Introductory Botulinum Presentation
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Transcript of Introductory Botulinum Presentation
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New Technologies for Facial Enhancement
s i m p l e
y o u n g e r
r e j u v e n a t e d
r e f r e s h e d
Introductory course to Vistabel
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• Starting off with Botox• Neurotoxin Pharmacology
• Contraindications and Cautions• Patient selection and treatment options
• Dilution and storage
Course AgendaCourse Agenda
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• Technique tips• Cosmetic indications1. Glabellar frown lines
2. Forehead lines3. Crows feet
Cont’Cont’
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• Live demonstration• Hands-on workshop
• Advanced techniques• Strategies for success
Cont’Cont’
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UK APPROVAL 2006
For Glabellar frown lines
BOTOX (100 Units)
Now launched as VISTABEL (50 Units)
Single patient use
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Developing A Botulinum Toxin Practice
Why develop an injection practice?
- Cosmetic surgery trends favour minimally invasive techniques
- No down time considered lunchtime procedure
- Nonsurgical procedures growing at a faster pace than surgical
- Want as opposed to need!!!!!!!
Personal Communication © Tim Flynn
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Top 5 nonsurgical cosmetic procedures in 2005 Top 5 nonsurgical cosmetic procedures in 2005
American Society for Aesthetic Plastic Surgery
Surgical & Non-surgical Cosmetic Procedures 9 Year - Comparison
1997-2005 1997
2005
154,153
481,227
65,157
159,232
101,176
176,863
485,690
556,172
3,294,782
231,467
364,610
455,489
Laser Skin Resurfacing
Chemical Peel
BOTOX®
Eyelid Surgery
Breast Augmentation
Liposuction (lipoplasty)
556,172
1,023,931
1,194,222
1,566,909
BOTOX®
Laser Hair Removal
Injectable Fillers
Microdermabrasion
Chemical Peels
3,294,782
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What Has Made Botulinum Toxin Type A a Popular Treatment?
Patient satisfaction
- Happy patients return more regularly for treatment
Physician satisfaction
- VISTABEL® provides the cornerstone of rejuvenation treatments of the ageing face
Personal Communication © Ph LEVY
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Cosmetic Maintenance
Patients perceive a “hierarchy” in cosmetic maintenance
Alteration Visible Changes Altering appearance ; major interventions, eg.
Face-Lift
Renovation Subtle, natural changes
Improving appearance viaNON-surgical treatments, eg. VISTABEL®, FILLERS
Prophylaxis Containment Preserving appearance as a part of everyday care,
eg. Anti-wrinkle creams
“Context” Research 2004 Paris, France
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Impact Of Wrinkles On Client’s Life
Just under 50% of the clients considered that wrinkles had a considerable impact on their life
Patients’ level of agreement with the following statements Score *
Wrinkles are a constant reminder of growing old 4.0
Having wrinkles depresses me 3.5
Having wrinkles reduces my self esteem 3.5
Having wrinkles impacts on my personal relationships 3.4
Having wrinkles impacts on my social life 3.3
Having wrinkles impacts on my career / work opportunities and success 3.0
Having wrinkles is just part of growing older and nothing to be too worried about 2.5
*Mean score on a scale from 1 (strongly disagree) to 5 (strongly agree)
“Genactis” Research 2004 France
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Patients Feeling Towards Recommending Treatment To A Friend
More than 90% of patients would recommend treatment to a friend concerned about wrinkles
Neither Recommend
for nor against10%
Recommend52%
Strongly Recomment
38%
Strongly Recommend
Against0%
Recommend Against
0%
“Genactis” Research 2004 France
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Age
1%
7%
17%
23%
32%
0.16
0.05
0% 5% 10% 15% 20% 25% 30% 35%
65 +
55 - 64
45 - 54
35 - 44
25 - 34
18 - 24
Under 18
N=1335Vivid Interface Ltd. Market Research Body Beautiful 2005
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Art and Science combined
It is very importantIt is very important
to learn that BOTOXto learn that BOTOX®® is both an is both an
artart and a and a science science before you become a userbefore you become a user
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Starting BOTOXStarting BOTOX®®
How can you introduce it into
your practice?
Starting BOTOX®
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Starting BOTOX®
Starting BOTOXStarting BOTOX®®
Getting started with BOTOX® can be the
hardest part…
collecting patients,promoting it in the practice,consent forms…
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Before offering BOTOXBefore offering BOTOX®® to patients to patients
• Attend a training course
• Review literature
• Develop a consent form(provided)
• Practice on partner, mother, close friend
• Share data with staff.
• Obtain suitable insurance cover
Starting BOTOX®
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Launching it in your Practice Launching it in your Practice – consider the following:– consider the following:
• Train reception staff to discuss the procedure
• Do some initial free treatments on staff and best patients for word of mouth advertising
• Build a before and after photo library to show prospective patients
Starting BOTOX®
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Launching it in your Practice – Launching it in your Practice – consider the following:consider the following:
• Schedule “BOTOX® days”
• Get local media exposure
• Inform patients with practice newsletter
Starting BOTOX®
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NeurotoxinNeurotoxin
PharmacologyPharmacology
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BOTOX®
Indicated for*;
-Blepharospasm
-Strabismus (USA)
-Hemifacial spasm
-Cervical dystonia
-Cerebral Palsy
-Axillary hyperhidrosis
-Glabellar lines
Photos © J Jankovic
*Approvals and product names vary from country to country – consult specific prescribing information
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Other Clinical Conditions Treated with Other Clinical Conditions Treated with
BOTOXBOTOX® (Un-licensed)® (Un-licensed)
Neurotoxin Pharmacology
•Migraine
•Tension Type Head-Ache
•Back Ache
•Hypersalivation
•Myofacial Pain Syndrome
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Botulinum Neurotoxin SerotypesBotulinum Neurotoxin Serotypes
Neurotoxin Pharmacology
• 1982 Jean Carruthers to San Francisco to work with Alan Scott – one of early co- investigators in FDA study
• 1982 Jean Carruthers brings “Oculinum” into Canada
• 1987 Jean Carruthers Blepharospasm patient comments on improvement in her wrinkles
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• Seven serotypes
- A, B, C1, D, E, F, G
- Type A has longest duration
of action
• Intracellular target varies
- SNAP-25
• Does not penetrate the skin
• No topical application COOH
NH2
NH2
COOH
S-S
SS
HeavyChain
LightChain
Botulinum Neurotoxin SerotypesBotulinum Neurotoxin Serotypes
Neurotoxin Pharmacology
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BOTOXBOTOX® - Mode of Action® - Mode of Action
Neurotoxin Pharmacology
1 Before BOTOX®:
Endplate sits upon muscle fibre
2 Binding:
Neurotoxin binds to nerve terminal
3 Internalization:
Neurotoxin internalized via receptor-mediated endocytosis.
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BOTOXBOTOX® - Mode of Action® - Mode of Action
Neurotoxin Pharmacology
4 Blocking:
Light chain blocks fusion of neurotransmitter vesicle with nerve membrane by cleaving SNAP-25.
5 Sprouting and re-establishment of sprouts:
Endplate expands and collateral axonal sprouts emerge. Sprouts subsequently retract and are eliminated; parent terminal is re-established.
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PRODUCT SAFETY• Botox has long clinical history
• Maximum dose per treatment session for Dystonia 400U
• Cosmetic doses range between 24 to 70U
• LD50 estimated to be 3000U
• Wide margin of safety.
• No relevant systemic effects observed
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How Toxic Is Botulinum Toxin?Look at the Ratio of Therapeutic dose to Life Threatening
dose
- Digitalis 1:2
- Insulin 1:3
- Lidocaine (s.c.) 1:5
- Botulinum toxin-A 1:50
Heckmann M Hauzart 2000
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Contraindications and Contraindications and cautionscautions
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ContraindicationsContraindications
Contraindications & cautions
• Pregnancy and Lactation •Neuromuscular transmission disorders.(Myasthenia Gravis)
• Co-administration with aminoglycoside antibiotics
• Bleeding disorders or anticoagulant therapy
•Patients with known hypersensitivity to any ingredient in BOTOX®
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CautionsCautions
Contraindications & cautions
• Lack of patient co operation
•Unrealistic expectations
•Local infection at injection site (active acne)
•Dysmorphophobia
•Unrealistic fear of systemic botulism
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Patient Selection and Patient Selection and treatment options treatment options
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Patient Selection and Treatment Options
Glogau wrinkle scaleGlogau wrinkle scale
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Patient Selection and Treatment Options
Glogau wrinkle scaleGlogau wrinkle scale
Type I (No Wrinkles) Topical therapyHowever, check
dynamic movementMay treat as
preventive therapy
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Patient Selection and Treatment Options
Glogau wrinkle scaleGlogau wrinkle scale
Type II (Wrinkles in Motion)
BOTOX® plus topicals
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Patient Selection and Treatment Options
Glogau wrinkle scaleGlogau wrinkle scale
Type III (Wrinkles at Rest) BOTOX® plus fillers
•Treat with Botox first•Botox and filler have
synergistic action
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Patient Selection and Treatment Options
Glogau wrinkle scaleGlogau wrinkle scale
Type IV (Nothing but Wrinkles)
Consider surgery
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KEY ELEMENTS• Assess patient’s desires. Are they realistic?
• Assess facial expression at rest and during animation
• Evaluate tonicity of muscles
1. Kinetic
2. Hyperkinetic
3. Hypertonic
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KEY ELEMENTS• Palpate muscles to assess mass
• Assess brow position
• Evaluate any asymmetries
• Begin with recommended starting dosages add more units in 2 week intervals
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Dilution &Dilution &
StorageStorage
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Dilution & Storage
Dilution of VialDilution of Vial• Wipe bung of Botox and saline with alcohol and allow to evaporate
• Vacuum should draw down saline
• Volumes of 1ml to 2.5mls recommended
• Use only Bacteriostatic saline
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Dilution & Storage
Dilution of VialDilution of Vial
• Volumes of 1ml to 2.5mls recommended
• US FDA trial protocol uses 2.5cc
• 1ml dilution allows greater control by reducing diffusion however more difficult to handle leading to increased wastage of expensive product.
• Also minor injection errors with 1ml dilution may lead to unpleasant consequences for patient
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StorageStorage• Unreconstituted can store in fridge or freezer
• DO NOT FREEZE BOTOX® ONCE RECONSTITUTED
- Ice crystals may form which damage the toxin and reduce potency
• Store in the refrigerator at 2 – 4 °C
• As a general rule store in fridge at all times
Dilution & Storage
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DILUTION
100 units botox in 2.5mls
20 units of botox in 0.5mls
2 units of botox in 0.05 mls
4 units of botox in 0.1mls
Each major gradation is 2 units
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DILUTION
50 units Vistabel in 1.25mls
20 units of Vistabel in 0.5mls
2 units of Vistabel in 0.05 mls
4 units of Vistabel in 0.1mls
Each major gradation is 2 units
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Some general Some general technique tips for:technique tips for:
• optimal treatment success
• satisfied, repeat patients
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General Injection Technique TipsGeneral Injection Technique Tips
• Patient should be seated or slightly reclining to best observe facial expressions
• The treatment should be pleasant or, at least, comfortable to encourage repeat visits. Relax the patient & talk soothingly to lessen perceived pain
• Thoroughly cleanse areas prior to injection, avoid alcohol as drying to skin and may interfere with Botox.
Technique Tips
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• Try to change 30 gauge needle after every 4 - 5 injections. A sharp needle is less painful!
• Gloves should be worn at all times, check for latex allergy
• Mark injection sites prior to injection – remember to use a non tattooing pen
• Record technique thoroughly on a patient worksheet so you can duplicate successful treatment and modify over- or under treatment.
Technique Tips
General Injection Technique TipsGeneral Injection Technique Tips
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• Have patients discontinue aspirin,Vit E and NSAIDS, 7 days prior to treatment, to decrease bruising
• Or at least warn patients of increased risk of bruising
• Hold a gauze pad in the non-injecting hand so you can apply gentle pressure to any site that bleeds to minimise chances of bruising
Technique Tips
General Injection Technique TipsGeneral Injection Technique Tips
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• Have the patient contract the muscles
• Mark (when learning) the injection sites
• Inject selected dose with 30 gauge needle
• Inject with patient’s muscle relaxed for comfort
Preparing to InjectPreparing to Inject
Technique Tips
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CHECK LIST• Med history
• Assess expectations
• Explain 2 to 3 days before visible signs, 14 days for maximum effect
• History,Skin status
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Cont’• Explain likely results discuss alternatives
• Peels,microdermabrasion,Laser resurfacing
• Sign consent form
• Photograph, Inject, Record
• Follow up instructions recall
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• Glabellar Frown Lines• Forehead Lines
• Crow’s Feet
• Eyebrow lift
Cosmetic IndicationsCosmetic Indications
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GlabellarGlabellar
Frown LinesFrown Lines
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• Convey negative emotions such as anger, depression,fatigue,biterness,disappointment and envy
• Consider utilising in younger individuals as habit breaker.Muscle group may atrophy in time allowing longer duration of action
• Women require 20 to 30U, Men 30 to 40U assess individually
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Procerus
Corrugators
Target Muscles for Frown LinesTarget Muscles for Frown Lines
Cosmetic Indications
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Muscles of the Glabellar Complex
Muscles Function
Corrugator Brow adductor (depressor)
• Moves eyebrow downward and medially
Procerus Brow depressor
• Depresses medial head of eyebrow; can produce transverse lines on nasal dorsum
Orbicularis oculi (medial); also known as depressor supercilii
Brow depressor
Carruthers J Fagien S et al Plast Reconstr Surg 2004
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Treating Glabellar Lines: Consensus Recommendations
Higher starting doses may be used depending on individual patient variables
Target Muscles
Usual Number ofInjection Points
(Range)
Total Starting Dose*
(Usual Range)
Corrugator, procerus, depressor supercilii, orbicularis oculi, frontalis
5 to 7; men may require more sites
Women: 20 to 30 UMen: 30 to 40 U
Carruthers J Fagien S et al Plast Reconstr Surg 2004
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Frown lines – Injection sitesFrown lines – Injection sites
Cosmetic Indications - Glabellar Frown Lines
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Post-injection: Advise patient to frown
as much as possible for 1 hour
Glabellar Frown LinesGlabellar Frown Lines
Cosmetic Indications - Glabellar Frown Lines
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Injection Technique (2)
Pinching stabilizes the patient
Pinching the facial skin with the non-dominant hand is helpful to control injection
Allows subtle feeling of needle entering muscle
Helps identify an intramuscular injection
Photo © Tim Flynn
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Cosmetic Indications - Glabellar Frown Lines
Glabellar Frown Lines – How Glabellar Frown Lines – How not to inject!not to inject!
Injecting down toward the globe
Patient supine
No gloves!
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Results (1)
Photos © Hervé Raspaldo
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Clinical ExamplesFemale in her Thirties
Before
30 Days
120 Days
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• Patients to return in 2 weeks to:
- assess results/technique
- photograph patient
- touch up (if necessary)
• Re-injection schedule
- Patient dependent
- 3 - 4 month intervals for first year
- Less frequent after repeated treatments
Glabellar Frown Lines - Follow UpGlabellar Frown Lines - Follow Up
Cosmetic Indications - Glabellar Frown Lines
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HorizontalHorizontal
Forehead LinesForehead Lines
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Anatomy - Frontalis MuscleAnatomy - Frontalis Muscle
Action: elevate brows, draw scalp posteriorly
Frontalis muscle
Cosmetic Indications - Horizontal Forehead Lines
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Horizontal Forehead Lines:Anatomy and Physiology
Muscle Function
Frontalis
(interacts with procerus, corrugators, and orbicularis oris)
Brow elevation
Carruthers J Fagien S et al Plast Reconstr Surg 2004
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Horizontal Forehead LinesHorizontal Forehead Lines
Cosmetic Indications - Horizontal Forehead Lines
• Leave some facial expression do not paralyze
• Use minimal dose to produce desired effect
• Males have more muscle mass
• Assess pre-existing brow position prior to deciding on frontalis doseage and injection sites
• Look for any brow asymmetry
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• Approach should be conservative- 10-20 Units BOTOX® in several divided doses
• In the lateral to mid-pupillary line, stay at least 1 finger width above the supra-orbital rim
Avoid ptosis bynot injecting shaded area
Horizontal Forehead LinesHorizontal Forehead Lines
Cosmetic Indications - Horizontal Forehead Lines
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Clinical ExamplesFemale in her Thirties
Before
30 Days
120 Days
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Cosmetic Indications - Horizontal Forehead Lines
Horizontal Forehead LinesHorizontal Forehead Lines
Standard technique: 2-4 units in 5 injection sites
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Cosmetic Indications - Horizontal Forehead Lines
Horizontal Forehead LinesHorizontal Forehead Lines
Additional sites to consider for males
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Before After
Horizontal Forehead LinesHorizontal Forehead Lines
Cosmetic Indications - Horizontal Forehead Lines
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Note enhancement of brow shape to soft flare
Before After
Horizontal Forehead LinesHorizontal Forehead Lines
Cosmetic Indications - Horizontal Forehead Lines
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Crow’s FeetCrow’s Feet
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Orbicularis oculi
Target Muscles for Crow’s FeetTarget Muscles for Crow’s Feet
Cosmetic Indications - Crow’s Feet
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• Caution in patients with eyebags may make worse
• Assess skin laxity and dlfferentiate between dynamic movement and skin ageing
• Be guarded with prognosis in individuals with laxity and aged skin
• Look closely for blood vessels and avoid
• The orbicularis oculi is a superficial muscle – there is no need to inject deeply
Crow’s FeetCrow’s Feet
Cosmetic Indications - Crow’s Feet
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• Patient at full smile
• Note upper and lower borders of the crow’s feet
Crow’s FeetCrow’s Feet
Cosmetic Indications - Crow’s Feet
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x
x
• Inject 1cm outside the orbital rim
• At least 3 injection sites 1cm apart suffice due to diffusion effect
• Inject 3 - 4 units of BOTOX® per injection site
OPTIONAL- IF PATIENT HAS LINES
REQUIRED
Crow’s FeetCrow’s Feet
Cosmetic Indications - Crow’s Feet
x
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Clinical ExamplesFemale in her Thirties
Before
30 Days
120 Days
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Crow’s FeetCrow’s Feet
Before After
Cosmetic Indications - Crow’s Feet
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Managing complications Managing complications
of BOTOXof BOTOX® treatment® treatment
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• Bruising is the most common side effect
• Avoid obvious blood vessels
• Apply gentle pressure to bleeding area
• Drooping of eyebrow
• Transient headache
• Nausea
• Diplopia
Potential Side EffectsPotential Side Effects
Managing complications
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Potential complicationsPotential complications
Managing complications
BruisingHeadacheEyelid ptosisBrow ptosisBrow repositioningDiplopia
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Treating ptosisTreating ptosis
Managing complications
Alpha-2 agent with weak alpha-1 activity [eg, apraclonidine 0.5% (Iopidine®]
Alpha-1 adrenergic stimulation of Müller’s muscle
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Treating ptosisTreating ptosis
Managing complicationsPtosis left lid 20 minutes after Iopidine®
Usually resolves in 1-6 weeksIopidine (Alcon) eyedrops 1 drop q.i.d. will temporarily resolve
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Brow ptosisBrow ptosis
Managing complications
Wait for natural resolution
Consider infrabrow injection at arch and laterally to raise brow
After BOTOX® to glabellar and brow
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Excessive brow elevation
• “Quizzical” or “Mr Spock” brows
• Correct with 1 to 2units of BOTOX® injected into the frontalis above the lateral brow
Brow repositioningBrow repositioning
Managing complications
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‘Mephisto’
If after glabella treatment “cruella” / mephisto inject 0.5-1.5U only
Photo © Ph LEVY
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Advanced techniques require a degree Advanced techniques require a degree
of judgement gained from of judgement gained from
approximately 3-6 months BOTOXapproximately 3-6 months BOTOX®®
cosmetic experiencecosmetic experience
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• Suborbital region
• Upper lip wrinkles
• Nasal scrunch (“bunny lines”)
• Nasolabial folds & marionette lines
• Platysmal bands
Advanced techniques and combination treatment
Advanced Cosmetic TechniquesAdvanced Cosmetic Techniques
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Infra Orbital Crinkle LinesPhotos© Ph LEVY
Before After
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Bunny Lines ResultsPhotos © K De Boulle
Before After
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Perioral Rhytides
Before After
Photos © K De Boulle
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Chin: Peau D’orange, Mental Crease
Before After
Photos © NJ Lowe
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Marionnette Lines Or Sad Corners Of The Mouth
Uplifts corners of the mouth
Technique: 1.5–3U into each depressor anguli oris muscle
Injection site
-7mm lateral , 8mm caudal OR mandib. border
© Ph LEVY
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Neck - Anterior bands 35-55 y.o.
Maximum dose per session: 60U
Rather tight skin
Before After
Photos © Ph LEVY
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Strategies for Strategies for successsuccess
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Choice of LanguageMedical Phrases Patient Positive Phrases
Frozen Smooth
Toxin Purified or natural protein
Paralyse Relax or soften muscle activity
Pain Minimal discomfort
Weaken Relax
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Strategies for success
Customer serviceCustomer service
• Prompt service availability is essential
•Offer free consultation
• The wait time for BOTOX® is best kept short
• Try and arrange BOTOX® days for efficient use of material
• Always have material available!!!!!!!!
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Strategies for success
Pricing PolicyPricing Policy
• In the UK pricing tends to be by facial areas
• Be consistent in your pricing policy with
single versus 3 areas
• Provide top up treatment free of chargeProvide top up treatment free of charge
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Strategies for success
MarketingMarketing
Don’t advertise BOTOX® or “Botulinum toxin”- it contravenes Advertising Standard Authority guidelines regarding the promotion of Prescription Only Medicines.
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Tips to avoid DisappointmentTips to avoid Disappointment
• Offer free consultation prior to treatment for first time treatment
• Make sure that you and the patient have realistic outcome objectives
• When treatment results are not up to expectations, assess situation and top up if appropriate
• Consider non responder(rare)
Strategies for success
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Cont’Cont’
Strategies for success
• If results are minimised because of additional muscle recruitment, explain with a mirror
• Some movement may return after only 28 days
• Refer patients back to initial photographs
• Make no guarantees concerning duration. Ranges are from 2 – 6 months
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BOTOX®/VISTABEL considered by
many cosmetic practitioners to be
the most successful cosmetic
procedure available due to patient
demand, level of satisfaction and
relative ease of placement.
Optimizing SuccessOptimizing Success
Strategies for sucess
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Conclusion
Long-term treatment with boNTA can prevent the development of imprinted facial lines that are visible at rest
Such treatment is well tolerated, with no adverse events reported during 13 years of regular treatment in this study
Binder WJ AAD 2006
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What Makes A Clinician Confident Using VISTABEL®?
Reproducible efficacy and safety with his/her patients
Satisfied patients
Increasing demand for treatment
Demonstrated long term safety profile
Number and quality of supporting publications
Ongoing basic and clinical research
Active support and training
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Reconstitution
BOTOX
100 units per vial
Reconstitute 2.5 mls Bacteriostatic saline
100 units in 2.5mls
20units in 0.5 mls
2 units in 0.05 mls (marked 5)
4 units in 0.1 mls (marked 10)
VISTABEL
50 units per vial(half of Botox vial)
dilute with1.25mls Bacteriostatic saline and use unit measurements as above.
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CONSENT FORM
Contraindications:You cannot receive Botox/Dysport if you are in the following categories :
Pregnant or Breast Feeding
Neuromuscular disorders/Myasthenia Gravis/Eaton Lambert Syndrome
Blood Coagulation Disorders or taking anticoagulants.
Currently taking Aminoglycoside antibiotics,Spectinomycin or Muscle relaxants.
Potential Side Effects(temporary)
Bruising /Swelling/Redness at injection site
Nausea/Headache
Occasional numbness
Drooping of the Eyebrow or upper Eyelid
Allergic reactions
Brief visual disturbances
Consent for Botox/Dysport Treatment
All foreseeable risks of Botulinum toxin therapy listed above have been thoroughly explained to me.My questions regarding the treatment procedure,its potential side effects and contraindications were answered to my full satisfaction. I also had adequate time to consider my decision.
I understand that I am free to revoke my consent at any time.
I consent to the administration of Botox/Dysport and have been given after care instructions.This consent form is also signed for future administration of Botox/Dysport.
Patient’s Name…………………………… Date………………..
Signature of Patient………………………
Witnessed by (Signature of Physician)………………………………..
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POST TREATMENT INSTRUCTIONS
1) Exercise muscles treated for 1 hour
2) Remain Upright for 3-4 hours
3) No chemical peels, sun beds or laser treatment for 7 days
4) Muscle weakening may not be evident for 3 days and may take as long as 10 days.
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Useful Numbers
Wigmore Pharmacy
23 Wigmore Street
London
W1U 1PL
Tel: 0207 4910111
Botox,0.5ml diabetic syringes
30ml 0.9% Bacteriostatic saline
Iopidine 5mg/ml eye drops
Hamilton Fraser Insurance Solutions(HFIS)
Tel: 0845 3106319(Jeanette Turner)
Steven Kaldor
07801428702
Allergan Ltd(Vistabel)
08003767965
Richard Crawford 0773358145(Rep)
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Thank youThank you