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
1
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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
4 Berthold Rzany, Hendrik Zielke
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.
Chapter 1 5Overview of Botulinum Toxin
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)
6 Berthold Rzany, Hendrik Zielke
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?
Chapter 1 7Overview of Botulinum Toxin
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
8 Berthold Rzany, Hendrik Zielke
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
14 Mauricio de Maio, Berthold Rzany
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
Chapter 2 15Patient Selection
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
16 Mauricio de Maio, Berthold Rzany
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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
Chapter 2 17Patient Selection
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
18 Mauricio de Maio, Berthold Rzany
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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
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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
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decreasewhileusingBNT-Areconstituteduptosixconsecutiveweeksbeforeapplication(Hexseletal.2003).
3.4.7 Tips and Tricks
■ 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
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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
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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
Chapter 5 33The Most Common Indications
• 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.
5.1.7 Tips and Tricks
■ 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).
5.2.3 Aim of Treatment
Theaimofthetreatmentistoreducetheverticalaswellasthehorizontallinesoftheglabella.
5.2.4 Patient Selection
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).
Chapter 5 35The Most Common Indications
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 Complications !
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).
Chapter 5 37The Most Common Indications
5.2.7 Tips and Tricks
■ 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)
5.3.3 Aim of Treatment
Theaimofthetreatmentistoliftthelateraleye-brow.Themedialaspectcanalsobeliftedinse-lectedcases.Withbrowlifting,patientsmayim-provethetiredorsadlookaswellasdecreasetheuppereyelidhooding.
5.3.4 Patient Selection
Patientsshouldbeanalyzedbothinthestaticanddynamicpositions.Inthestaticanalysis,thepa-tientsthatwillbenefitfromeyebrowliftingwithbotulinumtoxinarethosewithaweakfrontalisand strong depressors. Independent of age, theeyebrowhasalowposition;especiallyitslateralaspect,andfullnessintheuppereyelidcanalsobeobserved.Theremaybestaticlines,depend-
Chapter 5 3�The Most Common Indications
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).
Chapter 5 41The Most Common Indications
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
Chapter 5 43The Most Common Indications
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
Chapter 5 45The Most Common Indications
Fig. 5.36a,b. Technique3withfiveinjectionsites.Notethatthereisaliftingeffectofthemedial,intermediateandlateralaspectsoftheeyebrow.Thereisalsoimprovementoftheuppereyelidskinexcess
5.3.6 Complications !
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.
5.3.7 Tips and Tricks
■ 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
46 Berthold Rzany, Mauricio de Maio
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.
Chapter 5 47The Most Common Indications
Table 5.4. Characteristicsofthem.orbicularisoculi
Muscle Action Synergists AntagonistsM.orbicularisoculi Orbitalpart:protrusion
oftheeyebrowsandvol-untaryeyelidclosurePalpebralpart:closeslidsduringblinkingLacrimalpart:drawslidsandlacrimalpapillaemedially,compressesthelacrimalsac
M.corrugatorsuperciliiandm.procerus
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.
5.4.3 Aim of Treatment
Theaimoftreatmentattheeyelevelincludesre-ductionofhyperkinetic linesduringanimationandsofteningofhypertoniclinesatrest.
5.4.4 Patient Selection
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
48 Berthold Rzany, Mauricio de Maio
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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
Chapter 5 4�The Most Common Indications
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
50 Berthold Rzany, Mauricio de Maio
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Fig. 5.41. Samesideinjectiontechnique:theinjectormaybepositionedonthesamesideasthewrinklestobetreated.Superficialinjectionsarerecommendedtoavoidbruising,sincenormallythevesselsaredeeper
Fig. 5.42. Oppositesideinjectiontechnique:iftheinjectorispositionedontheop-positesidetothecrow’sfeet,theneedleisdirectedoutwardsandtherewillbenodangerfortheeyeball
Chapter 5 51The Most Common Indications
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.
5.4.7 Complications !
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
52 Berthold Rzany, Mauricio de Maio
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
Chapter 5 53The Most Common Indications
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
54 Berthold Rzany, Mauricio de Maio
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.
5.4.8 Tips and Tricks
■ 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
Chapter 5 55The Most Common Indications
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
LeeCJetal.(2006)Theresultsofperiorbitalrejuvenationwith botulinum toxin A using two different proto-cols.AestheticPlastSurg30(1):65-70
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
56 Berthold Rzany, Mauricio de Maio
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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
LeeCJetal.(2006)Theresultsofperiorbitalrejuvenationwith botulinum toxin A using two different proto-cols.AestheticPlastSurg30(1):65-70
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-
Chapter 5 57The Most Common Indications
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.
5.5.4 Patient Selection
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
58 Berthold Rzany, Mauricio de Maio
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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
5.5.6 Complications !
Themostcommoncomplicationwiththetreat-mentofbunnylinesisthepresenceofecchymo-
Chapter 5 5�The Most Common Indications
Fig. 5.53. Theinjectiontechniqueonthelateralbunnylinesshouldbesuperficialandawhealformationisdesirable.Careshouldbetakennottoinjectintobloodvesselstoavoidbruising
Fig. 5.54. Injectiontechnique:lateralinjectionpoints Fig. 5.55. Injectiontechnique:lateralanddorsalinjectionpoints
60 Berthold Rzany, Mauricio de Maio
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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
Chapter 5 61The Most Common Indications
sisorhematoma.Anunsatisfactoryresultmaybedue to inadvertent injection into blood vessels.Majorproblemssuchasdiplopiaandupper lipptosis may result from inadvertent blocking oftherectusinferiorisormedialisandthelevatorlabii superioris alaeque nasi, respectively. Moreseriouscomplicationsmayincludespeakingandchewingdifficulty.
5.5.7 Tips and Tricks
■ 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
62 Berthold Rzany, Mauricio de Maio
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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).
5.6.3 Aim of Treatment
ThepurposeofblockingthedepressorseptinasiwithBNT-A is to elevate the tipof thenoseatrestandavoiditsdroopingduringasmile.
Theblockingofthedilatornasimaydecreasethenostrilapertureincertaincases.
5.6.4 Patient Selection
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
Chapter 5 63The Most Common Indications
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
64 Berthold Rzany, Mauricio de Maio
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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).
5.6.7 Complications !
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.
Chapter 5 65The Most Common Indications
Fig. 5.63a,b. Theblockingofthem.dilatornasimayreshapethenostrilanddecreaseitssize,leadingtoamoredelicateappearanceofthenose
Fig. 5.64a,b. Thecontractionofthedepressoroftheseptummakesthetipofthenoseroundedandinclineddown-wards.TheinjectionofBNT-Apromoteselevationofthetipofthenoseandamoregraciousprofile
Fig. 5.65a,b. Theblockingofthem.depressorseptinasipromotesaslightliftingandupwardrotationofthetipofthenose.Itgivesamoreyouthfulappearance
66 Berthold Rzany, Mauricio de Maio
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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.
5.6.8 Tips and Tricks
■ 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
Chapter 5 67The Most Common Indications
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).
5.7.3 Aim of Treatment
Theaimof the treatmentof thenasolabial foldwithbotulinumtoxinistoreducemuscularhy-peractivity at this level.Theblockingof them.levator labii superiorisorm. levator labii supe-riorisalaequenasishouldflattenorsmooththeprominentnasolabialfold.
5.7.4 Patient Selection
Deeporprominentnasolabial foldsareconsid-eredsignsofaging.Youngpeoplewhohavedeepnasolabialfoldsconsiderthemselvestobeolderthantheyreallyare.Itisveryimportanttoexam-inethepatient instaticanddynamicpositions.
68 Berthold Rzany, Mauricio de Maio
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Table 5.7. Characteristicsofthem.levatorlabiisuperiorisandthem.levatorlabiisuperiorisalaequenasi
Muscle Action Synergists AntagonistsM.levatorlabiisuperioris Elevatesandevertsthe
upperlip.Createsandmovesthemiddleportionofthenasolabialfold.
Lateralpartofm.levatorlabiisuperiorisalaequenasi,m.levatoranguliorisandmm.zygomati-cusmajorandminor
M.depressoranguliorisandm.orbicularisoris
M.levatorlabiisuperiorisalaequenasi
Medialpart:dilatesthenostrilLateralpart:raisesandevertstheupperlipCreatesthemostupperportionofthenasolabialfold.
Medialpart:m.dilatornasiLateralpart:m.levatorlabiisuperioris,m.zygomaticusmajorandminorandm.levatorangulioris
M.depressoranguliorisandm.orbicularisoris
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
Chapter 5 6�The Most Common Indications
Fig. 5.66. Injectionpoints for thecorrectionof thena-solabialfold
5.7.6 Complications !
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.
5.7.7 Tips and Tricks
■ 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
70 Berthold Rzany, Mauricio de Maio
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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
Chapter 5 71The Most Common Indications
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).
5.8.3 Aim of Treatment
Thetargetinthetreatmentofcheeklinesisthereduction of wrinkling both at rest and duringanimationinselectedcases(Fig.5.70a,b).
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Fig. 5.70a,b. BeforeandaftertreatmentwithBNT-Aforreducingdynamiccheeklines.Theresultshouldalwaysbenaturalandshouldneverimpairmusclefunction
Table 5.9. Overviewofthemusclesindirectlyresponsibleforinfluencingthecheekarea
Muscle Action Synergists AntagonistsM.orbicularisoculi Orbitalpart:voluntary
eyelidclosureandcrow’sfeetformation.Thedownwardextensionfi-bersreachthecheekarea.
M.corrugatorsuperciliiandm.procerus
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
Chapter 5 73The Most Common Indications
Fig. 5.71a,b. Typical young patient with thin skin and cheek wrinkling before and after treatment with BNT-A.Anaturalreductionwithnocomplicationwasobtained
5.8.4 Patient Selection
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.
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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
Chapter 5 75The Most Common Indications
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
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• Onlyverysuperficialintra-orsubdermalinjections(seealsoSect.6.3formicroin-jectiontechnique)
• Botoxdose:1–3Utotaldosepercheek• Dysport dose: 3–9 U total dose per
cheek
5.8.6 Complications !
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.
5.8.7 Tips and Tricks
■ 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
Chapter 5 77The Most Common Indications
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
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Table 5.10. Overviewofthemusclesresponsibleforthegummysmile
Muscle Action Synergists AntagonistsM.levatorlabiisuperiorisalaequenasi
Medialpart:dilatesthenostrilLateralpart:raisesandevertstheupperlip
Medialpart:m.dilatornasiLateralpart:m.levatorlabiisuperioris,mm.zygomaticusmajorandminorandm.levatorangulioris
M.depressoranguliorisandm.orbicularisoris
M.levatorlabiisuperioris Elevatesandevertstheupperlip
Lateralpartofthem.levatorlabiisuperiorisalaequenasi,m.leva-toranguliorisandmm.zygomaticusmajorandminor
M.depressoranguliorisandm.orbicularisoris
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.
5.9.3 Aim of Treatment
The aim of treating gummy smile with botu-linum toxin is to avoid gingiva showing at restandtoreduceexcessivegumexposureduringasmile.
5.9.4 Patient Selection
Thepatientshouldbeanalyzedinastaticanddy-namicperspective.Thestaticanalysisshouldfo-cusonthelipsandthenose.Ingeneral,patientswith a gummy smile have a short distance be-tweentheupperlipandthebaseofthenose.Theupperlipismainlythinandthenasallabialangleis90°orless.Theupperlipisoftenretractedandtheupperincisorsarevisibleatrest.It iscalledtheopenlipposture.
Chapter 5 7�The Most Common Indications
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
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Fig. 5.80. ThetreatmentofgummysmilewithBNT-Amaybeconductedattheupperpartofthenasolabialfoldbyblockingthelateralslipofthelevatorlabiisupe-riorisalaequenasi.Thebestcandidatesforthislocationarethosewithaprominentnasolabialfoldandshortupperlip
Fig. 5.81. aApatientpresentinggummysmilebeforetreatmentwithBNT-A.bAftertreatment,thereiscorrectionofthegummyshowwithperfecthidingofjusttheupperthirdofthecentralincisors.Withthemedialmuscles(m.leva-torlabiisuperioris)blocked,thereisaslighttendencyforupperlateralpullingwiththezygomaticusmuscle.Thereisamodificationofthesmilepatternc Splitphotographofa,b,clearlydepictingthepositivechangesinthispatientwithgummysmile
Chapter 5 81The Most Common Indications
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
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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 Complications !
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.
5.9.7 Tips and Tricks
■ 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
Chapter 5 83The Most Common Indications
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.
5.10.3 Aim of Treatment
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
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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)
Chapter 5 85The Most Common Indications
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 Complications !
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.
5.10.7 Tips and Tricks
■ 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
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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.
5.11.3 Aim of Treatment
The aim of the treatment is to reduce themuscular strength of the m. depressor anguliorisand thefibersof theplatysmaand therebyinducea liftof thecornersof themouthwhilethepatientisatrest.
5.11.4 Patient Selection and Evaluation
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)
Platysmaparsmodiolusandm.depressorlabiiinferioris
M.levatorangulioris,m.zygomaticusmajor
Chapter 5 87The Most Common Indications
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
88 Berthold Rzany, Mauricio de Maio
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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
5.11.6 Complications !
Highdosesoraninjectionthatistooclosetothecorner of the mouth might lead to asymmetry
aswellasdifficultieswhileeatinganddrinking,suchasdrooling.
5.11.7 Tips and Tricks
■ 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
Chapter 5 8�The Most Common Indications
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
5.12.3 Aim of Treatment
Theaimofthetreatmentistoreducethecobble-stonepatternonthechin.
5.12.4 Patient Selection and Evaluation
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
5.12.6 Complications !
When an appropriate distance from the lowerlipiskept,complicationsapartfromhematomaarenil.Placingtheinjectionpointstoocloseto
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thelowerlipmightinvolvethem.depressorlabiiinferioris, which would lead to a dysfunctionalmouthwithptosisofthelowerlip.
5.12.7 Tips and Tricks
■ 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.
5.13.3 Aim of Treatment
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
5.13.4 Patient Selection
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).
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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
5.13.6 Complications !
Bruisingoccursnotinfrequentlyaspressureaf-tertheinjectioncanonlybeappliedcarefully.Inrare cases dysphagia and dysphonia have beenreportedafterBNT-A.
5.13.7 Tips and Tricks
■ 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
M.depressorangulioris M.levatorangulioris
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
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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:dilatesthenostrilLateralpart:raisesandevertstheupperlip
Medialpart:M.dilatornasiLateralpart:m.levatorlabiisuperioris,m.zygomaticusmajorandmi-norandm.levatorangulioris
M.depressoranguliorisandm.orbicularisoris
M.levatorlabiisupe-rioris
Elevatesandevertstheupperlip
Lateralpartofm.levatorlabiisuperiorisalaequenasi,m.levatoranguliorisandm.zygomaticusmajorandminor
M.depressoranguliorisandm.orbicularisoris
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
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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
Platysmaparsmodiolusandm.depressorlabiiinferioris
M.levatoranguliorisandm.zygomaticusmajor
Platysma Anteriorfibers:assistman-dibulardepressionIntermediatefibers:parsla-bialis–depressthelowerlipPosteriorfibers:parsmo-diolaris–depressthebuccalangle
M.depressorangulioris M.levatorangulioris
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
6.1.3 Aim of Treatment
The goals of treatment of facial asymmetriesinclude static balance with correction of facialdeviations and rotations, and reduction or to-talcontrolof facialdeviationduringanimationwhileavoidinganyfunctionalimpairment.
6.1.4 Patient Selection
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)
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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).
6.1.7 Complications !
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.
100 Mauricio de Maio, Berthold Rzany
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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
6.1.9 Tips and Tricks
■ 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
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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
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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-
Chapter 6 103Advanced Indications and Techniques
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
104 Mauricio de Maio, Berthold Rzany
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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
Chapter 6 105Advanced Indications and Techniques
6.2.3 Aim of Treatment
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).
6.2.4 Patient Selection
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
106 Mauricio de Maio, Berthold Rzany
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
Chapter 6 107Advanced Indications and Techniques
Table 6.7. Antagonistsandsynergistsinthemiddleandlowerthird
Function Muscle Action Synergists AntagonistsElevator M.levatorlabii
superiorisalaequenasi
Medialpart:dilatesthenostrilLateralpart:raisesandevertstheupperlip
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
108 Mauricio de Maio, Berthold Rzany
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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
110 Mauricio de Maio, Berthold Rzany
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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
Chapter 6 111Advanced Indications and Techniques
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
- - Notusuallyinjectedforthispurpose
Elevator M.levatorangulioris(caninus)
- - Notusuallyinjectedforthispurpose
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.
112 Mauricio de Maio, Berthold Rzany
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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
Chapter 6 113Advanced Indications and Techniques
Fig. 6.18a,b. Afterthetreatment,thereisanimprovementinthejawlineandtheskinseemstobetighter.Thereisalsoimprovementintheneckarea
Fig. 6.19a,b. Thecheekboneareaismoreprojectedandhasafullerappearanceafterthetreatment
Fig. 6.20a,b. Afterthetreatmentthereisanoverallimprovementinskinquality.Theeyebrowislifted,thecrow’sfeetreduced.Thezygomaareaislessflatandmoreprojected,thejawlineisbettershapedandtheplatysmabandshavedisappeared.Notethattheresultshouldbesubtleandtheprocedureshouldnotleadtoafrozenappearance
114 Mauricio de Maio, Berthold Rzany
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6.2.6 Complications !
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.
6.2.7 Tips and Tricks
■ 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
Chapter 6 115Advanced Indications and Techniques
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
116 Mauricio de Maio, Berthold Rzany
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.
6.3.7 Tips and Tricks
■ If you use the microinjection technique,pleaserememberthetotaldoseyouareus-ing in this area. Otherwise you might bepronetoover–orunderdose.
Fig. 6.22. Injectionpoints for the cheekareausing themicroinjectiontechnique
Chapter 6 117Advanced Indications and Techniques
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
120 Berthold Rzany, Hendrik Zielke
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
Carruthersetal.2005n=80
Botox10,20,30,40U
Glabellaandfrontal Notreported Notapplicable
Carruthersetal.2002n=264
Botox20U,placebo Glabella Notreported Notreported
Carruthersetal.2005n=80
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
Carruthersetal.2003n=59
Botox16,32,48U Frontal 10%,5.3%,15% Notapplicable
Rzanyetal.2006n=221
Dysport,3×10U5×10U,placebo
Glabellaandfrontal Notreported Notreported
Carruthersetal.2005an=80
Botox10,20,30,40U
Glabellaandfrontal Notreported Notapplicable
Carruthersetal.2002n=264
Botox20U,placebo Glabella Notreported Notreported
Carruthersetal.2005bn=80
Botox20,40,60,80U
Glabella 5%,0%,0%,0% Notapplicable
Ascheretal.2004n=119
Dysport25,50,75U,placebo
Glabella 0%,3%,0% 5.8%
Loweetal.2005n=162
Botox18,12,6,3U,placebo
Crow’sfeet 18.2%,9.7%,6.1%,3.0%
12.5%
Baumannetal.2003n=20
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
Carruthersetal.2003n=59
Botox16,32,48U Frontal 20%,15.8%,30% Notapplicable
Rzanyetal.2006n=221
Dysport,3×10U5×10U,placebo
Glabellaandfrontal
2.7 2.7
Carruthersetal.2005n=80
Botox10,20,30,40U
Glabellaandfrontal
20%,15%,5%,5% Notapplicable
Carruthersetal.2002n=264
Botox20U,placebo Glabella 15.3% 15%
Carruthersetal.2005n=80
Botox20,40,60,80U
Glabella 0%,15%,0%,0% Notapplicable
Ascheretal.2004n=119
Dysport25,50,75U,placebo
Glabella 3%,3%,0% 0%
Loweetal.2005n=162
Botox18,12,6,3U,placebo
Crow’sfeet 6.1%,3.2%,6.1%,12.1% 3.1%
Baumannetal.2003n=20
Myobloc500U,placebo
Crow’sfeet 25% 20%
122 Berthold Rzany, Hendrik Zielke
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.
Chapter 7 123Safety of Botulinum Toxin in Aesthetic Medicine
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
124 Berthold Rzany, Hendrik Zielke
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
Chapter 7 125Safety of Botulinum Toxin in Aesthetic Medicine
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
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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
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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
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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.
Chapter 8 133Combination Therapy – The Microlift Procedure
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
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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
Chapter 8 135Combination Therapy – The Microlift Procedure
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
–––