯嗯　輪到我了。

(詳細不說，很多比例可以更好啦嗚)

抄下的小筆記參考:

[從臉頰骨畫下垂直線，若距離→咀嚼肌少於１ｃｍ，

即是肌肉比較大....

就可以打來放鬆瘦臉囉。]

＜解說時的實際情況.....＞

他說我的臉會讓醫生很有滿足感!!!

(因為可藉現有科枝改善的地方有很多)

下巴啦，

我的lower face(撫臉)....唉唷。

總括而言是嚴謹中帶點輕鬆的補充training呢～

鳴謝: 

Appendix: 課後整理的個人小筆記:

Key Learning from aesthetic training by Dr. H

Date: 2nd Aug, 2015

Staff Name: Jessica Lee

Key Learning:

1. Aesthetic market overview: 3000 products rush into the cosmetic field yet less than 5% survives and retains. For non-surgical, Top five treatments rank as Botulinum toxin (more than 1 quarter), injectable fillers (HA: hyaluronic acid), Hair removal, laser and RF which stands for radio frequency.

2. Facial Anatomy: There are few muscles that an injector needs to be careful (try to avoid) during neurotoxin application: Levator palpebrae superioris muscle (to elevate the superior/upper eyelid, causes ptosis as an adverse event from forehead wrinkle reduction), Risorius (to elevate the corner of mouth, causes imbalance of smiling as an adverse event from masseter slimming), Depressor Labii Inferioris (to draw the lower lip down, cause distortion of month as an adverse event from the Depressor Anguli Oris [marionette line]).

3. Mechanism of Neuromodulators into body: BtxA consists of a light chain (toxin section) and a heavy chain (helps the toxin to reach the cholinergic neurons)
i. Cell surface binding; ii. Endocytosis; iii. Endosome Acidification; iv. Endopeptidase translocation; v. SNAP-25 cleavage and inhibition of acetylcholine in the presynaptic neuron.

4. Duration and Recovery of motor neuron from BtxA: Botulinum toxins exert irreversible action on the motor end-plates, rapid onset (24-48 hours) and long lasting action (over two months), muscle paralysis up to 3-4 months. Plasticity- induced recovery includes axonal sprouting, creation of a new motor endplate and muscle activity back to normal.

5. Dose, Injection points, and Planes (muscle, dermis layer): Three major factors are for injectors to bear in mind when applying facial neurotoxin. From origin to insertion, an injection of BtxA to different point of a single muscle gives various results, considering the force vector from the origin of muscle contraction.

6. Brand differentiation in production methods during manufacture: Currently three Botulinum toxins with FDA approvals in the aesthetic field and physicians' concerns raise. In terms of purification, Botox (Allergan) is from crystallization, Dysport (Ipsen) and Xeomin (Merz) are from chromatography; In terms of finishing Botox by vacuum dried, Dysport is by freeze dried and Xeomin is by lyophilized. 

7. Methodology in BtxA comparison: LD50 (of laboratory mice) should not be used as a index for any toxin's  clinical profile, instead, various neuromodulators can be fairly accessed in terms of dosage, time of onset, duration and the spread-field of effect (action halo) in clinical outcomes. Conversion ratio for Botox to Dysport ranges from 1: 2.5~4 in research trials, varies in subjects and application and hence direct conversion from one brand to another brand is unavailable.

8. The importance of the existence of neurotoxin accessory proteins(NAP) surrounding neuotoxins: Xeomin with zero proteins surrounding the core toxin substance, claiming itself free from refrigeration. The core protein(light chain) from botulinum toxin is a delicate substance with a structure much complicated than drug molecules. NAP helps in the stabilization of any distorted polarity of the core protein chain, and also protects its way along to the pre-synaptic motor neuron. Meanwhile, Dysport lines a protein load as less 40% by molecular weight than Botox.

9. Factors of diffusion in neurotoxins performance: Diffusion of neurotoxin solution within the same group of muscle occurs after injection across the concentration gradient. The diffusion rate of a certain neurotoxin mainly depends on the properties of drug, motor neuron respond, dilution and the injection techniques. Since the NAP will dissociate from the core light chain (both Dysport and Botox are ~150kDa) under skin pH(seconds after injection), the difference in the proteins weight shall not bear effects in diffusion along muscles.  

10. The trigger of immunity responses by neuromodulators: In rare cases of immunity response from repetitive injections, as most neutralizing antibody derived acts against NAP only(Jürgen Frevert, 2010), but not the functional core light chain of BtxA, not all the immune responses will attenuate Bxta's paralysing effects on the neurpmuscular junction. BtxA can still exert pharmaceutical functions with the existence of antibody towards its stabilizing proteins.

《完》