Botulinum Toxin in Aesthetic Medicine - M. de Maio, B. Rzany (Springer, 2007) WW

Mauricio de Maio & Berthold Rzany

Botulinum Toxin in Aesthetic Medicine

Mauricio de Maio & Berthold Rzany

Botulinum Toxin in Aesthetic MedicineWith 151 Figures and 36 Tables

123

ISBN 978-3-540-34094-2 SpringerBerlinHeidelbergNewYork

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Editors

B. RzanyProfessor of DermatologyClinical Epidemiologist, Division of Evidence Based Medicine (dEBM)Klinik für DermatologieCHARITÉ–UNIVERSITÄTSMEDIZINBERLINCharitéplatz 110117 Berlin, Germany

M. de MaioPlastic SurgeonFaculty of Medicine of the University of São PauloAv. Ibirapuera, 2907 – cj. 1202Moema – São Paulo – SPCEP: 04029-200, Brazil

ForewordBotulinumtoxin A in Aesthetic Medicine

GaryD.Monheit,M.D.

Probablythemostimportanteventintheevolutionofminimallyinvasivecosmeticproceduresisthedevelopmentofbotulinumtoxinforcosmeticusage.Fromasingleregionandprocedureforthetreatmentofthefrownlinesoveradecadeago,theuseofbotulinumtoxinhasevolved intomultipleareas, techniques,dosagesandnownewtoxinsinthiseverexpandingfield.Tocaptureitallinacomprehensiveyeteasilyreadandorganizedtext,DrsdeMaioandRzanyhaveputtogetherthisnewvolumeintheirapproachtofacialcosmetics.

This is a welcome addition to their first text on injectable fillers in AestheticMedicine.Itisorganizedinasimilarfashion,firstgivinganoverviewofthetoxindiscussingpharmacochemistry,sub-typesandproducts,efficacy,dosage,effective-nessandfinallysafety.Theclinicalapplicationsaredividedintopatientselection,basic requirements and injection techniques. The unique approach of correlatingindividualanatomicdifferencesinpatientsastodosageandinjectionpointswithmusclemassgivesthecliniciananewguidetosuccessfultreatment.Thetechniqueinjectionsectionsdiscussallthetreatableareasfromupperfacetolowerfaceandneck,coveringanatomy,treatmentaims,patientselection,technique,complicationsand“tipsandtricks”.

In this text theclinicianwillfindawealthof informationcollectedoveryearsofexperiencebythesetworenownedaestheticresearchersandclinicians.Ihighlyrecommendthistextforallaestheticcliniciansfromthenovicetothosewithyearsofexperienceasthelearningcurveisapplicableforall.

Gary D. Monheit, MDClinicalAssociateProfessorDepartmentsofOphthalmologyandDermatologyUniversityofAlabamaatBirminghamDermatologyAssociates,AshPlaceSuite202,210016thAvenueSouth,BirminghamAL,35205,USA

ForewordChristopherRowlandPayne

No cosmetic item has had more impact than botulinum toxin. It is a worldwidephenomenon that has revolutionised cosmetic practice since its introduction 15yearsago.Itisalmostimpossibletofindanyissueofawomen’smagazinefromthelasttenyearswhichdoesnotincludeamentionofbotulinumtoxin.Thistsunamiofinterestamongstthepublicandamongstphysicianshasbroughtforthadvancesinthewayinwhichbotulinumtoxincanbeusedtobenefitthefacecosmetically.Atthecrestofthiswaveofinnovationareanumberofnotabledoctors.AmongstthisselectgroupareMauriciodeMaioandBertholdRzany.Theirownoriginalworkonbotulinumhasachievedpeeradmirationaroundtheworld.Theyareknownnotonlyforthequalityoftheirscientificpapersbutalsofortheclarityoftheirpresenta-tionsatscientificandclinicalmeetingsandtheyeachhaveahugepersonalfollowingofloyalpatients.

Accordingly,itisabsolutelyappositethatMauriciodeMaioandBertholdRzanyshouldbepublishingthisbooknow.Itistheirsecondbookandwillbringthepracti-tionerreaderrightuptodate.Theydiscussthemovementawayfrom“moreismore”towards“individualisationandthemicroinjectiontechnique”.Thetextemphasisesclinicalmethodandclearlyoutlines“howtodoit”,makingelegantuseofhalfandhalf(beforeandafter)facialphotographyofthehigheststandard.Photographsofthissortrequireenormouscareandpatience.Practitioners–andalsopotentialpa-tients–willgreatlyappreciatetheseillustrations.

Important discussion points are covered in a ‘questions and answers’ section,including the thorny question of the frequency with which injections need to berepeated. The text, which is fully referenced and, where possible evidence-based,alsocovers themoreadvancedandmostrecentusesofbotulinum, including thebotulinumfacelift,thetreatmentoffacialasymmetryand,ofcourse,safetyconsid-erations,contraindicationsandsoon.

Thisbookfullydeservestobecomethevade mecumofaestheticbotulinumtoxin.

Christopher Rowland PayneSecretary-General(&PastPresident)oftheEuropeanSocietyofCosmetic&AestheticDermatology

LondonJanuary2007

Preface

Whyanotherbookonbotulinumtoxininaestheticmedicine?Thereareacoupleofreasons.First:themainreasonisthetremendousprogressthatweareseeingintheuseofthisdrug,whichrapidlyoutstripsthepresentliterature.Second:westillthinkthereisaneedforgoodbooksasthereisstillalotofconfusionandmisconceptionsaroundthedifferentindicationsandthedifferentdrugs.

Unlikeinthebeginning,whenbotulinumtoxinAwasusedalongtheprinciplesof‘thesameinjectionpointsanddosesforeverybody’and‘biggerdosesforbiggereffects’ it isnowused inamuchmoredifferentiatedway.Basedon themuscularpatterns(kinetic,hyperkineticandhypertonic),wehaveamuchmoreindividual-izedapproachtothetreatmentofourpatients.Newindicationsinthemiddleandlowerthirdofthefacehavebeenaddedtothewell-knownareasoftheupperface.Multiplefacialareasarenowtreatedduringonevisit,withtheaimofglobalfacialrejuvenationwiththeultimateaimofthebotulinumtoxin‘facelift’.Besidestheclas-sic intramuscular injection technique, microinjection techniques are increasinglyused.Furthermore,thebotulinumtoxinworldisnotatwo-productworldanymore.Moreandmorebotulinumtoxinproductsareentering thefield tofight for theirshareinthemarket.

Basedontheviewsofaplasticsurgeonandadermatologist,thisbookaimstofamiliarizethenoviceaswellasskilleduserwiththesenewconceptsandnewprepa-rationstoenablebothtotreattheirpatientsinthebestpossibleway.

Thisbookcomplementsourbookoninjectablefillersinaestheticmedicine.Likeourfirstbook,wehavefollowedanhonest‘howwedoit’approach.Asouraimistoimproveourteachingswealwaysappreciatedirectfeedbackfromourreaders,andweencourageyoutogiveusyourcommentsandsuggestionsforimprovement.

BerlinandSaoPaulo,August2006

Mauricio de Maio Berthold Rzany

Acknowledgments

Neitherourfirst,northis,oursecondbook,wouldhavebeenpossiblewithouttheworkofmanyothers.Wewouldthereforeliketotaketheopportunitytothankourpatientswhohelpedusgettowherewearenow,especiallythosewhocontributedtheirphotographstothisbook.AtSpringer,wewould liketothankMrs.MarionPhilippandMrs.EllenBlasig,andfromtheGermanteam:Mr.HendrikZielkeforhishelpwiththecontentandformat,especiallyforhelpingusbuildthechaptersontheefficacyandsafetyofthedifferentbotulinumtoxinpreparationsandhisabilitytocopewithallthesoftware,andMr.TobiasGottermeierfortheexcellentphotographsandgraphicwork.

FromtheBrazilianteam:Mrs.EmmaMattosforhelpingwiththeupdatedref-erences of botulinum toxin treatments; Mrs. Liliann Amoroso for working onthephotolibrarywhichwasquitetiringanddemanding;andespeciallytheclini-cal assistants Mrs. Gisele Souza, Mrs. Liliane Carneiro, Mrs. Renata Sanches andMr.ThaisSorcinelliwhohaveawonderfullycarefulwaywithmypatients.

Contents

1 Overview of Botulinum Toxin . 1BertholdRzany,HendrikZielke

1.1 Introduction . . . . . . . . . . 11.2 DifferentSubtypes

ofBotulinumToxin . . . . . . . 11.3 ModeofAction . . . . . . . . . 11.4 Antidote . . . . . . . . . . . . 31.5 DifferentProducts . . . . . . . 31.6 UnitsofBotulinumToxin . . . . 31.7 Off-LabelUse . . . . . . . . . . 41.8 NewDrugs . . . . . . . . . . . 41.9 EvidenceBehindtheUse

ofBNT-A . . . . . . . . . . . 41.10 Efficacy:OptimalDosage . . . . 5

1.10.1 Botox . . . . . . . . . . 51.10.2 Dysport . . . . . . . . . 6

1.11 Effectiveness:DosagesandRepeatedTreatments . . . . 61.11.1 Botox . . . . . . . . . . 71.11.2 Dysport . . . . . . . . . 7

1.12 Safety . . . . . . . . . . . . . 71.13 Short-termSafety:EyelidPtosis . 7

1.13.1 Botox . . . . . . . . . . 71.13.2 Dysport . . . . . . . . . 7

1.14 Long-termSafety:EyelidPtosis . 81.14.1 Botox . . . . . . . . . . 81.14.2 Dysport . . . . . . . . . 8

1.15 MarketingandEvidence . . . . . 81.16 References . . . . . . . . . . . 9

2 Patient Selection . . . . . . 11MauriciodeMaio,BertholdRzany

2.1 IndicationsforBNT . . . . . 112.1.1 Introduction . . . . . 112.1.2 KineticPatients . . . . 13

2.1.3 HyperkineticPatients . 142.1.4 HypertonicPatients . . 152.1.5 OutcomeAnalysis . . . 172.1.6 TipsandTricks . . . . 182.1.7 References . . . . . . 18

2.2 ContraindicationsforBotulinumToxin . . . . . 182.2.1 General

Contraindications . . . 182.2.2 Drugspecific

Contraindications . . . 182.2.3 References . . . . . . 19

3 Requirements and Rules . . . 21BertholdRzany

3.1 Introduction . . . . . . . . . 213.2 Documentation . . . . . . . . 21

3.2.1 Chart . . . . . . . . . 213.2.2 Photograph . . . . . . 223.2.3 Consent . . . . . . . 223.2.4 TreatmentPlan . . . . 22

3.3 Staff . . . . . . . . . . . . . 223.4 TechnicalRequirements . . . . 22

3.4.1 Room . . . . . . . . . 223.4.2 Chair . . . . . . . . . 223.4.3 Mirror . . . . . . . . 223.4.4 CosmeticMarker . . . 223.4.5 StandardSetting . . . 223.4.6 TheToxin . . . . . . . 233.4.7 TipsandTricks . . . . 243.4.8 References . . . . . . 24

4 Injection Technique . . . . . 25BertholdRzany

4.1 Introduction . . . . . . . . . 25

XIV Contents

4.2 StandardTechnique . . . . . . 254.3 MicroinjectionTechnique . . . 254.4 OtherTechniques . . . . . . . 26

5 The Most Common Indications 27BertholdRzany,MauriciodeMaio

5.1 Forehead . . . . . . . . . . . 285.1.1 Introduction . . . . . 285.1.2 Anatomy . . . . . . . 285.1.3 AimofTreatment . . . 285.1.4 PatientSelection . . . . 295.1.5 Technique . . . . . . . 325.1.6 Complications . . . . . 335.1.7 TipsandTricks . . . . 33

5.2 Glabella . . . . . . . . . . . 335.2.1 Introduction . . . . . 335.2.2 Anatomy . . . . . . . 335.2.3 AimofTreatment . . . 345.2.4 PatientSelection . . . . 345.2.5 Technique . . . . . . . 355.2.6 Complications . . . . . 365.2.7 TipsandTricks . . . . 37

5.3 Browlift . . . . . . . . . . . 375.3.1 Introduction . . . . . 375.3.2 Anatomy . . . . . . . 375.3.3 AimofTreatment . . . 385.3.4 PatientSelection . . . . 385.3.5 Technique . . . . . . . 395.3.6 Complications . . . . . 455.3.7 TipsandTricks . . . . 455.3.8 References . . . . . . 45

5.4 Crow’sFeetandLowerEyelid . 465.4.1 Introduction . . . . . 465.4.2 Anatomy . . . . . . . 465.4.3 AimofTreatment . . . 475.4.4 PatientSelection . . . . 475.4.5 Technique . . . . . . . 485.4.6 Results . . . . . . . . 515.4.7 Complications . . . . . 515.4.8 TipsandTricks . . . . 545.4.9 References . . . . . . 54

5.5 BunnyLines . . . . . . . . . 565.5.1 Introduction . . . . . 565.5.2 Anatomy . . . . . . . 565.5.3 AimoftheTreatment . 57

5.5.4 PatientSelection . . . . 575.5.5 Technique . . . . . . . 585.5.6 Complications . . . . . 585.5.7 TipsandTricks . . . . 615.5.8 References . . . . . . 61

5.6 Nose . . . . . . . . . . . . . 615.6.1 Introduction . . . . . 615.6.2 Anatomy . . . . . . . 615.6.3 AimofTreatment . . . 625.6.4 PatientSelection . . . . 625.6.5 Technique . . . . . . . 625.6.6 Results . . . . . . . . 645.6.7 Complications . . . . . 645.6.8 TipsandTricks . . . . 665.6.9 References . . . . . . 66

5.7 NasolabialFold . . . . . . . . 665.7.1 Introduction . . . . . 665.7.2 Anatomy . . . . . . . 675.7.3 AimofTreatment . . . 675.7.4 PatientSelection . . . . 675.7.5 Technique . . . . . . . 685.7.6 Complications . . . . . 695.7.7 TipsandTricks . . . . 695.7.8 References . . . . . . 69

5.8 CheekLines . . . . . . . . . 715.8.1 Introduction . . . . . 715.8.2 Anatomy . . . . . . . 715.8.3 AimofTreatment . . . 715.8.4 PatientSelection . . . . 735.8.5 Technique . . . . . . . 735.8.6 Complications . . . . . 765.8.7 TipsandTricks . . . . 765.8.8 References . . . . . . 76

5.9 Gummysmile . . . . . . . . 775.9.1 Introduction . . . . . 775.9.2 Anatomy . . . . . . . 775.9.3 AimofTreatment . . . 785.9.4 PatientSelection . . . . 785.9.5 Technique . . . . . . . 795.9.6 Complications . . . . . 825.9.7 TipsandTricks . . . . 825.9.8 References . . . . . . 82

5.10 UpperandLowerLipWrinkling 825.10.1 Introduction . . . . . 825.10.2 Anatomy . . . . . . . 82

Contents XV

5.10.3 AimofTreatment . . . 835.10.4 PatientSelection

andEvaluation . . . . 835.10.5 Technique . . . . . . . 835.10.6 Complications . . . . . 855.10.7 TipsandTricks . . . . 855.10.8 References . . . . . . 85

5.11 MarionetteLines . . . . . . . 865.11.1 Introduction . . . . . 865.11.2 Anatomy . . . . . . . 865.11.3 AimofTreatment . . . 865.11.4 PatientSelection

andEvaluation . . . . 865.11.5 Technique . . . . . . . 865.11.6 Complications . . . . . 885.11.7 TipsandTricks . . . . 88

5.12 Cobblestonechin . . . . . . . 885.12.1 Introduction . . . . . 885.12.2 Anatomy . . . . . . . 885.12.3 AimofTreatment . . . 895.12.4 PatientSelection

andEvaluation . . . . 895.12.5 Technique . . . . . . . 895.12.6 Complications . . . . . 895.12.7 TipsandTricks . . . . 90

5.13 Platysmalbands . . . . . . . 905.13.1 Introduction . . . . . 905.13.2 Anatomy . . . . . . . 905.13.3 AimofTreatment . . . 905.13.4 PatientSelection . . . 915.13.5 Technique . . . . . . . 915.13.6 Complications . . . . . 925.13.7 TipsandTricks . . . . 92

6 Advanced Indications and Techniques . . . . . . . 93MauriciodeMaio,BertholdRzany

6.1 FacialAsymmetries . . . . . . 936.1.1 Introduction . . . . . 936.1.2 Anatomy . . . . . . . 946.1.3 AimofTreatment . . . 976.1.4 PatientSelection . . . . 976.1.5 Technique . . . . . . . 976.1.6 Results . . . . . . . . 996.1.7 Complications . . . . . 99

6.1.8 Conclusions . . . . . . 996.1.9 TipsandTricks . . . . 1016.1.10 References . . . . . . 101

6.2 FacialLiftingwithBotulinumToxin . . . . 1026.2.1 Introduction . . . . . 1026.2.2 AnatomyAntagonists

andSynergists . . . . . 1036.2.3 AimofTreatment . . . 1056.2.4 PatientSelection . . . . 1056.2.5 Technique . . . . . . . 1096.2.6 Complications . . . . . 1146.2.7 TipsandTricks . . . . 1146.2.8 References . . . . . . 114

6.3 TreatmentwithMicroinjections 1156.3.1 Introduction . . . . . 1156.3.2 Microinjectionsofthe

Crow’sFeetArea . . . . 1156.3.3 Microinjections

oftheLongitudinalLinesoftheCheeks . . . . . 115

6.3.4 DosestobeUsed . . . 1166.3.5 CombinationofMacro-

andMicroinjections . . 1166.3.6 Disadvantages

oftheMicroinjectionTechnique . . . . . . . 116

6.3.7 TipsandTricks . . . . 116

7 Safety of Botulinum Toxin in Aesthetic Medicine . . . . 119BertholdRzany,HendrikZielke

7.1 Introduction . . . . . . . . . 1197.2 AdverseSideEffectsDue

toInjection . . . . . . . . . . 1197.2.1 InjectionPain . . . . . 1207.2.2 Hematoma/InjectionSite

Bruising . . . . . . . 1207.2.3 Headache . . . . . . . 1207.2.4 LocalizedSkinDryness 122

7.3 AdverseEventsDuetoLocalDiffusion/Distribution . . . . 1227.3.1 EyelidPtosis . . . . . 1227.3.2 Ectropion . . . . . . . 1227.3.3 Strabismus . . . . . . 122

XVI Contents

7.3.4 Pseudoherniation . . . 1237.3.5 ComplicationsAfter

PerioralandNeckTreatment . . . . . . . 123

7.4 AdverseEventsDuetoHyperactivityofAdjacentMuscles/BrowMalposition . . 123

7.5 AdverseEventsduetoGeneralizedDistribution . . 124

7.6 AllergiestoBotulinumToxin-A 1247.7 FormationofAntibodies . . . 1247.9 References . . . . . . . . . . 124

8 Combination Therapy – The Microlift Procedure . . . 127MauriciodeMaio

8.1 Introduction . . . . . . . . . 1278.2 BotulinumToxin

andChemicalPeels . . . . . . 1288.3 BotulinumToxin

andLaserResurfacing . . . . . 1288.4 BotulinumToxinandFillers . . 1288.5 BotulinumToxinandBrowLift

withSuspensionThreads . . . 1328.6 BotulinumToxin,

EyeSurgery&OtherTinyDetails . . . . . . . . . . . . 132

8.7 BotulinumToxinandFacelift . 1328.8 TheMicroliftProcedure:

BNT-AasanImportantAlly! . 1348.9 TipsandTricks . . . . . . . . 1358.10 References . . . . . . . . . . 135

Berthold Rzany MD ScMProfessorofDermatologyClincialEpidemiologist

Hendrik Zielke MDEmail:[email protected](dEBM)KlinikfürDermatologieCHARITÉ–UNIVERSITÄTSMEDIZINBERLINCAMPUSCHARITÉMITTECharitéplatz1D-10117BerlinGermany

Phone:0049(0)30-450518-283Fax:0049(0)30-450518-927Email:[email protected]://www.debm.deorwww.rzany-berlin.de

Mauricio de Maio MD, PhD, MScPlasticSurgeonFacultyofMedicineoftheUniversityofSaoPauloAv.Ibirapuera,2907-cj.1202Moema-SãoPaulo-SPCEP:04029-200Brazil

Phone/fax:00551155359286Email:[email protected]

List of Contributors

List of Abbreviations

BNT Botulinumtoxin

EADV EuropeanAcademyofDermatologyandVenerology

EBM EvidenceBasedMedicine

MU Mouseunits

Chapter 1

1.1 Introduction

Botulinum toxin (BNT) is a fascinating drugwhich specifically targets the release of acetyl-choline. BNT is produced by the anaerobicbacterium Clostridium botulinum. In order tobeusedasadrug the toxinhas tobe isolated,purified and stabilized (Huang et al. 2000)(Table1.1).

1.2 Different Subtypes of Botulinum Toxin

Seven distinct antigenic botulinum toxins(BNT-A,-B,-C,-D,-E,-F,and-G)producedbydifferentstrainsofClostridium botulinum havebeen described. The human nervous system issusceptibletofivetoxinserotypes(BNT-A,-B,-E, -F, -G) and unaffected by 2 (BNT-C, -D).Although all toxins have different moleculartargets,theiractionleadstotheblockadeofthecholinergicnerves.However,onlytheAandBtoxinsareavailableasdrugs.Inaestheticmedi-cine,theBNTpredominatelyusedhasbeenoftypeAsofar,eventhoughsometrialshavebeenpublishedutilizingtypeBBNT(Baumannetal.2003).

1.3 Mode of Action

BNTblockstheactionofacetylcholine.Acetyl-choline is a common neural transmitter and

Contents

1.1 Introduction . . . . . . . . . . . . . 1

1.2 DifferentSubtypesofBotulinumToxin . 1

1.3 ModeofAction . . . . . . . . . . . . 1

1.4 Antidote . . . . . . . . . . . . . . . 3

1.5 DifferentProducts . . . . . . . . . . 3

1.6 UnitsofBotulinumToxin . . . . . . . 3

1.7 Off-LabelUse . . . . . . . . . . . . . 4

1.8 NewDrugs . . . . . . . . . . . . . . 4

1.9 EvidenceBehindtheUseofBNT-A . . 4

1.10 Efficacy:OptimalDosage . . . . . . . 51.10.1 Botox . . . . . . . . . . . . . . . . 51.10.2 Dysport . . . . . . . . . . . . . . . 6

1.11 Effectiveness:DosagesandRepeatedTreatments . . . . . . . 6

1.11.1 Botox . . . . . . . . . . . . . . . . 71.11.2 Dysport . . . . . . . . . . . . . . . 7

1.12 Safety . . . . . . . . . . . . . . . . 7

1.13 Short-termSafety:EyelidPtosis . . . . 71.13.1 Botox . . . . . . . . . . . . . . . . 71.13.2 Dysport . . . . . . . . . . . . . . . 7

1.14 Long-termSafety:EyelidPtosis . . . . 81.14.1 Botox . . . . . . . . . . . . . . . . 81.14.2 Dysport . . . . . . . . . . . . . . . 8

1.15 MarketingandEvidence . . . . . . . . 81.16 References . . . . . . . . . . . . . . 9

1 Overview of Botulinum ToxinBertholdRzany,HendrikZielke

2 Berthold Rzany, Hendrik Zielke

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Chapter 1 3Overview of Botulinum Toxin

stimulatesstriatedaswellassmoothmusclesandthesecretionofglandssuchassweatglands.

After BNT has been ingested or injected, itdiffusesintothehumantissueuntilitselectivelyand irreversibly binds to the presynaptic ter-minal of the neuromuscular or neuroglandularjunction,where it exerts itsactionsbycleavingspecificmembraneproteinsresponsibleforace-tylcholineexcretion.

ItisimportanttounderstandthattheactionoftheBNTdoesnotoccurimmediately.Usuallythemaximumeffectcanbeseenafteracoupleofweeks.Thefirsteffectsmightbevisibleafter48hours.Dependingonthestrengthofthemusclestreatedandthedosagesused,thedurationoftheeffectvariesfromacoupleofmonthstoseveralmonths.

Theactionofthedrugslowlydecreasesovertimeastheaffectedaxonssproutnewnerveter-minals which continually restore the impairedtransmission. During this phase the damagedsynapse itself will regenerate its function (dePaivaetal.1999).

Botulinum toxin only acts after ingestionor injection. Topical application is insuf-ficient.Claims of creams that induce botulinumtoxinAeffectshavetobequestioned.

1.4 Antidote

AlthoughaBNTantidoteexists, it isunable toreverse any drug effects that have arisen. Oncesymptomsbecomevisible,thetoxinhasalreadyboundtothesynapseandthelateapplicationofantibodieshasnoeffects.Pleasenote thatanti-bodiesareneverthelessquitehelpfulinbotulismoccurringafteraccidentalingestionofcontami-natedfoodswhenBNTmightstilldiffuseinthebodyfromthegastrointestinaltract.

1.5 Different Products

Sofar,thereareseveralBNT-AproductsandoneBNT-Bproductonthemarket.

The BNT-A products differ in their amountofproteinaswell as in theamountofalbuminadded (Table 1.1). At the moment Botox, alsomarketedinsomecountriesasBotoxAesthetic/Vistabel/Vistabex for aesthetic indications, andDysportsharethemajorityoftheaestheticmar-ket.ThenewGermanBNT-ApreparationXeo-min is only available in a few countries so far,andlacksclinicaldataonitsefficacyinaestheticmedicine. NeuroBloc (also marketed as Myo-bloc) is theonly commercially available typeBBNT.Althoughthereissomedataonitsefficacyinaesthetic indications, it isnotoftenused fortheseindications(Baumannetal.2003).

BotoxmaybemarketedasBotoxAesthet-ics,VistabelorVistabex.ForsimplificationinthisbookwewilltalkonlyaboutBotoxwhenreferringtodosages.

1.6 Units of Botulinum Toxin

Theconceptof calculating thedosageunits forthedifferentproductsBotoxandDysportisnoteasy to understand and may not be necessary.Theusermustonlybeawarethatthedosageunitsofdifferentproductsdonotrelatetoeachother.Therearesomeattemptstoofferratiosfortheseproducts.However,apartfromonetrialwithse-vere methodological shortcomings (Lowe et al.2005)therearenocomparativeclinicaltrialsforaesthetic indications. For Botox and Dysport,based on the available data from placebo con-trolledclinicaltrialsanddosagesrecommendedat consensus conferences, the ratio is close to1:2.5–1:3.ThemanufacturerclaimsthatXeominhasa1:1ratiotoBotox.However,wehavelittle


1experience and no published data on aestheticindicationsforthisBTN-Aformulationsofartosupportthisclaim(Table1.1).

Therefore, when in doubt, instead of usingratioswewouldrecommendthetreatingphysi-ciantogobacktothedatafromclinicaltrialsorconsensusconferences.

Donotgetconfusedbyunitsorratiosbe-tweendifferentproducts.Incaseofdoubtoneshouldgobacktotheclinicaltrialdataordatafromconsensusconferences.

In this book the dosages recommended arethedosagesthatinourexperiencehavethebesteffect in the majority of patients. For some in-dicationstheserecommendeddosagesarebasedonclinicaltrials.However,formostindicationsnoclinicaltrialshavebeenperformedsofar.

1.7 Off-Label Use

BotoxandDysportarenotlicensedforaestheticindications in all countries. In addition, the li-cense is usually limited to the glabella area. Incaseswherenolabellingoralimitedlabellingex-ists,thephysicianhastodealwithoff-labeluse.Thepatientmustbe informed if theproduct isusedforanoff-labelindication.

As is sometimes the case with licensing ofanother indication, thedrugname ischanged:basically the same brand may be available foroff-labelaswellaslabelleduse.Forexample,inGermany Botox is listed for various neurologi-calindicationsbutnotforaestheticindications.However, forthetreatmentoftheglabellaarea,thesamedrugisavailableasVistabel.BothdrugscontainexactlythesameBNT,butBotoxcomesin100UvialsandVistabelin50Uvials.

Allthecompaniesaretryingtoobtainlicens-es for aesthetic indications, therefore, it seemsquitelikelythatthenumberofcountrieswhere

themajoraestheticindicationsarestilloff-labelwill decrease over time. Nevertheless, it is alsoclearthatforthepresenttimeinmostcountriesonly some indications will be licensed, such asthetreatmentoftheglabella.

Do not worry too much about off-labeluse. For Botox and Dysport there areenoughstudiesprovingefficacyandsafety.The patient, however, must be informedwhentheproduct isused foranoff-labelindication.

1.8 New Drugs

At the moment several companies are workingonnewBNTpreparations.Thesenewproductsshouldbecarefullyevaluatedandcomparedwiththeproductspresentlyonthemarket.Itisalwaysimportanttoconsidertheevidencebehindthesenewdrugs.Randomizedcontrolledclinicaltrialsbasedonaestheticindicationsshouldbethegoldstandard which new BNT preparations have tomatch.A‘This brand of botulinum toxin is com-parable or even better than that brand of botuli-num toxin!’withoutgoodsupportingdataisnotenough.

1.9 Evidence Behind the Use of BNT-A

Incontrasttoinjectablefillers,theevidencebe-hindtheuseofBNT-Ainaestheticmedicineismuchlarger–atleastforthetwoleadingbrandsBotoxandDysport.

InthefollowingchaptertheevidencefortheefficacyandsafetyofthedifferentBNT-Aprepa-rationswillbediscussedforsomekeyquestions.In order to reduce bias only large studies, e.g.onlystudiesofmorethan50patientswillbein-cludedinthisreview.


1.10 Efficacy: Optimal Dosage

Key question 1: What is the optimal dosage for treating the glabella?

Thisisanimportantquestion.Theglabellaisprobably themost frequently treatedarea.For-tunatelythereareseveralclinicaltrialsavailablethat try to answer this question. The questionwillbediscussedforbothbrandsseparately.

What should efficacy measure? BNT targetstheactivityofthemimicmuscles.Therefore,theability of the toxin to reduce muscular move-mentsshouldbemeasured.Usuallyitisnotthemuscularstrengthitself,buttheeffectofthere-ductionofmuscularstrengthontheseverityofwrinkles,whichismeasuredbyclinicalscales.Inmostclinicaltrialsfour-pointratingscales(with0 for no and 3 for severe wrinkles) have beenusedtomeasureefficacy(Honecketal.2003).

Inaddition,subjectiveimprovementisanim-portant outcome measure. Here several scaleshavebeenused.

1.10.1 Botox

ThereareseveraltrialsfocusingontheoptimaldosageofBotoxintheareaoftheglabella.Thestandarddosageusedis20BotoxU.Inthefirstlargeplacebo-controlledtrial,patientswithmod-eratetosevereglabellarlinesatmaximumfrownreceivedintramuscularinjectionsof20UBNT-Aorplacebointofiveglabellarsites(Fig.1.1).Atotal of 264 patients were enrolled (203 treatedwithBNT-A,61withplacebo).Therewasasig-nificantlygreater reduction inglabellar line se-veritywithBTX-Athanwithplacebo(allmea-sures,everyfollow-upvisit;P<0.022).Theeffectwas maintained for many patients throughout120days(Carruthersetal.2002).

The same authors investigated in a double-blind, randomized clinical trial the efficacy,safetyanddurationof theeffectof fourdosag-es of BNT type A in the treatment of glabellar

rhytids in females. Eighty female subjects withmoderatetoseverewrinklesatmaximumfrownentered the study. Patients were randomly ad-ministered10,20,30or40BotoxUinsevenin-jectionpoints(Fig.1.2).Objectively,10UofBNTtypeAwassignificantlylesseffectivethan20,30or 40 U. The relapse rate at 4 months was sig-nificantlyhigherinthe10-Ugroup(83%)versus40,30or20U(28%,30%and33%respectively).Theauthorsconcludedthat20–40BotoxUwassignificantlymoreeffectiveatreducingglabellarlinesthan10U(Carruthersetal.2005).

A similar study in male patients was pub-lished the same year. In this comparable study,80menwererandomizedtoreceiveatotaldoseofeither20,40,60or80UofBotoxdistributedinsevenpoints in theglabellarand lower fore-headarea.The40,60and80UdosagesofBNTtypeAwereconsistentlymoreeffectiveinreduc-ingglabellarlinesthanthe20-Udose(duration,peakresponserate,improvementfrombaseline).Therewasadose-dependentincreaseinboththeresponserateatmaximumfrownandthedura-tion of effect assessed by the trained observer.

Fig. 1.1. Injection points as in the early Botox-Glabellastudies(basedonCarruthersetal.2002)


1

Fig. 1.2. InjectionpointsasintherecentBotox-Glabellastudies(basedonCarruthersetal.2005)

Theauthorsconcludethatmaleparticipantswithglabellarrhytidsbenefitfromstartingdosagesofatleast40UofBotox(Carruthersetal.2005).

Based on these studies, the recommendedBotoxdosagefortheglabellashouldbeat least20BotoxU.Menmightbenefitfromevenhigherdosagesstartingwith40BotoxU.

1.10.2 Dysport

So far there have been three trials publishedfocusingontheoptimaldosagefortheglabella(Ascher et al. 2004, Ascher et al. 2005, Rzanyet al. 2006). The first study from Asher et al.(2004) is a dose-ranging study comparing 25,50and75DysportUwithplacebo.Atotalof119patientswithmoderate tosevereglabellar linesatrestweretreated.Thedosagewasdistributedover five intramuscular glabellar sites formingabird-shapedpattern (Fig. 1.1).Outcomemea-sures included evaluations of glabellar lines byindependentexpertsfromblindedstandardizedphotographs at rest 1 month after treatment,physician evaluations and patient assessments

duringa6-monthperiod.AsignificantefficacywasreportedforthethreeBNT-Agroupsforatleast3monthsafter injection(at leastP<.015).Investigator and patient evaluations suggestedthat50Uwastheoptimaldosage(Ascheretal.2004).

Answer to key question 1:Theinitialdosesfo-cusedon20BotoxUfortheglabella.Intwosub-sequentstudieshigherdoseswererecommend-ed. However, different injection points wereused.Thelatterstudiesincludedtwoadditionalpointstargetingnotonlythecorrugatorbutalsoparts of the frontalis muscle. For Dysport therecommendeddosefortheglabellais50DysportU.Basedonthesestudies,aratioforBotoxandDysportof1:2.5seamsreasonable.

1.11 Effectiveness: Dosages and Repeated Treatments

Key question 2:How often do patients come back and does the required dosage change after frequent visits?


Thisisanimportantquestion.Thefrequencyofre-injectionvisitsdependsonseveralfactors:theregainingofmuscularmovement(whichde-pendsonthestrengthofmusclesandtheinitialdose), the consequently increased visibility ofmimicwrinkles,andotherfactorssuchascosts.

1.11.1 Botox

So far therehasbeennodatapublished.Thereis,however,informationfromaposterthatwaspresented during the EADV 2004 (CarruthersA and Carruthers J, 2004). In this study, datafrom a 50-patient cohort was investigated. Pa-tientsneededtohaveatleasttentreatments.Theglabella was the most frequently treated area.Nospecificdosagefortheglabellaisgiven.Themeandosageforallareastreatedwas40BotoxU.Themedianintervalbetweentreatmentswas17.1weekswitharangefrom0.43to155.3weeks.

1.11.2 Dysport

IntheGerman-Austrianretrospectivestudy,945patientswerefollowedforatleastthreeconsecu-tiveinjections.ThemedianintervalbetweenBNT-Atreatmentcycleswas5.9-6.5months(25th–75thpercentile: 4.4–8.9 months) and changed littlewithrepeatedtreatments(Fig.2.2).

For the glabella the median BNT-A dosageoverall treatmentcycles in thosewhoreceivedinjections in theglabellawas50–60DysportU(25th–75thpercentile:40–70U); for thosewhoreceivedinjectionsintheglabellaonly,theme-dianBNT-Adosagewas50–70DysportU(25th–75th percentile: 50–100 U) The dosage did notchangeoverthedifferentstudyperiods.(Rzanyetal.2007).

Answer to key question 2: There are two pa-tient cohorts. Based on these data, patientstreatedwithBotoxreturned three timesayear,

patientstreatedwithDysporttwiceayearforre-injection.

1.12 Safety

Hereitisimportantnotonlytoconsidershort-termsafetybutalsolong-termsafety.Short-termsafetyisaffectedbytheproportionofpatientsinwhommusclesadjacenttothetreatedareasareinfluenced.Fortheglabellaareathismeansthenumberofpatientswhowilldevelopeyelidpto-sis after injection with BNT-A. Again, it is theclinicaltrialsthatcount.

1.13 Short-term Safety: Eyelid Ptosis

Short-term safety will be measured by clinicaltrials.

Key question 3: How many patients developed eyelid ptosis after treatment of the glabella?

1.13.1 Botox

Using Botox in the glabellar area, Carrutherset al. reported a lid ptosis rate of 5.4% in theirfirst large placebo-controlled study (6 out of203 patients; Carruthers et al. 2002), decliningto 1.0% (2 out of 202 patients) in a subsequentstudy(Carruthersetal.2003).Inthemostrecentstudiesno lidptosisoccurred inastudyof160patients(Carruthersetal.2005;CarruthersandCarruthers2005).

1.13.2 Dysport

WhenusingDysport,Ascheretal.reportednoptosisinhis102patientstreatedwith25,50and75U(Ascheretal.2004).IntheGermanstudy,onlyonecaseofeyelidptosiswasreportedamong


1127patientstreatedwith50DysportU(Rzanyetal.2006).

Answer to key question 3: The risk for eyelidptosis ispresent.However, it is small and tem-porary.

1.14 Long-term Safety: Eyelid Ptosis

Long-termsafetywillusuallynotbeinvestigatedbyclinicaltrials.Herepatientcohortswillbeabletoanswerthequestions.Fortunately,wehavedatafromtwolargecohortsforthetwomajorbrands.

Key question 4:What is the risk for eyelid ptosis after repeated treatments?

1.14.1 Botox

In the Carruthers study (Carruthers and Car-ruthers2004),adverseeventsweredocumentedin5(0.6%)of853 treatments.Eyelidptosiswasreportedthreetimes.

1.14.2 Dysport

In the German/Austrian retrospective study,adverse events (AE) were, in general, uncom-mon. Of the 945 patients, 90.6% (n = 856) didnotexperienceanyAEoveranytreatmentcycle.The total AE rate per treatment cycle was 4.1%(n = 39/945) in cycle one, decreasing to 2.0%(n=11/553)incyclefive,givinganoverallmeanincidence of 2.5% per treatment cycle. Impor-tantly,mostAEsweremildandresolvedwithoutfurther intervention. There were no serious orunexpectedAEs.

Local hematoma was the most frequentlyreported AE (1.25% per treatment cycle; range:1.8–0.7%). Lid or brow ptosis was uncommon(0.46%oftreatmentcycles;range:0.85–0.1%)and

generallymild.Allpatientswhoexperiencedlidorbrowptosis(n=16)receivedinjectionstotheglabellaor frontalis.A totalof 3698 treatmentsintheglabellaorfrontalisweregivento907pa-tients. Therefore, the incidence of lid or browptosisinpatientswhoreceivedinjectionstotheglabella and/or frontalis regions was 0.51% pertreatmentcycleor1.8%perpatient(Rzanyetal.2007).Answer to key question 4: The risk for eyelidptosisafterrepeatedtreatmentsisverysmall.

PleasenotethatfurtherinformationonsafetyisavailableinChapter7.

1.15 Marketing and Evidence

Themarket forBNT-Ainaestheticmedicine isstillgrowing.However,asineverymarket,thereisclosecompetitionbetweencompanies.There-fore,itisimportanttokeepaclearmindwhenacompanyclaimssuperiorityinefficacyandsafetyfortheirproduct.Thefollowingquestionsmightcomeinhandywhenbeingapproachedbyarep-resentativeofthecompanywithnewdataclaim-ingtoshoweitherbetterefficacyorsafety.

What dosages and dilutions were used? Thisisveryimportant:ifyoucomparetwoproducts,onewithahigherandonewithalowerdosage,itmightnotbeasurprisethattheproductwitharelativelyhigherdosehasmoresideeffects.

How good is the clinical trial? Itisnotneces-sary to be a specialist of evidence based medi-cine(EBM).Justkeepthefollowingquestionsinmindwhenlookingataclinicaltrial.

Was the trial randomized?i.e.werethetreat-mentgroupsdistributedbychance? Ifnot, justdisregardit.

Was the trial blinded? Good clinical trialsshouldalwaysbeblinded.Agoodexampleofapossiblyabsoluteblindingisanexpertcommit-teewhogradesefficacybasedonphotographs.

Were the treatment groups equal after random-ization?Sometimesrandomizationmightfail.Iftherearedifferencesingenderoragebetweenthe

Chapter 1 �Overview of Botulinum Toxin

studygroups,beextremelycautiouswhenlook-ingatthedata.Insuchacase,theanalysisshouldbeatleastmultivariatetotrytoaccountforthefailure of randomization. Do not worry aboutthe statistical test! Just look to see whether theanalysiswasuni–ormultivariate.Iftheanalysiswasunivariate(e.g.comparingonlyonefactoratatime)itcouldbepronetomorebiasesthanamultivariateanalysis.

How big was the trial?IfyouhaveatrialwhichassessesthesuperiorityorinferiorityoftwoBNTpreparations, thenumberofpatients shouldbehighsinceonlysmalldifferencesarelikely.Soifahead-to-headtrialhaslessthan100patientsitmightbebettertodisregardit.

Whatshouldagoodclinicaltrialbe?Randomized,blinded,largeenoughtoan-swerthequestion!

1.16 References

AscherBetal.(2004)Amulticenter,randomized,double-blind,placebo-controlledstudyofefficacyandsafetyof3dosesofbotulinumtoxinAinthetreatmentofglabellarlines.JAmAcadDermatol51(2):223–33

BaumannLetal.(2003)Adouble-blinded,randomized,placebo-controlledpilotstudyofthesafetyandeffi-cacy of Myobloc (botulinum toxin type B)-purifiedneurotoxincomplexforthetreatmentofcrow‘sfeet:adouble-blinded,placebo-controlledtrial.DermatolSurg29(5):508–15

CarruthersA,CarruthersJ (2004)Long-termsafetyre-viewofsubjectstreatedwithbotulinumtoxinAforcosmeticuse.PosterattheEADV

Carruthers A, Carruthers J (2005) Prospective, double-blind, randomized, parallel-group, dose-rangingstudyofbotulinumtoxintypeAinmenwithglabel-larrhytids.DermatolSurg31(10):1297–303

Carruthers J et al. (2002) A multicenter, double-blind,randomized,placebo-controlledstudyoftheefficacyandsafetyofbotulinumtoxintypeAinthetreatmentofglabellarlines.JAmAcadDermatol46(6):840–9.

Carruthers A et al. (2003) A prospective, double-blind,randomized, parallel-group, dose-ranging study ofbotulinumtoxintypeAinfemalesubjectswithhori-zontalforeheadrhytides.DermatolSurg29(5):461–7

CarruthersAetal.(2005)Dose-rangingstudyofbotuli-numtoxintypeAinthetreatmentofglabellarrhytidsin females. Dermatol Surg 31(4):414–22; discussion422

dePaivaAetal.(1999)Functionalrepairofmotorend-platesafterbotulinumneurotoxintypeApoisoning:biphasic switch of synaptic activity between nervesprouts and their parent terminals. Proc Natl AcadSciUSA96(6):3200–5

Dressler D (2006) [Pharmacological aspects of thera-peutic botulinum toxin preparations.]. Nervenarzt77(8):912–921

Honeck P et al. (2003) Reproducibility of a four-pointclinical severity score forglabellar frown lines.Br JDermatol149(2):306–10

HuangWetal.(2000)Pharmacologyofbotulinumtoxin.JAmAcadDermatol43(2Pt1):249–59

Lowe PL et al. (2005) A comparison of two botulinumtype A toxin preparations for the treatment of gla-bellar lines: double-blind, randomized, pilot study.DermatolSurg31(12):1651–4

RzanyBetal.(2006)Efficacyandsafetyof3-and5-in-jectionpatterns(30and50U)ofbotulinumtoxinA(Dysport) for the treatment of wrinkles in the gla-bellaandthecentralforeheadregion.ArchDermatol142(3):320–6

RzanyBetal.(2007)RepeatedbotulinumtoxinAinjec-tionsforthetreatmentof linesintheupperface:Aretrospectivestudyof4103treatmentsin945patientsDermatolSurg33(s1),S18–S25

Chapter 2

Noteverypatient issuitable for treatmentwithBNT.Toavoiddissatisfiedpatients,orevenad-verse events, the indication for BNT treatmenthastobethoroughlyevaluated.

2.1 Indications for BNT

Mauricio de Maio

2.1.1 Introduction

Theagingprocessisasumofgeneticandenvi-ronmental influences. Intrinsic aging is mainlyrepresentedbychronologicalprocessesandleadstoatrophywithskinexcessandlaxity,eyebagsandthepresenceofgravitationalfolds(Fig.2.1).Themosteffectivetreatmentheremightbesur-gerywithmusclerepositioningandskinandeyebags excess removal. Extrinsic aging is mainlycausedbyphoto-damagewhichharmstheskin–epidermisanddermis–leadingtostaticwrin-kles,drynessandagingspots(Fig.2.2).Thetreat-mentofenvironmentalagingismainlyconduct-edthroughlasers,peels,bleachingagents,fillersandbotulinumtoxin.

Mimicwrinklesare signsof expressedemo-tions.Theexpressionofemotionsisfundamentalto communication between humans. Uninten-tionalprojectionofemotions,due toabnormalmuscular behavior, may be an impediment toaccurate communication and understanding. If

2

Contents

2.1 IndicationsforBNT . . . . . . . . . 112.1.1 Introduction . . . . . . . . . . . . . 112.1.2 KineticPatients . . . . . . . . . . . . 132.1.3 HyperkineticPatients . . . . . . . . . 142.1.4 HypertonicPatients . . . . . . . . . . 152.1.5 OutcomeAnalysis . . . . . . . . . . 172.1.6 TipsandTricks . . . . . . . . . . . . 182.1.7 References . . . . . . . . . . . . . . 18

2.2 ContraindicationsforBotulinumToxin . 182.2.1 GeneralContraindications . . . . . . . 182.2.2 DrugspecificContraindications . . . . 182.2.3 References . . . . . . . . . . . . . . 19

Patient SelectionMauriciodeMaio,BertholdRzany

12 Mauricio de Maio, Berthold Rzany

2

someoneprojectsangerorsadness,eventhoughheisperfectlyhappy,hewillbemisunderstood(Fig.2.3).

Experience has changed the way botulinumtoxin is now used. Not only has the techniquechanged but so has the dose to be injected inspecificareas.Patients’feedbackaftertheinjec-tions and the analyses of results has led to theunderstanding that muscular inhibition doesnotnecessarilypromoteacosmeticupgrade.Thefeared‘frozenlook’belongstothepastandbothpatientsandinjectorsunderstandthatanaturallookisdesired.Therearesomestigmatizedsignsthatshouldbeavoided.

Thedurationofeffect isnowthecurrent is-sue.Patientsdonotunderstandwhyinjectionsmaylastsevenmonthsinsomeandonlytwoinothers! Patients are different and so is muscu-larbehavior.Manyinjectorsdonotindividual-izethetreatment,andalsomaynotunderstandwhysomepatientshavesuchashortdurationofeffectwhenusing standarddoses.Someof thepatientsaresymmetricalwhileothersarequiteasymmetrical(Figs.2.4and2.5).Otherpatientshavesinglemuscleinsertionswhileothersmayhavemultiplemuscleinsertions,whichmayalso

varythechoiceoftheinjectionsite(Figs.2.6and2.7).

Beforetreatment,themuscularpatternmustbeevaluated.Patientsmaybedividedintothreegroupsbeforetreatment,basedontheirmusclestonus:kinetic,hyperkineticandhypertonic.De-

Fig. 2.2. This patient with asiatic skin with deep staticwrinklesindynamicareaspresentsacomplexpatternfortreatment. The single use of BNT-A in this patient willleadtofrustratingresults

Fig. 2.3. Thispatient,eventhoughaperfectlyhappyper-son,alwayslookssadduetodeepmarionettelines

Fig. 2.1. Thispatient,withsaggyskin,jowls,upperandlowereyelidskinexcessandeyebags,isatypicalsurgicalcandidate.TheuseofBNT-Ainthiscasewouldonlygivesuboptimalresults

Chapter 2 13Patient Selection

pendingontheareatobetreated,therewillbeadominantcharacteristic.Patientsmaybehyper-kinetic inoneareaandhypokinetic inanother,so the dose should be given according to themuscularpatternofeachpatient.

2.1.2 Kinetic Patients

The kinetic patient’s expression is “I move mymuscles when I want”. There is a concordanceof emotion and mimetic expression. If the pa-tient wants to express surprise while talking,

forexample, them. frontalis iscontractedandtheeyebrowsareraised.Ifthepatientwantstoexpress anger or concern, the muscles at theglabella area are contracted. There is a perfecttimingofthemimicsandtheemotionalfeeling.The interlocutor understands easily both whatissaidandwhatisexpressed.Theinterlocutor’seyesdeviatetothemuscularcontractionexactlywhentheemotionisexpressed.Instaticanaly-sis, there is no wrinkle formation at the treat-mentarea.

Thedurationofeffectinkineticpatientsisthelongestamongthegroups.Itmaylast7–9months

Fig. 2.4. Thispatientisquitesymmetricalandinjectionsitesshouldalsoobeythissymmetry

Fig. 2.5. This patient has a stronger corrugator on herleft.Notethatthedosecannotbethesameforbothsidesinthispatient

Fig. 2.6. Thedistributionoftheinjectionsitesshouldbeundertaken according to muscle insertion. This patienthasasinglecorrugatorinsertion

Fig. 2.7. IncontrasttoFig.2.6,thispatienthasmultiplecorrugatorfiberinsertionsalongtheeyebrow.Dissatisfac-tionwithBNT-Atreatmentisnotunusualiftheinjectionsitesanddosagesarenotadaptedforeachsituation


2

Fig. 2.8a,b. Kineticpatient:whileexpressingangerorconcern,themusclesattheglabellaareaarenotdeep.AfterBNT-A,thereareneitherstaticnordynamiclines.Thismaybeconsideredtheidealpatientwithcompletewrinkleremovalandalong-lastingresult.Pleasenotethatthereisnom.procerusactioninthispatient,onlytheactionofthem.corrugatores

Fig. 2.9a,b. ThisisalsoakineticpatientwithmildmusclecontractionandcompletewrinkleremovalaftertreatmentwithBNT-A.Notethatthispatientpresentsbothm.corrugatoresandm.procerusactions.Thismeansthattheinjec-tionsitesshouldbedifferentcomparedwithFig.2.8a,b

and sometimes even longer. The procedure isusually undertaken only once a year. They areideal candidates for treatment. Both cosmeticpractitionersandpatientsareverysatisfiedwiththeprocedure.Thereisabsolutelynolineforma-tionaftertheinjectionofBNT-A.However,somepatients may present only corrugator contrac-tion (Figs. 2.8), while others may present bothcorrugatorandproceruscontraction(Figs.2.9).Thechoiceof injection sites shouldbeadaptedforeachcase.

Kineticpatientsareknownbythephrase:“IexpressmyemotionwhenIwant”.Theduration of effect is the longest out of allgroups.

2.1.3 Hyperkinetic Patients

Inthisgroup,patientshavenoconcordancebe-tweenmuscularcontractionandtheemotiontobeexpressed.Ingeneral,themusclecyclesmore


rapidlythanthedesiredemotionorthecontrac-tionmayappearwithoutthewillingofemotion-alexpression.Forexample,aspeakerisdoingapresentationinfrontofanaudienceandistalk-ingslowlyandthemusclesintheforeheadmovewithoutthedesireofexpressingsurpriseorevenconcern.Them.frontalisandthem.corrugatorcontract in repeated cycles independently andexcessively. The interlocutor, instead of payingattentiontowhatissaid,keepshiseyesfixedonthemimics.Hyperkineticpatientsarevictimsoftheirmuscularcontraction:themusclecontractsinvoluntarily during speech and/or at a fasterrate, not necessarily expressing the emotion ofpreoccupation or angriness, pertinent to theglabellaarea,forexample.Verticaland/orhori-zontal dynamic lines are of a moderate degreebutarenotpresentatstaticpositions.Forthesepatients, theresultsmaylast from4–6months,sometimes even less. Patients return for treat-menttwiceorthreetimesayear.ThisisthemostcommongroupforBNT-treatment.Patientsandinjectorsarepleasedwiththeresultalthoughtheformermaywishitcouldlasta littlebit longer.Whentheeffectstartstofade,theyquicklycomeback for another injection. It is quite commonforthesepatientstocomebackforanextradosetoimprovetheresults(Fig.2.10a,b).

Hyperkineticpatientsarevictimsofexces-sivemuscularcontraction.Ingeneral,theydonotwaitfortotalmuscularrecoverytogetanothershot.

2.1.4 Hypertonic Patients

Hypertonic patients are the negative result oflack of control of hyperkinetic patients. Theirsentenceis“Icannotrelax”andgetdisappointedwhen asked “Are you angry?” In fact, they arehappy,havesleptwellandtheirlifeisatitsbest.Theiremotioniscompletelycontaminatedbytheinability of specific muscles to relax. How cansomeoneexpresslightnesswhenthem.corruga-torandm.procerusdonotrelax?Howcantheyprovetheyarenotangryorconcernedwhenthemimicsdemonstrateexactlytheseemotions?Forthese people, immediate acceptance by othershardlyeverhappens.Even to themselves, look-ing in themirroreachmorningandseeing them.depressoranguliorisover-contractedandtheoral commissure falling down, expressing sad-nessandtiredness,isnotencouraging.Theyarethegroupthatparticularlyneedstreatmentandusuallygetsfrustratedwithit.Thedurationofre-

Fig. 2.10a,b. Hyperkineticpatientshavestrongermusclesandtheresultafterthefirstinjectioncanbealmostcom-pleteremovalofwrinkles.However,theynormallyneedrepeateddosesorhigherdosestoobtainperfectresults.AftertreatmentthepatientstillpresentssomemusclecontractionattheglabellaareathatmaybereinjectedwithBNT-Atoobtainoptimalresults


2

sultinthesepatientsistheshortestofallgroups.Both patients and practitioners get disappoint-edwiththeinjectionfortwomainreasons:thewrinkledoesnotdisappearcompletelyandmus-cular contraction may be blocked for only 1 or2months.Thedisappointmentcomes fromthefact that thesameresultsas for thekineticandhyperkinetic patients are expected. In this spe-cial group the target is to inhibit hypertonic-ityandrelaxthemuscle.Thehypertonicpatient

shouldbecomehyperkineticandfinallykinetic.Toachievethis,itisnotuncommonforthepa-tient toundergo fourorfive treatmentsayear!In addition, fillers should be used to achievebetteroverallresults(Fig.2.11a,b).Itiseasiertounderstand the limitation of treatments whenwe compare kinetic and hypertonic patients(Figs.2.12and2.13).

Fig. 2.11a,b. Hypertonicpatient:aftercorrectinjectionandtheuseofanextradosethereisstillaverticallineattheglabellaarea.ThispatientwasadvisedbeforetheBNT-Atreatmentthattheadditionaluseofaninjectablefillerwouldbenecessary

Fig. 2.12. Thiskineticpatientpresentsamildcontractiononherleftandmildasymmetry

Fig. 2.13. In contrast, this hypertonic patient presentsverystrongcorrugatorsandprocerus.ThesingleuseofBNT-Awillnotbeable toprovidecomplete reshapeoftheglabellaareainthiskindofhypertonicpatient.Fillersshouldalsobeoffered


Bothhypertonicpatientsandinjectorsgetdisappointedwiththeresult.Theymayre-quirefourorfivetreatmentsayear!

2.1.5 Outcome Analysis

When botulinum toxin started to be used forcosmeticpurposes,oneofthemaincomplaintsfrompatientswasaboutthe‘frozenlook’.Thesetimes should be gone. Based on muscular be-havior after the injection, patients can also bedividedintothreegroups:atonic,hypotonicandhypokinetic.

When critically analyzing the result of thebotulinum toxin injection, we should be ableto have balanced the areas where we wanted acompleteabsenceofmovementbutmaintenanceofposition,andwhereaslightmovementisde-sired.Theresultinghypokinesisseemstobethemost desired effect for many areas in the face.Thedecreaseinmusclecyclesandtheslowdownofmuscle excursion isone themost importantaspectsthatleadstoanaturallook.However,pa-tientsmustunderstandthatsomeinitialmove-mentdoesnotmeanlossofeffectandtheymustbetoldsobeforethetreatment.

Theresultinghypokinesisistheidealmus-cular pattern after the treatment for pro-motinganaturallook.

Excessiveblockingof specificmusclesmay leadtoanunpleasantappearance.Therearemusclesthatshouldhavetheminimaltonuspreservedinorder to maintain the anatomic structure at itsrightposition.Forinstance,them.frontalis,be-sideselevating theeyebrows, isalso responsibleformaintainingthemattheircorrectlevel.Ifthem.frontalisisover-injected,theminimaltonusisblockedandasaconsequence,thebroworpseu-doptosismayresult.Whatisanaturallookthen?

Itdepends!Injectorsshouldinitiallyanalyzethemuscularpattern,adaptationbehaviorandwhatwould promote a cosmetic upgrade for the pa-tient.Ifwedidacticallydividethefaceintothreethirds,wehavetotrytomakethemharmoniousamongthemselves.Botulinumtoxinisapower-fulagentfortheupperthird:itcanerasewrinkles,lifttheeyebrowsandimprovetheeyecontour.Ifthe patient presents severe photo-damage, theskinofthethreethirdsiscompromisedandwhatcan be improved in the skin appearance in theupperthird,canbarelybeachievedinthelowerandevenlessinthemidthird.Thequestionthatshouldbeaskednowis:Isitreasonabletogiveafull treatment in theupper thirdwhile themidandlowerthirdscannotachievethesameperfor-mance?Botulinumtoxintreatmentswerecarriedoutlikethispreviously,andthismaybeoneofthemainreasonsthatitfrightenedmanypatients.

Notonlyshouldweavoidcompleteblockinginsomeareas,butweshouldalsoanalyzewheth-erpartialblockingisstilltooexcessive.

Anaturallookimpliesnotonlywhichareashouldbe fullyblocked,but also theper-centageofblockingthateachpartialtreat-mentmusthave.

Whenanalyzingthepatienttomaketherightdecision about full and partial blocking, it isgoodtocomebackandreviewwhathappensintheagingprocess.Letustrytovisualizeachildoranadolescent.Focusontheupperthird:therearenolines;them.frontalisexcursionislimitedand the m. corrugator and m. procerus pres-entdonotshowaveryevidentcontraction.Itismorecommontoseethesurpriseontheirfacesthantoseetheangrinessattheglabellalevel.Ifweanalyzetheface,wewillnoticethattheeleva-torsaremore important thanthedepressors inyouth.Withagingprocess,thisbehaviorchangesand the depressors start to play an importantrole, causing a tired and sad look. Botulinum


2

toxinshouldbeusedtoblockthedepressorsandgivethepatientsamorerefreshedlook.

Withagingthedepressorsbecomestrongerthan the elevators, leading to a tired andsad appearance. Botulinum toxin shouldbeusedtopromoteamorerefreshedlook.

2.1.6 Tips and Tricks

■ The idealpatients to startwith theuseofbotulinumtoxinarethekineticones.Hy-perkineticsarethosewhowillparticularlyneed our assistance and will return moreoftenforretreatmentinouroffices.Hyper-tonicpatientsshouldbe told immediatelyabout the limitations of treatment withBNT-A alone and should be treated withfillers or other surgical methods, such assubcisionordirectexcisionwithsuture.

2.1.7 References

Becker-Wegerich P, Rauch L, Ruzicka T. (2001) Botuli-numtoxinAinthetherapyofmimicfaciallines.ClinExpDermatol.26(7):619–30.Review

EllisDA,TanAK(1997)Cosmeticupper-facialrejuvena-tionwithbotulinumtoxin.JOtolaryngol.26(2):92–6

ManalotoRM,AlsterTS(1999)Periorbitalrejuvenation:areviewofdermatologictreatments.DermatolSurg.25(1):1–9.Review

Mendez-Eastman SK (2003) BOTOX: A review. PlastSurgNurs.23(2):64–9

PribitkinEA,GrecoTM,GoodeRL,KeaneWM(1997)Patientselection in the treatmentofglabellarwrin-kles with botulinum toxin type A injection. ArchOtolaryngolHeadNeckSurg.123(3):321–6

Robb-Nicholson C (2002) By the way doctor. I’ve beenreadingabout thecosmeticbenefitsofBotox injec-tions,butwhataretherisks?HarvWomensHealthWatch.10(3):8

Sclafani AP, Kwak E (2005) Alternative managementof the aging jaw line and neck. Facial Plast Surg.21(1):47–54

2.2 Contraindications for Botulinum Toxin

Berthold Rzany

To avoid adverse events certain contraindica-tionshavetoberuledoutpriortothetreatmentwithBNT.

2.2.1 General Contraindications

2.2.1.1 Dysmorphism

Dysmorphicpatientsarethoseobsessivelypreoc-cupiedwithrealorimaginarydefects.Theytakegreatmeasurestopointoutdefectswhicharenotviewedbythephysician.Ingeneral,thosedefectsareminorbutareperceivedbythemtobedis-figuring.The inability todealwithunavoidablescars is also a warning that dissatisfaction mayriseafterthecosmeticprocedure.Somepatientsdohavearealpsychiatricoremotionaldisorder.Patients with borderline personality, obsessive-compulsiveandnarcissisticdisordersshouldbeavoided.

Hereitisatthediscretionoftheaestheticphy-siciantotellthepatientinaverycompassionatewaythattheresulttheyarelookingforcannotbeobtainedbythisprocedure.

2.2.2 Drug specific Contraindications

2.2.2.1 Diseases with Pathological Neuromuscular Transmission

BNTtreatmentiscontraindicatedinpatientswithamyotrophiclateralsclerosis,myastheniagravis,

Chapter 2 1�Patient Selection

multiplesclerosisandEatonLambertsyndromesince all these conditions show pathologicalneuromusculartransmission,whichmayworsenbysystemicBNTeffects.InfactCoteetal(Coteetal.2005)reportacaseofaggravatedMyastheniagravisaftertheinjectionofBNT.Aswitheveryother drug too an absolute contraindicationwouldbeaknownhypersensitivityorallergytotheBNT-classor itsexcipients(Vartanianetal.2005).

No reliable data about teratogenic effects ofBTN inhumanshasbeenpublished so far.Al-thoughnocomplicationsinaccidentalpregnan-cieshavebeenreportedsofar,BNTtreatmentofpregnant women and nursing mothers shouldnotbeperformed.

2.2.2.2 Drug Interactions

FortheusageofBNTinaestheticmedicinetherehavebeennoreportsofclinicallysignificantdrug-druginteractionssofar,yetoneshouldconsiderpossible interactions with drugs that interferewithneuromuscularorneuroglandulartransmis-sion.Thesesubstancesincludeaminoglycosides,cyclosporine, d-penicillamine, depolarizing andnon-depolarizing muscle relaxants, quinidine,magnesiumsulfate,lincosamidesandaminoqui-nolones.Whilemostofthesesubstancespotenti-atetheBNT-effect,aminoquinolonesandchloro-quinecaninhibititsactivity(Simpson1982).

2.2.2.3 Injection related Contraindications

BNT is injected.Therefore, anybleedingdisor-derevenwhenusingverysmallneedleshasan

increasedriskofbruising.Theuseofdrugs in-terferingthebleedingtimeisusuallywiththesesuperficial injections not an absolute contrain-dication. Patients for example on acetylic acidshouldbeadvisedthatthereisanincreasedriskofbruisingrelatedtotheinjectionsbutmaybetreated.

2.2.3 References

AdamsonPA,KrausWM.(1995)Managementofpatientdissatisfactionwithcosmeticsurgery.FacPlastSurg11:99–104

BakerTJ(1978)Patientselectionandpsychologicaleval-uation.ClinPlastSurg5:3–14

CoteTR,MohanAKetal.(2005).BotulinumtoxintypeAinjections:adverseeventsreportedtotheUSFoodandDrugAdministrationintherapeuticandcosmet-iccasesJAmAcadDermatol53(3):407–15

LewisCM,LavellS,SimpsonMF(1983)Patientselectionandpatientsatisfaction.ClinPlastSurg1983321–332

Katez P (1991) The dissatisfied patient. Plast Surg Nurs11:13–16

SarwarD(1997)The‘obsessive’cosmeticsurgerypatient:a consideration of body image dissatisfaction andbody dysmorphic disorder. Plast Surg Nurs 17:193–197,209

SimpsonLL(1982)Theinteractionbetweenaminoquino-linesandpresynapticallyactingneurotoxins.JPhar-macolExpTher222(1):43–8

VartanianAJ,DayanSH(2005)Complicationsofbotu-linumtoxinAuseinfacialrejuvenation.FacialPlastSurgClinNorthAm13(1):1–10

VuykHD,ZijlkerTD(1995)Psychosocialaspectsofpa-tient counseling and selection: a surgeon’s perspec-tive.FacPlastSurg11:55–60

Chapter 3

Contents

3.1 Introduction . . . . . . . . . . . . . 21

3.2 Documentation . . . . . . . . . . . . 213.2.1 Chart . . . . . . . . . . . . . . . . 213.2.2 Photograph . . . . . . . . . . . . . . 223.2.3 Consent . . . . . . . . . . . . . . . 223.2.4 TreatmentPlan . . . . . . . . . . . . 22

3.3 Staff . . . . . . . . . . . . . . . . . 22

3.4 TechnicalRequirements . . . . . . . . 223.4.1 Room . . . . . . . . . . . . . . . . 223.4.2 Chair . . . . . . . . . . . . . . . . 223.4.3 Mirror . . . . . . . . . . . . . . . . 223.4.4 CosmeticMarker . . . . . . . . . . . 223.4.5 StandardSetting . . . . . . . . . . . 223.4.6 TheToxin . . . . . . . . . . . . . . 233.4.7 TipsandTricks . . . . . . . . . . . . 243.4.8 References . . . . . . . . . . . . . . 24

3.1 Introduction

The requirements and rules are basically thesameforeveryaestheticprocedure.Thefollow-inglistisnotintendedtogiveacompleteover-view but to give some hopefully helpful advicewhentreatingaestheticindicationswithbotuli-numtoxin(BNT).

3.2 Documentation

Athoroughdocumentationofall treatment-re-lated data is highly recommended. Besides be-ingusefulforlegalandbillingreasons,thoroughdocumentation will help to improve one’s ownperformanceandthuspatients’satisfaction,too.

3.2.1 Chart

Thepatient’sidentificationdata,age,thehistoryof relevant concomitant diseases, present rele-vantdrugintake(e.g.theintakeofacetylsalicylicacid!)andpreviousaestheticproceduresshouldbedocumented.

Furthermore, the procedure itself has to bedocumented.Thiscanbeeitherdoneastextoras text supported by figures of the areas to betreated.Here,theinjectionpoints,theinjectedUand/orvolumeshouldbestated.

3 Requirements and RulesBertholdRzany

22 Berthold Rzany

3

3.2.2 Photograph

It is advisable to document the status of thepatientbeforetreatment.Ifpossible,thephoto-graphsshouldbestandardized.Standardizationrequiressomeeffort,suchasusingafixedset-tingorfollowingstandardprocedures.Patientstendtoforgettheirpre-treatmentfeaturesandmight assume that nothing has changed. Insuchacase,aphotographpriortothetreatmentsessionmighthelpavoidunpleasantmisunder-standings.

3.2.3 Consent

Theconsentofeachpatientshouldbethorough-ly documented. Patients should date and signtheconsentforeachnewindication.Theconsentformshouldbeaccompaniedbyapatientinfor-mationbrochure that includesallnecessary in-formationontheestimatedefficacyandpossibleadverseevents.

3.2.4 Treatment Plan

A treatment plan is highly recommended forevery aesthetic procedure. Patients should beawareofthefactthatBNThasalimiteddurabil-ityandthreetofourtreatmentsperyearmightbenecessary.

3.3 Staff

Thestaffhavetobetrainedinseveralareas:mar-keting, quality control and assistance. Market-ing: the staff should be aware of the aestheticprocedures offered and should be able to givesome information about the use of botulinumtoxin. Staff are responsible for monitoring thechartaswellasensuringthatallnecessarydocu-mentsareavailableandsignedbythepatientifapplicable.

3.4 Technical Requirements

3.4.1 Room

The room should be brightly lit. No shadowsshould decrease the visibility of the area to betreated.

3.4.2 Chair

Although all indications can be treated in anuprightposition,a recliningposition is recom-mended,especiallyforanxiouspatients.Forthetreatment of platsymal bands patients shouldbe in an upright position; otherwise the bandswouldnotbevisible.

3.4.3 Mirror

A mirror should accompany patient-doctorcommunicationfromthestart.Usingthemir-rorthedoctorcanensurethatbotharespeakingabout exactly the same areas to be treated. Attheendofthetreatmentthedoctormightshowthepatienttheinjectionpointsandexplaintheprocedureagain.

3.4.4 Cosmetic Marker

A cosmetic pen to mark the injection pointscanbequitehelpfulinreducingasymmetry.E.g.asymmetrymighteasilyoccurwhentreatingtheforehead.Here,theuseofacosmeticpensuchasaliplinerwillgreatlyreducetheriskofasymmetry.

3.4.5 Standard Setting

All tools required should be within reach(Table3.1).AstandardsettingfortreatmentwithBNTmightprovetobehelpful.

Chapter 3 23Requirements and Rules

3.4.6 The Toxin

Storage of Undiluted ToxinBNT has to be stored either in the refrigerator(Botox,Dysport)orundernormalroomcondi-tions(Xeomin).DilutionAllBNTs-Apreparationshavetobedilutedwithsaline. Usually 2.5 ml saline is used to dilutethe BNT-A when used in aesthetic indications.Somecolleaguespreferlowerorhigherdilutions(Tables3.2and3.3).Theeffectofahigherdilutionisnotclear.Basedonasmallstudyinvestigatingonedoseintwodifferentvolumes,itappearsthatagreatervolumemeansgreaterdiffusionintotheadjacentmuscles,givinggreaterefficacy,butalsogreaterriskofadverseevents.Therewasnofol-low-uponthedurationoftheeffectinthisstudy(Hsuetal.2004).

ThestandarddilutionforBotoxandDys-portis2.5ml.

Storage of Diluted ToxinAllmanufacturersrecommendtheBNT-Atobeonlyusedforseveralhoursafterdilution.How-ever, inclinicalpractice,BNT-Aisoftenstoredintherefrigeratorforseveraldaysuptoacoupleofweeks.Withincreasedstoragetime,adecreaseinefficacyandincreasedriskofcontaminationislikely.However,DorisHexselreportednotsucha

Table 3.1. Necessarytoolstobearrangedbeforetreat-ment

Patientinformationandconsentform

Documentationmaterialforsourcedata(electronicorconventionalcharts)

Handmirror

Camera(conventionalordigital)forphotographicdocumentation

Topicallocalanesthetic(usuallynotneeded)

Topicaldisinfectant(preferablywithoutdyeandnon-alcoholic)

Non-steriledressings

Cosmeticpen,forexamplealipliner(markingtheinjectionpointsmaybequitehelpfultoensureharmoniousandsymmetricresults)

Vialwithbotulinumtoxin,salinefordilution(ifnecessary),appropriatesyringesandneedles(30-gaugeneedlesareamust,32-gaugeneedlesaregreat)

Coolpacksorpre-cooledsalinetosoakcompresses

Emergencykit(incaseoftheextremelyunlikelyeventofananaphylacticreaction)

Table 3.2. Botox:Upermlfordifferentdilutions

0.9% saline

Botox 100 U in

0.01 ml 0.02 ml 0.05 ml 0.1 ml 0.15 ml 0.2 ml

2.0ml 0.52 1 2.52 7

2.5ml 0.4 0.8 2 4

3.0ml 0.34 0.66 0.13 3.34 5

4.0ml 0.26 0.5 1.26 3.5 3.76 5

4.5ml 0.22 0.44 1.12 2.22 3.34 4.44

24 Berthold Rzany

3

decreasewhileusingBNT-Areconstituteduptosixconsecutiveweeksbeforeapplication(Hexseletal.2003).


■ Mostcomplaintsfromdissatisfiedpatientsmightbe traced to insufficient communi-cationbetweenthedoctorandthepatient.Thisalsoappliestothecostrelatedtotheseprocedures!Patientsshouldknowfromthestartwhattheycanexpectandhowmuchtheyhavetopay.

3.4.8 References

HexselDM,DeAlmeidaAT,RutowitschM,DeCastroIA,SilveiraVL,GobattoDO,ZechmeisterM,Maz-zucoR,ZechmeisterD(2003)Multicenter,double-blindstudyoftheefficacyof injectionswithbotuli-numtoxintypeAreconstituteduptosixconsecutiveweeksbeforeapplication.DermatolSurg.29(5):523-9

HsuTS,DoverJS,ArndtKA(2004)EffectofvolumeandconcentrationonthediffusionofbotulinumexotoxinA.ArchDermatol140(11):1351–4

RzanyB,FratilaA,HeckmannM.(2005)2.Expertentre-ffenzurAnwendungvonBotulinumtoxinA (Dys-port®) in der Ästhetischen Dermatologie. Kosme-tischeMedizin26:134–41

Table 3.3. Dysport:Upermlfordifferentdilutions(modifiedfromRzanyetal.2005)

0.9% saline

Dysport 500 U in

0.01 ml 0.02 ml 0.05 ml 0.1 ml 0.15 ml 0.2 ml

2.0ml 2.6 5 12.6 25

2.5ml 2 4 10 20

3.0ml 1.7 3.3 8.3 16.7 25

4.0ml 1.3 2.5 6.3 12.5 18.8 25

4.5ml 1.1 2.2 5.6 11.1 16.7 22.2

Chapter 4

4

4.1 Introduction

TopicalBNTtreatmentisawishfarawayfromrealization. BNT needs to be injected to exertitsaction.TherearebasicallytwowaystoinjectBNT: the standard technique and the microin-jectiontechnique.

4.2 Standard Technique

The standard technique is used if target areasare well-defined and there is a minimal risk ofadverse reactions.BNT inavolumeof0.05mlormoreisinjectedwitha30or32-gaugeneedleperpendicularorbeveledintotheskin.Thestan-dard technique is especially recommended forthe mm. corrugatores. The periosteum shouldnotbetouched.

4.3 Microinjection Technique

Themicroinjectiontechniqueisusedtoadminis-terlowdosesofBNTverysuperficially.BNTap-pliedbymicroinjectiontechnique in thecrow’sfeetareawilldecreasetheriskofaninvoluntaryco-treatmentof them.zygomaticusmajor.Themicroinjection technique follows an intrader-malapproach.SmallamountsofBNT(lessthan0.025ml)areinjectedapproximately1cmapart,verysuperficially, inatechniquecomparableto

Contents

4.1 Introduction . . . . . . . . . . . . . 25

4.2 StandardTechnique . . . . . . . . . . 25

4.3 MicroinjectionTechnique . . . . . . . 25

4.4 OtherTechniques . . . . . . . . . . . 26

Injection TechniqueBertholdRzany

26 Berthold Rzany

4

theintradermalskintest.Herethe32gaugeoratleasta30-gaugeneedleishighlyrecommended.If done correctly a small, sometimes whitish,papulecanbeseen(Fig.4.1).

4.4 Other Techniques

BNTshouldusuallynotbe injectedby feather-ingtechniquestoavoidadverseeventsduetotheinvoluntaryco-treatmentofadjacentmuscles.

Fig. 4.1. SmallwhitishpapulesafterapplyingBNT-Aus-ingthemicroinjectiontechniqueinthecrow’sfeetarea

Chapter 5

5

Contents

5.1 Forehead . . . . . . . . . . . . . . . 285.1.1 Introduction . . . . . . . . . . . . . 285.1.2 Anatomy . . . . . . . . . . . . . . 285.1.3 AimofTreatment . . . . . . . . . . . 285.1.4 PatientSelection . . . . . . . . . . . 295.1.5 Technique . . . . . . . . . . . . . . 325.1.6 Complications . . . . . . . . . . . . 335.1.7 TipsandTricks . . . . . . . . . . . . 33

5.2 Glabella . . . . . . . . . . . . . . . 335.2.1 Introduction . . . . . . . . . . . . . 335.2.2 Anatomy . . . . . . . . . . . . . . 335.2.3 AimofTreatment . . . . . . . . . . . 345.2.4 PatientSelection . . . . . . . . . . . 345.2.5 Technique . . . . . . . . . . . . . . 355.2.6 Complications . . . . . . . . . . . . 365.2.7 TipsandTricks . . . . . . . . . . . . 37

5.3 Browlift . . . . . . . . . . . . . . . 375.3.1 Introduction . . . . . . . . . . . . . 375.3.2 Anatomy . . . . . . . . . . . . . . . 375.3.3 AimofTreatment . . . . . . . . . . . 385.3.4 PatientSelection . . . . . . . . . . . 385.3.5 Technique . . . . . . . . . . . . . . 395.3.6 Complications . . . . . . . . . . . . 455.3.7 TipsandTricks . . . . . . . . . . . . 455.3.8 References . . . . . . . . . . . . . . 45

5.4 Crow’sFeetandLowerEyelid . . . . . 465.4.1 Introduction . . . . . . . . . . . . . 465.4.2 Anatomy . . . . . . . . . . . . . . 465.4.3 AimofTreatment . . . . . . . . . . . 475.4.4 PatientSelection . . . . . . . . . . . 475.4.5 Technique . . . . . . . . . . . . . . 485.4.6 Results . . . . . . . . . . . . . . . . 515.4.7 Complications . . . . . . . . . . . . 515.4.8 TipsandTricks . . . . . . . . . . . . 545.4.9 References . . . . . . . . . . . . . . 54

5.5 BunnyLines . . . . . . . . . . . . . 565.5.1 Introduction . . . . . . . . . . . . . 565.5.2 Anatomy . . . . . . . . . . . . . . . 565.5.3 AimoftheTreatment . . . . . . . . . 575.5.4 PatientSelection . . . . . . . . . . . 575.5.5 Technique . . . . . . . . . . . . . . 585.5.6 Complications . . . . . . . . . . . . 585.5.7 TipsandTricks . . . . . . . . . . . . 615.5.8 References . . . . . . . . . . . . . . 61

5.6 Nose . . . . . . . . . . . . . . . . . 615.6.1 Introduction . . . . . . . . . . . . . 615.6.2 Anatomy . . . . . . . . . . . . . . 615.6.3 AimofTreatment . . . . . . . . . . . 625.6.4 PatientSelection . . . . . . . . . . . 625.6.5 Technique . . . . . . . . . . . . . . 625.6.6 Results . . . . . . . . . . . . . . . . 645.6.7 Complications . . . . . . . . . . . . 645.6.8 TipsandTricks . . . . . . . . . . . . 665.6.9 References . . . . . . . . . . . . . . 66

5.7 NasolabialFold . . . . . . . . . . . . 665.7.1 Introduction . . . . . . . . . . . . . 665.7.2 Anatomy . . . . . . . . . . . . . . 675.7.3 AimofTreatment . . . . . . . . . . . 675.7.4 PatientSelection . . . . . . . . . . . 675.7.5 Technique . . . . . . . . . . . . . . 685.7.6 Complications . . . . . . . . . . . . 695.7.7 TipsandTricks . . . . . . . . . . . . 695.7.8 References . . . . . . . . . . . . . . 69

5.8 CheekLines . . . . . . . . . . . . . 715.8.1 Introduction . . . . . . . . . . . . . 715.8.2 Anatomy . . . . . . . . . . . . . . 715.8.3 AimofTreatment . . . . . . . . . . . 715.8.4 PatientSelection . . . . . . . . . . . 735.8.5 Technique . . . . . . . . . . . . . . 735.8.6 Complications . . . . . . . . . . . . 76

The Most Common IndicationsBertholdRzany,MauriciodeMaio

28 Berthold Rzany, Mauricio de Maio

5

Thefollowingchaptersdescribe themostcom-monindications.Althoughwrittenbybothau-thors separately, the chapters follow the samesequenceandtrytodepicttheproceduresinthemost‘handson’waypossible.

PleasenotethatthedosesaregiveninBo-tox and Dysport units. If you use BotoxAesthetics,VistabelorVistabexpleasekeepwiththeBotoxunits.

5.1 Forehead

Berthold Rzany

5.1.1 Introduction

Theforeheadmuscleisanelevator.Overtreatingthis muscle will result in brow ptosis, which isoneofthemajorsignsofaging.

5.1.2 Anatomy

Theventerfrontalisofthem.occipitofrontalisispartofthem.epicranius.Itderivesfromtheskinoftheeyebrowsandglabellaandinterveneswiththe fibres of the m. orbicularis oculi. It followsupwardswhereitinsertsintothegaleaaponeu-rotica,theextendedtendonofthem.epicranius.Thismuscleleads,whencontracted,tothehori-zontallinesoftheforehead.Itraisestheeyebrowandtheupperlidandbythismakestheeyelookopenandmuchbigger(Table.5.1).

5.1.3 Aim of Treatment

Theaimofthetreatmentistodecreasethefore-headwrinkles.

5.8.7 TipsandTricks . . . . . . . . . . . . 765.8.8 References . . . . . . . . . . . . . . 76

5.9 Gummysmile . . . . . . . . . . . . 775.9.1 Introduction . . . . . . . . . . . . . 775.9.2 Anatomy . . . . . . . . . . . . . . 775.9.3 AimofTreatment . . . . . . . . . . . 785.9.4 PatientSelection . . . . . . . . . . . 785.9.5 Technique . . . . . . . . . . . . . . 795.9.6 Complications . . . . . . . . . . . . 825.9.7 TipsandTricks . . . . . . . . . . . . 825.9.8 References . . . . . . . . . . . . . . 82

5.10 UpperandLowerLipWrinkling . . . . 825.10.1 Introduction . . . . . . . . . . . . . 825.10.2 Anatomy . . . . . . . . . . . . . . 825.10.3 AimofTreatment . . . . . . . . . . . 835.10.4 PatientSelectionandEvaluation . . . . 835.10.5 Technique . . . . . . . . . . . . . . 835.10.6 Complications . . . . . . . . . . . . 855.10.7 TipsandTricks . . . . . . . . . . . . 855.10.8 References . . . . . . . . . . . . . . 85

5.11 MarionetteLines . . . . . . . . . . . 865.11.1 Introduction . . . . . . . . . . . . . 865.11.2 Anatomy . . . . . . . . . . . . . . 865.11.3 AimofTreatment . . . . . . . . . . . 865.11.4 PatientSelectionandEvaluation . . . . 865.11.5 Technique . . . . . . . . . . . . . . 865.11.6 Complications . . . . . . . . . . . . 885.11.7 TipsandTricks . . . . . . . . . . . . 88

5.12 Cobblestonechin . . . . . . . . . . . 885.12.1 Introduction . . . . . . . . . . . . . 885.12.2 Anatomy . . . . . . . . . . . . . . 885.12.3 AimofTreatment . . . . . . . . . . . 895.12.4 PatientSelectionandEvaluation . . . . 895.12.5 Technique . . . . . . . . . . . . . . 895.12.6 Complications . . . . . . . . . . . . 895.12.7 TipsandTricks . . . . . . . . . . . . 90

5.13 Platysmalbands . . . . . . . . . . . 905.13.1 Introduction . . . . . . . . . . . . . 905.13.2 Anatomy . . . . . . . . . . . . . . 905.13.3 AimofTreatment . . . . . . . . . . . 905.13.4 PatientSelection . . . . . . . . . . . 915.13.5 Technique . . . . . . . . . . . . . . 915.13.6 Complications . . . . . . . . . . . . 925.13.7 TipsandTricks . . . . . . . . . . . . 92

Chapter 5 2�The Most Common Indications

5.1.4 Patient Selection

Patientselectionisquitestraightforward.Kineticpatientsarethosethatmaypresentthebestre-sult: complete static and dynamic line removalwithout or only with slight brow ptosis (Figs.5.1–5.4).Inhyperkineticandhypertonicpatients,browptosisisusuallyinevitable.Dependingonthedegreeofbrowptosistheresultmightstillbedesirable (Figs. 5.5–5.8). In hypertonic patientswithpronouncedelastosis,however,browptosiswillinevitablyleadtoanaestheticdisaster(Figs.5.9and5.10).Inhypertonicpatientswithapro-nouncedelastosis,BNT-Amightbeappliedonlytothemedialpartoftheforehead.

Restrictingtheinjectionstothemedialfibersmay lead to an undesired wrinkling just abovethelateralpartoftheeyebrow,theso-calledme-phistolook.Themephistolookresultsfromthecontraction of the lateral frontalis fibers in theabsenceofcontractionofthemedialfibers.Itismore visible when the glabella is treated at thesametime(Figs.5.11–5.14).

Bold patients: these patients might pose achallenge, especially when a brow ptosis is al-ready present. Restricting the treatment to themid forehead area might give a strange-look-ingappearancewithresidualwrinklingaboveawrinkle-freezone.

Table 5.1. Overviewofthemusclesresponsibleforforeheadlines

Muscle Action Synergists AntagonistsM.occipitofrontalis Raiseseyebrows,induces

horizontallines- M.corrugtores,m.

procerus,m.depressorsupercilii

Fig. 5.1. Injection points targeting the central foreheadareainamalekineticpatient

Fig. 5.2. Kineticmalepatient inhis thirties: raisinghiseyebrowsbeforetreatment


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Fig. 5.3. Kineticmalepatient inhis thirties: raisinghiseyebrows1weekaftertreatmentwithBNT-A

Fig. 5.4. Splitphotographofthekineticmalepatientinhis thirtiesraisinghiseyebrowsbeforeand1weekaftertreatmentwithBNT-A

Fig. 5.5. Injection points targeting the central foreheadareaandtheglabellainamalehyperkineticpatient

Fig. 5.6. Hyperkineticmalepatientinhisforties:raisinghiseyebrowsbeforetreatment

Fig. 5.7. Hyperkineticmalepatientinhisforties:raisinghiseyebrows4weeksaftertreatmentwithBNT-A

Chapter 5 31The Most Common Indications

Fig. 5.8. Splitphotographof thehyperkineticmalepa-tientinhisfortiesraisinghiseyebrowsbeforeand4weeksaftertreatmentwithBNT-A.Pleasenotetheslightbrowptosis

Fig. 5.9. Hyperkinetic/hypertonic patient in her sixtiesbeforetreatmentoftheforeheadarea

Fig. 5.10. Severebrowptosis4weeksaftertreatmentoftheforeheadareainahyperkinetic/hypertonicpatientinhersixtieswithBNT-A

Fig. 5.11. Injectionpointstargetingthecentralforeheadareaandtheglabellainahyperkineticfemalepatientinherearlyfifties


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5.1.5 Technique

5.1.5.1 Standard

Fourtosixinjectionpointsaresufficienttotreattheforehead(Figs.5.1,5.5and5.11).Theinjectionpoints should be distributed in the middle oftheforeheadarea.Ifthelateralinjectionpointisplacedinthemidpupillaryline,thelateralpartsofthem.frontaliswillliftthelateralpartsoftheeyebrowsupward(Fig.5.11).Thisdistributionofinjectionpointsispreferableinfemalepatients.

Inmalepatientsthelateralinjectionpointsmaybeplacedinalinewiththelateralcorneroftheeye.

5.1.5.2 High Forehead or Wrinkle-Free Forehead

Incaseofahighforeheadorwiththetreatmentgoalofawrinkle-freeforehead,higherdosesarepossible. In both cases a second line might beplacedabovethefirstline.

5.1.5.3 Combination with Glabella

Often the forehead is treated together with theglabella(seeChap.5.2).Inthiscasethetotaldosemightbereducedtoavoidafrozenexpression.

Treatmentoftheforehead• Fourtosixinjectionpointsinthemiddle

oftheforehead–thelateralpointsdeter-minethedegreeofmovementoftheeye-brows(moremediallyplacedtheyallowmorelateralmovementwithanelevationofthelateralpartsoftheeyebrow(female pattern)

Fig. 5.14. Splitphotographofhyperkineticpatientinherearlyfiftiesbeforeand4weeksaftertreatment

Fig. 5.12. Hyperkineticpatientinherearlyfifties:raisinghereyebrowsbeforetreatment

Fig. 5.13. Hyperkineticpatientinherearlyfifties:raisinghereyebrows4weeksaftertreatmentoftheglabella,thecentralforeheadregionandalateralbrowlift.Pleasenotetheappearanceoftheso-calledMephistosign


• Injection technique:deep,withoutcon-tactwiththeperiosteum

• Botox dose: 10–15 U total dose for oneline

• Dysportdose:25–40Utotaldoseforoneline

5.1.6 Complications !

5.1.6.1 Brow Ptosis

Browptosisisthemostcommonandunwantedadverseevent.Itwilloccurinmosthyperkineticpatients and in nearly all hypertonic patients.Thereisnocorrectionforbrowptosisexcepttoreassurethepatientthatthiseffectwillbetem-porary.

5.1.6.2 Mephisto Sign

Whenrestricting the forehead treatment to thearea between the midpupillary lines in somepatients, especially hypertonic patients, lateralmovementofthem.frontaliswillproducemorevisible wrinkles or make the existing wrinklesmore visible; the so-called Mephisto sign. TheMephisto sign may be carefully corrected withan injection in thepointofmaximumcontrac-tion when the patient raises the forehead. Theinjection point should be approximately 1 cmabove the orbital rim. However, be aware thatthisadditionalinjectionpointmayleadtobrowptosis.

5.1.6.3 Residual Upper Eyebrow Wrinkles

Insomepatientswhenthetotalforeheadistreat-edsomeresidualsmallwrinklesabovetheeye-browsmaypersist.Heremicroinjectionsofsmall

dosesofBNT-A(approximately2–3DysportUortheequivalentofBotox)mightbehelpful.Alowdoseismandatorytoavoidbrowptosis.Asabrowptosis-freealternative,thesuperficialinjec-tionofanappropriatenon-permanentinjectablefiller(e.g.hyaluronicacidorcollagen)mightberecommended.


■ Listentothepatient.Makesureofwhatthepatientwants.Forafirst-timetreatmentitmightbewisetostartwithaminimalap-proachtoavoidunhappypatients.Beverycarefulinhypertonicpatientswithelasto-sis. Here other treatment options mightcomefirst.

5.2 Glabella

Berthold Rzany

5.2.1 Introduction

For both the doctor and the patient, the gla-bellaisusuallythefirstregiontobetreatedwithBNT-A.

5.2.2 Anatomy

Glabellarlinesarecreatedbythreemuscles:them. depressor supercilii, m. corrugator and them. procerus. The m. depressor supercilii is themedialpartoftheorbicularisoculiparsorbitalis.Itderivesfromtheligamentpalpebralemedialeandinsertsinafanshapecraniallyinthedermisof the medial part of the eyebrow. Contractingthe m. depressor supercilii will draw the eye-browsdownandwillgivethispersonamenacing


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Table 5.2. Overviewofthemusclesresponsibleforglabellarlines

Muscle Action Synergists AntagonistsM.depressorsupercilii Drawsmedial

eyebrowsdownM.corrugator M.occipitofrontalis

M.corrugator Inducesverticallines M.depressorsupercilii M.occipitofrontalis

M.procerus Induceshorizontallines M.depressorsupercilii M.occipitofrontalis

Fig. 5.15. Injectionpointstargetingtheglabellaformalepatients

expression. The m. corrugator supercilii, alsoseenasanindependentdeeperpartoftheorbicu-larisoculiparsorbitalisderivesfromthemedialorbital ring and gradually proceeds laterally towherethemuscleinsertsabovethemiddleoftheeyebrowinthedermis.Contractingthem.cor-rugatorsuperciliileadstoverticallinesbetweenthe eyebrows. The m. procerus originates fromthebridgeofthenoseandinsertsintototheskinoftheglabella.Itsfibresareinterwovenwiththefrontalisventralfibresofthem.occipitofrontalis.Contractingthem.proceruswillinduceahori-zontallinebetweentheeyebrows(Table5.2).


Theaimofthetreatmentistoreducetheverticalaswellasthehorizontallinesoftheglabella.


Again, kinetic and hyperkinetic patients arebesttotreat.Kineticpatientsonlyproducegla-bellarwrinkles if theywant todenoteangerorconcentration and the lines are mainly super-ficial. Hyperkinetic patients present glabellarlines independently of willing to express angerorconcentration.Linesareseenindynamicsitu-ations and are deeper. Hypertonic patients aremoredifficulttotreat(Figs.5.60–5.62).Inthesepatients BNT-A has only a moderate effect on

glabellarwrinkles,becausetheyarepresentinastaticsituation.Here,usuallyanadditionaltreat-mentwithinjectablefillersisnecessarytoobtaingoodresults.

Menhavingstrongermusclesusuallyrequirehigherdosescomparedwithwomen(Figs.5.15–5.18).


5.2.5 Technique

The total dose is distributed over three to fiveinjectionpointsintheglabellaareacoveringallthree muscles involved in the formation of theglabellarlines.

In most patients, the first injection point isusedtotreatthem.procerus.Thetwomostim-portantpointsfortreatingtheglabellaarethein-jectionpointsinthecorrugatormuscles,which

arelocatedmediallyabout0.5–1cmabovetheedgeoftheorbitalbone.Twofurtherpossiblein-jectionpointsarelocatedlaterallyfollowingthecourseofthecorrugator(‘swallowshaped’)overthese two first points. The injection should bedone perpendicularly. Please take care NOT totouchtheperiosteum(Figs.5.15and5.19).

Treatmentoftheglabella• Threetofiveinjectionpoints

- Onepointforthem.procerus(inthemiddleofanimaginarycrossbetweenthecontralateraleyebrowsandtheme-dialcorneroftheeyelid)

- Onepointperm.corrugator(0.5–1cmabovethemedialorbitalriminexten-sion of the exit of the n. supraorbit-alis)

- Twoadditionalmore lateralpoints totreatthelateralpartsofthemm.cor-rugatoresandpartsofthem.frontalis(approx.1cmabovetheorbitalrim)

• Injection technique:deep,withoutcon-tactwiththeperiosteum

• Botoxdose:20–40U(totaldose)• Dysport dose: 50 U with a range from

30–70U(total dose)

Fig. 5.16. Hyperkinetic/hypertonicmalepatient:glabellaareafrowningbeforetreatment

Fig. 5.17. Hyperkinetic/hypertonicmalepatient:glabellaareafrowning4weeksaftertreatmentwithBNT-A

Fig. 5.18. Splitphotographofahyperkinetic/hypertonicmalepatientatrestbeforeand4weeksaftertreatmentoftheglabellawithBNT-A


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Fig. 5.20. Hypertonicfemalepatient:glabellaareafrown-ingbeforetreatment

Fig. 5.21. Hypertonicfemalepatient:glabellaareafrown-ing4weeksaftertreatmentwithBNT-A

Fig. 5.22. Splitphotographofahypertonicfemalepatientatrestbeforeand4weeksaftertreatmentoftheglabellawithBNT-A

Fig. 5.19. Injection points targeting the glabella for fe-malepatients


5.2.6.1 Eyelid Ptosis

Eyelid ptosis is the effect least wanted. Eyelidptosisoccursthroughthediffusionofasignifi-cantamountoftoxintothem.levatorpalpeprae(Fig.5.23).Thankfully,eyelidptosisistemporaryandusuallysubsidesafterafewweeks.

5.2.6.2 Flattening and Broadening of the Glabella Area

Especially in hypertonic patients, the area be-tweenthemedialpartsofthebrowsiswidenedconsiderablyleadingtoanundesirablecosmeticoutcome(Figs.5.20–5.22).



■ Threeinjectionpointsmightnotbeenoughinpatientswithastrongcorrugator.Here,treating only the middle part of the cor-rugator might lead to residual muscularmovementsofthemiddleandlateralpartsofthecorrugator.

■ When targeting the medial parts of themm. corrugatores, small arterial vesselsmightbeaccidentallyinjured.Usuallypre-and postinjection cooling helps to reduceunwantedhematoma.

5.3 Brow lift

Mauricio de Maio

5.3.1 Introduction

Intheupperthirdoftheface,theagingprocesscausesgradualdescentoftheforeheadandbrow,especiallyitslateralthird.Eyebrowmal-position-ingmayleadtouppereyelidfullnessthatmaybetargeted insufficiently by blepharoplasty alone.

In addition, hyperactivity of the central browmusculaturemaybequitecommon.Thefronta-lismuscleattemptstomaintainbrowpositioningbyover-contractingitsfibersandasaresultpro-ducestransverseforeheadcreases.

Eyebrow position differs between men andwomen.Inwomen,theeyebrowisideallyposi-tionedabovethesupraorbitalrim,whileinmen,itliesattherim.Themedialandlateralendsofthe eyebrow should lie at the same horizontallevel. Patients usually complain of a tired lookandupper-eyelidfullnesswhentheseparametersarelostandespeciallywhenthelateralpartoftheeyebrowdroops.

Manymethodshavebeendescribedforeye-browlifting;however,apartfromtheuseofin-jectable fillers, the majority of them are quiteinvasive.Themostcommontreatmentsincludecoronal incision, pre-trichial approach, endo-scopic suspensions and surgical threads. All ofthemneedsomekindofanesthesiaandalmostallofthemneedhospitalization.Theuseofbotu-linum toxin has changed the approach to eye-browlifting,sothatitisprobablythemostcom-monlyusedprocedureofall.

5.3.2 Anatomy

Thefacialupperthirdextendsfromthehairlinetothetopoftheeyebrows.Inmenwithrecedinghairlines, theupperpartof the foreheadequalsthe superior aspect of the frontalis muscle. Itsnormal resting tension is responsible for thenormalpositionoftheeyebrows.Theepicranialaponeurosis or galea aponeurotica covers theskull,justbeneaththefat.Them.frontalisistheanteriorpartof theoccipitofrontalismuscle. Infrontofthecoronalsuture,theaponeurosisgivesorigin to and is partly hidden by the frontalisbellies,whichdescendwithoutanybonyattach-menttoblendwiththem.orbicularisoculi.Themedialfibersof them. frontalisblendwith them.procerusfibersandbecomecontiguousatthenasallevel.Them.frontalishastwohalvesandin

Fig. 5.23. Eyelid ptosis 2 weeks after injection of 50DysportU(hypertonicpatientfromtheGLADYSstudy(Rzanyetal.2006))


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Table 5.3. Musclesresponsibleforeyebrowpositioning

Muscle Action Synergists AntagonistsM.frontalis Elevatestheeyebrowand

nasalskinM.occipitalis M.procerus,m.corru-

gatorsuperciliiandm.orbicularisoculi

M.corrugatorsupercilii Drawseyebrowsmediallyanddown

M.orbicularisoculiandm.procerus

M.frontalis

M.procerus Depressesthemedialendoftheeyebrow

M.corrugatorsuperciliiandm.orbicularisoculi

M.frontalis

M.orbicularisoculi Orbitalpart:protrusionoftheeyebrowsandvol-untaryeyelidclosurePalpebralpart:closeslidsduringblinkingLacrimalpart:drawslidsandlacrimalpapillaemedially,compressesthelacrimalsac

M.corrugatorsuperciliiandm.procerus

M.levatorpalpebraesuperioris:forclosingtheeyelids;m.frontalis:protrusionoftheeyebrows

thesuperioraspectofthemidlineforeheadthereisnomuscle,butafascialband.

Theusualactionofthem.frontalisistoraisethe eyebrows in the expression of surprise andevenhigherwithfright,andtofurrowthefore-headwithtransverselineswiththought.Theeye-browshaveoneelevatorandthreeopponentsasdepressors: the m. corrugator, the m. procerusandthem.orbicularisoculi.Them.frontalisin-terdigitateswiththeorbitalm.orbicularisoculiatthenasallevel.Italsoblendswiththeobliquelyoriented fibers of the m. corrugator supercilli.The corrugator is a small narrow muscle thatarises from the inner extremity of the superiorciliary ridge and inserts into the deep surfacesoftheskinaboveandbetweentheorbitalrims.It lies beneath the m. frontalis and m. orbicu-laris oculi. The corrugator draws the eyebrowsdownward and inward, producing the verticalwrinklesintheglabella.Itisusedtosquintandprotecttheeyes.Them.procerusoriginatesfromthe nasal bone and inserts into the skin of theforehead between the eyebrows. It pulls downthemedialaspectof theeyebrowandproduces

thehorizontal lineat this level.Them.orbicu-laris oculi when contracted pulls the completeeyebrowdownwards.(Table5.3)


Theaimofthetreatmentistoliftthelateraleye-brow.Themedialaspectcanalsobeliftedinse-lectedcases.Withbrowlifting,patientsmayim-provethetiredorsadlookaswellasdecreasetheuppereyelidhooding.


Patientsshouldbeanalyzedbothinthestaticanddynamicpositions.Inthestaticanalysis,thepa-tientsthatwillbenefitfromeyebrowliftingwithbotulinumtoxinarethosewithaweakfrontalisand strong depressors. Independent of age, theeyebrowhasalowposition;especiallyitslateralaspect,andfullnessintheuppereyelidcanalsobeobserved.Theremaybestaticlines,depend-


ingonthemuscularbehaviorandage.Inaddi-tion,thesizeoftheforeheadhastobeconsideredsincelargerareasneedmoreinjectionpointsandconsequentlyhigherdoses.

The dynamic analysis should be done whiletalkingtothepatientinordertocategorizethemas kinetic, hyperkinetic or hypertonic. Kineticpatientsonlyproduceimportanteyebroweleva-tioniftheywanttodenotesurprise.Horizontallineson the foreheadarenotvisiblewhenmo-tionless.Hyperkineticpatientspresenteyebrowelevation independently of expressing surprise.Horizontal linesontheforeheadduetofronta-lisover-contractioncanbeeasily seenanddis-appear easily when motionless. Hypertonic pa-tientscanrelaxneithertheeyebrowelevatornorthedepressors.Linesareseeninbothstaticanddynamicsituations.

Kineticpatientsarethosethatmaypresentthebestresult:completestaticanddynamiclinere-movalandaniceelevationofthewholeeyebrow.

Ahyperkineticm.frontalismayresultintheMe-phistolookduetotheblockingofitsmedialfiberswhen treating the forehead. The Mephisto lookmayresult fromtheover-contractionof the lat-eralfrontalisfibersandabsenceofcontractionofthemedialfibers.Itformsanundesiredwrinklingjustabovethelateralpartoftheeyebrow.Hyper-tonicpatientsaredifficulttotreat;heretreatmentofthelateralbrowmightresultinbrowptosis.

5.3.5 Technique

5.3.5.1 Technique 1

BNT-Ainjectionsareplacedintotheupperlater-alfibersofthem.orbicularisoculiparsorbitalis.Oneinjectionpointapproximately0.5cmabovetheorbitalrimshouldbesufficienttotargetthelateralpartofthem.orbicularisoculi.(Fig.5.24)

5.3.5.2 Technique 2

Another approach which is very efficient forlateraleyebrowliftingisthefullblockingofthedepressorsandpartialblockingofthemedialfi-bersofthem.frontalis.Thepropertechniqueisdescribed in the forehead and glabella sections(seeSects.5.1and5.2;Fig.5.25)

5.3.5.3 Technique 3

A third method that can be used by more ex-perienced injectors is theuseofmultiple injec-tionpointswithin thehairof theeyebrow.Theinjectionsshouldbesuperficial,withtheneedlepointing upwards. For lateral lifting only, threepointsare injected laterally to thesupra-orbitalforamen at the hemipupillary line (Fig. 5.26).If medial and lateral eyebrow lifting is desired,BNTshouldbedistributedinfiveinjectionsiteswithinthewholeeyebrow.(Fig.5.27)

Fig. 5.24. Injection points for brow lift (technique 1).Onepointtargetingtheparsorbitalisofthem.orbicularisoculiforeachside


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Fig. 5.25. Injection points for brow lift (technique 2).Herethecentralforeheadregionistreated

Fig. 5.26. Injection points for brow lift (technique 3).Here the lateral brow is treated with three injectionpoints

LateralBrowLiftTechnique1• Oneinjectionpointapproximately0.5cm

abovetheorbitalrim(Figs.5.24and5.28)- Botox:3–4Uperpoint- Dysport:10–12Uperpoint

Technique2• Seveninjectionpoints(seeFig.5.25)

- Botox: mm. corrugatores: 3–5 U perpoint, m. procerus: 3–5 U, medial m.frontalisfibers:2–6U(twopoints)

- Dysport: mm. corrugatores: 10–15 Uperpoint,m.procerus:10–15U,medialm.frontalisfibers6–15U(twopoints)

Technique3- Threetofiveinjectionpointsapproxi-

mately 0.5cm above the orbital rim(Figs.5.26–5.33)

- Botox:1Uperpoint- Dysport:3Uperpoint

Theresultsmayvaryfrompatienttopatientandthepurposeofeyebrowliftingshouldalwaysbetakenintoconsideration.Technique1issuitableformildlateraleyebrowliftingwhentheoppo-nent elevating lateral fibers of the m. frontalisare strong enough to promote the lifting effectwiththeantagonistblocking(Fig.5.34a,b).Tech-nique2presentsagoodperformancewhenonlythelateralaspectoftheeyebrowneedselevationandtherearenotmanyhorizontalfibers intheforehead,onlyinthemidline(Fig.5.35a,b).Tech-nique3isundoubtedlythemostappropriateformedial,intermediateandlateraleyebrowlifting,butmustbeconductedonlybyexperiencedin-jectors(Fig.5.36a,b).


Fig. 5.27. Injection points for brow lift (technique 3).Herethetotalbrowistreatedwithfiveinjectionpoints

Fig. 5.28. Thissingle injectionpoint isuseful forblockingthedepressoreffectoftheupperlateralfibersofthem.orbicularisoculiparsorbitalis(technique1).Careshouldbetakennottoaffectthelaccrimalglandpumpmechanism


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Fig. 5.29. Technique3:firstsite:atthislevel,theinjectionshouldbesuperficialandwithintheeyebrowhair.Itwillblocktheblendingfibersofthem.orbicularisoculi(upperlateralfibers)andm.frontalis(lowerlateralfibers)

Fig. 5.3o. Technique 3: second site: the injection is within the eyebrow hair, andsuperficial.ThesameblendingfibersareblockedasmentionedinFig.5.29


Fig. 5.31. Technique 3: third injection site: this can be the last point to promotelateraleyebrowlifting.Theneedleisinsertedparalleltotheskinintothedirectionofthesupra-orbitalforamenatthehemipupillaryline

Fig. 5.32. Technique3:thefourthinjectionsiteisusedwhentheintermediateaspectoftheeyebrowneedselevation.Theneedleisalsoinsertedparalleltotheskinandsuperficially.Atthislevel,thefibersblockedinclude:m.frontalislowerfibers,m.cor-rugatorinsertingfibers,m.orbicularisoculiupperfibers


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Fig. 5.33. Technique3:thefifthpoint:atthislevel,themostmedialaspectoftheeyebrowiselevated.Thesamerule:needleparalleltotheskinandsuperficialinjectionwithlowvolume

Fig. 5.34a,b. Technique1:asingleinjectionpointatthelateralaspectoftheeyebrowtoinhibitthedepressoreffectoftheupperlateralfibersofthem.orbicularisoculi

Fig. 5.35a,b. Technique2:theblockingofthem.corrugator,m.procerusandonlythemedialfibersofthem.frontalispromoteseyebrowlifting


Fig. 5.36a,b. Technique3withfiveinjectionsites.Notethatthereisaliftingeffectofthemedial,intermediateandlateralaspectsoftheeyebrow.Thereisalsoimprovementoftheuppereyelidskinexcess


Eyelid ptosis might rarely occur. In hypertonicpatientsBNT-A injections in the lateralpartofthe eyebrow might result in brow ptosis whenexcessivedosesareused.

Thetechniqueofinjectionwithintheeyebrow(technique3)mayleadtouppereyelidptosisifBNT-A is injected too deep and the needle di-recteddownwards.


■ Have the patient squeeze his eyes tightwhile you try to palpate the lateral partsof the m. orbicularis oculi. The injectionpoint shouldbeclose to this area,butal-ways above the orbital rim. Respect thelearningcurve: try technique1first, thentechnique2andafterthattechnique3withthreeinjectionsitesandwithenoughexpe-riencegotothefivepoints.

5.3.8 References

AhnMSetal.(2000)Temporalbrowliftusingbotulinumtoxin A. Plast Reconstr Surg 105(3):1129-35; discus-sionpp1136-9

BalikianRV,ZimblerMS(2005)PrimaryandadjunctiveusesofbotulinumtoxintypeAintheperiorbitalre-gion.FacialPlastSurgClinNorthAm13(4):583-90

Bulstrode NW, Grobbelaar AO (2002) Long-term pro-spectivefollow-upofbotulinumtoxintreatmentforfacialrhytides.AestheticPlastSurg26(5):356-9

ChenAH,FrankelAS(2003)Alteringbrowcontourwithbotulinum toxin. Facial Plast Surg Clin North Am11(4):457-64

CookBEJretal.(2001)Depressorsuperciliimuscle:anat-omy, histology, and cosmetic implications. OphthalPlastReconstrSurg17(6):404-11

de Almeida AR, Cernea SS (2001) Regarding browliftwithbotulinumtoxin.DermatolSurg27(9):848

Frankel AS, Kamer FM (1998) Chemical browlift. ArchOtolaryngolHeadNeckSurg124(3):321-3

HuilgolSCetal.(1999)Raisingeyebrowswithbotulinumtoxin.DermatolSurg25(5):373-5;discussionp376

KleinAW(2004)Botoxfortheeyesandeyebrows.Der-matolClin22(2):145-9

KochRJetal.(1997)Contemporarymanagementoftheagingbrowandforehead.Laryngoscope107(6):710-5


5

KokoskaMSetal.(2002)Modificationsofeyebrowpo-sitionwithbotulinumexotoxinA.ArchFacialPlastSurg4(4):244-7

KokoskaMSetal.(2002)Modificationsofeyebrowpo-sitionwithbotulinumexotoxinA.ArchFacialPlastSurg4(4):244-7

LeLouarnC(1998)Botulinumtoxinandfacialwrinkles:a new injection procedure. Ann Chir Plast Esthet43(5):526-33

LeLouarnC(2001)BotulinumtoxinAandfacial lines:the variable concentration. Aesthetic Plast Surg25(2):73-84

Le Louarn C (2004) Functional facial analysis afterbotulin on toxin injection. Ann Chir Plast Esthet49(5):527-36

LeeCJetal.(2006)Theresultsofperiorbitalrejuvenationwith botulinum toxin A using two different proto-cols.AestheticPlastSurg30(1):65-70

Matarasso A, Hutchinson O (2003) Evaluating rejuve-nation of the forehead and brow: an algorithm forselecting the appropriate technique. Plast ReconstrSurg112(5):1467-9

MichelowBJ,GuyuronB(1997)Rejuvenationoftheup-per face. A logical gamut of surgical options. ClinPlastSurg24(2):199-212

MuhlbauerW,HolmC(1998)Eyebrowasymmetry:waysofcorrection.AestheticPlastSurg22(5):366-71

OzsoyZetal. (2005)Anewtechniqueapplyingbotuli-numtoxininnarrowandwideforeheads.AestheticPlastSurg29(5):368-72

RedaelliA,ForteR(2003)Howtoavoidbrowptosisafterforeheadtreatmentwithbotulinumtoxin.JCosmetLaserTher5(3-4):220-2

SadickNS (2004)ThecosmeticuseofbotulinumtoxintypeBintheupperface.ClinDermatol22(1):29-33

5.4 Crow’s Feet and Lower Eyelid

Mauricio de Maio

5.4.1 Introduction

Theeyesareamongthemostimportantareasoftheface.Throughtheeyes,wecommunicate;wecanunderstandeachother’sfeelings.

Theagingprocessintheeyeareamayleadtoskinexcess,eyebags,staticanddynamicwrinklesandpigmentationdisturbances.Thewrinklingisusuallyonlynoticedduringthesmileandlocal-izedatthelateralpartofthelowereyelid.Itcansimplyappearasafineskincrepingorbeasdeepascreases.Insomecases,itcanbeseenwithoutanimationandisdenominatedasstaticwrinkles.Static wrinkles result from skin photo-damageand may be present in young people. They areusuallyworsenedwithanimationandevenmorewithskinexcess.

Static and dynamic wrinkles have differentetiology;however,theyhaveasynergisticeffectattheeyearea.Thepresenceofonecomponentworsens the other and the single treatment ofonlyonecomponentdoesnotpromoteanover-all aesthetic improvement at the eye area. Forexample,ifthepatientpresentsskinexcess,eyebags, scleral show, staticanddynamicwrinklesandpigmentedspots,theuseofbotulinumtoxinwillnotproducetheamazingoutcomeitusuallydoes. Patients can become frustrated and maytendtoseeonlythenegativeaspectsofthistreat-ment.

5.4.2 Anatomy

Them.orbicularisoculiisinnervatedbythetem-poralandzygomaticbranchesofthefacialnerve.The m. orbicularis oculi arises from the nasalportionofthefrontalbone,thefrontalprocessofthemaxilla,andthemedialpalpebral ligament.


Table 5.4. Characteristicsofthem.orbicularisoculi

Muscle Action Synergists AntagonistsM.orbicularisoculi Orbitalpart:protrusion

oftheeyebrowsandvol-untaryeyelidclosurePalpebralpart:closeslidsduringblinkingLacrimalpart:drawslidsandlacrimalpapillaemedially,compressesthelacrimalsac


M.levatorpalpebraesuperioris:forclosingtheeyelidsM.occipitofrontalis:pro-trusionoftheeyebrows

Itiscomposedofthreeportions:orbital,palpe-bralandlacrimal.Theorbitalportionformsthemajorityofthemusclebulk.Fibersarearrangedinanellipticalpatternandpresentnointerrup-tionlaterally.Thesuperiororbitalportionoftheorbicularis oculi runs more superficially thanthem.corrugatorandblendsmedially into thefrontalis.Laterally, themuscleextendsover thetemporalfascia.Inferiorly,itcontinuesandcov-erstheupperportionofthem.masseter.Moremedially,attheinferiororbitalmargin,itsexten-sionscovertheelevatorsoftheupperlip.

Thepalpebralportionoriginatesfromtheme-dialpalpebral ligamentandadjacentbone. It issubdividedintopreseptalandpretarsalportions.Thepretarsalfibersspreadacrosstheeyelids,thepreseptalfiberscourseinfrontoftheorbitalsep-tum and both fibers interdigitate laterally withthelateralpalpebralraphe.Theciliarybundleisasmallgroupoffinefiberslyingatthepalpebralmargin.

Thelacrimalportionhasbothsuperficialanddeepheadsthatarisefromthemedialpalpebralligamentandtheposteriorlacrimalcrest.Thefi-bersextendlaterallytoattachtothetarsiandtothelateralpalpebralraphe(Table5.4).

Withnormalmusclefunction,maximalorbit-alclosuredependsontheconcentratedeffortofallthreeportionsofthem.orbicularisoculi.Thecontractiondrawstheskinandeyelidsmedially

toward the bony attachments, which leads thelacrimal flow from the laterally and superiorlyplacedlacrimalglandtowardtheinferiorlyandmediallyplacedlacrimalsac.Theorbitalportionof the muscle is under voluntary control. Thepalpebral portion is under both voluntary andreflexcontrol.


Theaimoftreatmentattheeyelevelincludesre-ductionofhyperkinetic linesduringanimationandsofteningofhypertoniclinesatrest.


5.4.4.1 Crow’s Feet

In general, patients with fair skin and blondor redhair show theeffectsof agingat anear-lierstage.Blueorgreeneyesaremoresensitiveto daylight and as a consequence, squinting inbright sunlight may mechanically contributeto the lateralperiorbital skinwrinkles.Patientswithdarkercomplexionshavemoreprotection,especiallyiftheirskinismoresebaceous.Eyelidskin wrinkling may also result from ultraviolet


5

ray damage, the desiccating effect of wind andfromsmoking.

Patientswith thinner skinpresentverydeli-cate wrinkling and patients with thicker skinpresent more prominent and deeper wrinkles.The more atrophic the skin is, the greater thequantity of fine wrinkles that may be found.Wrinkle extension also varies according to themusclesize,andsomewrinklescangodowntothecheekarea.

Eyebrowptosismaycontributetouppereyelidskinexcessandskinwrinkling.Thelowereyelidmaypresentwitheyebags.Eyebagsmayresultfrom the laxity of the orbicularis oculi and areconsidered to be a pseudo-herniation. It is notadvisabletoinjectbotulinumtoxinforthetreat-ment of crow’s feet in patients with prominenteye-bags. If the muscle gets more relaxed, theeye-bags may get worse and a more tired lookmayresult.

5.4.4.2 Lower Eyelid

Whenanalyzingthelowereyelid,thequalityofskin,presenceofeyebagsandwrinklingshouldbe evaluated. The skin wrinkling in the lowereyelidresultsfromthehyperkineticbehaviorofthe palpebral portion of the orbicularis oculi.Thepretarsalportionofthemusclemayproduceorbicularishypertrophywhichreduces thepal-pebral aperture, especially in Asiatic patients.Thisperiocularfoldisknownas‘jellyrolls’.Theinjection of botulinum toxin softens the bulgi-nessatthissiteandpromoteseyewidening.ItisaverynicetreatmentforAsiaticpatients.

5.4.4.3 Eye Bags

Older patients present thinner and less elasticskin.Theorbitalseptumisalsolesseffectiveandweak.Withthisweakening,theinferiorperior-bitalfatbulgesandcreatesthesuborbitaleyebags

whichresults inavery tiredappearance. Injec-tionofbotulinumtoxininpatientswitheyebagsand scleral show is not advisable because theymaygetworse,soitshouldnotbeperformedbyinexperiencedpractitioners.

5.4.5 Technique

Good lighting avoids unwanted injection intobloodvesselswhichmayleadtobruisingandec-chymosis.

Aftercleansing,markingisinitiated.Thepa-tient should be asked to contract the eyes. Thelateralextensionofthecrow’sfeet,andthepres-enceofexcessivewrinklingonthe lowereyelidandnasal skinshouldbeevaluated.Marking isundertakenaccordingtotheareastobetreated.Normal sized lateral extension needs only onerowofthreeorfourpoints;withlongerlateralex-tensions,asecondrowismorelaterallymarked(Figs.5.37–5.40).

Theinjectormaypositionhimselfonthesamesidetobeinjectedorontheoppositeside.Iftheinjectorispositionedoppositetothepatient,theneedle will be pointed laterally and away fromthepatient’seye(Figs.5.41and5.42).

Beforetheinjection,stretchingoftheskinwillbehelpfultoavoidperforatingbloodvessels.Astheperiorbitalskinisthin,theneedlemaybein-sertedalmostparalleltotheskinandthebotuli-numtoxinwilldiffusetotheunderlyingmuscle.With deeper injection, it is more likely to pro-duceskinbruising.Injecting into theperiorbitalarea isalsousefulfor lifting the lateral aspectof the eyebrow.Anupperlateralcanthalinjectionblocksthedepres-soreffectofthelateralfibersofthem.orbicularisoculi, which in conjunction with glabellar andthemedialfrontalisfibersmaypromotealateraleyebrowlift(seeSect.5.3Browlift).

Thebestinjectionsiteinthelowereyelidisatthepretarsalinthemidpupilaryline(Figs.5.43–5.45).Aswellasthepossibilityofimprovinglower


Fig. 5.38. Crow’sfeet:normal-sizedlateralorbitalfibers.The treatment of these patients is usually very satisfac-tory.Thedynamiclinesarebasicallylimitedtotheorbitalbone’slateralmargin.Twopointsmaybeenoughforsuchcases

Fig. 5.39. Crow’s feet: moderate-sized lateral orbital fi-bers:thesearethetypicalpatientsforwhomtheconven-tionalthreepointsareindicated.Thesatisfactionrateisalwayshighwithcorrecttechnique

Fig. 5.37. Crow’sfeet:basicinjectionsites

Fig. 5.40. Crow’sfeetwithanexcessivelateralorbitalfi-bersextension:patientswiththispatternoffibersshouldbe treated in a different way. A greater number of sitesshould be injected, not necessarily increasing the finaltotaldosetoomuch.Themicroinjectiontechniqueisrec-ommendedheretoreducetheriskofcomplicationsandtoproduceabetterfinalresult


5

Fig. 5.41. Samesideinjectiontechnique:theinjectormaybepositionedonthesamesideasthewrinklestobetreated.Superficialinjectionsarerecommendedtoavoidbruising,sincenormallythevesselsaredeeper

Fig. 5.42. Oppositesideinjectiontechnique:iftheinjectorispositionedontheop-positesidetothecrow’sfeet,theneedleisdirectedoutwardsandtherewillbenodangerfortheeyeball


eyelidwrinkling, itproducesawideningof theeye which leads to aesthetic enhancement. Theneedleshouldbeinsertedparalleltotheskinsothataverysuperficialpapuleisseen.Anymedialorlateralinjectiontothemidpupillarylinemustbe avoided or undertaken by very experiencedinjectors;otherwisecomplicationsmayresult.

Treatmentofcrow’sfeetandlowereyelid• Threetofiveinjectionpoints

- Forcrow’sfeet:threepointslateralap-proximately1cmfromtheorbitalrim

- Forlowereyelid:onetotwoinjectionpoints,infraorbital

• Injectiontechnique:microinjectiontech-niquefortheinfraorbitalpointsrecom-mended

• Botoxdose:- Forcrow’sfeet:totaldose6–15U- Forlowereyelid:totaldose1–2U

• Dysportdose:- Forcrow’sfeet:totaldose15–30U- Forlowereyelid:totaldose2–4U

5.4.6 Results

Menusuallyacceptapartialresultandaresatisfiedwith partial wrinkling reduction (Fig.5.46a,b).Womenaremoredemandingandrequireamoreeffectivereductioninwrinkling.

Inmildandmoderatecases,periorbitalwrin-klingdisappears in staticanddynamicanalysis(Figs. 5.47a,b–5.49a,b). In patients with photo-damage,theresultmaybedisappointingiftheywerenotadvisedthatcombinedtherapyshouldbeundertaken.


Ecchymosisandbruisingmayresultfrominjec-tionintothelowereyelidordeeperinjectionsatthecrow’sfeet.Topreventecchymosis,theuseoficebagsbeforeandafterinjectionmaybehelp-ful.Bruisingmaylastfrom7to15days.

Analyzingthefunctionofthethreeportionsoftheorbicularisoculimayleadtounderstand-ing of complications with its treatment. Inject-ing into the lateralfibersof theorbicularisorisshould decrease the crow’s feet. Complicationssuch as upper lip asymmetry and cheek ptosismayresultfrominjectingintothelowestexten-sions of the crow’s feet at the m. zygomaticusmajor. Usually, these complications result fromdeepinjections(seeFig.7.1and7.2inSect.7).Atthis level, the injection should be intradermaland of low volume. With excessive blocking ofthepalpebralportion,thelacrimalpumpmecha-nism, forcedeyelidclosureandtheblinkreflexmaybeimpaired.Thismayleadtodryeyesandcornealexposure,especiallyinolderpatients.Toprevent lagophtalmos and scleral show, a snaptestshouldbeundertaken.IfasluggishreactionFig. 5.43. Lowereyelid:pre-septalinjectionpoints


5

Fig. 5.44. Injection technique: pretarsal treatment with BNT-A should be under-takenwithcaution.Theinjectionshouldbesuperficial,andpapuleformationshouldbetheend-point

Fig. 5.45. ThetreatmentoflowerlidskinwrinklingmaybeconductedwithBNT-A.Prominenteyebags,scleralshowandanegativesnaptestshouldcontra-indicatetheinjectionatthislevel


Fig. 5.46a,b. BNT-Atreatmentinmenshouldbeevenmorenaturalthaninwomen.Ingeneral,menacceptpartialresultsverywellandrefuseexcessiveblocking

Fig. 5.47a,b. Before and after of a patient with normal-sized crow’s feet. There is absolute removal of dynamicwrinkles

Fig. 5.48a,b. Beforeandafterofapatientwithalargelateralextensionofcrow’sfeet.Toobtainareductionofsuchwrinkling,multiplemicroinjectionsarerecommended.Thetotaldoseshouldbeevenlydistributedamongallpoints.Careshouldbetakenwiththelowestpoints;heremicroinjectionsatthezygomalevelaremandatory


5

Fig. 5.49a,b. Hypertrophyofthem.orbicularisoculiparspalpebralisatthepre-tarsalareaatthelowereyelid.AftertheinjectionofBNT-A,evenwithmoresquinting,thereisnoprominentcontractionatthislevel.Notethatalthoughonlythelefteyehastheinjectionsitemarkedwithablackdot,bothsideswereinjected

results,anypretarsalinjectioninthelowereyelidshouldbeavoided.

Pretarsal injectionswiththe intentionofde-creasinglowereyelidwrinklingshouldbeinthemidpupillaryline.Lateralinjectionstothispointmayleadtoeyelidectropionandroundedlateralcanthus. Medial injections to the midpupillarylinemaycauseepiphoraanddryeyes.

Caremustbe takenwhile treating the lowereyelid.Blockingof thepalpebralportionof theorbicularis oculi may lead to impairment ofeyeclosure,forbothvoluntaryandinvoluntaryfunctions.Ifpatientswitheyebagsareexcessivelytreated,aworseningineyebagsmayresult.Thisistheso-calledpseudo-herniation(Fig.5.50a,b)and may be due to muscular weakness orlymphatic drainage impairment or both. Thereis no effective treatment for this. Lymphaticmassages may promote a mild improvement.However, it is only the decrease of muscularblocking that will lead to an improvement. Itis very important to have taken pictures of thepatients before treatment. Some of them maybelieve and insist that the eye bags got worseafterthetreatment.


■ Avoid treating patients with prominenteye bags and skin excess; surgery is stillthe best option there (Fig. 5.51a,b). Pro-longedwrinklingtothecheekareashouldbe treatedwith intradermal injectionandverylowdoses.

5.4.9 References

BatnijiRK,FalkAN(2004)Updateonbotulinumtoxinuseinfacialplasticandheadandnecksurgery.CurrOpinOtolaryngolHeadNeckSurg12(4):317-22

BaumannLetal.(2003)Adouble-blinded,randomized,placebo-controlledpilotstudyofthesafetyandeffi-cacy of Myobloc (botulinum toxin type B)-purifiedneurotoxincomplexforthetreatmentofcrow’sfeet:adouble-blinded,placebo-controlledtrial.DermatolSurg29(5):508-15

Carruthers J et al. (2004) Consensus recommendationsontheuseofbotulinumtoxintypeainfacialaesthet-ics.PlastReconstrSurg114(6Suppl):1S-22S

Fagien S (2000) Intraoperative injection of botulinumtoxinAintoorbicularisoculimuscleforthetreatmentofcrow’sfeet.PlastReconstrSurg105(6):2226-8


Fig. 5.50a,b. Notetheworseningofthelowereyelideyebagsafterthetreatmentoftheglabellaandcrow’sfeetwithBNT-A

Fig. 5.51a,b. Thetreatmentofthecrow’sfeetmayaccentuatelowerskinexcess.EitherlowerskinremovalwithsurgeryorlowereyelidinjectionwithBNT-Ashouldbeundertakentoavoidundesirableresults

FlynnTCetal. (2003)BotulinumAtoxin(BOTOX)inthe lowereyelid:dose-findingstudy.DermatolSurg29(9):943-50;discussion950-1

GuerrissiJO(2000)IntraoperativeinjectionofbotulinumtoxinAintoorbicularisoculimuscleforthetreatmentofcrow’sfeet.PlastReconstrSurg104(6):2219-25

Kane MA (2003) Classification of crow’s feet patternsamongcaucasianwomen:thekeytoindividualizingtreatment.PlastReconstrSurg112(5Suppl):33S-39S

KleinAW(2004)Botoxfortheeyesandeyebrows.Der-matolClin22(2):145-9

Klein AW (2004) Contraindications and complicationswith the use of botulinum toxin. Clin Dermatol22(1):66-75

Guerrissi JO (2003) Intraoperative injection of botuli-num toxin A into the orbicularis oculi muscle forthetreatmentofcrow’sfeet.PlastReconstrSurg112(5Suppl):161S-3S


LevyJLetal.(2004)BotulinumtoxinA:a9-monthclini-caland3Dinvivoprofilometriccrow’sfeetwrinkleformationstudy.JCosmetLaserTher6(1):16-20

LoweNJetal.(2005)Double-blind,randomized,place-bo-controlled,dose-responsestudyofthesafetyandefficacyofbotulinumtoxin typeA in subjectswithcrow’sfeet.DermatolSurg31(3):257-62


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LoweNJetal.(2002)Bilateral,double-blind,randomizedcomparisonof3dosesofbotulinumtoxintypeAandplaceboinpatientswithcrow’sfeet.JAmAcadDer-matol47(6):834-40

MatarassoSL,MatarassoA(2001)TreatmentguidelinesforbotulinumtoxintypeAfortheperiocularregionandareportonpartialupperlipptosisfollowingin-jectionstothelateralcanthalrhytids.PlastReconstrSurg108(1):208-14;discussionpp215-7

Naik MN et al. (2005) Botulinum toxin in ophthalmicplasticsurgery.IndianJOphthalmol53(4):279-88

SemchyshynN,SengelmannRD(2003)Botulinumtox-in A treatment of perioral rhytides. Dermatol Surg29(5):490-5;discussionp495

FlynnTCetal. (2003)BotulinumAtoxin(BOTOX)inthe lowereyelid:dose-findingstudy.DermatolSurg29(9):943-50;discussionpp950-1

Flynn TC et al. (2001) Botulinum-A toxin treatment ofthe lower eyelid improves infraorbital rhytides andwidenstheeye.DermatolSurg27(8):703-8

BalikianRV,ZimblerMS(2005)PrimaryandadjunctiveusesofbotulinumtoxintypeAintheperiorbitalre-gion.FacialPlastSurgClinNorthAm13(4):583-90

FrankelAS(1999)Botox forrejuvenationof theperior-bitalregion.FacialPlastSurg15(3):255-62

KimDWetal. (2003)BotulinumtoxinA for the treat-mentof lateralperiorbital rhytids.FacialPlastSurgClinNorthAm11(4):445-51


Spiegel JH (2005) Treatment of periorbital rhytids withbotulinumtoxin typeA:maximizing safetyandre-sults.ArchFacialPlastSurg7(3):198-202

5.5 Bunny Lines

Mauricio de Maio

5.5.1 Introduction

Bunny lines are defined as those wrinkling onthelateraland/ordorsalaspectofthenose.They

maybenaturallypresentinsomepatientswhenthey smile, laugh, frown or speak. However,theymayappearorworsenaftertreatmentwithBNT-A,especiallyinthecrow’sfeetandglabellaarea,leadingtotheso-calledBNT-sign.Patientsusually blame the injector if those lines resultfrom the injection of BNT-A for any cosmeticpurpose.

When blocking a specific muscle, it is verylikelythatitssynergisticmusclemaycontractaswell and sometimes may even react with over-contraction.Whentheeyeandnosecomplexisunderanimation,thereisparallelcontractionofthe mm. corrugatores, m. procerus, m. nasalisand mm. orbiculares oculi and, depending onthepatient,theupperlipelevatorsaswell.

Themostcommontreatmentwithbotulinumtoxinintheupperthirdincludestheblockingofthem.frontalis,mm.corrugatores,m.procerusandm.orbicularisoculi.Ifthem.nasalisisnottreated, undesired bunny lines may result. De-pending on the skin complexion, there will bemoreorlesswrinkleformation.Forexample,pa-tientswiththinskinandfaircomplexionaremorepronetodevelopwrinklingonthenasaldorsumandlateralwalls.Sometimes,therearewrinklingextensionstothelowereyelid.Darkercomplex-ion and oily skin produce thick wrinkling andareusuallylimitedtothenasaldorsum.

The choice of treating the bunny lines con-comitantwithcrow’sfeetorglabellaareawillde-pendonthepatient.Iftheyarenottreatedduringthesamesession,andbecometooevidentafterthetreatment,theycanbetreatedafterwards.

5.5.2 Anatomy

Theskinisthinnerandmoremobileintheup-pertwothirdsofthenose,anditisthickerandmore adherent in the lower third. The thinnerandoldertheskinis,themorewrinklingistobeformedonthenasaldorsum.

Thenosecontainsthreemainmuscles:them.procerus,them.nasalisandthem.depressorsep-


Table 5.5. Characteristicsofthem.nasalisandthem.levatorlabiisuperiorisalaequenasi

Muscle Action Synergists AntagonistsM.nasalis Compressionnaris:com-

pressesthenasalapertureDilatornaris:widenstheanteriornasalaperture

Medialpartsofthem.levatorlabiisuperiorisalaequenasiandm.de-pressorsepti

None

M.levatorlabiisuperiorisalaequenasi

Medialpart:dilatesthenostrilLateralpart:raisesandevertstheupperlip

Medialpart:m.dilatornasiLateralpart:m.levatorlabiisuperioris,m.zygomaticusmajorandminorandm.levatorangulioris

M.depressoranguliorisandm.orbicularisoris

tinasi.Them.procerusdrawsthemedialpartoftheeyebrowdown.Itoriginatesatthenasalrootandblendswiththefrontalisfibers.Them.de-pressorseptinasidropsthetipofthenosewhencontracted.Finally,them.nasalisisthemostim-portantoneforpromotingthebunnylinesandwillbethemainfocusofthissection.Althoughthem.levatorlabiisuperiorisalaequenasiisnotan intrinsic nasal muscle, it may contribute tothebunnylinesduetoitsmedialfibers.

The m. nasalis originates in the transitionfrom the nasal bone with the maxilla and in-serts into theaponeurosisof thenasaldorsum.Itlookslikeanupside-downhorseshoe,withtheupperorcurvedpartformedbytransversefibersonthenasaldorsum.Itsactionistonarrowthenostrils(alsodenominatedasm.compressorna-ris).Thetransversefibersofthem.nasalislead,whencontracted,tothelateralnasallines(bun-ny lines)and toadditional lines in the internalinfra-ocular region.The two lowerpartsof them. nasalis run vertically down the sides of thenose (alsoknownas thedilatornasi)and theiractionistoopenthenostrils(Table5.5).

5.5.3 Aim of the Treatment

The aim of the treatment is to reduce bunnylines;eitherthosenaturallypresentorthoseap-

pearingaftertreatmentoftheglabellaandcrow’sfeetareawithBNT.


Bunnylinesmaybetreatedaloneorinconjunc-tion with the treatment of the crow’s feet andglabellar lines. Kinetic patients usually do notpresentlinesonthenasaldorsumwhensmilingandconcomitanttreatmentwithcrow’sfeetmaynotbenecessary.

Instaticanalysis,hyperkineticandhypertonicpatientsmaypresentwrinklesonthenasaldor-sum.Thepresenceofthoselinesatrestindicatestheneedforbunny line treatmentconcomitantwithcrow’sfeetandglabellarlines.

During animation, patients should be askedto laugh, tosniffand tosquint intenselyas ifavery bright light is before their eyes. Usually,bunny lines are not present in kinetic patientswith a mild smile. They only become evidentwhen smiling at maximum contraction. In hy-perkineticpatients,bunnylinesarefoundwithamildsmileandworsenatmaximumcontraction.Due to constant squinting, the m. nasalis maybecomehypertrophicandmayreducethedura-tionofeffectofBNT-Aatthenasallevel.

Bunnylinesmaybelimitedtothenose,withextension to lower eyelid and reach the nasal


5

Fig. 5.52a,b. Notethedifferencebetweenthetwopatternsofbunnylines.Thepatientinahaslinespredominantlylim-itedtothelateralaspectofthenose.Thepatientinbhasbunnylineextensionstothenasaldorsum,lowereyelidandnasalflare.Itiseasiertoimprovethoselinesinthefirstpatient.Thesecondpatientpresentsamorecomplexsituation

flare. Depending on the patient, they may bepresent only at the lateral aspect of the nasaldorsumorattheupperaspectofthenasalbone(Fig.5.52a,b).

5.5.5 Technique

After static and dynamic evaluation, the injec-tion points can be marked on the lateral andupper aspect of the nasal bone if needed. Theinjectionshouldbeverysuperficialbecausetheskinatthislevelisverythinandcontactwiththeperiosteummaybepainful(Fig.5.53).Theneedleshouldbeatanangleof30°,becauseitiseasiertoavoidtouchingtheperiosteum.Thereisanevi-dentpapuleorwheal formationafterthe injec-tion.Careshouldbetakenwithbloodvesselsatthislevel,otherwisebruisingmayresult.

Atotaldoseof2–5UofBotoxor6–15UDys-portshouldbedistributedonbothlateralsides(Fig.5.54).Inselectedcases,extradosesfrom1to2UBotoxor3to5UDysportmaybeinjectedinthemidline(Figs.5.55and5.56).It is impor-tant not to inject too laterally down the nasalsidewalls;otherwise, the levator labiisuperiorisalaequenasimaybeblockedandupperlipptosisandasymmetrymayresult.

Careshouldbe takentoavoid injection intotheangularvesselswhichwouldproducebruis-ingandecchymosis.Partialornoeffectoftenre-sults from inadvertent injection into the bloodvessels.

Patients usually get disappointed if bunnylines result after the blocking of the glabellarandforeheadlines(Fig.5.57a,b).Assoonasevi-denced,thepatientshouldbetreated.If,duringthepre-treatmentevaluation,bunnylinesappearwithfrowning,concomitanttreatmentwiththeglabellarlinesmustbeundertaken(Fig.5.58a,b).

Treatmentofbunnylines• Twoinjectionpoints,oneforeachsideof

the nose. In certain cases an additionalmedialpointmaybeadded

• Botoxdose:2–5Utotaldoseforthetwopoints,1–2Ufortheextrapoint

• Dysportdose:6–15Utotaldose for thetwopoints,3–5Ufortheextrapoint


Themostcommoncomplicationwiththetreat-mentofbunnylinesisthepresenceofecchymo-


Fig. 5.53. Theinjectiontechniqueonthelateralbunnylinesshouldbesuperficialandawhealformationisdesirable.Careshouldbetakennottoinjectintobloodvesselstoavoidbruising

Fig. 5.54. Injectiontechnique:lateralinjectionpoints Fig. 5.55. Injectiontechnique:lateralanddorsalinjectionpoints


5

Fig. 5.56. Somepatientsmayalsopresentlinesonthenasaldorsum.Injectionshouldbesuperficialaswell.Herebruisingaftertheinjectioncanbequitecommon

Fig. 5.57a,b. ThispatientwassubmittedtoBNT-Aintheglabella,foreheadandcrow´sfeet.Notethatduringanima-tion,thereisnocontractionofthem.nasalis.Afterblockingthespecificmuscles,bunnylinesappearedduetotheblockingofupperthirdmusclesofthefaceexceptthem.nasalis

Fig. 5.58a,b. Thispatientshowedbunnylineswhilefrowning,beforetreatment.Inthesepatientsitisrecommendedthatthebunnylinesaretreatedatthesametimeastheglabella.AfterinjectionwithBNT-Aanimprovementinbothglabellarandbunnylinescanbeobserved


sisorhematoma.Anunsatisfactoryresultmaybedue to inadvertent injection into blood vessels.Majorproblemssuchasdiplopiaandupper lipptosis may result from inadvertent blocking oftherectusinferiorisormedialisandthelevatorlabii superioris alaeque nasi, respectively. Moreseriouscomplicationsmayincludespeakingandchewingdifficulty.


■ Bunny line treatment reallydoesproducean upgrade in cosmetic evaluation in pa-tientstreatedwithBNT-A.So,donotfor-getthem!

5.5.8 References

Ahn KY et al. (2000) Botulinum toxin A for the treat-mentoffacialhyperkineticwrinklelinesinKoreans.PlastReconstrSurg105(2):778-84

CarruthersJ,CarruthersA(2003)AestheticbotulinumAtoxininthemidandlowerfaceandneck.DermatolSurg29(5):468-76

Carruthers J et al. (2004) Consensus recommendationson theuseofbotulinumtoxin typeA in facialaes-thetics.PlastReconstrSurg114(6Suppl):1S-22S

Huang W et al. (2000) Browlift with botulinum toxin.DermatolSurg26(1):55-60

5.6 Nose

Maurício de Maio

5.6.1 Introduction

The volume, mass and shape of the three aes-theticthirdsandthemagnitudeofnasalpromi-

nence and projection determine what we mayconsiderasaestheticbeauty.Anydiminutionorenhancement insize inonefacialzonedirectlyand inversely impacts the others. The nose issuchanimportantlandmarkinfacialbeautythateven slightmodificationsmay lead todramaticchanges.Thetipofthenoseplaysanimportantrole in nasal beauty. Preferably, the nasolabialangleinwomenshouldbe95–100°andinmen,approximately90–95°.

Aging processes may alter the shape of thenose. It is primarily the drooping of the nasaltipandtheincreasingprominenceofthedorsalhumpwhichcanbeobserved.Thereisarelativeshortening of the lower third of the face and arelativelengtheningofthenosewhich,togetherwith a loss of support of the lateral cartilages,gives the appearance of a drooping tip and ac-centuatesanydorsalconvexity.

5.6.2 Anatomy

The nose contains three main muscles: the m.procerus, the m. nasalis and the m. depressorseptinasi.Them.procerushastwoventersthatoriginateatthenoserootandtheinsertionfibersareintertwinedwiththoseofthefrontal.Itsac-tionismoreconcentratedattheglabellaarea.Itdepressesthemedialportionoftheeyebrowsandformsthehorizontallineontheglabella.Them.nasalisoriginatesinthetransitionfromthena-salbonewiththemaxillaandinsertsintheapo-neurosisofthenasaldorsum.Itmovesthenoseandisauxiliarytotheopeningofthenostrils.Itformsthelaterallinesonthenose.

The most important muscle that acts on thepositionofthenosetipisthem.depressorseptinasi.Itsoriginisatthebaseofthenasalseptumand it blends with the fibers of the orbicularisoris.Itsfibersarelongitudinalandwithcontrac-tion,itshortenstheupperlipandcandecreasetipprojectiononanimation.Therearethreedistinctvariations of this muscle. The more common


5

Table 5.6. Characteristicsofthem.nasalisandthem.depressorsepti

Muscle Action Synergists AntagonistsM.nasalis Compressionnaris:com-

pressesthenasalapertureDilatornaris:widenstheanteriornasalaperture

Medialpartsofthem.levatorlabiisuperiorisalaequenasiandm.de-pressorsepti

None

M.depressorsepti Drawsthenasaltipdownwardsandtherebyconstrictsthenostrils

M.nasalis M.dilatornasi

typeIdepressorseptimuscles(62%)arevisibleand identifiable and present full interdigitationwiththeorbicularisorisfromtheiroriginatthemedial crural footplate. Type II muscles (22%)are also identifiable but insert into the perios-teumandpresentlittleornointerdigitationwiththeorbicularisoris.The least common type IIImuscles(16%)presentnooronlyarudimentarydepressorseptimuscle(Table5.6).


ThepurposeofblockingthedepressorseptinasiwithBNT-A is to elevate the tipof thenoseatrestandavoiditsdroopingduringasmile.

Theblockingofthedilatornasimaydecreasethenostrilapertureincertaincases.


Routinepre-treatmentexaminationshouldeas-ily identify those young patients who presenta drooping nasal tip and upper lip shorteningwhen smiling. The shape of the face is usuallyconvexwithaprominentnoseandanunderde-velopedchin.Thosepatientsaremainlymouthbreathers.

Anothersituationthatmaybefoundwiththedrooping tip is during the aging process. Withnoseelongationandmusclechanges, the tipof

thenosetendstodropmainlyinthosepatientswithacutenasolabialangles.

Infrontalview,thereisanevidentdownwardmovementwhenthepatientsmiles,especiallyatmaximum contraction. On profile analysis, thenasolabial angle is usually less than 90o at restanddecreaseswhenthepatientsmiles.

Excessive opening of the nasal flare maybe found in some individuals during physicaloremotionalstress.Thedilatornasicontractionmaycausethisexcessiveopening.

5.6.5 Technique

Thepatientshouldbeevaluatedaccordingtothelengthoftheupperlipandthenasal-labialangle.Therearetwowaysofblockingthem.depressorseptinasiwithBNT-A:throughtheskinandin-tra-orally.Asthenasalareaisquitesensitive,theuseoftopicalanesthesiaoricebagstoreducethepainisadvisable.

Asmentionedabove,therearethreedifferentanatomical patterns for the m. depressor septinasi. That is one of the main reasons why theoutcomemayvaryfrompatienttopatient.

5.6.5.1 Technique 1

Thetrans-cutaneousapproachiscarriedoutbymarking the injection points at the base of the


columella at the medial crural footplate. Twopointsaremarked,oneateachsideofthemedialcrura,andtheinjectionisstarted(Fig.5.59).Asthefibersofthem.depressorseptinasiareinter-twinedwiththoseofthem.orbicularisoris,theinjectionshouldbesuperficial.Usually,thefirstthirdofthe30-gaugeneedleisinserted(+/-3–4mm).Thedoseateachsideis1–2UBotoxor4–6UDysport.

5.6.5.2 Technique 2

Another option for the trans-cutaneous ap-proachisasingleinjectionpointatthecolumellabase between the two medial crura (Fig. 5.60).At this level, the muscle is also superficial and2–3UBotoxor5–9UDysportcanbe injected(Figs.5.61and5.62).

5.6.5.3 Technique 3

Theintra-oralapproachislesspainfulbutitmaybe considered more difficult by some to injectinto the correct level. The same needle may beused;however,theinjectionmustpreferablybeundertaken in two sites right beside the frenu-lum.Them.depressorseptinasifibersareinter-twinedwiththeorbicularisoris,soat leasthalfof the30gaugeneedle shouldbe insertedwithitsbeveldirectedtothecolumellabase.Atotaldose of 1–3 U Botox or 3–7 U Dysport at eachsideshouldbeinjected.

Treatmentofthem.depressorseptinasiTechnique1• Two transcutaneous lateral injection

points(Fig.5.59)• Botoxdose:1–2Uperside• Dysportdose:4–6Uperside

Fig. 5.59. Transcutaneousapproach:twoinjectionpoints,oneateachsideofthemedialcrura

Fig. 5.60. Transcutaneousapproach:oneinjectionpointatthebaseofthecolumella


5

Fig. 5.61. Injection of BNT-A at the base of the collu-mella.Thefibersofthem.depressorseptinasiruncloseto themedial crural footplate.This location is ideal forpatientswithnormalorshortupperlips

Fig. 5.62. Them.depressorseptinasifibersrunupwardstothetipofthenose.InjectionofBNT-Aatthemiddleportionofthecollumellaisidealforthosepatientswhopresentalongupperlip

Technique2• One transcutaneous medial injection

point(Figs.5.60–5.62)• Botoxdose:2–3U• Dysportdose:5–9U

Technique3• Twointraorallateralinjectionpoints• Botoxdose:1–3Uperside• Dysportdose:3–7Uperside

Toinjectintothedilatornasi,thepatientshouldbeaskedtobreatheinandtheexactlocationofthe muscle movement should be marked. Theskin at this level is much adhered to the carti-lage and injection may be quite painful. Thebevel should be turned downwards, especiallyinpatientswithlargeporesintheskin.Duringthe treatment, it iscommontoseean immedi-atebleachingwiththeinjection,whichsubsidesshortlyafter.Atotalof 1–2UBotoxand3–5UDysportshouldbeinjected(Fig.5.63a,b).

Treatmentofthem.dilatornasi• Oneinjectionpoint• Botoxdose:1–2Utotaldose• Dysportdose:3-5Utotaldose

5.6.6 Results

Theinjectionofbotulinumtoxin in them.de-pressor septi nasi may achieve the followinggoals:1.Enhancementofthenasolabialangleinstaticanddynamicpositions,2.Slightupperliplengthening,3.Slightfullnessoftheupperlip,4.Elevationofthetipofthenose,5.Improvementofthehorizontallinesbetweentheupperliprimandthenasalbase(Figs.5.64a,band5.65a,b).


Complications are rare when patients are se-lectedproperlyandcorrecttechniquesareused.Complications such as hematoma and edemahardly ever happen. Pain is the adverse eventmost often reported. Injection into the dilatornasibarelyresultsincomplications.Incontrast,atthenasalbase,over-blockingofthem.depres-sorseptinasimayresultinupperlipptosis.Thisismoreproneinpatientswitha longupper lipinwhomanyrelaxationmayleadtoelongationatthemedialtubercleandphiltrum.Asaresult,the central upper incisors become hidden andthrough the contraction of the m. zygomaticusmajorwithupperlateralpullingofthelips, the‘joker’smilemayresult.


Fig. 5.63a,b. Theblockingofthem.dilatornasimayreshapethenostrilanddecreaseitssize,leadingtoamoredelicateappearanceofthenose

Fig. 5.64a,b. Thecontractionofthedepressoroftheseptummakesthetipofthenoseroundedandinclineddown-wards.TheinjectionofBNT-Apromoteselevationofthetipofthenoseandamoregraciousprofile

Fig. 5.65a,b. Theblockingofthem.depressorseptinasipromotesaslightliftingandupwardrotationofthetipofthenose.Itgivesamoreyouthfulappearance


5

Ifthezygomaticusmajortractionisexcessiveand there is social impairment for the patient,averycarefulinjectionattheupperpartofthemodiolus where the m. zygomaticus major in-serts should be conducted. A next-to-nothingdose(0.5UBotox,1UDysport)mustbecarriedout very superficially. Extra tiny doses may beinjectedatthesamelevelwith7daysapartuntilthedesiredeffectisobtained.Toimproveupperlipptosis,very littlecanbedone.Ingeneral, 15daysaftertheinjectionthereissomerecoveryofthemuscletonuswithupperlipliftingandaes-theticimprovement.


■ The best candidates to start treatment ofthem.depressorseptinasiarethosewithashortupperlipandpreferablyagummysmile.Evenifthereisupperliplengthen-ingaftertheBNT-Ainjection, thepatientwillbenefitcosmetically.

5.6.9 References

Rees TD (1978) Rhinoplasty in the older patient. AnnPlastSurg1:27

Patterson C (1980) The aging nose: characteristics andcorrection.OtolaryngolClinNorthAm13:275

Rohrich RJ et al. (2000) Importance of the depressorseptinasimuscleinrhinoplasty:anatomicstudyandclinicalapplication.PlastReconstrSurg105:376

BatnijiRK,FalkAN(2004)Updateonbotulinumtoxinuseinfacialplasticandheadandnecksurgery.CurrOpinOtolaryngolHeadNeckSurg12(4):317-22

Carruthers J et al. (2004) Consensus recommendationsontheuseofbotulinumtoxintypeainfacialaesthet-ics.PlastReconstrSurg114(6Suppl):1S-22S

DayanSH,Kempiners JJ (2005)Treatmentof the lowerthirdof thenoseanddynamicnasal tipptosiswithBotox.PlastReconstrSurg115(6):1784-5

DeMaioM(2004)Theminimalapproach:aninnovationin facial cosmetic procedures. Aesthetic Plast Surg28(5):295-300

Kane MA (2003) The effect of botulinum toxin injec-tionsonthenasolabialfold.PlastReconstrSurg112(5Suppl):66S-72S;discussionpp73S-74S

LeLouarnC(2001)BotulinumtoxinAandfacial lines:the variable concentration. Aesthetic Plast Surg25(2):73-84

TamuraBMetal.(2005)Treatmentofnasalwrinkleswithbotulinumtoxin.DermatolSurg31(3):271-5

5.7 Nasolabial Fold

Mauricio de Maio

5.7.1 Introduction

One of the aging signs in the mid third of thefaceistheprominentnasolabialfold.Facialcos-meticsurgeriesareunabletosolvethisissuebymuscle traction and skin removal alone. Usu-ally,thebesttreatmentfordeepnasolabialfoldsistheinjectionoffillers.Insomecases,though,thesingleuseoffillersinthenasolabialfoldmayproduceundesirableresults,especiallywhenthemain component that produces the prominentnasolabial fold is muscular over-contraction.Cosmetic practitioners tend to inject excessiveamountsoffillerstofillwhatshouldnotbefilled,but blocked. Overcorrection of the folds withfillerscanresultinabizarreappearance,makingpatientslookfatorswollen.

The natural muscle action on the nasolabialfoldmayexpressdifferentemotions.Whenitistheupperpartthatisdeepened,itexpressesdis-gust or anger. In contrast, when it is the lowerpart,itmeansgrief,sadnessorjoy.

Duetothequantityofmusclesthatactattheperioralarea,thetreatmentofthenasolabialfoldmust be carried out with great care. The pres-enceofmildasymmetriesaftertreatmentisnotrare and should be promptly corrected when


diagnosed.Itisnoteasytodeterminetheproperdose the first time we treat a new patient. Forthisreason,itisadvisablethatthetreatmentbeconductedintwostepsuntilthecorrectdoseisdetermined.

Itshouldbeemphasizedthatthepresenceofanaturalnasolabialfoldisnotanegativecosmeticsign. It is its depth and prominence that mayaffect and disturb facial expression and beauty.Also,thecompleteeliminationofitcouldbedet-rimentaltofacialharmony.

5.7.2 Anatomy

Thenasolabialfoldextendsfromtheupperlateralpartofthenasalflaredowntotheoralcommis-sure. It can vary from individual to individual:becompleteabsentorflatorevenverydeepwithskin excess and premaxillary deficiency. It canstoplaterallytotheoralcommissureorgodown-wardtothechinarea.Ingeneral,aprominentna-solabialfoldmayresultfrommorethanoneetiol-ogy.Itcanresultfromthelossofskinthicknessoverthesulcus;fromthepresenceofredundantskindroopingoverthesulcus;fromexcessivefatdepositslaterallytothesulcus;fromptosisand/orlaxityofthemalarfatpadandfrommuscularhy-peractivity.Inolderpatients,morethanonefac-torusuallycausestheprominentnasolabialfold.

With theagingof the face, there is a lossofsubcutaneous fullness which is associated withyouth.Thefatlossresultsinalesstightenedskinwhichproducesfoldsandwrinkles.Thenasola-bialfoldbecomesmoreprominentanduninten-tionalemotionsareexpressed.With the lossofbiomechanical support, the skin suffers the ac-tionofmuscularhyperactivityevenmore.

Themusclesatthenasolabiallevel,fromme-diallytolaterally,arethem.levatorlabiisuperi-orisalaequenasi,m.levatorlabiisuperioris,m.zygomaticusminor,m.zygomaticusmajorandatadeeperlevel,them.levatorangulioris.Itisim-portanttoemphasizethatthezygomaticusmajorhaslittleornoeffectonthenasolabialfold.

Them.levatorlabiisuperiorisisthemainel-evator of the upper lip and functions to createand move the middle portion of the nasolabialfold.Itoriginatesfromthelowermarginoftheorbit,abovetheinfraorbitalforamenandbelowtheorbicularisoculi.Itcontinuesdownwardbe-tween the levator labii superioris alaeque nasiandzygomaticusminorandinsertsintothecen-tralandlateralaspectsoftheupperlip.Itelevatesandevertstheupperlip.

Another important muscle that acts uponthe nasolabial fold is the m. levator labii supe-riorisalaequenasi.Itoriginatesfromthefrontalprocessofthemaxillaanddescendsanddividesitselfintotwomusclebundles:themostmedialsmallerfibersinsertintothenasalcartilageandtheskinofthenoseandalargerandmorelateralbundlecontinuesdownwardandinsertsintotheupperlip,mergingitsfiberswiththem.levatorlabiisuperiorisandwiththem.orbicularisoris.Them.levatorlabiisuperiorisalaequenasicre-atesthemedialmostupperportionofthenaso-labialfold.Itsmedialnasalmusclebundledilatesthenostrilanddisplacesthesulcuslaterally,ele-vatingthenasolabialfold.Thelabialmusclebun-dlesevertandelevatetheupperlip(Table5.7).


Theaimof the treatmentof thenasolabial foldwithbotulinumtoxinistoreducemuscularhy-peractivity at this level.Theblockingof them.levator labii superiorisorm. levator labii supe-riorisalaequenasishouldflattenorsmooththeprominentnasolabialfold.


Deeporprominentnasolabial foldsareconsid-eredsignsofaging.Youngpeoplewhohavedeepnasolabialfoldsconsiderthemselvestobeolderthantheyreallyare.Itisveryimportanttoexam-inethepatient instaticanddynamicpositions.


5

Table 5.7. Characteristicsofthem.levatorlabiisuperiorisandthem.levatorlabiisuperiorisalaequenasi

Muscle Action Synergists AntagonistsM.levatorlabiisuperioris Elevatesandevertsthe

upperlip.Createsandmovesthemiddleportionofthenasolabialfold.

Lateralpartofm.levatorlabiisuperiorisalaequenasi,m.levatoranguliorisandmm.zygomati-cusmajorandminor


M.levatorlabiisuperiorisalaequenasi

Medialpart:dilatesthenostrilLateralpart:raisesandevertstheupperlipCreatesthemostupperportionofthenasolabialfold.

Medialpart:m.dilatornasiLateralpart:m.levatorlabiisuperioris,m.zygomaticusmajorandminorandm.levatorangulioris


In static analysis, there should be a prominentnasolabialfold.Thesurroundingstructuressuchascheeks,lipsandchinshouldalsobeevaluated.Iftheprominentnasolabialfoldissurroundedbyatrophictissuesandtheupperlateralpartofthenasalflare isflat, it is likely that thebest treat-ment should be the injection of fillers. In con-trast, if the surrounding tissues are prominentand there is a bulging area at the upper lateralpartofthenasalflare,theinjectionofbotulinumtoxinshouldbeconsidered.

In the dynamic analysis, patients should beasked to smile at maximum contraction. Themostupperpartofthenasolabialfoldshouldbeeven more pronounced. Palpation at this levelconfirmsthecontractionofthelevatorlabiisu-periorisalaequenasiwhereitdividesitsfiberstothenasalflareandupperlip.

TheidealpatientstostartwiththeinjectionofBNT-Aarethosewithashortdistancebetweenthevermillionborderandthenasalbase(shortupperlip).Whensmiling,thesepatientsshouldpresentexcessivegumexposure.Patientswithalongupperlip(vermillionbordertonasalbase)should be carefully treated, because one of theundesirableresultsoftheinjectionatthenasola-bialfoldlevelistheupperliplengthening.

5.7.5 Technique

Afterproperpatientassessment,thebulgingareaattheupperpartofthenasolabialfoldismarked.Usually,noanestheticisrequired.Inmoresen-sitivepatients, topicalanestheticcreamscanbeapplied20minutesbeforethetreatment.Thein-jection should be superficial at an angle of 30°and only the first third (+/- 3 mm) of the 30-gauge needle should be inserted into the skin(Figs.5.66and5.67ab).Thedosemayvaryfrom1–3UBotoxorfrom3–8UDysport.Inpatientswithalongupperlip,moresuperficialinjectionswiththelowestdosesshouldbeinitiallyapplied.

Itisadvisabletoconductatwo-steptreatmentinpatientsthataretreatedforthefirsttime.After7–15days,dependingontheresultobtained,anextradosemaybeapplied.

Treatmentofthem.levatorlabiisuperiorisalaequenasi• Oneinjectionpointperside• Botoxdose:1–3Uperside• Dysportdose:2–8Uperside


Fig. 5.66. Injectionpoints for thecorrectionof thena-solabialfold


Excessiveblockingofthenasolabialfoldmayre-sultinlengtheningoftheupperliporcompleteupper lip drooping at one or both sides. Thecentral and lateral incisors become excessivelyhidden.Partialtocompleteupperlipdrooping,due to hypotony or atony of the central eleva-torsmay lead toexcessiveupper lateralpullingofthezygomaticusmajorandasaconsequence,a‘jokersmile’mayresult.

Amorecommonfinding isasymmetryafterthe injection.Instaticanalysis, thetreatedareamay present no problem with a nice flatteningofthebulgingareaattheupperpartofthena-solabialfold(Fig.5.68a,b).However,duringani-mation, the asymmetry becomes evident (Fig.5.69a,b). Asymmetries are easily resolved withtheinjectionofanextradoseatthesidewherethemuscleisstillover-contracted.


■ Startwiththebestcandidatesforthetreat-ment of the nasolabial fold with botuli-num toxin: young, no skin atrophy, shortupper lip and gummy smile. Avoid olderpatientswithanexcessivelylongupperlip,flatcheeksandmusclehypotonicityduringanimation.

5.7.8 References

deMaioM(2004)Theminimalapproach:aninnovationin facial cosmetic procedures. Aesthetic Plast Surg28(5):295-300

Kane MA (2003) The effect of botulinum toxin injec-tionsonthenasolabialfold.PlastReconstrSurg112(5Suppl):66S-72S;discussion73S-74S

Kane MA (2005) The functional anatomy of the lowerfaceasitappliestorejuvenationviachemodenerva-tion.FacialPlastSurg21(1):55-64

Klein AW (2004) Contraindications and complicationswith the use of botulinum toxin. Clin Dermatol22(1):66-75

McCracken MS et al. (2006) Hyaluronic acid gel (Re-stylane)fillerforfacialrhytids:lessonslearnedfromAmericanSocietyofOphthalmicPlasticandRecon-structiveSurgerymembertreatmentof286patients.OphthalPlastReconstrSurg22(3):188-91


5

Fig. 5.68a,b. Before,andsevendaysafterthefirsttreatmentwithBNT-Ainthenasolabialfold.Theresult isquitesymmetricalatrest

Fig. 5.69a,b. SevendaysaftertheinitialinjectionwithBNT-Atosmooththeprominentnasolabialfold,thepatientpresentedanasymmetryduringanimation,withover-contractionofthem.levatorlabiisuperiorisalaequenasi.Notethattheteethshowmainlyontheleft-handside.ThepatientwasgivenanextrainjectionofBNT-Atobalancetheasymmetry(seeblackdot)

Fig. 5.67. aTheinjectionofBNT-Ashouldbedirectedatthebulgingareaattheupperpartofthenasolabialfold.Themostsuperficialfibersshouldbeblocked.Ifthedeeperfibersareblocked,upperlipptosismayresult.bPinchingthemedialslipofthelevatorlabiisuperiorisalaequenasifacilitatesthecorrectinjectionofBNT-Aanddecreasespain


Table 5.8. Overviewofthemusclesresponsibleforcheeklines

Muscle Action Synergists AntagonistsM.zygomaticusmajor Retractsandelevatesthe

modiolusandtheangleofthemouth

Alltheotherfoureleva-tors

M.orbicularisoris,m.depressoranguliorisandplatysma

M.risorius Retractstheangleofthemouth

M.zygomaticusmajorandm.buccinator

M.orbicularisoris

5.8 Cheek Lines

Mauricio de Maio

5.8.1 Introduction

The use of botulinum toxin in the upper andlowerthirdsofthefacehasbeencarriedoutwithaverysafeprofileandgoodreproducibleresults.Manystudieshavebeenpublishedintheseareas.In the mid third, however, to avoid unpleasantadverse effects, care should be taken wheneverinjectingclosetothemusclesthatinfluencetheperioralarea.

Cheeklinesarepresentinpatientswiththinskin and hyperkinetic musculature. Usually,they are curvilinear and are seen with advanc-ing age in patients with skin atrophy or earlierin those people who have sun-damaged skin.These wrinkles result from a thin or atrophicskinthatissubmittedtorepeatedcontractionofthezygomaticusmajorandrisorius.

Theportionof facial fatplaysavery impor-tantroleforcheeklinesaswell.Muscletractionontheskinformsmorewrinklingwhenthereisnoor little fatdeposit.Evenyoungpeoplewhoareverythinpresentcheekwrinklingthatmakesthem look older. One of the aging aspects thatcompromisethefaceisthereductionofthesub-cutaneouslayer.Dermalatrophyandlackoffatfacilitatetheformationofwrinklingevenwhen

thereisnoevidentmuscularhyperactivity.Los-ingweightafteracertainagemaybebeneficialforbodyshape,butitcandoubtlesslybeanunfa-vourablechoicefortheface.

5.8.2 Anatomy

Hyperkineticcheeklinesresultfromtheexcessivemuscleexcursionofmainlythelateralandupperlaterallipelevators.Hyperkineticlinesarealwaysperpendiculartomusclefibers;forthisreasonwemayeasilyidentifywhichmuscleisdominantforwrinkleformation.Althoughtheremaybeapre-dominanceofaspecificmuscle,itistheresultingvectorthatdirectsthewrinklingmovement.

All the mimetic muscles blend their fiberswiththesurroundingmuscles.Thecheekareaisdirectlyinfluencedbythem.zygomaticusmajorandm.risoriusandindirectlybythem.orbicu-larisoculi(superiorly)andthem.depressoran-guliorisandplatysma(inferiorly,Table5.8).As mentioned before, there are other musclesthat may indirectly influence the vector forcesthatactuponthecheekarea(Table5.9).


Thetargetinthetreatmentofcheeklinesisthereduction of wrinkling both at rest and duringanimationinselectedcases(Fig.5.70a,b).


5

Fig. 5.70a,b. BeforeandaftertreatmentwithBNT-Aforreducingdynamiccheeklines.Theresultshouldalwaysbenaturalandshouldneverimpairmusclefunction

Table 5.9. Overviewofthemusclesindirectlyresponsibleforinfluencingthecheekarea

Muscle Action Synergists AntagonistsM.orbicularisoculi Orbitalpart:voluntary

eyelidclosureandcrow’sfeetformation.Thedownwardextensionfi-bersreachthecheekarea.


M.levatorpalpebraesuperioris:forclosingtheeyelidsM.frontalis:protrusionoftheeyebrows

M.depressorangulioris Depressesthemodio-lusandtheangleofthemouthandmayproducewrinklinginthelowercheek

Platysmaparsmodiolusandm.depressorlabiiinferioris

M.levatoranguliorisandm.zygomaticusmajor

Platysma Anteriorfibers:assistmandibulardepressionIntermediatefibers:parslabialis–depressthelowerlipPosteriorfibers:parsmodiolaris–depressthebuccalangleAsitisapotentdepres-sor,itmayalsoinfluencecheekwrinkling

M.depressorangulioris M.levatorangulioris


Fig. 5.71a,b. Typical young patient with thin skin and cheek wrinkling before and after treatment with BNT-A.Anaturalreductionwithnocomplicationwasobtained


Patients should be evaluated in static and dy-namicpositions.Staticcheeklinesarenormallyfound in patients with photo-damage whiledynamic wrinkling is mainly presented in pa-tients with thin and fair skin. On palpation,the skin feels thin and fragile. Dermal atrophyshouldalsobeevaluatedaswellasreductionoffatcontent.Youngpatientswiththinskinusuallydislike cheek wrinkling because it makes themlook older. (Fig. 5.71a,b) Patients with dry skinare also more likely to present fine wrinkling.Patients with oily skin usually present coarserwrinkling.(Fig.5.72a,b)

Older patients are more likely to developcheek lines,either fromphoto-damageor fromdermal or subcutaneous atrophy. The presenceofstaticcheeklinesmakethemlookevenolder.Thebesttreatmentsformultiplefinestaticcheeklines are chemical peels or laser resurfacing.Cheekatrophymaybe improvedwithfillersorfatgrafts,whichwill interposeabiomechanicalblockingformusculartraction.

Duringanimation,somepatientsmaypresentmuscularhyperactivityof the lateralandupperlateral muscles; the risorius and zygomaticusmajor,respectively.Dynamiccheeklinescanbemildandbepresentonlyfrom1to2cmlaterallyfromtheoralcommissureorbeveryprominent

andalong thewholecheek (Fig. 5.73a,b).Staticlinesresultingfromphoto-damageorskinatro-phyusuallyworsenduringanimation.Althoughstatic cheek lines are better treated with eitherfillers or exfoliative methods, botulinum toxinmayalsobehelpfulbyrelaxingthemusclefibersthatinsertintothedeepdermis.

5.8.5 Technique

Themostimportantmessageconcerningthetech-niqueofinjectionintothecheeklinesisthatthemuscularexcursionshouldnotbeimpaired.Themuscularcontractionshouldbeslightlyreducedsothatsuperficialskinwrinklingissoftened.

Usuallythereisnoneedforanyuseoftopicalanesthetics, because the injection on the cheekisnotpainful.Aftercleansing,thepatientisex-aminedinstaticanddynamicpositions.Asthequantity of lines may vary from patient to pa-tient,themarkingshouldalsovaryfromasinglerow with two injection sites to two rows withfourinjectionsites(Figs.5.74and5.75).

The dynamic analysis should guide the po-sitioning of the injection sites. The first and(ifneeded)thesecondrowshouldbeontheareawiththehighestconcentrationofdynamiclines.Usually the dynamic lines start from 1 to 2 cmfromtheoralcommissure.


5

Fig. 5.72. aMalepatientwiththickandoilyskinwhichproducescoarsewrinkling.bNicereductionofcheekwrin-klingduringanimationaftertreatmentwithBNT-A

Fig. 5.73a,b. PatientwithhyperkineticcheeklinesbeforeandaftertreatmentwithBNT-A.Notethatskinwrinkling,andmuscleexcursionstrengthwasreduced.Thismaybeconsideredacomplexcase,andareviewofthesectiononasymmetries(Sect.6.1)isadvisable

To proceed with the marking, an imaginarylinefromtheoralcommissuretothepre-auric-ularareaat thetragal levelshouldbeusedasaguideline.Thefirstrowshouldbefrom1to2cmawayfromtheoralcommissure,andtwoinjec-tionsitesmarked0.5cmaboveand0.5cmbe-lowtheimaginaryline.Ifneeded,asecondrowshouldbefrom1to2cmawayfromthefirstrow,and twootherpointsmarkedexactlyason thefirstrow(Fig.5.76a,b).

After the marking is finished, the needleshouldbe insertedparallelabout2–3mmintotheskinatdermalorsub-dermallevel.Deeperinjections may result in muscular excursionimpairment (Fig. 5.77a,b). A low volume and

low dose of BNT-A is also important to avoiddiffusion down into the deeper muscle fibers.Initially, 1–3 U Botox or 3–9 U Dysport in to-tal should be injected into each cheek side. Ifneeded,asecondtreatmentafter7–15daysmayincrease the dose. Of utmost importance isthat a papule should be seen at the needle tiptoguaranteethattheinjectionisintradermalormaximumsub-dermal.(seeSection6.3.micro-injections)

Treatmentofcheeklines• Onesinglerowtouptotworowsoftwo

injectionpointsperside


Fig. 5.74. Minimal injectionsites for intradermal treat-ment of mild cheek lines. Note that these injectionsshouldnotreachthemusclelayers.Theblockingshouldbetargetedatthesubdermalmuscularfibersthatproduceskinwrinkling

Fig. 5.75. For stronger muscles, oily and thick skin, orfor multiple cheek lines, the two-row technique shouldbeused

Fig. 5.76a,b. Beforeandafterthreesessionsoftreatmentofthecheeksusingthetwo-rowtechnique


5

• Onlyverysuperficialintra-orsubdermalinjections(seealsoSect.6.3formicroin-jectiontechnique)

• Botoxdose:1–3Utotaldosepercheek• Dysport dose: 3–9 U total dose per

cheek


The complications with the treatment of cheeklines include asymmetry, upper lip ptosis andmuscle excursion impairment. The complica-tionsaremainlyresultsofdeepinjectionsortheuseofhighdosesandvolumeinthecheekarea.With the inadvertent blocking of the m. zygo-maticusmajor,upperlipptosismayresult.Withm.risoriusblocking,smileexcursionmaybeim-pairedandresultinimbalanceofthelipelevatorsanddepressors.


■ Thecheeklinesarebesttreatedwitheitherintradermal or subdermal injections (Fig.5.78).Multipletreatmentsareusuallynec-essarytoobtainaniceresult.

5.8.8 References

BikhaziNB,MaasCS(1997)Refinementintherehabili-tation of the paralyzed face using botulinum toxin.OtolaryngolHeadNeckSurg117(4):303-7

DeMaioM(2004)Theminimalapproach:aninnovationin facial cosmetic procedures. Aesthetic Plast Surg28(5):295-300

EllisDA,TanAK(1997)Cosmeticupper-facialrejuvena-tionwithbotulinum.JOtolaryngol26(2):92-6

MatarassoSL,MatarassoA(2001)TreatmentguidelinesforbotulinumtoxintypeAfortheperiocularregionandareportonpartialupperlipptosisfollowingin-jectionstothelateralcanthalrhytids.PlastReconstrSurg108(1):208-14;discussionpp215-7

Fig. 5.78. TheinjectionofBNT-Aatthislevelshouldbeintradermalinordernottocompromisethedeepfibersandimpairmuscleexcursion

Fig. 5.77a,b. Thispatientcomplainedaboutthelineonherrightcheek.Beforeandafterinadvertentdeepinjectionatthecheekline.Notethatwiththeblockingofboththem.zygomaticusmajorandm.risorius,thereisanawkwardchangeofthesmilelinewithpredominanceoftheupperelevatorsandthedepressors


SpiegelJH,DeRosaJ(2005)Theanatomicalrelationshipbetweentheorbicularisoculimuscleandthelevatorlabii superiorisandzygomaticusmusclecomplexes.Plast Reconstr Surg 116(7):1937-42; discussion pp1943-4

5.9 Gummy smile

Mauricio de Maio

5.9.1 Introduction

Excessive gum show during smile or laugh de-finesthegummysmile.Fromanaestheticpointofview, it isundesirable topresent this typeofsmile. Patients usually are not aware of it andonlyrealizeitafterbeingphotographed.Insomecases,itisconsideredquitedisturbing,especiallyfor women. Some patients are prone to exhibitthiskindofsmile,suchasthosewithashortdis-tancebetweenthenasalbaseandCupid’sbowaswellasthosewithafacialconvexprofilewithaprominentnoseandunderdevelopedchin.Theyare mainly mouth breathers with upper lip re-tractionandvisibleupperincisors.Deepnasola-bialfoldsarealsofoundinthesepatients.

5.9.1.1 Types of Smile

There are three different patterns of smile. Thesecondmostcommon(35%)istheonethatmayproducethegummysmile.Itisalsoknownasthecaninesmileduetothefactthatitisthecentralpartofthemouththatiselevated.Them.leva-torlabiisuperioristhatelevatestheupperlipisresponsible for this pattern of smile. If there isa natural over-contraction of this muscle, thegummysmileresults.Them.levatorlabiisuperi-orisalaequenasicanalsoplayanimportantroleinproducingthegummysmile.Boththemedialpartoftheupperlipandthenasalflareareele-vatedwhenthismuscleiscontracted.Inpatientswithgummysmileitisverycommontoseethe

inversion of the upper lip while smiling. Thesepatientsareusuallybadcandidatesforupperlipaugmentationwithfillers,whichusuallyresultsinexcessivefillingofthevermillion.Thebestap-proachinthesecasesisacombinationoffillersand botulinum toxin. The synergism of bothtreatmentsleadstoamorenaturallook.

Other patterns can also be found. The mostcommon type of smile (67%), the ‘Mona Lisa’smile,resultsfromthedominantactionofthem.zygomaticusmajor.Itisastrongoutwardpullofthecornersofthemouthwithagentleliftingofitscentralpart.Thefulldenturesmile(2%)istheleastcommonofall,whereboththeupperandlowerteethareexposed.

The golden proportion establishes that theupper lip should cover the upper third of thecentralincisors.

5.9.2 Anatomy

The orbicularis oris is a sphincter around themouth. It is a bilateral circumferential musclethatclosesandpuckersthemouthandformsapursestring.Itanchorstothenasalseptumandthemaxillaaboveandtothemedialpartofthemandiblebelow.Thedeeperlayersoftheorbicu-larisorisarethefibersofthebuccinatorandarereinforcedbytheincisivebundles.

Fromtheskin,shortobliquefiberstraversethethicknessofthelipinthedirectionofthemuco-sa.Themoresuperficiallayerisformedbythein-sertionofsevensmallmuscles:fiveelevatorsandtwodepressors.Atthecornerofthemouth,thereisanareadenominatedmodiolus,itiswherethemusclesthatelevateanddepressthelipinterdigi-tate.Theelevatorsconsistofthem.zygomaticusmajorandminor,m. levator labii inferioris,m.levatorlabiisuperiorisalaequenasiandm.leva-tor anguli oris. The zygomaticus major muscleoriginatesfromthezygoma(anteriortothezy-gomaticotemporal suture) and runs inferiorlyandmediallytotheangleofthemouthandcon-tributestothemodiolus.Thezygomaticusminormusclearises fromthemalarbone(behindthe


5

Table 5.10. Overviewofthemusclesresponsibleforthegummysmile

Muscle Action Synergists AntagonistsM.levatorlabiisuperiorisalaequenasi


Medialpart:m.dilatornasiLateralpart:m.levatorlabiisuperioris,mm.zygomaticusmajorandminorandm.levatorangulioris


M.levatorlabiisuperioris Elevatesandevertstheupperlip

Lateralpartofthem.levatorlabiisuperiorisalaequenasi,m.leva-toranguliorisandmm.zygomaticusmajorandminor


maxillarysuture)andpassesdownwardandin-ward and in continuity with the m. orbicularisoris at the outer margin of the m. levator labiisuperioris.Theactionofthem.zygomaticusma-jor is toelevate thecornerof themouthand ithaslittleornoeffectonthenasallabialfold.Itisboththem.levatorlabiisuperiorisandthem.le-vatorlabiisuperiorisalaequenasithatcreateandmovethemiddle-andthemedial-mostportionsonthenasallabialfold,respectively.

Them.zygomaticusmajorelevatesthecor-nerofthemouthandhaslittleornoeffectonthenasolabialfold.

Themainelevatorofthelipisthem.levatorla-biisuperiorisanditarisesfromthelowermarginof theorbit justabove the infraorbital foramenand its fibers insert into the midportion of thenasal labial fold.Them. levator labii superiorisalaeque nasi arises from the frontal process ofthemaxillaandinsertsonthealarcartilageandmedialupper lip.Itdilatesthenaresandevertsandelevatesthemedialupperlip.Itdeepensthemedialuppernasolabialfold(Table5.10).

Thegummysmilemayresult fromexces-siveactionofthem.levatorlabiisuperiorisalaequenasiand/orthem.levatorlabiisu-perioris.


The aim of treating gummy smile with botu-linum toxin is to avoid gingiva showing at restandtoreduceexcessivegumexposureduringasmile.


Thepatientshouldbeanalyzedinastaticanddy-namicperspective.Thestaticanalysisshouldfo-cusonthelipsandthenose.Ingeneral,patientswith a gummy smile have a short distance be-tweentheupperlipandthebaseofthenose.Theupperlipismainlythinandthenasallabialangleis90°orless.Theupperlipisoftenretractedandtheupperincisorsarevisibleatrest.It iscalledtheopenlipposture.


On animation or during the smile, the gin-givaishighlyvisible.Onthefrontalandprofileviews,thereisexcessivegumshowand,normal-ly,droopingofthetipofthenose.Theupperlipmayalso invertbecomingeven thinner.This isalsooneofthecaseswherelipaugmentationwithfillerspresentsaninefficientresult.Patientsandinjectorsgetdisappointedwiththelipaugmen-tationprocedure,mainlybecauseitresultsinex-cessivelipaugmentation,leadingtoanunnaturallook.Thedynamicormusclecomponentwhichprovokestheupperlipthinningisnottreated.

Astherearemanymusclesthatactupontheperioral area with synergistic and antagonisticbehavior,carefulpatientselectionismandatory.To minimize complications, one should selectpatientswithaveryshortupperlipatstaticposi-tionandmajorgummyshowatrestandduringanimation.

5.9.5 Technique

The patient should be asked to smile at maxi-mumcontraction.Itmustbeevaluatedwhetherthe patient presents only a gummy smile or ifthereisalsoadeepeningofthenasolabialfoldatthenasalflarelevel.Ifthepatientpresentsboththegummysmileand thedeepnasolabial fold,theinjectionshouldbeatthelabialcomponentofthelevatorlabiisuperiorisalaequenasi(Figs.5.79–5.81a-c).Theinjectionshouldbepositionedatthebulgingareaattheuppermostpartofthenasolabialfold.Atthislevel,themuscleissuper-ficialandonlythefirst third(+/-3mm)of the30-gaugeneedleshouldbeinsertedintotheskinandmuscle.Thedoseshouldbe2or3UBotoxor5–7UDysportateachside.

If the patient has a flat nasolabial fold andgummysmile,theinjectionshouldbedoneatalowerlevel,intothelevatorlabiisuperioris(Figs.5.82–5.84a,b).Also,alowerdoseshouldbegiven,from1to2UBotoxor3–4UDysport.Theinjec-tionatthislevelshouldbebelowtheorbicularisoris.

After15daysthepatientshouldbeevaluated,focusingonthetreatmenteffectandasymmetries.Inthecaseofapartialresult,anextradoseshouldbegiven,from50to100%oftheinitialdoseac-cording to the percentage of effect obtained. Ifasymmetryresults,onehastodeterminewhichsideisstillelevatingexcessivelyandanextradoseshouldbegiventobalancebothsides.

Treatmentofthegummysmileinpatientswithaprominentnasolabialfoldandshortupperlip• One injection point per side: upper in-

jection(m. levator labii superiorisalae-quenasi)

• Botox dose: 2-3 U (upper injection)(startingdose)

• Dysport dose: 5-7 U (upper injection)(startingdose)

Fig. 5.79. Injectionpointsforcorrectingagummysmilein patients with a prominent nasolabial fold and shortupperlip


5

Fig. 5.80. ThetreatmentofgummysmilewithBNT-Amaybeconductedattheupperpartofthenasolabialfoldbyblockingthelateralslipofthelevatorlabiisupe-riorisalaequenasi.Thebestcandidatesforthislocationarethosewithaprominentnasolabialfoldandshortupperlip

Fig. 5.81. aApatientpresentinggummysmilebeforetreatmentwithBNT-A.bAftertreatment,thereiscorrectionofthegummyshowwithperfecthidingofjusttheupperthirdofthecentralincisors.Withthemedialmuscles(m.leva-torlabiisuperioris)blocked,thereisaslighttendencyforupperlateralpullingwiththezygomaticusmuscle.Thereisamodificationofthesmilepatternc Splitphotographofa,b,clearlydepictingthepositivechangesinthispatientwithgummysmile


Fig. 5.82. Injectionpointsforcorrectinggummysmileinpatientswithflatnasolabialfoldsandalongerupperlip

Fig. 5.83. Thelowerinjectionissuitableforpatientswithaflatnasolabialfoldandlongerupperlip.Theinjectionshouldbebeneaththem.orbicularisoris,sotheyshouldbe placed more deeply. At this injection level, both thefibersofthem.levatorlabiisuperiorisalaequenasiandm.levatorlabiisuperiorismaybereached.Theupperlipshouldnotbelengthenedbythistechnique

Fig. 5.84a,b. ExcessivemedialandlateralshowmaybecorrectedwiththeinjectionofBNT-A.Notethatthereisupperlipelongationandanimprovementofvermillionfullnessafterthetreatment.Beforemuscleblocking,theupperliplooksthinduetouppermusculartractionandvermillioninversion


5

Treatmentofthegummysmileinpatientswithflatnasolabialfoldsandlongerupperlips.• Oneinjectionpointperside:lowerinjec-

tion (m. levator labii superiorisalaequenasiandm.levatorlabiisuprerioris)

• Botox dose: 1-2 U (lower injection)(startingdose)

• Dysport dose: 3-4 U (lower injection)(startingdose)


5.9.6.1 Asymmetries

Themostcommoncomplicationswiththetreat-mentofgummysmileareasymmetriesandup-perlipdrooping.Asnobodyis100%symmetric,it is important that any asymmetry should beshowntothepatientsbeforethetreatment.Pho-tographicdocumentationshouldalsobeunder-taken.

Symmetrical injections in asymmetrical pa-tientsmayresultinworseningoftheasymmetry.Usually, static analysis does not show any signof imbalance; it is seen only during animation.Mild asymmetries are tolerable and should becorrectedasrequiredby thepatients.However,moderatetosevereasymmetriesshouldbecor-rected as soon as evidenced. To avoid furthercomplications, 25 to 50% of the initial doseshouldbeadministeredandtheoutcomeevalu-atedafter7–15days.

5.9.6.2 Upper Lip Drooping

Excessivedroopingofthemedialpartoftheup-per lipmayhappenifexcessiveblockingisun-dertaken. As a consequence, there is excessivelateral pulling of the zygomaticus major, andthe‘joker’smilemayresult.Aslightblockingof

thezygomaticusmajormayreducetheexcessivelateralpulling.


■ Selectpatientswiththeopenlippostureatrestandwithashortupperlip.Evenifex-cessiveupperlipelongationresults,itwillbenefitthepatient.

5.9.8 References

CorlissR(2002)Smile--you’reonbotox!Time159(7):59TulleyPetal.(2000)Paralysisofthemarginalmandibu-

larbranchofthefacialnerve:treatmentoptions.BrJPlastSurg53(5):378-85

5.10 Upper and Lower Lip Wrinkling

Berthold Rzany

5.10.1 Introduction

Verticallinesontheupperlipareastrongsignofaging.Evenwhenusinginjectablefillerssomeoftheselinesmightstillremain.

5.10.2 Anatomy

Thelipscomprise theredpartof themouthaswell as the skinadjacent to it.Bothpartsmustbeconsideredasananatomicunit that reachesfrom the nose to the chin (Salasche and Bern-stein 1988). Perfect lip structure in the mucosaand skin consist of a ‘V’-shaped Cupid’s bow,apronouncedvermillionandmedialtubercleaswellasascendantlinesintheoralcommissures.The ratio between the upper and lower lips, at


goldenproportions,is1:1.618.Averyimportanttopographiclandmarkisthephiltrum.Themid-pointoftheuppercutaneouslipishighlightedbythetwoverticallyorientedridgesofthephiltrum.TheCupid’sbowis theconcavityat thebaseofthephiltrum.

Theskinoftheupperlipisverythinandlackssubcutaneousfat.Thelackofadditionalsupportof this area together with extensive muscularmovementofthemainmusclesmayleadtopro-nouncedwrinkles.Them.orbicularisorisisthemajormuscleof the lips. Ithascircumferentialfibersthatareresponsibleforthesphincterfunc-tionofthemouth.


Theaimofthetreatmentistopreventorreducelongitudinalwrinklesoftheupperandlowerlip.

5.10.4 Patient Selection and Evaluation

Treating the upper lip will inevitably lead tosome functional impairment. Therefore it ispreferabletotreatpatientswithpreviousBNT-Aexperience. The treatment of the upper lip is agoodpreventiveindicationforBNT-Ainyoung-er women trying to avoid future longitudinalwrinkles.

Before starting the treatment a careful casehistory is recommended as the m. orbicularisisinvolvedinmorethanjustformingwrinkles.

Forinstance,patientswhoplaytheGermanfluteshouldingeneralnotbetreated.

5.10.5 Technique

Coolingoftheupperlipregionbeforetheinjec-tionmightbehelpfulasmanypatientsconsiderthe treatment of this area to be quite painful.There are basically two techniques that can becombined. The injection points may focus onthe central part of the lip, which is called thephiltrum(Fig. 5.85)or follow theredof the lip(Fig.5.86).

5.10.5.1 Technique 1

When treating the philtrum area, BNT-A willnotonlydecreasethelongitudinalwrinklesbutwill also flatten the philtrum area and so willreducethelandmarksofaperfectlip(Figs.5.87and5.88).

5.10.5.2 Technique 2

Whentreatingtheareaadjacenttotheredpartof the lip without treating the philtrum (Figs.5.89and5.90)thewholeupperlipmightformapout.Inthiscaseahorizontallinemightappearintheareaoftheupperlipaftertreatment.

Verysmalldosesshouldbeused inorder toavoidadysfunctionalmouth.Furthermore,slightasymmetriesarequitecommonforthisarea.

Table 5.11. Overviewofthemusclesresponsibleforthegummysmile

Muscle Action Synergists AntagonistsM.orbicularisoris Deepfibers:directclosure

oflipsSuperficialanddecussat-ingfibers:lipprotrusion

M.incisivuslabiisuperi-orisandinferiorisandm.mentalis

Thefiveupperliplevators,them.depressorangulioriandm.labiiinferiorisandthem.buc-cinator


5

Fig. 5.87. Female with hyperkinetic upper lip wrinklesbeforetreatmentofthephiltrumarea

Fig. 5.88. Femalewithhyperkineticupperlipwrinkles2weeksaftertreatmentofthephiltrumareawithBNT-A

Fig. 5.85. Injection point targeting the philtrum (tech-nique1)

Fig. 5.86. Injection points following the lip red (tech-nique2)


UpperlipwrinklesTechnique1• Twoorfour(twoupperandtwolower)

injection points in the philtrum area(this will flatten the central part of thelip)(Fig.5.85)

Technique2• Two or four injection points along the

red part of the lip (this might increasethe total area of the red part of the lipand may therefore lead to a fuller lip)(Fig.5.86)

• Botox dose: 1–2.5 U per side startingdose

• Dysport dose: 2–6 U per side startingdose


5.10.6.1 Functional Impairment

A relative overdose will lead to functionalimpairment of the lip which might significant-ly influencethewaypatientsdrink,eatorevenspeak.Patientsmightbeunabletosipacocktail

through a straw and certain letters might bedifficulttopronounce.


■ The upper and lower lip is the perfectarea for the combination of botulinumtoxin A with injectable fillers. Reducingthe strength of the muscles will decreasethe mimic wrinkles. However, it will alsochangetheshapeofthelip.Injectionpointsinthephiltrumareawillweakenthephil-trum.Theshapeofthephiltrummaybere-constructedbypreferablynon-permanentinjectable fillers. Therefore, the combina-tion provides both: (1) reduction of themimicwrinklesbyBNT-Aand(2)recon-structionofthevolumeandthelandmarkofthelipbyinjectablefillers.

5.10.8 References

SalascheS,BernsteinG(1988)SenkarikM:Surgicalanat-omyoftheskin.AppletonandLange,EastNorwalk,CT

Fig. 5.89. Femalewithhyperkinetic lipwrinklesbeforetreatment

Fig. 5.90. Femalewithhyperkineticlipwrinkles2weeksaftertreatmentwithBNT-Aintheupperandthelowerlip


5

5.11 Marionette Lines

Berthold Rzany

5.11.1 Introduction

The marionette lines are important landmarksfor the overall impression of the face. Deepmarionette lines might give the total face anexpression of being dissatisfied, sullen or evenscornful. Marionette lines are a perfect targetfor treatment with BNT-A, often in addition toinjectablefillers.

5.11.2 Anatomy

Theperioralmusclesformseveralstrata.Intheareaofthelowerlipandthechin,threemusclesarestructuredovereachotherliketiles.Contrac-tionofthosemuscleswillleadtoacrankyorsadexpression.Themostsuperficialpart formsthem.depressorangulioris.Thistriangularmusclederivesfromthebaseofthemandibleandcon-tinueslaterallyandcranially.Itinsertsinthefi-bresof thecornerof themouthwhere it inter-weaveswith theelevatorsof themouth, them.levatoranguliorisandthem.zygomaticusma-jor.Them.depressorangulioris, togetherwiththefibers fromtheplatysma,drags thecornersofthemouthdown.Thismovementwillinduceavisiblecreasethatdescendsfromthecornerofthemouthandgivesthetotalfaceadissatisfied,sullenorevenascornfulexpression.


The aim of the treatment is to reduce themuscular strength of the m. depressor anguliorisand thefibersof theplatysmaand therebyinducea liftof thecornersof themouthwhilethepatientisatrest.


Kineticandhyperkineticpatientsarebest(Figs.5.91–5.96).PatientsinwhomthemarionettelinesaremostlyduetotheptosisoftheSMASarelesssuitable patients for treatment with BNT-A.Here, injectable fillers are the treatment firstchoice.

5.11.5 Technique

Them.depressoranguliorisaswellasadditionalplatysmal bands can usually be easily palpatedwhen the patient is asked to grimace. Severaltreatment options exist. Usually one point tar-gets them.depressoranguliorisand theotherpoint the platysmal bands inserting at the lat-eral parts of the m. orbicularis oris (Fig. 5.97).Toavoidadverseeventsdue to the involuntarytreatmentofpartsofthem.orbicularisorisitisrecommendedtokeepadistanceofatleast1cmfromthecornersofthemouthofthepatient.

Table 5.12. Characteristicsofthem.depressorangulioris

Muscle Action Synergists AntagonistsM.depressorangulioris Depressesthemodiolus

andangleofthemouth(e.g.drawsthecornerofthemouthdown)


M.levatorangulioris,m.zygomaticusmajor


Fig. 5.95. Patient inher fortiesgrimacing2weeksaftertreatmentwithBNT-A

Fig. 5.96. Splitphotographofpatientinherfortiesgri-macingbefore,and2weeksafter,treatmentwithBNT-A

Fig. 5.91. Patient in her fifties with increased elastosis,grimacingbeforetreatment

Fig. 5.92. Patient in her fifties with increased elastosis,grimacing2weeksaftertreatmentwithBNT-A

Fig. 5.93. Splitphotographofpatient inherfiftieswithincreasedelastosisatrestbeforeand2weeksaftertreat-mentwithBNT-A

Fig. 5.94. Patient in her forties grimacing before treat-ment


5

Marionettelines• One injection point per site targeting

the m. depressor anguli oris. The pointshouldbeatleast1cmawayfromthecor-nerofthemouth.Themusclecanbefeltwhile contracted. Usually the point canbefoundintheelongationofthenasola-bialfold(Fig.5.97)

• Another injection point should be putmorelaterallyintheareaofthemandibleinordertotargettheplatsymalbands

• Botox dose: max. 5 U per injectionpoint

• Dysport dose: max. 10 U per injectionpoint


Highdosesoraninjectionthatistooclosetothecorner of the mouth might lead to asymmetry

aswellasdifficultieswhileeatinganddrinking,suchasdrooling.


■ Like the upper and lower lip, the area ofthemarionettelinesisaperfectareaforthecombinationofBNT-Awithinjectablefill-ers.Reducing the strengthof themuscleswillliftthecornerofthemouthandflattentheMarionettelines.Injectablefillers,pref-erablybiodegradableones,mightbeusedtodecreasetheselinesevenmore.

5.12 Cobblestone chin

Berthold Rzany

5.12.1 Introduction

Thecobblestonechinordimpledchindevelopswhenthem.mentalis,whichinsertswithseveralfibers in the dermis of this area, is contracted.Contractioncanbeachievedbypullingthelowerlipdown. InjectionswithBNT-Awill lead toasmoothingofthisareaofthechin.

5.12.2 Anatomy

The m. mentalis belongs to the muscles of theperpendicular system of the perioral area andis the most medial and deepest muscle of thisarea. Itderives from the lower incisorsand in-sertstransversallyinthedermisofthechin.Themuscles from both sides crisscross each other.Whilecontracted,thechinmayshowacobble-stonepattern.Inaddition,thementolabialcreasemightbe increasedwhile shoving the lower lipforward.

Fig. 5.97. Injection points for the marionette lines.Both them.depressoranguliorisand theplatysmaaretargeted


Fig. 5.98a,b. Kineticpatientinherfortieswithcobblestonechinbefore,and2weeksafter,treatmentwithBNT-A

Table 5.13. Overviewofthemusclesresponsibleforthecobblestonechin

Muscle Action Synergists AntagonistsM.mentalis Raisesthementaltissue

(mightshowcobblestonepattern),mentolabialsulcusandbaseofthelowerlip

M.levatoranguliorisandzygomaticusmajor

M.depressorlabiiinfe-riorisandm.depressorangulioris


Theaimofthetreatmentistoreducethecobble-stonepatternonthechin.


A patient rarely just asks for treatment of thecobblestonepattern.Moreoftenpatientsaskforarejuvenationofthelowerfaceinwhichtheco-treatment of the m. mentalis will add to treat-mentsatisfaction(Fig.5.98a,b).

5.12.5 Technique

BNT-Acanbeeitherinjectedinonesinglepointorintwolateralpoints,oneontheleftandone

ontherightsite,approximately0.5–1cmabovethechin(Fig.5.99).No injectionpointsshouldcomecloserthan1cmofthelowerlip.Althoughthemuscleisquitedeeplylocated,superficialin-jectionsarefineandwillleadtoquitesatisfactoryresults.

Cobblestonechin• Oneortwoinjectionpoints,approx.0.5–

1cmabovethechin• Botoxdose:totaldose4–8U• Dysportdose:totaldose10–20U


When an appropriate distance from the lowerlipiskept,complicationsapartfromhematomaarenil.Placingtheinjectionpointstoocloseto

�0 Berthold Rzany, Mauricio de Maio

5

thelowerlipmightinvolvethem.depressorlabiiinferioris, which would lead to a dysfunctionalmouthwithptosisofthelowerlip.


■ Althoughthemuscleliesquitedeep,super-ficial injectionswill lead toquite satisfac-toryresults.

5.13 Platysmal bands

Berthold Rzany

5.13.1 Introduction

Inslimkineticandhyperkineticpatientsplatys-malbandsarisewhenthepatientsactivateother

mimicmuscles e.g.while speaking.Duringag-ing they may become very visible forming theso-calledturkeyneck.

5.13.2 Anatomy

The platysma is the largest mimic muscle. Itoriginates at the border of the lower jaw, cov-ering the chin up to the angulus mandibulae.Thelateralfibresofthismuscleextendovertheangulus mandibulae in the area of the lowercheekandalsoradiatetowardsthecornerofthemouth, where they interwine with the othermusclesofthemodiolus.Thecaudalpartoftheplatysmarunsasabroadthinsheetofmusclestowards the clavicle and inserts approximatelyaround the second rip at the fascia pectoralis.The platysma does not usually cover the me-dial area where the cartilage of the larynx canbefound.

The platysma covers the superficial fascia ofthe neck and is closely connected to the skin.It draws the lower jaw and the corners of themouthdown,expandstheskinoftheneckandextendstheskininvertical lines.Intheareaofthe upper thorax, the décolleté, contraction oftheplatysmamightcausediagonalwrinkles.

When treating the platysma, the close rela-tionship to the group of supra- and infrahyalmusclesandtotheouter larynxmuscleshastobe taken into account. Apart from the diago-nal m. sternocleidomastoideus, only the fasciaoftheneckwillseparatetheplatysmafromthemusclesofthelarynx.


The aim of treatment with BNT-A in the neckareaisareductionoftheverticalbandsthatap-pear when the patient contracts the platysma(Figs.5.100and5.101).Furthermore,lateralcheeklinesandmarionettelinescanbeimprovedwhenreducingthestrengthoftheplatysmalbands.

Fig. 5.99. Injectionpointsforcobblestonechin

Chapter 5 �1The Most Common Indications

Fig. 5.100. Contractedplatysmalbandsbeforeinjection Fig. 5.101. Contractedplatysmalbands2weeksafterin-jectionwithBNT-A

Fig. 5.102. Injectionofpla-tysmalbands:pleasenotethesmallpapulesthatariseaftertheverysuperficialinjection


Kineticandhyperkineticpatientswhocontracttheplatysmalbandsactivelywhenspeakingarebest. Please be aware that BNT-A is not treat-mentforhorizontalnecklines.Hereothermeth-odsmightbemoreappropriate,suchasthecom-bination of biodegradable injectable fillers andablativeprocedures.

5.13.5 Technique

Patients must be in a sitting position as this isthebestpositiontocontracttheplatysmabandsactively. Treatment follows the course of thecontracted platysmal bands. BNT-A is injectedevery1–2cm.Graspingthebandwiththenon-injectinghandmightbehelpfulwhile injectingvery superficially (intradermally) in the con-tractedmuscle(Fig.5.102).

�2 Berthold Rzany, Mauricio de Maio

5

Thepharynxregionshouldbeavoidedas inrare cases dysphagia and dysphonia have beenreportedafterBNT-A.

Treatmentoftheplatysmalbands• Sittingpositionofthepatient• Contractionof thebandsbyhavingthe

patientgrimace• Fourtoeightinjectionpointsperband,

approximately1cmfromeachother(thenumber of injection points depends onthelengthofthebands)(Fig.5.102)

• Injection technique: very superficially(intradermally) in the contracted mus-cularband

• Botoxdose:2–2.5Uperpoint• Dysportdose:5–10Uperpoint


Bruisingoccursnotinfrequentlyaspressureaf-tertheinjectioncanonlybeappliedcarefully.Inrare cases dysphagia and dysphonia have beenreportedafterBNT-A.


■ Thisisanareainwhichpretreatmentwithtopicalanaesthetics suchasEMLAcream(a eutetic mixture of 2.5% lidocaine and2.5% prilocaine) might make a BNT-Atreatment impossible as local anestheticswill not only decrease the injection painbutalsoinactivatetheplatysmalbands,i.e.youcannotseewheretoinject.

■ As platysmal bands rarely occur as singlebands, treatment might become quite ex-pensive as each band will require four tosixinjectionpoints.Patientsshouldbein-formedaboutthisbeforehandtoavoiddis-satisfaction.

Table 5.14. Overviewofthemusclesresponsiblefortheplatysmalbands

Muscle Action Synergists AntagonistsPlatysma Showsverticalbands

Anteriorfibers:assistmandibulardepressionIntermediatefibers:parslabialis–depressthelowerlipPosteriorfibers:parsmodiolaris–depressthebuccalangle


Chapter 6

6

The following three chapters will focus on ad-vanced indications and techniques. Some oftheseindicationsandtechniquesmayhavebeendiscussedbefore.However, the followingchap-terswillofferadifferentviewonthesetopics.

6.1 Facial Asymmetries

Mauricio de Maio

6.1.1 Introduction

Facialparalysistriggersaestheticandfunctionalchanges,withphysicalandpsychologicalreper-cussions. Static and dynamic imbalances canaffect,inastrikingmanner,aperson’sabilitytoexpressemotions.Thephysicalaspectscanbringdisastrousresultstoapatient’sself-imageaswellasemotionalstate.

Asmilecanexpresssuchfeelingsasthosere-latedtopleasure,friendship,acceptance,embar-rassment, happiness, delight and/or agreement.Wecommunicatethroughoursmiles.Notbeingable to smile would be to deprive ourselves ofoneofourmostbasictoolsforcommunicationinasocialenvironment.

Uponanalyzingthehalfofthefacenotaffect-edbyfacialparalysis,onecanperceivethegreatvariationsinstaticanddynamicpatternsofad-aptationthatthemimeticmuscletissuessufferintheabsenceofmovementintheotherhemiface.

Gaining knowledge regarding the facialnerve,themimeticmuscletissuesandthetypes

Contents

6.1 FacialAsymmetries . . . . . . . . . . 936.1.1 Introduction . . . . . . . . . . . . . 936.1.2 Anatomy . . . . . . . . . . . . . . 946.1.3 AimofTreatment . . . . . . . . . . . 976.1.4 PatientSelection . . . . . . . . . . . 976.1.5 Technique . . . . . . . . . . . . . . 976.1.6 Results . . . . . . . . . . . . . . . . 996.1.7 Complications . . . . . . . . . . . . 996.1.8 Conclusions . . . . . . . . . . . . . 996.1.9 TipsandTricks . . . . . . . . . . . 1016.1.10 References . . . . . . . . . . . . . 101

6.2 FacialLiftingwithBotulinumToxin . 1026.2.1 Introduction . . . . . . . . . . . . 1026.2.2 Anatomy:AntagonistsandSynergists . 1036.2.3 AimofTreatment . . . . . . . . . . 1056.2.4 PatientSelection . . . . . . . . . . 1056.2.5 Technique . . . . . . . . . . . . . 1096.2.6 Complications . . . . . . . . . . . 1146.2.7 TipsandTricks . . . . . . . . . . . 1146.2.8 References . . . . . . . . . . . . . 114

6.3 TreatmentwithMicroinjections . . . 1156.3.1 Introduction . . . . . . . . . . . . 1156.3.2 MicroinjectionsoftheCrow’sFeetArea 1156.3.3 MicroinjectionsoftheLongitudinal

LinesoftheCheeks . . . . . . . . . 1156.3.4 DosestobeUsed . . . . . . . . . . 1166.3.5 CombinationofMacro-andMicroin-

jections . . . . . . . . . . . . . . 1166.3.6 DisadvantagesoftheMicroinjection

Technique . . . . . . . . . . . . . 1166.3.7 TipsandTricks . . . . . . . . . . . 116

Advanced Indications and TechniquesMauriciodeMaio,BertholdRzany

�4 Mauricio de Maio, Berthold Rzany

6

ofsmilesthatcanbeproducedisofvitalimpor-tanceforprofessionalswhodealwiththisquitecomplex group of patients. The expertise thatderivesfromtreatingpatientswithasymmetriesenables any practitioner to inject any cosmeticpatientwithexcellenceandconfidence.

Forehead asymmetries are easily treatedand are very similar to the cosmetic tech-niquesthatmaybefoundinthespecificsection.Other asymmetries require more anatomicalknowledge.

6.1.2 Anatomy

The facial nerve (cranial nerve pair VII) is re-sponsibleforstimulatingthemimicmuscles,cre-atingabalancebetweenthesynergicandantago-nisticforcesthatactuponthefacialstructures.Itisalsoresponsibleforthemusculartonuswhenapersonisinarelaxedstate,andthevoluntaryand involuntary contraction of the muscles ofeachsideoftheface.

Thefacialnerveemergesinthestylomastoidforamenandgivesorigin to itsmany ramifica-tions.Thefirstramification is theposteriorau-ricularbranch,thesecondisthetemporal-facialbranchthatdividesintothetemporal,zygomaticandbuccalramificationsandthethirdisthecer-vical-facialbranchthatdividesitselfupintothemarginalmandibularandcervicalramifications(Table6.1).

Themostcomplexgroupofmimeticmusclesistheonethatcontrolsthemovementsofthelipsand cheeks. It is very important to know eachmuscleactionandtherespectivesynergistsandantagonistswhen injectingpatientswithasym-metriesintheperibucalarea.Theinteractionofthesemusclescreatesanalmostunlimitednum-berof facialmovementsandindividualexpres-sions (Fig. 6.1). There are different patterns forthesmiles,dependingonthemuscleswhicharedominant.Thesmilemaybeclassifiedintothreetypes:‘MonaLisa’,inwhichthem.zygomaticus

majorisdominant;‘canine’,whenthem.levatorlabiisuperiorisisdominantand‘fulldenture’,thesmile in which all of the elevators and depres-sorsareinvolved.Theshapeofaperson’ssmileistheresultofthedynamicactionoftheforcesthatactuponthemouth,anditvariesfrompatienttopatient.Asmilemayalsobeclassifiedasacom-monsmile,inwhichtheteetharenotshown,ora ‘square’ smile, in which the upper and lowerteeth are displayed. In the former type, the m.zygomaticus major is predominant, whereas inthelatter,theboththeelevatorsanddepressorsoftheliparepredominant.

There are five elevators for the upper lip;three of them act more on the upper lip (m.levator labii superiorisalaequenasi,m. levatorlabiisuperiorisandm.zygomaticusminor)andtheothertwoactontheangleofthemouth(m.levator anguli oris and m. zygomaticus major)(Table6.2).

Themusclesthatactonthelowerlipmaybedivided into one levator and three depressors.Them.mentalisisthelevatorandthedepressorsincludethem.depressorlabii inferioris,m.de-pressoranguliorisandplatysma(Table6.3).

There are other muscles that influence thebalanceof themouthwhich include them.or-bicularis oris, m. risorius and m. buccinator(Table6.4).

Table 6.1. Specificfacialregionsandthecorrespondingramificationsofthefacialnerve

Area Facial NerveFrontal Temporalbranch

Orbital Zygomaticbranch

Upperlip Buccalbranch

Lowerlip Marginalmandibularbranch

Neck Cervicalbranch

Chapter 6 �5Advanced Indications and Techniques

Fig. 6.1. Musclesresponsibleforseverefacialasymmetries

Table 6.2. Descriptionoftheelevatorsofthelip,theiractionsandthesynergistsandantagonists.NB:themodiolusistheareawherethemusclesthatelevateanddepressthelipinterdigitate,laterallytotheoralcommissure

Muscle Action Synergists AntagonistsM.levatorlabiisuperi-orisalaequenasi


Medialpart:M.dilatornasiLateralpart:m.levatorlabiisuperioris,m.zygomaticusmajorandmi-norandm.levatorangulioris


M.levatorlabiisupe-rioris

Elevatesandevertstheupperlip

Lateralpartofm.levatorlabiisuperiorisalaequenasi,m.levatoranguliorisandm.zygomaticusmajorandminor


M.zygomaticusminor Elevatestheupperlipandassistsinelevatingtheintermediatepartofthenasolabialfold

Lateralpartofthem.levatorlabiisuperiorisalaequenasi,m.levatorlabiisuperioris,M.levatorangulioris,m.zygo-maticusmajor

M.orbicularisorisandm.depressorangulioris

M.levatorangulioris(caninus)

Raisestheangleofthemouthandfixesthemodiolus

Alltheotherfourelevators M.depressorangulioris,platysmaandm.orbicularisoris

M.zygomaticusmajor Retractsandelevatesthemodiolusandtheangleofthemouth

Alltheotherfourelevators M.orbicularisoris,m.depressoranguliorisandplatysma


6

Table 6.3. Descriptionofthemusclesthatactonthelowerlip

Muscles Action Synergists AntagonistsM.mentalis Raisesthementaltissue,

mentolabialsulcusandbaseofthelowerlip

M.levatoranguliorisandzygomaticusmajor

M.depressorlabiiinfe-riorisandm.depressorangulioris

M.depressorlabiiinferioris

Depressesthelowerliplater-allyandassistsineversion

Platysmaparslabialisandm.depressorangulioris

M.orbicularisoris

M.depressorangulioris

Depressesthemodiolusandangleofthemouth


M.levatoranguliorisandm.zygomaticusmajor

Platysma Anteriorfibers:assistman-dibulardepressionIntermediatefibers:parsla-bialis–depressthelowerlipPosteriorfibers:parsmo-diolaris–depressthebuccalangle


Table 6.4. Othermusclesinfluencingthebalanceofthemouth

Muscle Action Synergists AntagonistsM.orbicularisoris Deepfibers:directclosure

oflipsSuperficialanddecussat-ingfibers:lipprotrusion

M.incisivuslabiisuperi-orisandinferioris*m.mentalis

Thefiveupperliplevators,them.depressorangulioriandm.labiiinferiorisandthem.buc-cinator

M.buccinator Compressesthecheekagainsttheteethanddrawstheangleofthemouthlaterally

M.risorius M.orbicularisoris

M.risorius Retractstheangleofthemouth

M.zygomaticusmajorandm.buccinator

M.orbicularisoris

*Thesemusclesassisttheactionoftheorbicularisorisinprotrudingthelip.

Chapter 6 �7Advanced Indications and Techniques


The goals of treatment of facial asymmetriesinclude static balance with correction of facialdeviations and rotations, and reduction or to-talcontrolof facialdeviationduringanimationwhileavoidinganyfunctionalimpairment.


Damagesufferedtothefacialnervemayproducedeformitiesofvaryingdegrees,resultinginaes-theticandfunctionaldisordersinsuchpatients.The side of the face affected by facial paralysispresentscommoncharacteristicsamongallpa-tients.Onthesurfaceoftheskin,therearefewerwrinkles,duetothelackofmusculartractiononthedermis;thenasolabialfoldbecomeslessevi-dent,andthereisadroopingofboththecornerof the mouth and the brow. Depending on theextentoffacialparalysis,andthetimeofonset,theaestheticaspectsmaybeaffectedtoagreaterorlesserextent(Fig.6.2).

The ‘normal’ side or the side opposite tothat affected by facial paralysis replies with a

hyperkinetic reactionof themuscle tissuesdueto the lackof tonusontheparalyzedside.Thisimbalance of vector forces creates facial devia-tions. The dynamic deviations to the ‘normal’sidearelessevidentinparalysesthathavelastedashorttime.Withlongerperiods,therearealsostatic deviations in the labial, nasal and orbitalregions, leading to shortening of the face (Fig.6.3).Itisonthishyperkineticorhypertonicsideofthefacethatbotulinumtoxinplaysthemostimportantrole.

6.1.5 Technique

Forbestresultsandfacialbalance,all themainmusclesonthehyperkineticsideshouldbetreat-ed(Fig.6.4).Thebotulinumtoxinshouldbead-ministeredthroughintramuscularinjectionwitha30-gaugeneedle.Theneedleshouldbeinsertedatanangleof45°fromtheskin’ssurface,withthepatientlyingonhisback.Itisadvisabletoavoidcontactwiththeperiosteum.

The botulinum toxin should be distributedin theperioralmuscles toenable thecoordina-tionofthemusclesthatactuponboththeupper

Fig. 6.3. Themuscleover-contractiononthehypertonicside(right)mayprovokefacialdeviationsandshorteningduetoalongperiodoflackofmuscleantagonismontheleftside.Thelongertheparalysis,themoremuscleover-contractionontheoppositeside

Fig. 6.2. Notethedifferencesinskinwrinkling.Onthehyperkineticside(left)themusclehyperactivityproducesevidentandnumerouswrinkles.The lackofmuscleac-tivityresultsinayounger-lookingskinontheparalyzedside(right)


6

Table 6.5. Suggestedinjectionpointanddoses

Site Botox DoseRange

Dysport DoseRange

M.zygomaticusmajoratitspointoforigin 3–4U 9–12U

M.zygomaticusminoratitspointoforigin 1–2U 2–6U

M.levatorlabiisuperiorisalaequenasi 1–2U 2–6U

M.levatorlabiisuperiorisattheorbitalmargin

1–2U 2–6U

Themodiolus,atadistanceof0.5cmfromthecornerofthemouth

3–4U 9–12U

M.risorius2cmfromthecornerofthemouth

3–4U 9–12U

M.depressorlabiiinferiorisat0.5cmfromthecornerofthemouth

3–4U 9–12U

M.depressorlabiiinferiorisatadistanceof1cmfromthewhitelinetransition

3–4U 9–12U

Fig. 6.4. Injectionpointsforfacialasymmetries

Chapter 6 ��Advanced Indications and Techniques

Fig. 6.6. Schematic portrayal of the vector forces thatactuponthesideaffectedbyfacialparalysis,thehyperki-neticside.Itshouldbenotedthattherearebothstraightand curved vectors, which represent the traction androtation that the perioral region suffers due to musclehyperkinesis

Fig. 6.5. Schematicrepresentationofthevectorsofforcesthatactupontheperioralarea

andlowerlips(Table6.5,Figs.6.5and6.6).Itisimportant to point out that the dose may varyaccordingtothetypeofmuscularcontraction.Itisadvisabletostartwithhalfofthedoseinitiallyandafter15daystoaddanextradosedependingonthemuscularresponse.

6.1.6 Results

With the decrease of hyperkinesis after theinjection of botulinum toxin, improvement inboth static and dynamic positions is found. Instatic analysis, it is very common to achievean excellent symmetry and correction ofdeviationsandrotationoftheface(Fig.6.7a,b).Inanimation,thereductioninthehyperkinesiscontrols the excessive muscular excursion andcorrectstheexcessivelabialdistortionandteethshow(Fig.6.8a,b).


The adverse events with the use of botulinumtoxin are generally linked to high doses of the

drug. After the injection of botulinum toxinthere is anabrupt change in themimeticmus-cle behavior and, consequently, in the patients’learningandadaptationpatterns.Despiteanen-hancedaestheticappearance,thesechangesmaylead to functional impairment. Usually, theremaybemilddifficultyinspeaking,chewingandswallowing. Oral incontinence for liquids andsolids may happen with a high dose and mis-placedinjections.

6.1.8 Conclusions

Inthetreatmentofpatientssufferingfromfacialparalysis, botulinum toxin may be consideredas a single treatment, as a pre-operative test oras a complementary measure in post-surgicaltreatments. It may reduce facial deviations androtations,minimizingaestheticsequelae.Yet,itsmost important feature seems to be the poten-tialforuseinchildrenandadolescents,whowillgreatlybenefit fromthe treatmentduringmus-cularandskeletaldevelopment.


6

Fig. 6.7a,b. Before treatment,under staticanalysis, thepatientpresentedacommonhyperkinetic reactiononherright-handside:adeepnasolabialfold,withnasalflareandlipdeviations.Aftertreatment,astaticbalanceofthefaceisobtained.Thepatientreportedsocialre-integrationandanimprovementinself-esteem

Fig. 6.8a,b. Onanimation,thepatientpresentedexcessiveteethshowwithdistortionofthesmile.Afterinjection,thereisabalanceofallmusclesthatactuponthehyperkineticside,resultinginanimprovedsmile

Chapter 6 101Advanced Indications and Techniques


■ Focusthetreatmentoffacialasymmetrieson the muscle vectors and distribute thebotulinum toxin in an even manner. Re-member that blocking one single musclemayunbalance theothers.Whenstartingtotreatfacialasymmetriesdonottrytoaimforasingletreatmentsession;becautiousanduseatleastatwo-steptreatmentwithlowerdosestominimizecomplications.

6.1.10 References

Adant, JP (1998) Endoscopically assisted suspension infacialpalsy.PlastReconstrSurg102:178

ArdenRL,SunhatPK(1998)Verticalsutureplacationofthe orbicularis oris muscle: a simple procedure forthe correction of unilateral marginal mandibularnerveparalysis.FacialPlastSurg14:173

ArmstrongMWetal.(1996)Treatmentoffacialsynkine-sisandfacialasymmetrywithBotulinumtoxintypeAfollowingfacialnervepalsy.ClinOtolaryngol21:15

AvivJE,UrkenML(1992)Managementoftheparalyzedface with microneurovascular free muscle transfer.ArchOtolaryngolHeadNeckSurg118:909

BadarnySetal. (1998)Botulinumtoxin injectioneffec-tiveforpost-peripheralfacialnervepalsysynkinesis.Harefuah135:106

Bento RF et al. (1994) Treatment comparison betweendexamethasoneandplaceboforidiopathicpalsy.EurArchOtolaryngolDec:S535

BernardesDFFetal.(2004)Functionalprofileinpatientswith facial paralysis treated in a myofunctional ap-proach.ProFono16:151

BikhaziNB,MaasCS(1997)Refinementintherehabili-tationof theparalyzed faceusingBotulinumtoxin.OtolaryngolHeadNeckSurg117:303

BleicherJNetal.(1996)Asurveyoffacialparalysis:etiol-ogyandincidence.EarNoseThroatJ75:355–358

Boerner M, Seiff S (1994) Etiology and management offacialpalsy.CurrOpinOphthalmol5:61

BoroojerdiBetal. (1998)Botulinumtoxintreatmentofsynkinesia and hyperlacrimation after facial palsy.JNeurolNeurosurgPsychiatr65:111

Brans, JW et al. (1996) Cornea protection in ptosis in-duced by Botulinum injection. Ned Tijdschr Ge-neeskd.140:1031

BurresSA,FischU(1986)Thecomparisonoffacialgrad-ing systems. Arch. Otolaryngol. Head Neck Surg112:755

BurresSA(1985)Facialbiomechanics:Thestandardsofnormal.Laryngoscope95:708

Burres SA (1986) Objective grading of facial paralysis.AnnOtolRhinolLaryngol95:238

BurresSA(1994)Thequalificationofsynkinesisandfa-cialparalysis.EurArchOtolaryngolDec:S177

CarruthersA,CarruthersJ(2001)BotulinumtoxintypeA:historyandcurrentcosmeticuseintheupperface.SemCutMedSurg20:71

ClarkRP,BerrisCE(1989)Botulinumtoxin:atreatmentforfacialasymmetrycausedbyfacialnerveparalysis.PlastReconstrSurg84:353

Dawidjan B (2001) Idiopathic facial paralysis: a reviewandcasestudy.JDentHyg75:316

DobieRA,FischU(1986)Primaryandrevisionsurgery(selectiveneurectomy)forfacialhyperkinesia.ArchOtorhinolaringolHeadNeckSurg112:154

DoddSLetal.(1998)Acomparisonofthespreadofthreeformulations of botulinum neurotoxin A as deter-mined by effects on muscle function. Eur J Neurol5(2):181–6

Dressler D, Schonle PW (1991) Hyperkinesias after hy-poglossofacial nerve anastomosis – treatment withBotulinumtoxin.EurNeurol31:44

FariaJCM(2002)Acriticalstudyofthetreatmentoffa-cialpalsythroughagracilistransfer.Doctoralthesis,MedicalCollege,UniversityoftheStateofSaoPaolo.

Farkas LG (1997) Anthropometry of the head and face.Secondedition.NewYork:RavenPresspp545–57

FineNAetal.(1995)Useoftheinnervatedplatysmaflapinfacialreanimation.AnnPlastSurg34:326

Guereissi JO (1991) Selective myectomy for postpareticfacialsynkinesis.PlastReconstrSurg87:459

HariiKetal.(1998)One-stagetransferofthelatissiumusdorsi muscle for reanimation of a paralyzed face: anewalternative.PlastReconstrSurg102:941


6

KermerCet.al.(2001)Muscle-nerve-muscleneurotiza-tionoftheorbicularisorismuscle.JCraniomaxillo-facSurg29:302

KozakJetal.(1997)Contemporarystateofsurgicaltreat-mentoffacialnerveparesis.Preliminaryexperiencewithnewprocedures.ActaChirPlast39:125

KukwaAetal.(1994)Reanimationofthefaceafterfacialnerve palsy resulting from resection of a cerebello-pontineangletumor.BrJNeurosurg8:327

KumarPA(1995)Cross-facereanimationoftheparalysedfacewitha single stagemicroneurovasculargracilistransferwithoutnervegraft:apreliminaryreport.BrJPlastSurg48:83

LabbeD(2002)Lengtheningtemporalismyoplasty.RevStomatolChirMaxillofac103:79

Laskawi R (1997) Combination of hypoglossal-facialnerve anastomosis and Botulinum toxin injectionsto optimize mimic rehabilitation after removal ofacousticneurinomas.PlastReconstrSurg99:1006

MayMetal.(1989)Bell’spalsy:managementofsequelaeusingEMGrehabilitation,Botulinumtoxin,andsur-gery.AmJOtol10:220

MoserG,OberascherG(1997)Reanimationofthepara-lyzedfacewithnewgoldweightimplantsandgoretexsoft-tissuepatches.EurArchOtorhinolaryngol1:S76

MuhlbauerWetal.(1995)Mimeticmodulationforprob-lemcreasesoftheface.Aesthet.Plast.Surg.19:183

Neuenschwander MC et al. (2000) Botulinum toxin inotolaryngology:areviewofitsactionsandopportu-nityforuse.EarNoseThroatJ79:788

RiemannRetal.(1999)SuccessfultreatmentofcrocodiletearsbyinjectionofBotulinumtoxinintothelacri-malgland:acasereport.Ophthalmology106:2322

RubinLR(1977)Anatomyoffacialexpression.InRubinLR(Ed.)Reanimationoftheparalysedface.NewAp-proaches.St.Louis:Mosbypp2–20

SadiqSA,DownesRN(1998)Aclinicalalgorithmforthemanagementoffacialnervepalsyfromanoculoplas-ticperspective.Eye12:219

SamiiM,MatthiesC(1994)Indication,techniqueandre-sultsof facialnervereconstruction.ActaNeurochir130:125

ShumrickKA,PensakML(2000)Earlyperioperativeuseof polytef suspension for the management of facialparalysisafterextirpativeskullbasesurgery.ArchFa-cialPlastSurg2:243

SulicaL(2001)Botulinumtoxin:basicscienceandclini-calusesinotolaryngology.Laryngoscope111:218

TerzisJK,KalantarianB(2000)Microsurgicalstrategiesin 74 patients for restoration of dynamic depressormusclemechanism:aneglectedtargetinfacialreani-mation.PlastReconstrSurg105:1917

TulleyPet.al.(2000)Paralysisofthemarginalmandibu-larbranchofthefacialnerve:Treatmentoptions.BrJPlastSurg53:378

UedaKet.al.(1999)Evaluationofmusclegraftusingfa-cialnerveontheaffectedsideasamotorsource inthetreatmentoffacialparalysis.ScandJPlastRecon-strSurgHandSurg33:47

WongGBet.al.(1999)Endoscopicallyassistedfacialsus-pensionforthetreatmentoffacialpalsy.PlastRecon-strSurg103:970

6.2 Facial Lifting with Botulinum Toxin

Maurício de Maio

6.2.1 Introduction

Theagingprocesscausesavarietyofchangesinskin,musclesandbones.Volumetric lossof fattissue in the face produces a saggy appearancewhich is worsened by the gravitational forcesthattendtopullthefacialtissuesdown.Musclesresponddifferentlydependingontheirpositionintheface:theelevatorsaremoreimportantthanthedepressorsinyouthandthedepressorsover-contractduringtheagingprocess.Theelevatorsget weaker and weaker with time and, as a re-sult,thevectorsofforceswhichwereantagonisttogravitationalforcesandwereabletomaintainthefacialstructuresinanupwardposition,sim-plyinvert(Fig.6.9).Thedepressorscorroboratewithgravitationalforcesandtendtodropthefa-cialstructures.

Understanding muscular behavior with itssynergistic and antagonistic effects has enabledthe development of new techniques such as‘BNT-Alifting’.Whenblockingthecorrectmus-


cular group, we can again invert the vectors toanupwardposition,anda facelifteffectcanbeobtained.

6.2.2 Anatomy: Antagonists and Synergists

To understand how the mimetic muscles acton the face, it is important to understand thedefinitionoftheprimemovers,antagonistsandsynergists.

Prime movers are the principal muscles ac-tively generating the movement. Antagonistsaredefinedasthemusclesthatactinoppositionto the prime movers and by their contractionarecapableofpreventingorreversingthemove-ment.Iftheprimemoverscontract,theantago-nistsrelaxtoassisttheirmovement.Itmustbehighlightedthatthisrelaxationisas importantastheprimemovers’contraction.Forexample,

intheforehead,thebrowelevationisonlypos-sible because the frontalis contracts AND thebrow depressors relax! When promoting eye-browelevation,weblockthemm.corrugatores,them.procerusandthelateralfibersofthemm.orbicularesoculi.Partialeyebrowelevationoc-curs if only partial blocking of the depressorsisundertaken.Majoreyebrowelevationoccurswiththemaximumdepressorblockingpossibleand the frontalis with its all strength is main-tained.Theinabilitytorelaxtheopponentswillpreventtheexecutionoftheprimemovertotalaction.

Theantagonistsarealsoimportantforassist-ing and modulating the prime movers’ action.Thestrongertheactionofprimemoversandthegreatertheresistanceencountered,themorere-laxedtheantagonistsare.Iftheprimemoversareinvolvedinaprecisemovement,theantagonistsare relaxed but immediately ready to steady ormoderatethemovement.Primemoversandan-tagonistsmayactatthesametime.Thisisfoundin isometric contraction, for example, the con-tractionofthemm.corrugatoresandm.fronta-liswhenexpressingconcernandsurprise.

Synergists are defined as fixation muscles,whicharethosemusclesthatprovideafirmbaseformovementsexecutedbyothermuscles.Theyare also important for providing precision andavoidingexhaustionoftheprimemovers.Intheglabella, the procerus acts as a synergist to themm.corrugatoresforthemovementoftheme-dialportionoftheeyebrows.

There are various systems for dividing theface. The classic system divides the face intothree thirds: upper, mid and lower thirds. Theupperthirdisfromthehairlinetothebrow;themidthirdisfromthebrowtothebaseofthenoseandthelowerthirdisfromthebaseofthenoseto the chin. The platysma influences the lowerandmidthirds.

The upper third has only one levator whichis the frontalis, whose medial fibers are stron-gerthanthelateralfibers.Incontrast,therearethree or four depressors that tend to lower theeyebrow. The medial fibers of the m. frontalis

Fig. 6.9. Withtheagingprocessthereisaninversionofvectorswhich,togetherwithgravitationalforces,pullthefacialsofttissuedown


6

have the mm. corrugatores, m. procerus andmm. depressores supercilii as the main oppo-nents.Althoughthemm.orbicularesoculimayalso counteract the frontalis medial fibers, it isthe mm. depressores supercilii that influencesthis level. The mm. orbiculares oculi lateral fi-bers(theonesthatproducethecrow’sfeet)tendto depress the lateral aspect of the eyebrow.(Table6.6andFigs.6.10and6.11a–c)Pleasenotethatthemm.depressoressuperciliiisconsideredbysomeasonlya thickeningof theorbicularisoculiandnotasaseparatemuscle.

Themidthird,asdescribedabove,istheareafromthebrowdowntothebaseofthenose.Di-dacticallyspeaking,forBNT-Alifting,elevatorswillbedescribedaccordingtotheirabilitytoactinoppositiontogravitationalforces.Fromme-dialtolateral,wemayfindthem.levatorlabiisu-periorisalaequenasi,m.levatorlabiisuperioris,m. zygomaticus minor, m. zygomaticus majorandm.levatorlabiisuperiorisinadeeperplane.Itisalsoimportanttopointoutthatthecontrac-tionof the lowerfibersof theorbicularisoculi

parsorbitaliselevatesthecheekarea.Theeleva-torsatthislevelobeythesameruleasfoundinthefrontalis:whenthemedialfrontalisfibersareblocked, the lateralfibers tend toelevatemoreforacompensatorybalance.Thesamehappenswiththeelevatorsattheupperliplevel: ifoverblockingat them. levator labiisuperiorisalae-quenasiandm.levatorlabiisuperiorisoccurs,overcontractionofthezygomaticusmajorandthe‘jokersmile’mayresult.

The depressors are those muscles thatsupplement the effect of gravitational forces.They aggravate the descent of facial structures.There are three depressors: the m. depressorlabii inferiorisandthem.depressorangulioris(frommedialtolateral)(Figs.6.12a,b).Themostimportant one is the platysma (Figs. 6.13a,b).Although the vast majority of the fibers of theplatysmaarelocatedintheneck,itsfibersblendwith the m. depressor labii inferioris and m.depressorangulioris:someauthorsevenregardthe m. risorius as simply a thickening of theplatysmaatthelevelofthelips(Table6.7).

Table 6.6. Antagonistandsynergistsintheupperthird

Function Muscle Action Synergists AntagonistsElevator M.frontalis Elevatestheeye-

browM.occipitalis M.procerus,m.

corrugatorsuper-cilii,m.orbicularisoculiandm.depres-sorsupercilii

Depressor M.corrugatorsupercilii

Drawseyebrowsmediallyanddown

M.orbicularisoculi,m.procerusandm.depressorsupercilii

M.frontalis

Depressor M.procerus Depressesthemedialaspectoftheeyebrow

M.corrugator,m.or-bicularisoculiandm.depressorsupercilli

M.frontalis

Depressor M.orbicularisoculi Orbitalpart:lowersandprotrudestheeyebrows

M.corrugator,m.procerusandm.depressorsupercilii

M.frontalis

Depressor M.depressorsu-percilii

Pullsdownmedialeyebrow

M.corrugator,m.procerus,m.orbicu-larisoculi

M.frontalis



ThetargetofthetreatmentforBNT-Aliftingisthe complete blocking of the depressors of theupper, mid and lower face and neck as well asthe subtleblockingof themedial elevatorsandnoblockofthelateralelevators.Withthedepres-sorsblocked, theelevatorswill strengthenwithtime(Fig.6.14).


Patients must be evaluated at rest and duringanimation.Staticevaluationshouldbedirectedto important landmarks of the face: eyebrows,cheeks, oral commissure, mandible and neck.Thestatusofthesestructuresshouldbeanalyzed(Table6.8).

Asmentionedabove, thebestcandidates forBNT-Aliftingarethosewhodonotpresentsig-nificant saggy skin in the mid and lower faceand neck. They are from 30 to 50 years of ageand present no important asymmetries duringanimation.Theyarepreciselythosepatientswhoaretooyoungforasurgicalfacelift,evenaminorone,butwouldbenefitfromamildnon-surgicalfacelift.TheidealpatientforBNT-Aliftingusu-allypresentsthetypicalsigns(Table6.9):

Fig. 6.11. a,b Weakening the medial portion of the m.frontalisandthedepressorsusingBNT-Awillmakethelateral part of the eyebrow lift and erase the horizontallineintheforehead.c Splitphotographofthepatientina,b, showingtheeffectofBNT-Aafter injections in thecentralforeheadregion

Fig. 6.10. Contractionofthedepressorsoftheeyebrowprovokesdroopingoftheforehead.Itwillgraduallypro-duceanagedappearance.Inyoungerpatientstheelevator(m.frontalis)isstrongerthanthedepressors


6Fig. 6.12. aContractionof thedepressorangulioris,depressor labii inferiorisandmentaliscausedroopingof themidthird,resultinginflatcheekbones.bAftertreatmentofthemidthirdbyblockingthedepressoranguliorisandmentalisthereisimprovementofthemalarprojectionandoralcommissure

Fig. 6.13. aHypertoniclateralplatysmalbandsdistortingthemandibleshape.Theyarepullingdownthelowerface,worseningthejowls.TheblackspotsarethesitesofBNT-Ainjection.bAftertreatmentwithBNT-A.Notetheweaken-ingofthelateralplatysmalbandswhichdonotdistortthemandibleshape.Usingthismethod,aliftingofthelateralaspectofthefaceisachieved


Table 6.7. Antagonistsandsynergistsinthemiddleandlowerthird

Function Muscle Action Synergists AntagonistsElevator M.levatorlabii

superiorisalaequenasi


Medialpart:m.dilatornasiLateralpart:m.levatorlabiisupe-rioris,m.zygomaticusma-jorandminorandm.levatorangulioris

M.depressoranguliorisandm.orbicu-larisoris

Elevator M.levatorlabiisuperioris

Elevatesandevertstheupperlip

Lateralpartofthem.levatorlabiisuperioris,alaequenasi,m.levatoranguliorisandm.zygomaticusmajorandminor

M.depressoranguliorisandm.orbicu-larisoris

Elevator M.zygomaticusminor

Elevatestheupperlipandassistsinelevatingtheintermediatepartofthenasolabialfold

Lateralpartofthem.levatorlabiisuperiorisalaequenasi,m.levatorlabiisuperioris,m.leva-torangulioris,m.zygomaticusmajor

M.orbicularisorisandm.depressorangulioris

Elevator M.levatorangulioris(caninus)

Raisestheangleofthemouthandfixesthemodiolus

Alltheotherfourelevators

M.depressorangulioris,platysmaandm.orbicularisoris

Elevator Zygomaticusmajor Retractsandelevatesthemodiolusandtheangleofthemouth

Alltheotherfourelevators

M.orbicularisoris,m.depressoranguliorisandplatysma

Depressor M.depressorlabiiinferioris

Depressesthelowerliplaterallyandassistsineversion

Platysmaparslabia-lisandm.depressorangulioris

M.orbicularisoris

Depressor M.depressorangulioris

Depressesthemodio-lusandangleofthemouth

Platysmaparsmo-diolusanddepres-sorlabiiinferioris

M.levatoranguliorisandm.zygo-maticusmajor

Depressor Platysma Anteriorfibers:assistmandibulardepres-sionIntermediatefibers:parslabialis–depressthelowerlipPosteriorfibers:parsmodiolaris–depressthebuccalangle

M.depressorangulioris

M.levatorangulioris


6

Table 6.8. DesiredoutcomesandindicationsforBNT-Aliftingand/orsurgery

Structure Eyebrow Cheekbones Oral Commis-sure

Mandible Neck

Desirable Elevatedandcurvedshapedwithitslateralaspectslightlyhigher

Projectedwithfullness

Upwardlineatthecornerofthemouthwithaslightlypro-jectedmodiolus

Welldefinedwithnojowlsandnosaggyskin

Nobandsorsaggyskin

BNT-ALifting Downwardsmainlyatitslateralaspect

Flatwithnoprojectionandnolaxity

Horizontalormilddescentlinewithnosaggyskin

Mildpresenceofjowls

Medialandlateralplatysmabandswithnosaggyskinorfatdeposit

Surgery Downwardswithexcessiveskinexcessatuppereyelid

Flatwithlaxityandsaggyskin

Verydeepmari-onettelineswithsaggyskin

Saggyskinandevidentjowlsdeformingthemandibleshape

Evidentsaggyskinwithsignifi-cantlaxityandfatcontent

Fig. 6.14. TheaimoftheBNT-Aliftingistoweakenthedepressorsandstrengthentheelevatorstopromoteamorerefreshedlook

Chapter 6 10�Advanced Indications and Techniques

6.2.5 Technique

6.2.5.1 Upper Third Treatment

The frontalis plays the most important role ineyebrow lifting. Its medial fibers are strongerthanthelateralfibersandthatisoneoftherea-sons why the lateral part of the eyebrow dropswithtime.Theoppositemusclestothefrontalisarethedepressorsoftheeyebrows.Themm.cor-rugatoresandthem.proceruslowerthemedialpartoftheeyebrowwhilethelateralfibersofthemm. orbiculares oculi pars orbitalis lower thelateraleyebrowwhenitcontracts.

Theeyebrowliftingresultsfromtheblockingofthesuperiormedialfibersofthefrontalisandtheblockingoftheeyebrowdepressors:mm.cor-rugatoressupercilli,m.procerus,andthelateralfibersofthemm.orbicularesoculi.Theblocking

of the m. procerus plays an important role fortheliftingofthemedialportionoftheeyebrows.Onlythemedialfibersofthem.frontalisshouldbeblockedtoenabletheliftingofthelateralpor-tion of the eyebrow. The mm. corrugatores, m.procerusandtheupperfibersofthemm.orbicu-laresoculiparsorbitalisshouldbefullyblocked.The m. frontalis fibers should only be partiallyblockedsothattheelevatingfibersarestillabletopromoteeyebrowlifting.

6.2.5.2 Mid and Lower Thirds Treatment

Crow’sfeetshouldbetreatedwithregulardoses,observingthatitisadvisabletoblocktheinferiormedial extension of the orbicularis oculi fibersonlyverysuperficially.

Table 6.9. SignsindicatingagoodpatientforaBNT-Afacelift

Structure SignsForehead Horizontallinesespeciallyduringanimationandnoneormildlinesatrest

Glabella Verticallinebetweeneyebrowsmainlyatfrownandstronghorizontallineatthenasalradixatfrown.Linescanbeevidentatrest,butnotdeep

Eyebrow Themedialaspectatnormalpositionorslightlylowandthelateralaspectevidentlylow

UpperEyelid Noormildskinexcesswithnoeyebags

LowerEyelid Evidentcrow’sfeetwithnoeyebags

Nose Presenceofbunnylinesandtipdroopwhensmiling

NasolabialFold Prominentduetomusclehyperactivityespeciallyatitsupperposition.Noevidentsaggyskinorfatdeposit

Cheekbones Flatorwithmildprojectionwithnosaggyskin

UpperAndLowerLip Perioralwrinklingwhenpursing

OralCommissure Downwardswithmildmarionettelinesatrest

Chin Mildwrinkling

Mandible Mildjowlspresencebutevidentdowntractionwiththeplatysmalateralbandcontraction

Platysma Evidentmedialandevenstrongerlateralplatysmabandswithnoorminorsaggyskinandnofatdepositintheneckarea


6

Itmustbeverifiedwhetherthereisapromi-nentnasolabial foldandwhether this isdue tothehyperactivityof themm. levatores labii su-perioris alaeque nasi and/or the mm. levatoreslabii superioris. Otherwise, injecting BNT-Ainto thesemuscleswillpromotenoeffectat allandmayleadtocomplications.Theblockingofthesemusclessoftensthenasolabialgroove.Thecorrect indication together with precise dosingmayalsoproduceaninterestingliftofthelateralmalarzone:blockingthemedialelevatorsoftheupperlipwillsynergisticallymakethelateralel-evatorscontract,liftingthelateralpartofthemidthirdoftheface,andprojectthecheekbones.

Patients with a short distance between theupper lipand thebaseof thenoseare thebestcandidates for nasal tip lifting. If the tip of thenosedropsduringasmile,theblockingofthem.depressorseptinasiwillproduceadelicateeleva-tionofthenoseandayoungerappearance.

Perioralwrinklingintheupperandlowerlipsshouldalsobetreatedtosmooththeskininthisarea. If wrinkling appears only during pursing,major improvement is obtained with BNT-A.Deepwrinklingshouldbetreatedwiththecom-binationofothermethodssuchaspeelsandfill-ers.Injectingintotheupperlipmedially,closetothephiltrumandintotheskinandmucosatran-sitionlineisadvisableandthedoseshouldbeaslowaspossible.

6.2.5.3 Lower Third and Neck

Thelowerthirdisthepartofthefacethatoftenshowsthemostundesirableagingsigns,suchasdeep oral commissure, loss of definition of themandible arch, and platysma bands. Blockingthemm.depressoresangulioriswillliftthecor-nerofthemouthbecausetheoppositemuscles,theelevatorsoftheoralcommissure,willenablethisareatolift.Thesadlookaroundthemouthwillbeimproved.

Injectingintotheplatysmamayproduceabet-terneckcontour.Theover-contractionofthelat-eralplatysmabandsusuallypullsdownthelateral

partofthefaceandaltersthemandibleshape.Toobtainanimprovementatthemandiblearch,onemustblockthelateralplatysmabandsbeginningwiththeveryupperfibersthatinterdigitatewiththefacialmuscularfibers.Majorliftingofthefaceisachievedwhenthelowerthirdofthemasseterfibers are blocked. As a result, the upper fiberswillcontract,pullingupthezygomaticzoneandthinningthelowerpartoftheface.

ThedosetobeusedforBNT-Aliftingwillde-pendontheneedsofeachpatient.Asmentionedbefore,thegoalistopromotefullblockingofthedepressorsandmildornoblockingoftheeleva-tors.Belowyoumayfindsuggestedinitialdoses,whichhoweverdoesnotmeanthatallthelistedmusclesshouldbeinjectedinthefirsttreatment.Properphysicalexaminationatrestandduringanimation will identify the injection sites andmusclestobetreated(Fig.6.15,Table6.10).

Fig. 6.15. TheinjectionsitesforBNT-Alifting.Theinitialdoses should be low during the first treatment session.Thesecond treatment shouldbeviewedasanopportu-nitytoimprovetheperformanceoftheliftingeffect


Table 6.10. DosesforthetreatmentofdifferentmusclesforaBNT-facelift

Function Muscle Botox Dysport CommentsElevator M.frontalis 6–10U 15–30U Theblockingshouldbe

onlyonthemostsuperfi-cialfiberstoremovethewrinklingandNOTitsliftingeffect

Depressor M.corrugatorsupercilii

20–30U 30–60U Fullblockingisdesirable

Depressor M.procerus 3–6U 7.5–15U Fullblockingisdesirable

Depressor M.orbicularisoculi 12–30U 30–60U Thelowerfibersshouldbeinjectedataverysuperfi-ciallevel

Depressor M.depressorseptinasi

2–4U 8–12U Intothenasalbase,prefer-ablyinpatientswithshortupperlip

Elevator M.levatorlabiisuperiorisalaequenasi

2–6U 4–8U Verysuperficially,prefer-ablyintoitsmedialpart

Elevator M.levatorlabiisuperioris

- - Notusuallyinjectedforthispurpose

Elevator M.zygomaticusminor


Elevator M.levatorangulioris(caninus)


Elevator M.zygomaticusmajor

2–6U 6–18U Onlyifcheeklinesarepresentandverysuperfi-cially(intradermal)

Depressor M.depressorlabiiinferioris

- - SHOULDNOTBEBLOCKED

Depressor M.depressorangulioris

5–10U 10–20U Veryimportantforcor-recting‘sadmouth’

Depressor Platysmamedialbands

10–30U 30–60U Superficialifnofatcon-tentanddeeperwithfatdepositsintheneck

Depressor Platysmalateralbands

20–40U 30–100U Sameasaboveandthemostimportantdepressorsthatdroptheface

Alldosagesaregivenforthetotalarea,e.g.bothsidesifapplicable.ThedosagesareforsomeindicationssometimeslowerasdescribedinSection5toavoidovertreatment.


6

The evaluation of results should be completelydifferentfromasurgicalapproach.Anatural,re-freshed look should be the target in the upper,midand lowerthirdandintheneckarea.This

treatmentisquitesuitablewhenpatientsdonothaveaformalsurgicalindicationandarewillingtohaveaquick,effectiveandminimallyinvasivenon-surgicalprocedure(Figs.6.16.a,b–6.20a,b).

Fig. 6.16a,b. Theidealpatientshouldpresentatiredap-pearancewithonlymildlysaggyskin.Afterthetreatment,thepatientpresentsanaturalandrefreshedlook

Fig. 6.17a–c. Before and after the treatment. Eyebrowlifting is evident as can been seen clearly in the splitphotograph


Fig. 6.18a,b. Afterthetreatment,thereisanimprovementinthejawlineandtheskinseemstobetighter.Thereisalsoimprovementintheneckarea

Fig. 6.19a,b. Thecheekboneareaismoreprojectedandhasafullerappearanceafterthetreatment

Fig. 6.20a,b. Afterthetreatmentthereisanoverallimprovementinskinquality.Theeyebrowislifted,thecrow’sfeetreduced.Thezygomaareaislessflatandmoreprojected,thejawlineisbettershapedandtheplatysmabandshavedisappeared.Notethattheresultshouldbesubtleandtheprocedureshouldnotleadtoafrozenappearance


6


BNT-Aliftingisconsideredthemostchalleng-ingtreatmenttoachievewithbotulinumtoxin,not only because of the use of a considerablenumber of units, but also because of the areasinvolved. If proper static and dynamic evalua-tionisnotconducted,unnecessarymusclesmaybe injected and more probability of complica-tionsresults.

By far the most common complication isasymmetry, due to the inexperience of practi-tionersinevidencingthembeforethetreatmentand injecting the site symmetrically. Anothercommoncomplicationis imbalanceof thesyn-ergistsandantagonistsduetoinexperiencewithvectorforcesthatactuponthemimeticmuscles.

Other complications such as eyelid ptosis,forehead pseudo ptosis, eye dryness, upper lipptosis, ‘joker smile’ and swallowing problemsare not direct complications of BNT-A lifting,butcouldbefoundinanycaseofimpropertech-niquetoanysinglearea.Therefore,BNT-Alift-ingshouldonlybetriedbyexperiencedinjectorsofupper,midandlowerfaceandneck.


■ ToensurethatnocomplicationmayresultfrominjectingBNT-Afora facelifteffect,a two-step treatment is advisable untiltheexactdose isdefinedforeachpatient.Generally,thedepressorsshouldbetreatedwith a full dose and the elevators shouldgetstrongerwith theabsenceof theiran-tagonists’forces.

■ Theyoungerthepatientis,thestrongertheelevators are, and as a consequence, theeasier it is to obtain a better result. Witholder patients, the rule is not to let thedroopingmuscles(thedepressors)recover.Inthiswaytheelevatorswillbecomestron-gerandthedepressorswillnotpulldownthefacialstructures.

6.2.8 References

AhnMSetal.(2000)TemporalbrowliftusingbotulinumtoxinA.PlastReconstrSurg.105(3):1129–35;discus-sionpp1136–9

Atamoros FP (2003) Botulinum toxin in the lower onethirdoftheface.ClinDermatol21(6):505–12

BalikianRV,ZimblerMS(2005)PrimaryandadjunctiveusesofbotulinumtoxintypeAintheperiorbitalre-gion.FacialPlastSurgClinNorthAm13(4):583–90

Bulstrode NW, Grobbelaar AO (2002) Long-term pro-spectivefollow-upofbotulinumtoxintreatmentforfacialrhytides.AestheticPlastSurg26(5):356–9

CarruthersJ,CarruthersA(2004)Botox:beyondwrin-kles.ClinDermatol22(1):89–93

Carucci JA, Zweibel SM (2001) Botulinum A exotoxinforrejuvenationoftheupperthirdoftheface.FacialPlastSurg17(1):11–20

ChenAH,FrankelAS(2003)Alteringbrowcontourwithbotulinum toxin. Facial Plast Surg Clin North Am11(4):457–64

CookBEJretal.(2001)Depressorsuperciliimuscle:anat-omy, histology, and cosmetic implications. OphthalPlastReconstrSurg17(6):404–11

de Almeida AR, Cernea SS (2001) Regarding browliftwithbotulinumtoxin.DermatolSurg27(9):848

deMaioM(2004)Theminimalapproach:aninnovationin facial cosmetic procedures. Aesthetic Plast Surg28(5):295–300

Frankel AS, Kamer FM (1998) Chemical browlift. ArchOtolaryngolHeadNeckSurg124(3):321–3

Harrison AR (2003) Chemodenervation for facial dysto-niasandwrinkles.CurrOpinOphthalmol14(5):241–5

HuilgolSCetal.(1999)Raisingeyebrowswithbotulinumtoxin.DermatolSurg25(5):373–5;discussion376

KleinAW(2004)Botoxfortheeyesandeyebrows.Der-matolClin22(2):145–9

KochRJetal.(1997)Contemporarymanagementoftheag-ingbrowandforehead.Laryngoscope107(6):710–5

KokoskaMSetal.(2002)Modificationsofeyebrowpo-sitionwithbotulinumexotoxinA.ArchFacialPlastSurg4(4):244–7

LeLouarnC(1998)Botulinumtoxinandfacialwrinkles:a new injection procedure. Ann Chir Plast Esthet43(5):526–33


Le Louarn C (2001) Botulinum toxin A and faciallines: the variable concentration. Aesthetic PlastSurg.25(2):73–84

Le Louarn C (2004) Functional facial analysis afterbotulin on toxin injection. Ann Chir Plast Esthet49(5):527–36

LeeCJetal.(2006)Theresultsofperiorbitalrejuvenationwith botulinum toxin A using two different proto-cols.AestheticPlastSurg30(1):65–70

Matarasso A, Hutchinson O (2003) Evaluating rejuve-nation of the forehead and brow: an algorithm forselecting the appropriate technique. Plast ReconstrSurg112(5):1467–9

Mendez-EastmanSK(2003)BOTOX:areview.PlastSurgNursSummer;23(2):64–9

MichelowBJ,GuyuronB(1997)Rejuvenationoftheup-per face. A logical gamut of surgical options. ClinPlastSurg24(2):199–212

MuhlbauerW,HolmC(1998)Eyebrowasymmetry:waysofcorrection.AestheticPlastSurg22(5):366–71

OzsoyZetal. (2005)Anewtechniqueapplyingbotuli-numtoxininnarrowandwideforeheads.AestheticPlastSurg29(5):368–72

RedaelliA,ForteR(2003)Howtoavoidbrowptosisafterforeheadtreatmentwithbotulinumtoxin.JCosmetLaserTher5(3–4):220–2

SadickNS (2004)ThecosmeticuseofbotulinumtoxintypeBintheupperface.ClinDermatol22(1):29–33

Sclafani AP, Kwak E (2005) Alternative managementof the aging jawline and neck. Facial Plast Surg21(1):47–54

6.3 Treatment with Microinjections

Berthold Rzany

6.3.1 Introduction

The microinjection technique has always beenthe favorite technique for some doctors. In re-centyears,moreandmoredoctorsare startingtousethistechniqueinadditiontothestandardtechnique.Theadvantageof themicroinjectiontechnique lies in the decreased risk of adverse

reactionsasvery smalldosesare injectedquitesuperficially. This allows the treatment of areaslikethecheeks,whichforalongtimehadbeenthoughttobeuntreatable.

6.3.2 Microinjections of the Crow’s Feet Area

Oneof thefirstareaswhere themicroinjectiontechniquewasusedwasthecrow’sfeetarea(Fig.6.21; see also Sect. 5.4). Here the most caudalpointmightbeveryclosetothefibresofthezy-gomaticus major, which is not a perfect candi-date for thetreatmentwithbotulinumtoxinA,astreatmentmightresultinalongerupperlip.

6.3.3 Microinjections of the Longitudinal Lines of the Cheeks

Anotherexampleofagoodindicationformicro-injectionsarethelongitudinallinesofthecheeks

Fig. 6.21. Injectionpointsforthecrow’sfeetareausingthemicroinjectiontechnique


6

thatappearwhenthepatientssmiles(Figs.6.22,6.23a,b). Here the muscles responsible, the m.risorius and the m. zygomaticus major are tar-geted.Toodeeplyplacedmicroinjectionsmightas well act like macroinjections and can causeunwantedasymmetry(Fig.6.24a,b).

6.3.4 Doses to be Used

Thedosestobeusedarethedosesforthemac-roinjection.Theonlydifferenceisthatinsteadofthree injection points, the dose will be distrib-utedin10–15injectionpoints.

6.3.5 Combination of Macro- and Microinjections

Thecombinationofmacro–andmicroinjectionscanbeveryrewarding.Agoodexampleisagainthe crow’s feet area. Here two macroinjections1cmlateraltotheorbitalrimwilleffectivelyin-hibittheactivityofthem.orbicularisoculi.Themorecaudalareamightbetreatedwithfourtofivesuperficialmicroinjections,therebyreducingtheriskofanunwantedptosisoftheupperlip.

6.3.6 Disadvantages of the Microinjection Technique

The main disadvantage of the microinjectiontechnique lies in the multiple injections whichincreasetheriskofpunctualhematomaandthe

intensityofrealorperceived injectionpain.Asthe existing needles are not made for repeatedinjections, thebevelof theneedlemaybecomedullquiteeasily.


■ If you use the microinjection technique,pleaserememberthetotaldoseyouareus-ing in this area. Otherwise you might bepronetoover–orunderdose.

Fig. 6.22. Injectionpoints for the cheekareausing themicroinjectiontechnique


Fig. 6.23a,b. CheekareabeforeandaftermicroinjectionswithBNT-A.Lightdecreaseof longitudinalwrinklesonbothsides

Fig. 6.24a,b. Asymmetryinthecheekareaaftertreatmentwithmicroinjections.Ontheleftside,oneoftheinjec-tionpointswasplacedtooclosetothemodiolus,leadingtoanimpairmentofthem.risoriusandthem.zygomaticusmajor

Chapter 7

Contents

7.1 Introduction . . . . . . . . . . . . 119

7.2 AdverseSideEffectsDuetoInjection . 1197.2.1 InjectionPain . . . . . . . . . . . 1207.2.2 Hematoma/InjectionSiteBruising . . 1207.2.3 Headache . . . . . . . . . . . . . 1207.2.4 LocalizedSkinDryness . . . . . . . 122

7.3 AdverseEventsDuetoLocalDiffusion/Distribution . . . . . . . . . . . . 122

7.3.1 EyelidPtosis . . . . . . . . . . . . 1227.3.2 Ectropion . . . . . . . . . . . . . 1227.3.3 Strabismus . . . . . . . . . . . . . 1227.3.4 Pseudoherniation . . . . . . . . . . 1237.3.5 ComplicationsAfterPerioralandNeck

Treatment . . . . . . . . . . . . . 123

7.4 AdverseEventsDuetoHyperactivityofAdjacentMuscles/BrowMalposition . . . . . . . . . . 123

7.5 AdverseEventsduetoGeneralizedDistribution . . . . . . . . . . . . 124

7.6 AllergiestoBotulinumToxin-A . . . 124

7.7 FormationofAntibodies . . . . . . 1247.9 References . . . . . . . . . . . . . 124

7

Botulinum toxin is a very safe drug. Inaesthetic medicine serious adverse eventswereonly reportedafterusingbotulinumtoxinofdubiousorigin.

7.1 Introduction

AlthoughBNTisoneofthemostpotenttoxinsknowntoday,itisaverysafedrugwhenusedap-propriately. Irreversible medical complicationsare not known and the transient and localizedcomplications that are reported from time totimewhenusedinaestheticmedicinemirrorthereversibleandlocalizedactionofthecompound.Especially noteworthy is the high therapeuticindex(requireddoseforaesthetictreatmentap-prox. 30 U, estimated LD50 is 3000 U Botox).Seriousadverseeventswereonlyreportedafterusingbotulinumtoxinofdubiousorigin(Aller-gan2004).

In the following chapter the most commonadverse events of BNT when used in aestheticmedicine will be reviewed. Other indications,which might require higher doses of BNT, willnotbereviewed.

7.2 Adverse Side Effects Due to Injection

Commonly reported side effects after BTN-in-jectionarepain,edemaandhematomaatthein-jectionsite.Allthesereactionstypicallysubsidewithinafewdayswithouttreatment.

Safety of Botulinum Toxin in Aesthetic MedicineBertholdRzany,HendrikZielke


7

7.2.1 Injection Pain

Injection site pain can be reduced by applyingtopicalanesthetics(suchasEMLAcream,aeu-tetic mixture of 2.5% lidocaine and 2.5% prilo-caine)orpre-cooledgauzeorcoolpacksat theinjectionsite(Table7.1).PleasenotethatEMLAcreamappliedintheneckareawillmakethepla-tysmalbandslessvisible.Inasmallstudyof15patientsthereconstitutionof the BNT with bacteriostatic benzyl-alcoholpreserved saline was found to reduce injectionpain(Alametal.2002).

7.2.2 Hematoma/Injection Site Bruising

BruisingisreportedintheBTNaswellasintheplacebogroupinupto40%ofpatients.Possiblerisk factors include co-medication with antico-

agulantdrugs,NSAID,vitaminE,ginseng,ginkoandhighdosesofgarlic.BruisingafterBNTin-jectionseemstobemorecommonincertainar-eas, suchas thecrow’s feetarea.Pre-coolingofthe injection site as well as manual pressure inthecaseofapuncturedvessel isrecommended(Table7.2).

7.2.3 Headache

Theincidenceofheadachesintheevaluatedclini-caltrialsvariesintheBTNaswellasintheplace-bogroupfrom0%–30%(Table7.3).Interestingly,headacheisnotonlyreportedafter injectionofBTN in the glabella but also after treatment ofthecrow’sfeetarea.Headachesareusuallymildand lastonly fora fewhours (Carruthersetal.2002;Vartanianetal.2005).Since,accordingtoAlametal.,upto1%ofthepatientsdevelopase-vereheadachelasting2–4weeks,patientsshould

Table 7.1. Incidenceofinjectionpainasdocumentedinclinicaltrials

AuthorYearno. of patients

Drug and dose Area of injection % of injection pain in verum or different verum groups

% of injection pain in placebo group

Carruthersetal.2003n=59

Botox16,32,48U Frontal Notreported Notapplicable

Rzanyetal.2006n=221,146verum

Dysport,3×10U5×10U,placebo

Glabellaandfrontal 0.7 0


Botox10,20,30,40U

Glabellaandfrontal Notreported Notapplicable


Botox20U,placebo Glabella Notreported Notreported


Botox20,40,60,80U

Glabella Notreported Notapplicable

Ascheretal.2004n=119

Dysport25,50,75U,placebo

Glabella Notreported Notreported

Loweetal.2005n=162

Botox18,12,6,3U,placebo

Crow’sfeet Notreported Notreported

Baumannetal.2003n=20

Myobloc500U,placebo

Crow’sfeet Notreported Notreported

Chapter 7 121Safety of Botulinum Toxin in Aesthetic Medicine

Table 7.2. Incidenceofhematoma/injectionsitebruising

AuthorYearno. of patients

Drug and dose Area of injection % of hematoma in verum or dif-ferent verum groups

% of hematoma in placebo group


Botox16,32,48U Frontal 10%,5.3%,15% Notapplicable

Rzanyetal.2006n=221


Glabellaandfrontal Notreported Notreported

Carruthersetal.2005an=80

Botox10,20,30,40U

Glabellaandfrontal Notreported Notapplicable


Botox20U,placebo Glabella Notreported Notreported

Carruthersetal.2005bn=80

Botox20,40,60,80U

Glabella 5%,0%,0%,0% Notapplicable



Glabella 0%,3%,0% 5.8%

Loweetal.2005n=162


Crow’sfeet 18.2%,9.7%,6.1%,3.0%

12.5%


Myobloc500U,placebo

Crow’sfeet 25% 40%

Table 7.3. Incidenceofheadache

AuthorYearNo. of patients

Drug and dose Area of injec-tion

% of headache in verum or different verum groups

% of headache in placebo group


Botox16,32,48U Frontal 20%,15.8%,30% Notapplicable

Rzanyetal.2006n=221


Glabellaandfrontal

2.7 2.7


Botox10,20,30,40U

Glabellaandfrontal

20%,15%,5%,5% Notapplicable


Botox20U,placebo Glabella 15.3% 15%


Botox20,40,60,80U

Glabella 0%,15%,0%,0% Notapplicable



Glabella 3%,3%,0% 0%

Loweetal.2005n=162


Crow’sfeet 6.1%,3.2%,6.1%,12.1% 3.1%


Myobloc500U,placebo

Crow’sfeet 25% 20%


7

beinformedaboutthepossibilityofidiosyncrat-ic severe headaches (Alam et al. 2002). On theotherhand,theresultsofsomestudiespointtoadecreaseinheadacheoccurrenceafterrepeatedBNTtreatment.However,theseresultswerenotsignificant(Carruthersetal.2004).

7.2.4 Localized Skin Dryness

Onestudyfoundanincidenceof localizedskindrynessin3.8%ofthepatientsandthereforerec-ommendedtheuseofskinmoisturizersfortreat-edareas (Bulstrodeet al. 2002).Localizeddry-ness could be explained by a decrease of sweatglandactivity.However,intheexperienceoftheauthors, localized skin dryness is usually not acomplaint.

7.3 Adverse Events Due to Local Diffusion/Distribution

Typical adverse events are those caused by lo-caldiffusionofBNTintoareasnotmeanttobetreated.Severalof theadverseeventsdescribedherehavealreadybeendiscussedinthepreviouschapters.

7.3.1 Eyelid Ptosis

Here,themostwell-knownadverseeventistheeyelid ptosis which is caused by the diffusionof the BNT into the levator palpebrae muscles(seeFig.5.23inSect.5.2onthetreatmentoftheglabella).

Injections into the orbicularis oculi, corru-gator supercilii and procerus muscles have thehighest risk of producing lid ptosis. Lid ptosisusuallymanifestswithintwotosevendaysandcan last for weeks. Using Botox in the glabellaarea, Carruthers and colleagues reported a lidptosis rate of 5.4% in their first large placebo-

controlledstudy(Carruthersetal.2002),declin-ingto1.0%inasubsequentstudy(Carruthersetal.2003).Intheirmostrecentstudiesnolidpto-sisoccurredaftertreatmentof160patients(Car-ruthersetal.2005a;Carruthersetal.2005b).Thesame results were obtained from a 102-patientstudy,wherenocaseofptosiswasreportedaftertreatmentof theglabellaareawith25,50,or75UDysport(Ascheretal.2004).IntheGermanstudy,onlyonecaseofeyelidptosiswasreportedamong127patients, inonepatient treatedwith50DysportU(Rzanyetal.2006).

Apraclonidine,anα2-adrenergicagonist,canbeusedtodecreasetheseverityof lidptosisbystimulatingtheMueller’smuscle;thusaneleva-tionoftheuppereyelidofabout1–3mmcanbeobtained.Themostcommondosingschemeforapraclonidine0.5%eyedropsisoneortwodropsuptothreetimesdailyintotheaffectedeyeuntilptosisresolves.Similaragentsforthetreatmentofptosisincludebrimonidine(0.1%or0.2%)andneosynephrinehydrochloride(2.5%)(Scheinfeld2005).

7.3.2 Ectropion

BNT injections placed around the lower eyelidcan affect the function of the orbicularis oculimuscle and lead to ectropion, causing cornealdamage throughdesiccation.Potential risk fac-torsare lowereyelidsurgeryorahigherageofpatient.

7.3.3 Strabismus

Transient strabismus may be observed aftermisplacedlateral(crowsfeet)ormedial(bunnylines)periorbital treatment. Ifanectropionoc-curs,anophthalmologicalconsultationisadvis-abletoassistinaccuratediagnosisandinestab-lishingatreatmentplan.


7.3.4 Pseudoherniation

In patients with lax septal support, pseudoher-niationofinfraorbitalfatpadsmightoccurafterinfraorbital treatment with BNT (Paloma et al.2001;seeFig.5.50a,binSect.5.4oncrow’sfeet).Aptosisoftheupperlipcanoccuriffibersofthezygomaticusmajorareaffectedfollowinglateralperiorbitaltreatment(Figs.7.1and7.2).

7.3.5 Complications After Perioral and Neck Treatment

Perioralcomplicationsaftertreatmentofnasola-bialfoldsandradialperiorallinesincludeupperlipweakness.

Temporary dysphagia and hoarseness havebeendocumentedespeciallyinolderpatientsaf-tertreatmentoftheplatysmalbands.Inanearlystudy,Matarassoandcolleaguesreportedanin-cidenceof 10%mildand transientcervicaldis-comfort,1%neckweaknessand0.05%clinicallysignificantdysphagia in treatedpatients (Mata-rassoetal.2001).

7.4 Adverse Events Due to Hyperactivity of Adjacent Muscles/Brow Malposition

Reducingthemuscleactivityinoneareacanleadtoanovercompensationofmuscles inadjacentregions. A typical example includes the effectknown as the Mephisto sign, a quizzical look,Spock’s eyebrow, a sinister look or ‘joker’ facewhentreatingthecentralpartsoftheforehead.Paralysis of the medial parts of the eyebrowscombined with a compensated hyperactivity ofthelateralfrontalismuscleleadstotypicallateralraised eyebrows, making a following touch-uptreatmentnecessary.

InsomepatientstheMephistosignmightbea visual impression that does not reflect a realovercompensationofmuscles.Inthesecasestheglabellaareaisloweredaftertreatmentofthem.procerusandthemm.corrugatores(seeFig.5.1inSect.5.1onforeheadtreatment).

Inaddition, in somepatients localizedmus-cularspasmsmightoccur(Coteetal.2005).

Fig. 7.1. Ptosisoftheupperlipduetoimpairmentofthem. zygomaticus major following injection of the crow’sfeetarea

Fig. 7.2. Injectionpointinthecrow’sfeetareathatpro-vokedtheupperlipptosis


7

7.5 Adverse Events due to Generalized Distribution

BNT,evenwheninjectedlocally,canbedistrib-uted over the whole body. In contrast to otherindications, generalized adverse events are re-portedveryrarely inaestheticmedicine,whereonlyverylowdosesofBTNareused.

DependentontheBTNdoseandthenumberofmuscles injected, theonsetof systemicreac-tions typically occurs within 1 week and theycontinue for 1–2 weeks. These anticholinergiceffects remain peripheral since the BNT is un-able to penetrate the blood-brain-barrier intothe central nervous system. Typical effects ofsystemicBNTactionswouldincludedrymouth,red eyes, accommodation disturbance and gas-trointestinalsymptoms.SofaritseemsthatsuchgeneralizedadverseeventsaremorecommonforBNT-BthanforBNT-A(Dressleretal.2003).

7.6 Allergies to Botulinum Toxin-A

There are hardly any reports about hypersensi-tivity or allergic responses after aesthetic BNTtreatments.LeWittdescribesapersistentrashatthefacialinjectionsite(LeWittetal.1997).Cotereportsabouttwocasesofallergicreactionsfiledto theUSFDAbetween12/1989and5/2003af-teruseofBNT-Aforcosmeticindications(Coteetal.2005).

Althoughthereporteddataisquitescarceandnotverydetailed,theGermanpackagelabelfore.g.Botoxstatesthatreportsaboutanaphylacticreactionshavealsobeenforwardedtothemanu-facturer and therefore appropriate precautionsarerecommended.

7.7 Formation of Antibodies

Formation of antibodies against the toxin willlead to a decreased efficiency due to an inacti-vationofBNT.Intheliterature,Carruthersandcolleagues investigated antibody levels in 405

patientstreateduptothreetimeswith20UBo-tox(Carruthersetal.2004).In235patientswhocompletedthefollow-up,antibodieswerefoundin1.1%–1.4%ofthesampleswhichcouldbeeval-uated.However, innocasedid thepresenceofantibodiesleadtoadecreaseindrugefficiency.

Ahigherdoseimplicatesagreaterriskofin-ducing antibodies; in aesthetic medicine whereusuallyverylowdosesareused,theproblemofneutralizing antibodies seems to be negligible(ConsensusConference1991).

7.9 References

AlamM,DoverJS,ArndtKA(2002)PainassociatedwithinjectionofbotulinumAexotoxinreconstitutedus-ingisotonicsodiumchloridewithandwithoutpre-servative: a double-blind, randomized controlledtrial.ArchDermatol138(4):510–4

AlamM,ArndtKA,DoverJS(2002)Severe,intractableheadacheafterinjectionwithbotulinumaexotoxin:reportof5cases.JAmAcadDermatol46(1):62–5

AllerganInc.(2004)Pressrelease:http://www.sharehold-er.com/agn/ReleaseDetail.cfm?ReleaseID=150344

Ascher B, Zakine B, Kestemont P, Baspeyras M, Bou-garaA,SantiniJ(2004)Amulticenter,randomized,double-blind, placebo-controlled study of efficacyand safety of 3 doses of botulinum toxin A in thetreatment of glabellar lines. J Am Acad Dermatol51(2):223–33

BaumannL,SlezingerA,VujevichJ,HalemM,BrydeJ,Black L, Duncan R (2003) A double-blinded, ran-domized,placebo-controlledpilotstudyofthesafetyand efficacy of Myobloc (botulinum toxin type B)-purified neurotoxin complex for the treatment ofcrow‘s feet: a double-blinded, placebo-controlledtrial.DermatolSurg29(5):508–15

Bulstrode NW, Grobbelaar AO (2002) Long-term pro-spectivefollow-upofbotulinumtoxintreatmentforfacialrhytides.AestheticPlastSurg26(5):356–9

CarruthersA,CarruthersJ,SaidS(2005a)Dose-rangingstudyofbotulinumtoxintypeAinthetreatmentofglabellarrhytidsinfemales.DermatolSurg31(4):414–22;discussionp422


CarruthersA,CarruthersJ(2005b)Prospective,double-blind, randomized, parallel-group, dose-rangingstudyofbotulinumtoxintypeAinmenwithglabel-larrhytids.DermatolSurg31(10):1297–303

CarruthersA,CarruthersJ,CohenJ(2003)Aprospec-tive,double-blind,randomized,parallel-group,dose-ranging study of botulinum toxin type A in femalesubjectswithhorizontalforeheadrhytides.DermatolSurg29(5):461–7

CarruthersA,CarruthersJ,LoweNJ,MenterMA,GibsonJ,NordquistM,Mordaunt J (2004)One-year, ran-domised,multicenter,two-periodstudyofthesafetyandefficacyof repeated treatmentswithbotulinumtoxin type A in patients with glabellar lines. J ClinRes(7):1–20

CarruthersJ,LoweNJ,MenterMA,GibsonJ,NordquistM,Mordaunt J,WalkerP,EadieN (2002)Amulti-center, double-blind, randomized, placebo-con-trolledstudyoftheefficacyandsafetyofbotulinumtoxintypeAinthetreatmentofglabellarlines.JAmAcadDermatol46(6):840–9

Carruthers J, Lowe NJ, Menter MA, Gibson J, Eadie N(2003) Double-blind, placebo-controlled study ofthe safety and efficacy of botulinum toxin type Aforpatientswithglabellarlines.PlastReconstrSurg112(4):1089–98

ConsensusConference(1991)Clinicaluseofbotulinumtoxin. National Institutes of Health Consensus De-velopment Conference Statement, November 12–14,1990.ArchNeurol48(12):1294–8

CoteT,MohanAK,PolderJA,WaltonMK,BraunMM(2005) Botulinum toxin type A injections: adverseeventsreportedtotheUSFoodandDrugAdminis-trationintherapeuticandcosmeticcases.JAmAcadDermatol53(3):407–15

DresslerD,BeneckeR(2003)AutonomicsideeffectsofbotulinumtoxintypeBtreatmentofcervicaldysto-niaandhyperhidrosis.EurNeurol49(1):34–8

LeWittPA,TroschRM(1997).Idiosyncraticadversereac-tionstointramuscularbotulinumtoxintypeAinjec-tion.MovDisord12(6):1064–7

LoweNJ,AscherB,HeckmannM,KumarC,FraczekS,EadieN(2005)Double-blind,randomized,placebo-controlled, dose-response study of the safety andefficacyofbotulinumtoxin typeA in subjectswithcrow‘sfeet.DermatolSurg31(3):257–62

MatarassoSL,MatarassoA(2001)TreatmentguidelinesforbotulinumtoxintypeAfortheperiocularregionandareportonpartialupperlipptosisfollowingin-jectionstothelateralcanthalrhytids.PlastReconstrSurg108(1):208–14;discussionpp215–7

PalomaV,SamperA(2001)Acomplicationwiththeaes-theticuseofBotox:herniationoftheorbitalfat.PlastReconstrSurg107(5):1315

Rzany B, Ascher B, Fratila A, Monheit GD, Talarico S,SterryW(2006)Efficacyandsafetyof 3-and5-in-jectionpatterns(30and50U)ofbotulinumtoxinA(Dysport) for the treatment of wrinkles in the gla-bellaandthecentralforeheadregion.ArchDermatol142(3):320–6

Scheinfeld N (2005) The use of apraclonidine eyedropstotreatptosisaftertheadministrationofbotulinumtoxintotheupperface.DermatolOnlineJ11(1):9

Vartanian,AJ,DayanSH(2005)Complicationsofbotu-linumtoxinAuseinfacialrejuvenation.FacialPlastSurgClinNorthAm13(1):1–10

Chapter 8

Contents

8.1 Introduction . . . . . . . . . . . . 127

8.2 BotulinumToxinandChemicalPeels . 128

8.3 BotulinumToxinandLaserResurfacing . . . . . . . . 128

8.4 BotulinumToxinandFillers . . . . . 128

8.5 BotulinumToxinandBrowLiftwithSuspensionThreads . . . . . . . . 132

8.6 BotulinumToxin,EyeSurgery&OtherTinyDetails . . 132

8.7 BotulinumToxinandFacelift . . . . 132

8.8 TheMicroliftProcedure:BNT-AasanImportantAlly! . . . . 134

8.9 TipsandTricks . . . . . . . . . . . 1358.10 References . . . . . . . . . . . . . 135

8

8.1 Introduction

Facial aging is recognized as a loss of volume(lossofunderlyingsofttissuesupport),increas-ing skin wrinkling, and skin folding. Age, sundamage, tobacco and alcohol use, trauma, andpoornutritionallcontributejointlytofacialag-ing,butitischronicsunexposurethatcausesthemost significant skin changes. Over time, skinbecomesprogressivelythinner,drier,lesselastic,and less resilient, and as a result of the loss ofelasticity,facialskinbecomesmorelax.Wrinklesform,andjowlsarecreatedbyptosisofthefacialportion of the platysma muscle and an altereddistributionoffatunderthechin.

Many procedures are available for patientsseeking treatment to reduce the appearance offacialwrinklesandfolds;namelyablativetreat-mentssuchaschemicalpeelsandlaserresurfac-ing,injectionswithBNT-Aandfillersaswellasfacelifts. Patients desiring to re-establish theirjaw lines may benefit from neck liposuction.Each of these techniques is effective in reduc-ingcertainsignsof facialaging.However,eachof these techniqueshave limitationsanddisad-vantages,especiallyforthepatientwhowantstosee an immediate improvement with minimaldiscomfortandtimeawayfromsocialandworkengagements. Based on the above, it is easy tounderstand that a single procedure will not beabletosolvethecomplexityofthefacialchangesthathappenwithtime.Combinationtherapyisandalwayswillbethebestsolutionfordealingwith different facial alterations. A facelift in awoman with severe photo-damage without any

Combination Therapy – The Microlift ProcedureMauriciodeMaio

128 Mauricio de Maio

8

resurfacingtreatmentwillleadtoanoldwomanwithanexcessivelypulledface!

Combinationtherapyisandalwayswillbethebestsolutionfordealingwithdifferentfacialalterations.

8.2 Botulinum Toxin and Chemical Peels

Photodamage is theprimary trigger forextrin-sicaging.Itresultsfromcumulativeexposuretoultravioletlightandisresponsibleformanyun-wantedagingsigns.Themostcommonclinicalsigns include aging spots on a shallow coloredskin,keratoses,staticrhytids,telangiectasiaandlossofelasticity.Thedegreeofphotodamagevar-iesfrompatienttopatientandcanbemild,mod-erateorsevere.Fillersandbotulinumtoxinalonewillnotbeabletosolveeveryskinwrinkle.Thebest way to reduce static wrinkling is throughablativemethodssuchaschemicalpeels.Skinre-newalandcollagenremodelingimprovestheap-pearance of photo-damaged skin. With dermalthickening,lesswrinklingappearsduetomuscletractionontotheskin.

Thefactthatsuperficialskinwrinklingmaybetreated with chemical peels does not mean thatdynamic wrinkles should not be treated. Bothmethodsshouldbeusedtogethertoallowbetterresults.WhycombineBNT-Aandchemicalpeels?BecausetheBNT-Atreatsdynamicwrinkles,andthechemicalpeelstreatsuperficialskinwrinklingandpigmentation.Manypeoplewith sunexpo-suredevelophyperpigmentationandcrow’sfeet.Theyare the idealpatients tobe submitted toalightpeelandBNT-Atreatment(Fig.8.1a,b).

8.3 Botulinum Toxin and Laser Resurfacing

Laser resurfacing is another effective ablativemethod for the treatment of static rhytids. The

two most common applications are the CO2andErbiumlasers.TheCO2laser,incontrasttothe Erbium laser, will produce more collateralthermal damage and will coagulate bleedings.CO2 lasers are used like deep chemical peelsagainst severe photodamage. Erbium lasers areusedlikemediumpeels.Erbiumlaserswillleadto less swelling and redness. Both of them areeffective in promoting inflammation that leadsto collagen remodeling and finally to a thickerdermis.Muscletractiononathickerdermiswillproducelesswrinkling.

BNT-A plays an amazing role with resur-facingmethods. If there isnoexcessivemusclemovement, collagen remodelling will proceedin a smoother fashion and will probably de-crease the risk of hypertrophic scars. Also, theabsence of excessive muscle contraction avoidsrewrinkling.

WhencombininglaserresurfacingandBNT-A, the injection of the botulinum toxin shouldbeperformed1or2weeksbeforetheprocedure.The concomitant injection of BNT-A, and theimmediate use of lasers after, especially CO2,maynotbeadvisable.ExcessivethermalheatingmayaltertheBNT-Amoleculeandinactivationmayresult.Althoughthe layersof treatment inbothmethodsarenot thesame, the immediateresultingedemaafterlaserapplicationmayalsoalter BNT-A activity. So, the injection may beconductedbeforelasertreatmentorwhenedemasubsides.ThecombinationofBNT-Aandlasersis recommended, since otherwise, even with averydeepandeffectivepartialdermalremoval,patients will still produce dynamic wrinkling(Fig.8.2a,b).

8.4 Botulinum Toxin and Fillers

The combination of BNT-A with fillers is oneof the most interesting non-surgical cosmeticprocedures. It leads to no downtime and gen-erally nobody can tell what has been done. Itis theperfect treatment formalepatients(Fig.8.3a,b).

Chapter 8 12�Combination Therapy – The Microlift Procedure

Fig. 8.1a,b. Crow’sfeetareabeforeandaftercombinationtreatmentofBNT-Ainjectionwithalightchemicalpeel.Pleasenotethenicewrinklingreductionandthelighteningoftheskin

Fig. 8.2a,b. Onemonthafterfullfacelaserresurfacingthepatientwasagaindepictinglineswhilefrowning.AsthiswouldjeopardizetheresurfacingresultthepatientwastreatedwithBNT-Aintheglabellaarea.AfterBNT-Atreatmentthereisnovisuallineformationduringfrowning.ThiscasedemonstratedtheusefulnessofthecombinationofBNT-Awithablativeprocedures


8

Very superficial and superficial skin wrin-klingisbesttreatedwithablativemethods,suchaslasersorchemicalpeels.However,mediumordeepwrinklesandfoldsareideallytreatedwithfillers.Dependingonthedepthofawrinkleorfold, the appropriate filler should be chosen.WhycombineBNT-Aandfillers?Ifweanalyzethenegativecosmeticlandmarksoftheface,wemaynoticethatsomeofthemostevidentwrin-kling occurs on the area where mimic activityisthegreatest.ThekineticsofmimeticmusclesandskinatrophydeterminehowBNT-Aand/orfillers are used. Muscles do produce more in-tense skin wrinkling when the skin is thin oratrophic.Thesingleuseoffillerstoincreasethedermal thickeness may be enough to decreasethe mimetic action on the skin. Hyperkineticor hypertonic patients, however, will continueto move the dermis even when it is thick. Inthesepatientsthedurabilityofabiodegradableinjectablefillermightbeshorter.Byblockingthemuscularactivityorevenhyperactivity,BNT-Awilldirectlyreducethedegradationofthebio-degradablefillerandsoprolongthedurationoftheeffect.

Dependingontheareaoftreatment,thedeci-sionregardingthetimingofinjectionofBNT-Aoruseoffillersmaydiffer.Usually,thedynamiccomponent should be treated before the staticcomponent of the wrinkle, mainly because theuseofBNT-Amaybeenoughforresolvingthehyperkinetic line. However, in selected cases,dermal atrophy or deep static lines do not dis-appear after BNT-A injection. These patientsusuallygetdisappointedwithBNT-Aaloneandthe experienced injector should recommendtheconcomitantuseoffillers in thosepatients.In more complicated areas, such as in perioralwrinkling or the nasolabial fold, fillers are bestscheduled to be injected first. If, after the fillerinjection,manywrinklesarestillevidentduringanimation, the subsequent injection of BNT-Ashouldbeconsidered.

Experienced practitioners may know first-hand that combined use of fillers and BNT-Awill be necessary and can do both in the samesession. One procedure does not interfere withtheotherbecausebothareinjectedintodifferentlayers.Usually,BNT-Awillbeinjectedfirstandfillerssoonafter(Table8.1).

Fig. 8.3a,b. Patientpresentingwithacnescarsanddeepdynamicwrinklesintheforeheadandglabellaarea.Also,aslightasymmetryinhisupperlipontherightsidecanbenoticed.BeforeandaftertreatmentwithacombinationofinjectablefillersandBNT-A.Theresultisverynaturalandthereisnoevidenceofanycosmeticproceduredoneinthismalepatient

Chapter 8 131Combination Therapy – The Microlift Procedure

Table 8.1. CombinationofBNT-Awithinjectablefillers

Area BNT-A Fillers ObservationForeheadlines First Afterifneeded BNT-Aisusuallyenough

Glabella First Afterifneeded Fillersatthislevelareverybeneficialforglabellareshap-ing.Thedurationofbothprocedureswillbelonger

Periorbital First Afterifneeded Fillersarebarelyneededatthisarea

Nasolabialfold Afterifneeded First TheuseofBNT-Ashouldbedonewithcautiontoavoidasymmetries

Nose Tobeusedintothedepressorseptinasitoblockthedroopingeffectofmusclecontrac-tion

Tobeusedintothenasaldorsum,atthefronto-nasalandnasolabialangle.

Theirusemaybecon-comitantwithnon-surgicalreshapeofthenose

Perioral Afterifneeded* First Usuallyfillersareenoughinthisarea.TheuseofBNT-Aisusedtoimproveperfor-manceofresult

Cheek Afterifneeded* First BNT-Ainjectioninthisareashouldbecarriedoutwithcaution

Oralcomissure Firstifthemaincom-ponentresultsfrommuscledepression

Firstifthemaincompo-nentistissueatrophy

Thesynergistuseofbothproceduresisidealinmod-eratetoseverecases

Chin First Afterifchinenlargementistargeted

Skinwrinklingismorecom-monthanchinreshapewithfillers

Neck Idealforplatysmabands(vertical)

Idealformoderatetodeephorizontallines

Bothprocedurescanbeun-dertakeninthesamesession

*SomecolleaguesmaystartwithBNT-Afirstifthereisastrongmuscularcomponent


8

Cheeklinesusuallyappearinadvancedagingorearlierinpatientswithphoto-damagedskin.The repeated contraction of the zygomaticusmajorandrisoriusonthethinoratrophicskindeepensthecurvilinearcheekwrinkling. It isatypical facial area that presents both the staticanddynamiccomponent.Incontrasttothegla-bella,forexample,wedonotwanttoblockthemuscle action completely, which would lead tofunctional impairment and atrophy. The use offillers in such cases will lead to a thicker der-mis.Thesingleuseoffillers,especiallythebio-degradable ones, may lead to quick absorptionanddiminishtheresult.Theintradermaluseofbotulinum toxin on the cheek combined withfillerswillenabletheuseofasmallerquantityofbothproducts(seeSect.6.3onmicroinjections)(Fig.8.3ab).

8.5 Botulinum Toxin and Brow Lift with Suspension Threads

The injection of botulinum toxin in the upperthird before the use of suspension threads isquitenew.Asmentionedinthebrowliftsection(seeSect.5.3),BNT-Amaybeusedforliftingthebrow, mainly its lateral parts. Surgical suspen-sionthreads(mersileneorprolene3.0)areoftenused for lifting the brow, too. A blunt canullaof2mmisinsertedatthem.frontalislevelandthesurgicalthreadisanchoredintothesubder-malormuscle layerbelow thebrowhair.Afterthedesired liftingeffect isobtained, the threadis then sutured into the periosteum and/or thegaleaatthehairlinelevel.Anover-correctionisusuallyundertaken.

TheadvantagesofBNT-Atreatment2weeksbefore placing the suspension threads includesthepriorBNT-A-basedliftingeffectoftheeye-brow and a better healing result through de-creased movements due to paralysis of the m.frontalisandthedepressors.But,aboveall,pa-tientsfeelmoreconfidentabouttheeffectivenessofbothprocedures(Fig.8.4a,b).

8.6 Botulinum Toxin, Eye Surgery & Other Tiny Details

It is amazing to point out that the vast major-ityofpatientsstillbelievethat thetreatmentofcrow’s feet is undertaken with blepharoplasty.Thepurposeofthiscosmeticeyesurgeryisba-sicallytheremovalofeyebagsandskinexcess.Itislikelythatwiththeresectionofskinexcesstherewillbeamildtomoderateimprovementincrow’sfeetwrinkling.However,wemustmakeitcleartoourpatientsthatcrow’sfeetresultfrommuscleactionandthepropertreatmentforthisisBNT-A.

Withmedicaldevelopment,westartedtore-alizethatthereisnotasinglemiraculousmethodthatisabletocorrectallthecomplexalterationsthat may compromise the eye area. Surgery isbeneficial for skin excess and eye bags, whileBNT-A is useful for decreasing wrinkle forma-tion.SomeplasticsurgeonsinjectBNT-Aduringsurgeryandreportalonger-lastingresult.Thereseems to be no harm for the surgical outcomeif BNT-A is injected before surgery. However,some patients present unsatisfactory results ifBNT-Aisinjectedsoonaftertheblepharoplastyduring the edematous phase. It is advisable toinjectBNT-Awhenedemasubsides,whichmaymean1–3monthsafterthesurgery.Sometimes,patientsarenotaware that simpleand tinyde-tailsmakeall thedifference.Thefollowingpic-turesdemonstratewhatcombined therapymaypromote.(Fig.8.5a,b)

8.7 Botulinum Toxin and Facelift

The advent of botulinum toxin has evidentlychangedthesurgicalapproachtothefacefromthe 1980s when very aggressive surgery with acoronal approach to the forehead was the rule,leading patients to complain about a very longdowntime and sometimes an unnatural faciallook.


Fig. 8.4a,b. Patientwithlowlateraleyebrowsanddeepnasolabialfolds.Before,and15daysafter,BNT-Aintheupperthird;fillersandBNT-Ainthenasolabialfoldandsuspensionsurgicalthreadsintheeyebrows.Notethattheeyebrowsremainover-correctedforthefirst7days.ItisalsoimportanttotellthepatientbeforehandthatBNT-Ainthenasola-bialfoldmayelongatetheupperlip

Fig. 8.5a,b. Thispatientpresentedamilduppereyelidskinexcess,aprominentnasaldorsumandfatdepositintheunderchin.Fortreatmentthepatient’snosewasreshapedusinginjectablefillersandBNT-Awasinjectedintothem.depressorseptinasi.Theneckwasreshapedusingchinliposuction.TheupperthirdwastreatedwithuppereyelidsurgeryfollowedbyBNT-Ainjectionintothecrow’sfeetarea


8

With the development of less and less inva-siveprocedures,theupperthirdisnowbasicallytreatedwithBNT-Aalone,whichpromotes re-juvenation improvement such as: brow lifting,erasing of horizontal lines in the forehead andverticallinesintheglabellaareawithoutscarringor downtime. So mini-lifts may focus basicallyonthemiddleandlowerfaceandneck.Althoughmini-liftsarelessinvasivethattheconventionalfacelift, a shorterbut stillnot that shortdown-timeisneverthelessanissue(Fig.8.6a,b).

Astheproceduresarenotundertakenat thesamedermal level, allproceduresmaybedonesimultaneously.

8.8 The Microlift Procedure: BNT-A as an Important Ally!

The minimal approach technique (de Maio,2004)wasaninnovationinfacialcosmeticpro-ceduresthatisfaster,lesspainful,andlesscostly

than surgical facelifts. The technique utilizes avarietyofbiodegradableinjectableproductsandBNT-A to improve appearance with a fast andrelativelypainlesslunchtimeprocedure.Thislifthasbeenexpandedtothemicroliftprocedure.

The microlift facelift appeals to the patientseeking a more long-lasting improvement thanfillers and surface treatments offer but withoutthediscomfortandcostofasurgicalfacelift.Thetechnique utilizes three common treatmentsto improve facial contours: liposuction of theneckandunderthechin,injectionoffacialfill-ers into wrinkles and folds, and suspension offacialmusclesusingpolypropyleneormersilenethreads. Alongside this, injection of botulinumtoxinintheupper,midandlowerthirdsisalsoa rule. Chemical peels can be added for somepatients to further improve skin appearance.Patients appreciate that the microlift techniqueofferslittlescarring,minimaldiscomfort,andaquickrecoverytime.(Fig.8.7a,b)

Fig. 8.6a,b. Thispatientpresentedintrinsicandextrinsicaging:saggyskinandexcessivecheekwrinkling.Aftermini-liftingofthefaceandneck,amedium-depthchemicalpeel(TCA)andBNT-Aintheupperthird,averynaturalandpleasantresultwasachieved


MicroliftProcedure• BNT-A in the upper, mid and lower

thirds• Fillers for wrinkles, folds and nose re-

shapefold• Minimal skin undermining from a tiny

incision in the inferior portion of theearlobe

• Surgical suspension threads (mersileneorprolene)for:- Jowls:always- Malarandeyebrow:ifneeded

• Liposuctionofthechin• Chemicalpeelormildlaserresurfacing:

ifneeded

8.9 Tips and Tricks

■ Minimalinvasiveproceduresaremostim-portant: put them all together! Be mini-malandeffectiveandgiveyourpatientsamorecompletetreatmentwithaveryshortdowntime.

8.10 References

Carruthers J etal. (2003)Deeprestingglabellar rhytid-es respond to BTX-A and Hylan B. Dermatol Surg29(5):539–44

Carruthers J, Carruthers A (2003) A prospective, ran-domized,parallelgroupstudyanalyzingtheeffectofBTX-A (Botox) and nonanimal sourced hyaluronicacid(NASHA,Restylane)incombinationcomparedwith NASHA (Restylane) alone in severe glabellarrhytidesinadultfemalesubjects:treatmentofsevereglabellar rhytides with a hyaluronic acid derivativecomparedwiththederivativeandBTX-A.DermatolSurg29(8):802–9

CarruthersJ,CarruthersA(2004)Theeffectoffull-facebroadband light treatments alone and in combina-tionwithbilateralcrow‘s feetBotulinumtoxin typeA chemodenervation. Dermatol Surg 30(3):355–66;discussionp366

CarruthersJ,CarruthersA(2005)Facialsculptingandtis-sueaugmentation.DermatolSurg31(11Pt2):1604–12

ColemanKR,CarruthersJ(2006)CombinationtherapywithBOTOXtrademarkandfillers:thenewrejuve-nationparadigm.DermatolTher19(3):177–88

deMaioM(2004)Theminimalapproach:aninnovationin facial cosmetic procedures. Aesthetic Plast Surg28(5):295–300.Epub2004Nov4

Fig. 8.7a,b. Thispatientpresentedwithupperandlowerblepharochalasis,deepnasolabialfoldsandoralcomissures.Inthemandiblearea,thereisamildpresenceofjowls.Aftermicrolifting,ablepharoplasty,BNT-Ainjectionsintheupperthird,aswellasinjectablefillersfortheeyebrows,nasolabialfoldsandoralcommissuresthepatientpresentedaverynaturalresult


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Fagien S, Brandt FS (2001) Primary and adjunctive useof botulinum toxin type A (Botox) in facial aes-thetic surgery: beyond the glabella. Clin Plast Surg28(1):127–48

FagienS(1999)Botoxforthetreatmentofdynamicandhyperkinetic facial lines and furrows: adjunctiveuse in facial aesthetic surgery. Plast Reconstr Surg103(2):701–13

KikkawaDO,KimJW(1997)Lower-eyelidblepharoplas-ty.IntOphthalmolClin37(3):163–78

GuerrissiJO(2000)Intraoperativeinjectionofbotulinumtoxin A into orbicularis oculi muscle for the treat-mentofcrow‘sfeet.PlastReconstrSurg105(6):2219–25;discussionpp2226–8

MoleB(2003)Optimalforeheadrejuvenation.Combin-ingendoscopy-peel-botulinumtoxin.AnnChirPlastEsthet48(3):143–51

Patel MP et al. (2004) Botox and collagen for glabellarfurrows: advantages of combination therapy. AnnPlastSurg52(5):442–7;discussionp447

SemchyshynNL,KilmerSL(2005)Doeslaserinactivatebotulinumtoxin?DermatolSurg31(4):399–404

YamauchiPSetal.(2004)BotulinumtoxintypeAgivesadjunctive benefit to periorbital laser resurfacing. JCosmetLaserTher6(3):145–8

ZimblerMSetal.(2001)Effectofbotulinumtoxinpre-treatmentonlaserresurfacingresults:aprospective,randomized, blinded trial. Arch Facial Plast Surg3(3):165–9

Zimbler MS, Nassif PS (2003) Adjunctive applicationsforbotulinumtoxininfacialaestheticsurgery.FacialPlastSurgClinNorthAm11(4):477–82

Subject Index

Aaging 11

extrinsic 11intrinsic 11

asymmetry 12,70,76,93,101,114

BBotox 2,3bruising 19,51,92,120

CClostridiumbotulinum 1

Ddilution 23Dysport 2

EEMLA 92

Ffrozenlook 12,17

MM.corrugator 34M.corrugatorsupercilii 38M.depressorangulioris 72,86M.depressorsepti 62M.depressorsupercilii 34M.frontalis 38M.levatorlabiisuperioris 68,78

––

M.levator labiisuperiorisalaequenasi 57,68,78

M.mentalis 89M.nasalis 57,62M.occipitofrontalis 29M.orbicularisoculi 38,47,72M.orbicularisoris 83M.procerus 34,38M.risorius 71M.zygomaticusmajor 71Mephistosign 32,33microinjection 49,51,74,115Myobloc 2,3

NNeuroBloc 2,3

Pphiltrum 83platysma 72,92ptosis 7,8,31,33,36,37,122,123

brow 31,33eyelid 7,8,36,37,122upperlip 123

VVistabel 2,3

XXeomin 2,3

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Documents

Botulinum Toxin in Aesthetic Medicine - M. de Maio, B. Rzany (Springer, 2007) WW