No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Consensus Recommendations on the Use of Botulinum Toxin Type A in Facial Aesthetics
Abstract
The use of botulinum toxin type A for facial enhancement is the most common cosmetic procedure currently undertaken in the United States. Overall clinical and study experience with botulinum toxin type A treatment for facial enhancement has confirmed that it is effective and safe in both the short and long term. Nevertheless, consistent guidelines representing the consensus of experts for aesthetic treatments of areas other than glabellar lines have not been published. Therefore, a panel of experts on the aesthetic uses of Botox Cosmetic (botulinum toxin type A; Allergan, Inc., Irvine, Calif.) was convened to develop consensus guidelines. This publication comprises the recommendations of this panel and provides guidelines on general issues, such as the importance of the aesthetic evaluation and individualization of treatment, reconstitution and handling of the botulinum toxin type A, procedural considerations, dosing and injection-site variables, and patient selection and counseling. In addition, specific considerations and recommendations are provided by treatment area, including glabellar lines, horizontal forehead lines, "crow's feet," "bunny lines" (downward radiating lines on the sides of nose), the perioral area, the dimpled chin, and platysmal bands. The review of each area encompasses the relevant anatomy, specifics on injection locations and techniques, starting doses (total and per injection point), the influence of other variables, such as gender, and assessment and retreatment issues. Factors unique to each area are presented, and the discussion of each treatment area concludes with a review of key elements that can increase the likelihood of a successful outcome. Summary tables are provided throughout.
... Of the 23 other studies, those by Fagien et al. [31] and by Bertossi et al. [32] were each separately updated by the same group and therefore were excluded from the summary. Carruthers et al. [33] updated their consensus in 2008 and again in 2013 [34,35]. The initial 2004 consensus was grouped with the 2008 consensus, but the 2013 consensus was summarized because of slightly different parameters. ...
... Crow's feet are caused by contraction of the superficially situated orbicularis oculi muscle. It is a sphincter muscle encircling the orbit and is divided into three portions: palpebral, orbital, and lacrimal [33]. The muscle originates from the nasal part of the frontal bone, the medial palpebral ligament, and the frontal process of the maxilla. ...
... To minimize complications, 6 U to 12 U of BoNT per side should be injected intracutaneously, producing a wheal (Figure 3). Three injections should be targeted 1.5 cm lateral to the lateral canthus or 1 cm outside the bony orbital wall to reduce the chances of diplopia, ectropion, and drooping of the lower eyelid [33]. To prevent asymmetrical smiles, injections should not be targeted close to the inferior margin of the zygoma. ...
Botulinum toxin (BoNT) is an anaerobic rod-shaped-neurotoxin produced by Clostridium botulinum, that has both therapeutic and lethal applications. BoNT injection is the most popular cosmetic procedure worldwide with various applications. Patients with dynamic wrinkles in areas such as the glabella, forehead, peri-orbital lines, nasal rhytides, and perioral rhytides are indicated. Excessive contraction of muscles or hyperactivity of specific muscles such as bulky masseters, cobble stone chins, gummy smiles, asymmetric smiles, and depressed mouth corners can achieve esthetic results by targeting the precise muscles. Patients with hypertrophic submandibular glands and parotid glands can also benefit esthetically. There are several FDA-approved BoNTs (obabotuli-numtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, letibotulinumtoxinA, prabotulinumtox-inA, daxibotulinumtoxinA, rimbotulinumtoxinB) and novel BoNTs on the market. This paper is a narrative review of the consensus statements of expert practitioners and various literature on the injection points and techniques, highlighting both the Asian and Caucasian population separately. This paper can serve as a practical illustrative guide and reference for optimal, safe injection areas and effective doses for application of BoNT in the face and oral and maxillofacial area. The history of BoNT indications, contraindications, and complications, and the merits of ultrasonography (US)-assisted injections are also discussed.
Background
This is a quantitative study on the reconstitution of botulinum toxin type A, whether medical aesthetics nurses use normal saline or bacteriostatic saline to reconstitute and what wider factors influence this clinical decision. Medical aesthetics nurses have not previously participated in this area of research. The existing research uses doctors as participants and excludes nurses. Ultimately, the decision lies with the prescriber, but there is a notable gap in knowledge and a need to explore the preferred practice of medical aesthetics nurses.
Methods
An anonymous online survey was conducted with participants who were medical aesthetics nurses, based in the UK and members of the British Association of Cosmetic Nurses. The survey tool was used to gather data on whether medical aesthetics nurses reconstitute botulinum toxin type A with preserved or normal saline.
Results
93.2% of participants used bacteriostatic saline to reconstitute botulinum toxin type A. Some 88.6% of participants were nurse independent prescribers, while 45.4% of participants had a minimum of 10 years' experience in medical aesthetics. All participants were trained by either a nurse or doctor.
Conclusions
Medical aesthetics nurses are highly educated and motivated independent nurses. They have enterprising skillsets and it is highly unusual to find nurses with established private practices outside the specialism of medical aesthetics. Botulinum toxin type A treatments are one of the core treatments in any patient-centred, independent practice and are very much results driven. Sustaining high levels of patient satisfaction is an essential part of medical aesthetics nursing.
Options for nonsurgical facial rejuvenation treatment have increased significantly in both availability and popularity over the past two decades. However, there remains a paucity of clinical practice guidelines and evidence-based recommendations for these procedures. The purpose of this article is to assess for the presence of current high-level research for various methods of nonsurgical facial rejuvenation. Botulinum toxin injections remain the best studied method, with several randomized controlled trials guiding recommendations for safety and efficacy. Several studies on injectable fillers document complications and recommendations to avoid these, but sample sizes are small, and many are non-comparative. Deoxycholic acid has been well examined with FDA-approved to address submental fat, but has not been studied in other areas of the face. Although chemical peels, laser skin resurfacing, energy-based facial rejuvenation, microneedling and platelet-rich plasma have a variety of facial rejuvenation applications with minimal side effect profiles, there is significant variability with treatment protocols, outcomes measures, and randomized controlled trials with extended follow-up to develop clinical practice guidelines.
This chapter presents the use of neuromodulators to temporarily paralyze selective muscles of facial expression for the prevention, minimization, or elimination of facial rhytids. Multiple trade names exist using Botulinum Toxin A differing in their accessory attachment proteins. Botulinum Toxin B also exists under the trade name Myobloc. The chapter focuses on facial aesthetic indications, contraindications, anatomy, technique, postoperative management, and complications. Botox is ideally allowed to mix for 15minutes prior to use. It is recommended that Botox be used within 24 hours of reconstitution; however, studies demonstrate consistent potency if administered up to 4 weeks after reconstitution. Evaluating facial expression at rest and during animation allows for identification of the muscle groups and guides placement of the injection sites. Botox should be injected directly into the mass of the muscle. The chapter provides several case reports with high‐quality images.
Background:
Botulinum toxin injection is a common cosmetic procedure often used to treat dynamic wrinkles, but it has also been observed to have a lightening effect on the skin. It is thought that this lightening effect develops due to muscle innervation blockage; however, the change in the amount of melanin levels has not been quantified.
Method:
Thirty-one patients who presented to the dermatology clinic of a tertiary hospital for botulinum toxin injection for wrinkle treatment were included in the study. A standard dose of botulinum toxin was injected to each patient's forehead, glabellar, and crow's feet region, and then the melanin index (MI) was measured with the Mexameter® MX 18 (Courage + Khazaka Electronic, Köln).
Results:
After botulinum toxin treatment, a statistically significant decrease was found in the forehead and upper face MI. The upper face total baseline MI was significantly lower in the Glogau 1 group than in the Glogau 2 group (P = 0.033). The forehead 15th day MI was significantly lower in the Glogau 1 group than in the Glogau 2, 3, and 4 groups (P = 0.030).
Discussion:
Botulinum toxin application to healthy skin for wrinkle treatment can cause facial skin lightening by reducing MI. It was also remarkable that this decrease was more pronounced in the forehead, which is a region that is particularly vulnerable to sun exposure, compared to other regions. Younger people, who are included in the Glogau type 1 group, may benefit more from this lightening effect.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
In the last 20 years there has been an explosion of new cosmetic surgery procedures developed for a large base of office-based dermatologists, cosmetic surgeons, plastic and reconstructive surgeons, and otolaryngologists. Tricks and techniques are swapped across the globe, with practitioners in Europe, Asia, and North and South America. This is a practical, simple manual of those tricks and techniques, with input from specialists around the world. This book is aimed at practitioners who want to add new procedures to their scope of practice and learn new methods of application. A wide range of procedures, from fillers and neurotoxins to suture suspension and chemical peels, are covered here in a comparative format and accompanied by more than 200 color illustrations. In addition to detailing the procedures, chapters also cover anesthetic techniques and brands. This book is designed to be an easy and useful reference for the beginning practitioner or more senior physician.
Many patients who undergo CO2 laser resurfacing for correction of rhytides experience recurrence of movement-associated wrinkles within 6 to 12 months following the laser procedure.
The purpose of this study was to evaluate the effect of botulinum toxin type A (Botox) injections on movement-associated rhytides following cutaneous laser resurfacing.
Forty patients who had received full face CO2 laser resurfacing for the treatment of facial rhytides were randomized to receive Botox injections to the glabella, forehead or lateral canthal regions or to receive no additional treatment (control group). Clinical and photographic assessments were performed at baseline and at 3, 6 and 9 months.
Enhanced and more prolonged correction of forehead, glabellar and/or lateral canthal rhytides was observed in patients treated with Botox injections postoperatively compared to non-Botox treated control patients.
The use of botulinum toxin type A following cutaneous CO2 laser resurfacing results in prolonged correction of movement-associated rhytides. It is advised that patients receive information regarding the benefits of maintenance therapy with botulinum toxin as part of their routine preoperative education.
Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. In this paper, we present a paradigm shift from the traditional methods of presurgical infant orthopedics. Some of the problems that the traditional approach failed to address include the deformity of the nasal cartilages in unilateral as well as bilateral clefts of the lip and palate and the deficiency of columella tissue in infants with bilateral clefts. The nasoalveolar molding (NAM) technique we describe uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into normal form and position during the neonatal period. This technique takes advantage of the malleability of immature cartilage and its ability to maintain a permanent correction of its form. In addition, we demonstrate the ability to nonsurgically construct the columella through the application of tissue expansion principles. This construction is performed by gradual elongation of the nasal stents and the application of tissue-expanding elastic forces that are applied to the prolabium. Use of the NAM technique has eliminated surgical columella reconstruction and the resultant scar tissue from the standard of care in this cleft palate center.
Facial laser resurfacing and chemodenervation with botulinum toxin type A are used independently as means of nonsurgical facial rejuvenation. Recent reports in the literature have described combining these 2 therapies, claiming improved and longer-lasting laser resurfacing results. To date, no scientific investigation has been undertaken to prove or disprove this theory.
Institutional review board-approved, prospective, randomized, blinded study at university-affiliated outpatient cosmetic surgery offices.
Patients had one side of their face injected, at specific anatomic subsites (crow's feet, horizontal forehead furrows, and glabellar frown lines), with botulinum toxin 1 week before laser resurfacing. After receiving an injection, patients underwent cutaneous laser exfoliation on both sides of the face with either a carbon dioxide or an erbium dual-mode laser.
Patients' injected (experimental) and noninjected (control) sides were compared after laser resurfacing. Follow-up was documented at 6 weeks, 3 months, and 6 months after laser resurfacing. Subjective evaluation, based on a visual analog scale, was performed in person by a blinded observer. Furthermore, a blinded panel of 3 expert judges (1 facial plastic surgeon, 1 oculoplastic surgeon, and 1 cosmetic dermatologist) graded 35-mm photographs taken during postoperative follow-up visits.
Ten female patients were enrolled in the study. A 2-tailed t test showed that all sites that were pretreated with botulinum toxin showed statistically significant improvement (P< or =.05) over the nontreated side, with the crow's feet region showing the greatest improvement. Comparing results between the carbon dioxide and erbium lasers did not result in any statistically significant differences.
Hyperdynamic facial lines, pretreated with botulinum toxin before laser resurfacing, heal in a smoother rhytid-diminished fashion. These results were clinically most significant in the crow's feet region. We recommend pretreatment of movement-associated rhytides with botulinum toxin before laser resurfacing. For optimum results, we further recommend continued maintenance therapy with botulinum toxin postoperatively.
Some wrinkles and unsightly facial expressions are due to hyperactivity of the underlying facial musculature. Clostridium botulinum type A exotoxin reversibly paralyzes selected muscles and is a safe, helpful adjunct to many other treatments for facial rejuvenation. Fifty-two patients were treated and all data recorded in a prospective fashion. Only areas requested by the patient were treated. The dosage and dilution given in each area were carefully noted and all patients had pretreatment and posttreatment photographs. The effect of botulinum toxin injections on the horizontal brow rhytides was recorded by measuring the distance from the frontal hairline to the superior edge of the eyebrow in the mid-pupillary line. Patients were followed for one to three years (mean 16.3 months). One patient was not responsive to botulinum toxin in spite of repeated injections. Three further patients required touch-up injections two weeks after the initial treatment due to a weak initial response. Repeat injections were required every three to six months (mean 4.05) to maintain the desired improvement. Asymmetry of the brow was seen in two patients and corrected with further administration of botulinum toxin. Twenty-five patients had their forehead rhytides injected and the appropriate measurements taken. Brow ptosis occurred in 22 of the 25 patients and varied 1-6 mm with a mean value of 2.3 mm. This difference was statistically significant (paired t-test p <0.001). Two patients reported dryness and flakiness of the frontal area after injections. No cases of eyelid ptosis or hypersensitivity were seen. Botulinum toxin injections are safe and all undesired effects are reversible. Great care has to be taken not to aggravate the degree of brow ptosis. Injection of the forehead depressors minimizes the risk of brow ptosis. Careful planning of injection sites and doses avoids a mask-like upper face. The use of botulinum toxin provides a useful adjunct to laser and surgical procedures for facial rejuvenation.
Botulinum toxins are the causative agents of the severe food-borne illness botulism. With lethal doses approximating 10(-9) g/kg body weight, these neurotoxins represent some of the most toxic naturally occurring substances. Regardless, botulinum toxin is considered a safe therapy for inappropriate muscle spasms with adverse effects being typically self-limited. This article deals with some of the complications that have occurred with these treatments. The greatest concern with the use of BOTOX is probably the formation of blocking antibodies leading to nonresponse of subsequent treatment. Prevalence of resistance is less than 5%. Most complications associated with its aesthetic use are few and anecdotal. Nevertheless, the common problems and pitfalls associated with aesthetic treatment of the various areas of the face and neck with botulinum toxin are discussed. Also included are recommendations as to how to avoid these very undesirable, yet common, problems.
Background: Facial laser resurfacing and chemodenervation with botulinum toxin type A are used independently as means of nonsurgical facial rejuvenation. Recent reports in the literature have described combining these 2 therapies, claiming improved and longer-lasting laser resurfacing results. To date, no scientific investigation has been undertaken to prove or disprove this theory. Design: Institutional review board—approved, prospective, randomized, blinded study at university-affiliated outpatient cosmetic surgery offices. Intervention: Patients had one side of their face injected, at specific anatomic subsites (crow's feet, horizontal forehead furrows, and glabellar frown lines), with botulinum toxin 1 week before laser resurfacing. After receiving an injection, patients underwent cutaneous laser exfoliation on both sides of the face with either a carbon dioxide or an erbium dualmode laser. Main Outcome Measures: Patients' injected (experimental) and noninjected (control) sides were compared after laser resurfacing. Follow-up was documented at 6 weeks, 3 months, and 6 months after laser resurfacing. Subjective evaluation, based on a visual analog scale, was performed in person by a blinded observer. Furthermore, a blinded panel of 3 expert judges (1 facial plastic surgeon, 1 oculoplastic surgeon, and 1 cosmetic dermatologist) graded 35-mm photographs taken during postoperative follow-up visits. Results: Ten female patients were enrolled in the study. A 2-tailed t test showed that all sites that were pretreated with botulinum toxin showed statistically significant improvement (P.05) over the nontreated side, with the crow's feet region showing the greatest improvement. Comparing results between the carbon dioxide and erbium lasers did not result in any statistically significant differences. Conclusions: Hyperdynamic facial lines, pretreated with botulinum toxin before laser resurfacing, heal in a smoother rhytiddiminished:fashion. These results were clinically most significant in the crow's feet region. We recommend pretreatment of movement-associated rhytides with botulinum toxin before laser resurfacing. For optimum results, we further recommend continued maintenance therapy with botulinum toxin postoperatively.
Context
Botulinum A exotoxin is used for various indications, including the treatment of dynamic forehead lines.Objective
To determine whether injection with botulinum A exotoxin reconstituted with preservative-containing normal saline (isotonic sodium chloride) is less painful than injection with exotoxin that has been reconstituted with preservative-free saline.Design
Two arms: (1) retrospective study; (2) double-blind, randomized controlled trial.Setting
A multiple-physician dermatology practice.Patients
(1) Retrospective study—20 consecutive adult patients presenting for treatment of upper-face dynamic lines; (2) prospective study—15 consecutive adult patients presenting for treatment of upper-face dynamic lines.Intervention
In prospective study only, one side (left or right) of the face was treated with exotoxin reconstituted with preservative-containing saline, and the other side, with exotoxin reconstituted with preservative-free saline.Main Outcome Measures
(1) Retrospective study—discomfort at current treatment (with preservative-containing saline) compared with discomfort with most recent prior treatment (with preservative-free saline); (2) prospective study—discomfort on the side treated with preservative-containing saline compared with discomfort on the side treated with preservative-free saline.Results
(1) Retrospective study—18 (90%) of 20 patients reported that treatment with exotoxin reconstituted with preserved saline was less painful than prior treatment with exotoxin reconstituted with preservative-free saline; (2) prospective study—15 (100%) of 15 patients reported less pain in the side of their face treated with exotoxin reconstituted with preservative-containing saline (P<.001). Pain on the preservative-containing side was 54% less. No difference in treatment efficacy between the sides was observed by investigators or patients.Conclusion
Use of preservative-containing saline to reconstitute botulinum A exotoxin can significantly decrease patient discomfort on injection.
background. Cosmetic denervation of hyperfunctional facial lines using botulinum toxin (Botox, Allergan, Inc., Irvine, CA) has gained growing popularity over recent years. Understanding the clinical use and effects of botulinum toxin requires a thorough understanding of the muscular anatomy of the treatment areas.objective. The purpose of this article is to review the anatomy of the frown, forehead, and periocular regions. Function of individual muscles is discussed to understand proper injection technique.conclusions. The anatomy of the frown, forehead, and periocular regions is complex. Individual muscles are tightly intertwined and treatment of one anatomic region may affect many different muscles. A complete understanding of the anatomy of the upper face is essential to ensure proper injection technique, safe and predictable results as well as anticipating complications.
Background. Many patients who undergo CO2 laser resurfacing for correction of rhytides experience recurrence of movement-associated wrinkles within 6 to 12 months following the laser procedure.
Objective. The purpose of this study was to evaluate the effect of botulinum toxin type A (Botox) injections on movement-associated rhytides following cutaneous laser resurfacing.
Methods. Forty patients who had received full face CO2 laser resurfacing for the treatment of facial rhytides were randomized to receive Botox injections to the glabella, forehead or lateral canthal regions or to receive no additional treatment (control group). Clinical and photographic assessments were performed at baseline and at 3, 6 and 9 months.
Results. Enhanced and more prolonged correction of forehead, glabellar and/or lateral canthal rhytides was observed in patients treated with Botox injections postoperatively compared to non-Botox treated control patients.
Conclusion. The use of botulinum toxin type A following cutaneous CO2 laser resurfacing results in prolonged correction of movement-associated rhytides. It is advised that patients receive information regarding the benefits of maintenance therapy with botulinum toxin as part of their routine preoperative education.
To determine if the medial brow can be elevated following administration of botulinum toxin type A (Botox, Allergan, Irvine, Calif).
A before-after interventional study comparing pretreatment and posttreatment brow height. Objective measurements and subjective comparisons of pretreatment and posttreatment slides were made by 7 independent observers unaware of treatment status. All measurements and observations were based on standardized photographs taken with identical lens settings.
Private facial plastic surgery practice. All injections were performed in office examination rooms without anesthesia or sedation.
Thirty adult patients electively seeking improvement of glabellar frown lines or low-positioned medial brows (angry appearance).
Twenty units of botulinum toxin type A was injected into the corrugator supercilli and procerus muscles. An electromyographic needle was used for the initial 10 injections, and a 30-gauge needle was used for the remainder.
In the objective arm, change in brow height was measured from the medial canthus and midpupil directly vertical to the brow hairs; the change in interbrow distance was also measured. In the subjective arm, the number of patients who were found to have an elevated medial brow by the independent observers was noted. Objective and subjective findings were correlated.
Objective measurements yielded a raise in the medial brow in 8 (32%) of 25 patients from the medial canthus and in 12 (48%) of 25 from the midpupil and an increase in interbrow distance in 17 (59%) of 29 patients. Subjective comparison found 18 (62%) of the 29 patients to have higher medial brows after treatment.
Botulinum toxin type A treatment can create a chemical browlift. Further studies with more specific selection criteria are needed to better evaluate this effect.
Eighteen patients with glabellar frown lines were treated with C. botulinum-A exotoxin. Sixteen of the 17 patients followed showed improvement for periods ranging from 3 months to 11 months. Side-effects were minimal and transient. Because C. botulinum-A exotoxin therapy of glabellar frown lines treats the underlying cause of these lines, it is more effective than soft tissue augmentation although this improvement is temporary. Treatment with C. botulinum-A exotoxin is a simple, safe procedure.
Previous work on patients with muscular dystonia has shown that small intramuscular doses of botulinum toxin A eliminated hyperkinetic facial lines for approximately 6 months. The purpose of this study was to determine the efficacy of botulinum toxin A injections in eliminating facial wrinkles in aesthetic surgery patients who do not have muscular dystonia. Eleven healthy subjects were studied in a double-blind fashion. On both sides of the face, 0.2 cc of either normal saline or botulinum toxin A was injected into the forehead or into the periorbital wrinkles (crow's feet). Documentation of results was made by photographs taken of the patients during repose and during facial animation before and after injection. Assessment of facial wrinkles was done from a grading system in which the patient and the facial plastic surgeon were asked to judge the severity of the wrinkles on a scale from 0 to 3, with 0 reflecting no facial wrinkles and 3 reflecting severe facial wrinkling. Nine of 11 subjects injected with botulinum toxin A noted a significant improvement in the severity of their facial wrinkles in comparison with the side of the face injected with saline, with a rating improvement of 2 points. Two of 11 subjects noted a moderate improvement, with a rating improvement of 1 point. No patient injected with saline reported an improvement in the severity of the facial wrinkles on the control side. There were no serious complications. Botulinum toxin A is an efficacious method of nonsurgically eliminating facial wrinkles and may play a role in the cosmetic enhancement of the aging face.
A clinical trial was undertaken to evaluate the effects of commercially available botulinum toxin on 14 hyperactive corrugator muscles, 14 procerus muscles, one case of congenital aplasia of the depressor labii inferioris muscle, and one case of iatrogenic injury to the ramus mandibularis branch of the facial nerve with paralysis of the depressor labii and mentalis muscles. Of the 31 muscles injected, 28 were appropriately paralyzed with the initial injection. The desired results were obtained in the 3 remaining muscles following a second injection. The ability to frown was nullified in all subjects, resulting in the elimination of glabellar lines. Facial symmetry was achieved in both patients with muscle imbalance. The average duration of the paralysis was 8 weeks, with a range of 2 to 16 weeks. However, this period was prolonged in the latter part of the study with an adjustment of the toxin dose. Our results demonstrate that botulinum toxin injected into overactive facial muscles does produce a predictable and reversible paralysis and eliminates or ameliorates deep frown lines. We also illustrate its use in achieving facial symmetry in one patient with congenitally absent depressor labii inferioris and platysma muscles and in another with postrhytidectomy facial nerve paralysis.
To determine the effectiveness of botulinum toxin injections for the management of hyperfunctional facial lines in patients with dystonia.
Twenty-six patients were included in the study: 24 patients had dystonic movement of the face as either a primary or secondary component, and two patients were treated for purely hyperfunctional lines. Botulinum toxin type A was injected via a monopolar hollow-bore Teflon-coated electromyography needle into the facial muscles associated with the hyperfunctional lines. Doses were divided into 1.25- to 10-U aliquots. Qualitative assessments by the patient and physician were made before injection and 2 to 3 weeks after injection.
Twenty-six patients (two male and 24 female) with hyperfunctional lines were included. The ages were from 32 to 84 years with an average age of 59 years. Twenty had dystonia, four had hemifacial spasm, and two had pure hyperfunction without neuromuscular disease.
All of the patients had an effect of toxin within the first 24 to 72 hours. All of the patients experienced benefit from the toxin injections with partial or total resolution of painful contractions or unsightly hyperfunctional lines and spasms. The effects of the injection lasted 3 to 6 months. No systemic side effects were noted. Adverse effects included mild, temporary eyelid or lip weakness.
Based on this initial pilot study, botulinum toxin may be an important new option for the treatment of patients with hyperfunctional facial lines.
Botulinum toxin has been used for facial hemispasm, strabismus, and blepharospasm. Recently it has been advocated to treat the frown lines. We have extended this program to treatment of other muscles of facial expression.
Botulinum toxin is injected into the muscles of facial expression in two or three sessions to produce a temporary loss of muscle tone. A standard method of cooling, injection, and compression was developed to minimize pain and bruising.
To complete a dose-response study to document the optimum timing and amount of toxin needed for each muscle group.
Two to five Botulinum toxin units per muscle was as adequate as higher doses. Toxin that was reconstituted 30 days earlier produced the same loss of muscle tone as freshly mixed toxin. With two or three injection sessions loss of muscle tone lasted for up to 1 year.
Botulinum toxin is highly effective as an adjuvant therapy for facial rejuvenation. This minor surgical procedure can temporarily reduce the lines on the upper face and produce a pleasing effect. With proper dosing and dilution this rejuvenation program becomes cost effective.
Botulinum toxin (BT) prevents the release of acetylcholine at the neuromuscular junction and produces reversible paralysis of striated muscle. This effect was initially used for ophthalmologic indications, particularly strabismus. The idea of using the toxin for purely cosmetic purposes arose from the observation that therapy for facial dystonias markedly decreased lines and wrinkles in the treated areas. The ease of application, high safety profile, and impressive results from the cosmetic use of BT have led to its rapid acceptance by many clinicians. As use of BT increases and its indications expand, an understanding of this therapeutic modality is timely. This article discusses the pharmacologic aspects of BT as well as the methods for administration as they relate to its cosmetic use.
Botulinum A exotoxin (BTX) has been used successfully to treat a variety of hyperkinetic movement disorders. BTX is also capable of reducing hyperkinetic facial lines including prominent glabellar frown lines.
The purposes of this study were to (1) confirm the efficacy of BTX in a double-blind, placebo-controlled investigation; (2) evaluate the use of an electromyogram attached to the injection needle to confirm intramuscular corrugator placement of the BTX; and (3) determine the optimum direction injection technique.
Length and depth of glabellar frown lines were measured before treatment and 4 and 12 weeks after injection of 10 units of BTX or saline solution.
Patients treated with BTX had a highly significant reduction in depth and length of glabellar frown lines compared with control subjects.
BTX appears to be effective and safe for reduction of glabellar frown lines.
To determine the dose-response characteristics and side-effects profile of Clostridium botulinum type A exotoxin (Botox) used to treat glabellar wrinkles and develop guidelines for patient selection based on the nature and severity of the treated wrinkles.
Prospective, nonrandomized pilot and electromyogram (EMG)-guided studies.
Two ambulatory care clinics at university hospitals.
For the pilot study, volunteer samples of 23 patients with glabellar wrinkles; for the EMG-guided study, volunteer samples of 57 patients with glabellar wrinkles.
For the pilot study, 23 patients were serially injected with up to 10.0 mouse units (MU) of Botox into each corrugator muscle; for the EMG-guided study, 57 patients were injected under EMG guidance with an initial dose of 10.0 MU of Botox into each corrugator muscle. Eleven patients with persistent corrugator activity were reinjected with 10.0 MU of Botox.
For the pilot study, slide photographs were obtained before and 2 weeks after injection; for the EMG-guided study, slide photographs were obtained before and at 2 weeks and at 2 months after injection. Patients were asked to evaluate results numerically.
For the pilot study, injection of up to 10.0 MU of Botox into each corrugator muscle produced a satisfactory improvement in 12 patients; for the EMG-guided study, 43 patients were satisfied with improvement after full abolition of corrugator or accessory lateral brow muscle activity. Women were more likely to achieve satisfactory results than were men (80% [40/50] vs 43% [3/7]; P < or = .03). Improvement was not age related. No significant side effects or complications were observed.
Glabellar wrinkles may be satisfactorily treated with Botox injection into the corrugator supercilii muscles. Improvement is temporary, dose dependent, and may not be seen in some patients even with successful denervation of the treated muscles. Clinicians may begin treatment with a dose of 10.0 MU of Botox into each corrugator muscle, and may select candidates for injection by determining the type of wrinkle to be treated and its spreadability (glabellar spread test).
To determine the optimum dose and efficacy of botulinum toxin injections in the management of hyperfunctional facial lines.
This study included 210 hyperfunctional facial sites in 162 different patients. The patients had preinjection and postinjection photographic documentation and ratings on a 4-point qualitative evaluation scale of lines at rest and with action. The patients then had botulinum toxin type A injections via a monopolar hollow bore, Teflon-coated electromyographic needle into the facial muscles associated with the hyperfunctional lines. The total dose for each region of 1.25 to 25 U was divided into 1.25- to 5-U aliquots representing 0.1 to 0.2 mL per injection site, depending on the site and the prior experience with that patient on using toxin. The patients had their reevaluation at 2 to 3 weeks after injection. Patients returned for further follow-up when the therapeutic effect diminished.
One hundred sixty-two patients had 210 hyperfunctional sites evaluated and injected. The group consisted of 25 male patients and 137 female patients ranging in age from 21 to 78 years with a mean (+/-SD) of 46.1 (+/-1.98) years. All patients had cosmetically troubling hyperfunctional lines involving the forehead, glabella, crow's feet (lateral canthal lines), nasolabial area, platysma, and mentalis region.
All patients had an effect of toxin within the first 24 to 72 hours. Ninety-five percent of the patients treated had cosmetic improvement of unsightly facial lines or contractions. The best results were achieved in management of the forehead lines, followed by glabella, crow's feet, and nasolabial. The dose for forehead lines was 5 to 25 U (mean +/- SD, 17.3 +/- 6.2 U); glabellar lines, 5 to 20 U (mean +/- SD, 11.1 +/- 3.1 U); crow's feet, 5 to 15 U (mean +/- SD, 6.2 +/- 1.6 U); nasolabial, 2.5 to 5 U (mean +/- SD, 3.12 +/- 1.2 U); and platysma, 10 to 20 (mean +/- SD, 15 +/- 4.0 U). Evaluation by age and site suggested a trend of increased toxin dose with increased age. Effects of the toxin are usually seen 24 to 72 hours after injection, and last from 3 to 6 months, whereon the increased muscular activity returns, as do the hyperfunctional lines. The only morbidity was related to temporary mild weakness of other adjacent facial muscles. There were no systemic side effects noted.
Botulinum toxin is a safe and important adjunctive technique for the management of patients with symptomatic hyperfunctional facial lines.
Many substances have historically been used to address facial soft tissue defects. Currently in the United States autologous fat and injectable bovine collagen are the most commonly utilized injectable fillers. Additionally, the judicious application of BOTOX in the upper face as well as neck has all but revolutionized the use of filling agents in these locales. While other agents are briefly mentioned, this is an in-depth review of the characteristics and application of autologous fat, bovine collagen.
The purpose of this clinical investigation is to confirm the efficacy of eliminating facial wrinkles by injecting botulinum toxin A into mimetic muscles. Fifty-four patients were injected with BOTOX A-14 in the corrugator superciliaris, 19 in the frontalis muscles, and 13 in the orbicularis oculis. Dilution was obtained by adding 4 ml preservative-free saline to 100 IU of BOTOX A. The dose used varied according to the patient. The severity of wrinkles and the intensity of muscle contraction (facial expression) were taken into account. The paralysis obtained in the mimetic muscles was effective for 6 months in 39 patients, 8 months in 10 patients, and 9 months in 1 patient. The results were documented by photographs, videotape, and electromyographies pre- and postinjection. To preserve the results, 21 patients (39%) demanded a second infiltration to achieve satisfactory results. Neither local nor general adverse effects were noted, except transitory eyebrow palsy in 2 patients, and edema and ecchymosis in 4 patients. The improvement obtained in facial mimetic wrinkles was satisfactory to the patient and to us.
Clostridium botulinum type A exotoxin is one of the recent advances for treatment of the aging face. Due to the sudden and exponential surge in popularity, there is little precise consensus regarding its safety and efficacy. Many of the reported complications associated with its aesthetic use are few and anecdotal. As we gain more experience and long-term follow-up with this procedure, complications and their treatment can be better documented. As most of the salutary effects of Botulinum toxin are temporary, fortunately, so too are the complications associated with this form of therapy.
Since Botulinum toxin A became a mainstay therapy for blepharospasm, its use in treating other dystonic conditions, spasticity disorders, as well as hyperfunctional lines of the face has increased exponentially in recent years. The following article summarizes our experience in establishing a safe and reliable method of administration of botulinum toxin A for treating hyperfunctional lines of the face.
Botulinum A exotoxin injection is a well-established method for treatment of glabellar frown lines, crow's feet, and horizontal furrows of the forehead. However, there is no consensus as to the optimal dosage per injection site or the concentration of injectate to be used.
The purpose of this study was to determine the minimal effective dose per injection site to be used as well as the effect of concentration in response to treatment.
A total of 46 subjects were divided into ten groups and injected with escalating doses and concentrations of botulinum toxin. The response and longevity of treatment were then followed on a monthly basis. A dose between 2.5-4 U per injection site (12.5-20 U total) was determined to be an effective starting dose, with a duration of 2-5 months (median 14 weeks).
There was no statistically significant difference in safety or efficacy for concentrations ranging from 50 to 200 U/ml of botulinum toxin.
There has been an ongoing controversy as to the best dilution for botulinum toxin for use in cosmetic applications. Recommended dilutions have ranged from 1 ml per vial to 10 ml per vial. There has also been much discussion on the diluent, i.e., preserved versus unpreserved saline, to be used and on storage time of the material after dilution.
The objective of this paper is to examine the literature and experience of practitioners in the field to try to resolve some of the questions concerning dilution and storage of botulinum toxin.
Although there is great variation in the dilutions adopted by various physicians, much of this is a matter of personal preference. It does seem to appear that most clinicians use a dilution near 2.5 to 3.0 ml per vial and three-quarters of them limit the storage of the diluted product to 1 week or less.
Cosmetic denervation of hyperfunctional facial lines using botulinum toxin (Botox, Allergan, Inc., Irvine, CA) has gained growing popularity over recent years. Understanding the clinical use and effects of botulinum toxin requires a thorough understanding of the muscular anatomy of the treatment areas.
The purpose of this article is to review the anatomy of the frown, forehead, and periocular regions. Function of individual muscles is discussed to understand proper injection technique.
The anatomy of the frown, forehead, and periocular regions is complex. Individual muscles are tightly intertwined and treatment of one anatomic region may affect many different muscles. A complete understanding of the anatomy of the upper face is essential to ensure proper injection technique, safe and predictable results as well as anticipating complications.
Our improved understanding of the pathophysiology of facial lines, wrinkles, and furrows has broadened the treatment options for a variety of facial cosmetic blemishes. The persistence or recurrence of certain facial rhytids after surgery has confirmed the lack of full comprehension of their origin. Glabellar forehead furrows (frown lines) and lateral canthal rhytids (crow's feet) have been the most popular facial lines that have been shown to be mostly the result of regional hyperkinetic muscles, and their eradication may be more suitable, at times, to chemodenervation than to soft-tissue fillers, skin resurfacing, or surgical resection. Aesthetic surgical procedures that have yielded suboptimal results may also occur from failure to recognize other causative factors including hyperkinetic or dynamic musculature, which may contribute to etiology of the visible soft-tissue changes and lack of persistent effect after surgery. Chemodenervation with botulinum toxin A (Botox) has proven to be useful both as a primary treatment for certain facial rhytids and as an adjunctive agent for a variety of facial aesthetic procedures to obtain optimal results.
Botulinum toxin A has been used therapeutically in humans for over 20 years for a variety of medical indications. For the past 7 years, the author has injected it for cosmetic purposes in a variety of muscles of the head and neck. Fifty patient-injections of the platysma muscle were performed in an attempt to correct platysmal banding. An improvement was seen in all patients who presented to the office for follow-up in a timely manner (44 injections). Results were limited by redundant skin. No incidence of dysphagia or airway obstruction was encountered. The only complication noted was bruising. Although at least a small improvement in platysmal banding was seen in all patients, in no patient was there evidence of lifting of the lower face. All results were temporary.
Injections of botulinum A exotoxin are successfully used to treat neuromuscular disorders and to improve hyperkinetic muscles and dynamic rhytids of the upper face. Using these principles, we extended its use to the treatment of the aging neck (hypertrophic platysma muscle bands). A classification system (I to IV) based on horizontal neck rhytids, platysma bands, and skin laxity was devised to categorize the degree of deformity and serve as a guideline for suggested dosages of botulinum. The results correlated with the degree of age-related neck degeneration. Type II (mild horizontal neck rhytids; thin, mild platysma muscle flaccidity; and mild skin laxity) and III (moderate horizontal neck rhytids; thick, moderate platysma muscle flaccidity; and moderate skin laxity) patients were the most satisfied, followed closely by types I and IV. A total of 1500 patients were treated by three independent practices. The majority of them achieved good-to-excellent results, as evaluated by both the physician and patient. The degree of muscle flaccidity and hypertrophy were the factors that most influenced success rates, not the anatomic variations in muscle configuration.
There are a number of different causes for facial wrinkle lines, such as aging, gravity, and chronic pulling of mimetic muscles on the face. Among these, pulling by mimetic muscles on the skin not only involves facial expression but also has a great role in forming facial wrinkle lines as a result of repetitive action, such as dynamic or hyperkinetic wrinkle lines. Botulinum toxin A is currently being used for eliminating facial hyperkinetic wrinkles by causing paralysis of the underlying mimetic muscles. Because there are some histologic differences between Asians and Caucasians, such as thick dermis and more abundant collagen fiber, etc., the chronic pulling by mimetic muscles on the skin is expected to affect facial wrinkles differently. Therefore, the purpose of this study was to determine the efficacy of botulinum toxin A injection in eliminating facial hyperkinetic wrinkle lines among Korean patients. This study included 38 patients and 59 injection sessions from January of 1996 to April of 1997. We used Botox containing 100 U. Toxin was diluted with 4 ml of sterile normal saline and yielded 2.5 U for each 0.1 cc. A dose of 5 to 10 U was used in each muscle. Ages ranged from 26 to 56 years. There were 33 women and 5 men included in this study. Thirty-two of the patients were followed from 3 months up to 12 months after injections. The number of injection sessions that were performed on each patient was as follows: one session, 23 patients; two sessions, 10 patients; three sessions, 4 patients; four sessions, 1 patient. The number of injections per target site among these 38 patients was as follows: lateral canthal area, 33; glabellar area, 9; forehead, 9; nasal dorsum, 5. The most common duration of effective response was about 4 months, but in eight patients the period was over 5 months. After the response, complete recovery took about 1 or 2 months. Two patients felt unsatisfied, 5 patients felt slightly improved, and 25 patients retained only a slight line and were satisfied with the results. None of the patients experienced complete removal of wrinkle lines. Adverse effects included altered facial looks or appearances, mild local swelling, and ecchymosis at the injection sites. No systemic side effects were noted. Based on these results, the injection of botulinum toxin A seems to be an effective method of eliminating wrinkle lines on the upper third of the face in Korean patients, and it was a simple and effective nonsurgical procedure.
The purpose of this investigation was to evaluate the degree of efficacy of eliminating crow's feet by means of direct injection of botulinum toxin A into orbicularis oculi muscles under direct surgical vision during either blepharoplasty or face lift operations. Eighteen patients were injected with Botox A-14 in each orbicularis oculi muscle. Dilution was obtained by adding 4 ml of preservative-free saline to 100 IU of Botox A. Doses ranged from 15 to 50 IU in each muscle, varying according to the severity of wrinkles and intensity of muscle contraction. In 10 patients (56 percent), the Botox was injected throughout the outer surface of both orbicularis oculi dissected during a face-lift operation. In eight other patients (44 percent), the toxin was injected into the inner surface of both orbicularis oculi exposed during classic blepharoplasty procedures. Most authors have demonstrated that the effect produced by transcutaneous Botox lasts between 4 and 6 months; the paralysis obtained by direct muscular injection was effective for 9 months in 14 patients (78 percent) and 10 months in the other 4 patients (22 percent). Results were documented by means of preinjection and postinjection photographs, videotapes, and electromyographs. Neither local nor general adverse effects were noted. The improvement obtained in crow's feet was satisfactory to the patient and to us. The use of Botox intraoperatively permitted at the same time not only the treatment of crow's feet by paralysis of orbicularis oculi muscles but also the correction of senile changes in the lids and face by means of either blepharoplasty or face-lift operations.
Our improved understanding of the functional anatomy of the face and of the action of the botulinum toxin A leads us to determine a new injection procedure which consequently decreases the risk of eyebrow and eyelid ptosis, and increases the toxin injection's possibilities and efficiencies. Variable toxin injection concentrations adapted to each injected area are used. Thanks to the new procedure in the upper face, toxin A action is quite close to an endoscopic surgical action. In addition, interesting results are achievable on the nose, upper part of the nasolabial fold, jawline and neck regions. Lastly, a smoothing effect on the skin is obtained by the anticholinergic action of the toxin A on the dermal receptors.
Inactivation of the orbicularis oculi muscle by chemodenervation with botulinum toxin type A (Botox, Allergan, Inc., Irvine, Calif.) as a sole procedure or in conjunction with blepharoplasty has proved to be a reliable method to improve the appearance of the periocular area. Botox has the unique and ideal characteristic in that, with repeated use, there is potential for a prolonged clinical effect with smaller dosages. In addition, if a complication does arise--while not aesthetically acceptable and potentially untoward--it is time-limited, and the anatomical area will eventually return to its pretreatment baseline status. In this study, in three cases [in more than 1000 crow's feet treatment sessions (2000 sides)] over the course of 1 year, partial lip ptosis resulting from weakening of the zygomaticus major muscle after the injection of Botox into the periocular region are reported. This article reviews suggested treatment guidelines and anatomic considerations for the periocular region to maintain injection standardization and improve the safety profile of Botox as the aesthetic indications for its use expand and the number of individuals who inject it increases.
Botulinum toxins are the causative agents of the severe food-borne illness botulism. With lethal doses approximating 10(-9) g/kg body weight, these neurotoxins represent some of the most toxic naturally occurring substances. Regardless, botulinum toxin is considered a safe therapy for inappropriate muscle spasms with adverse effects being typically self-limited. This article deals with some of the complications that have occurred with these treatments. The greatest concern with the use of BOTOX is probably the formation of blocking antibodies leading to nonresponse of subsequent treatment. Prevalence of resistance is less than 5%. Most complications associated with its aesthetic use are few and anecdotal. Nevertheless, the common problems and pitfalls associated with aesthetic treatment of the various areas of the face and neck with botulinum toxin are discussed. Also included are recommendations as to how to avoid these very undesirable, yet common, problems.
Two kinds of botulinum toxin type A were clinically evaluated in rhytidectomy. Twenty Korean patients with facial wrinkles were fully assessed following treatments with random injections. The mean degree of wrinkles before the injections was 2.83 and the mean corrective effect was 70.0% at least 3 months afterward. The effect lasted less than 6 months in only 9 cases. The complications were tingling sensations in 3 cases (15.0%), temporary lid swelling in 5 cases (25.0%) and lagophthalmos in 3 cases (15.0%). No serious or permanent adverse effects were observed. Botulinum toxin type A rhytidectomy was a very effective method of removing various facial wrinkles although the treatment for complications and side effects will need to be considered.
Botulinum A exotoxin is used for various indications, including the treatment of dynamic forehead lines.
To determine whether injection with botulinum A exotoxin reconstituted with preservative-containing normal saline (isotonic sodium chloride) is less painful than injection with exotoxin that has been reconstituted with preservative-free saline.
Two arms: (1) retrospective study; (2) double-blind, randomized controlled trial.
A multiple-physician dermatology practice.
(1) Retrospective study-20 consecutive adult patients presenting for treatment of upper-face dynamic lines; (2) prospective study-15 consecutive adult patients presenting for treatment of upper-face dynamic lines.
In prospective study only, one side (left or right) of the face was treated with exotoxin reconstituted with preservative-containing saline, and the other side, with exotoxin reconstituted with preservative-free saline.
(1) Retrospective study-discomfort at current treatment (with preservative-containing saline) compared with discomfort with most recent prior treatment (with preservative-free saline); (2) prospective study-discomfort on the side treated with preservative-containing saline compared with discomfort on the side treated with preservative-free saline.
(1) Retrospective study-18 (90%) of 20 patients reported that treatment with exotoxin reconstituted with preserved saline was less painful than prior treatment with exotoxin reconstituted with preservative-free saline; (2) prospective study-15 (100%) of 15 patients reported less pain in the side of their face treated with exotoxin reconstituted with preservative-containing saline (P<.001). Pain on the preservative-containing side was 54% less. No difference in treatment efficacy between the sides was observed by investigators or patients.
Use of preservative-containing saline to reconstitute botulinum A exotoxin can significantly decrease patient discomfort on injection.
Botulinum toxin type A (BTX-A) is widely used for facial esthetics but is incompletely studied.
This study was conducted to evaluate the efficacy and safety of BTX-A treatment of glabellar lines.
Patients with moderate to severe glabellar lines at maximum frown received intramuscular injections of 20 U BTX-A (BOTOX, Allergan, Inc, Irvine, Calif) or placebo into 5 glabellar sites. Patients were followed up for 120 days after injection. Outcome measures were physician rating of glabellar line severity at maximum frown and rest, patient assessment of improvement, and vital sign and adverse event monitoring.
Two hundred sixty-four patients were enrolled (BTX-A: 203, placebo: 61). There was a significantly greater reduction in glabellar line severity with BTX-A than with placebo (all measures, every follow-up visit; P <.022). The effect was maintained for many patients through day 120. There was a low occurrence (5.4%) of mostly mild blepharoptosis in the BTX-A group.
BTX-A injections are safe and effective in reducing the severity of glabellar lines.
Botulinum toxins are the causative agents of the severe food-borne illness botulism. With lethal doses approximating 10(-9) g/kg body weight, these neurotoxins represent some of the most toxic naturally occurring substances. Regardless, botulinum toxin is considered a safe therapy for inappropriate muscle spasms with adverse effects being typically self-limited. This article deals with some of the complications that have occurred with these treatments. The greatest concern with the use of BOTOX is probably the formation of blocking antibodies leading to nonresponse of subsequent treatment. Prevalence of resistance is less than 5%. Most complications associated with its aesthetic use are few and anecdotal. Nevertheless, the common problems and pitfalls associated with aesthetic treatment of the various areas of the face and neck with botulinum toxin are discussed. Also included are recommendations as to how to avoid these very undesirable, yet common, problems.
THE TREATMENT of hyperfunctional facial lines with botulinum A exotoxin injection is safe, usually effective, and without serious adverse effects. Millions of individual clinical doses have been delivered without major complications. The average lethal dose, at 40 U/kg (eg, 2800 U for a 70-kg person), is orders of magnitude greater than the average dose delivered for glabellar frown lines (15-50 U).1 Indeed, cosmetic use of botulinum A exotoxin has become routine within dermatology. Initiated by pioneering dermatologists, ophthalmologists, and otolaryngologists during the 1980s, and honed by leaders in dermatologic surgery during the past decade,2- 6 techniques for botulinum injection are now commonly taught in residency and postgraduate education programs. Overall safety and efficacy, however, do not imply that bothersome adverse effects seldom occur. There is understandable reluctance to document these, which are usually mild and time limited.7- 12
Yet adherence to a few simple guidelines can reduce the likelihood that the patient will be dissatisfied and the physician embarrassed. Injecting botulinum toxin without subsequent undesired effects is largely a function of knowing where not to inject.
Optimum dosing for botulinum toxin type A (BTX-A) in crow's feet remains to be defined.
Our purpose was to compare the efficacy and safety of 3 doses of BTX-A and placebo in patients with crow's feet.
Patients were treated with 6, 12, or 18 units of BTX-A in orbicularis oculi muscle on one side and placebo contralaterally (double-blind design). At 16 weeks after injection, patients were treated with 12 or 18 units of BTX-A bilaterally (open-label design). Trained observers and patients rated the wrinkles on a scale of 0 (none) to 3 (severe) at maximum contraction and repose and at baseline and 4-week intervals over a 16-week period after injection.
All doses of BTX-A were significantly superior to placebo with no clear dose-response relationship. Benefits of the second injection lasted longer than the first. Few and mild adverse events were seen.
BTX-A is a safe and effective treatment for crow's feet. Benefits are more sustained with repeat treatment.
Background:
The obligate bacterium Clostridium botulinum produces exotoxins (A, B, C-1, C-2, D, E, F, G) that are serologically and antigenically distinct. All serotypes have similar neurotoxic properties resulting in flaccid muscle paralysis. Types A and B are commercially available and are used widely for the reduction of dynamic facial rhytides. Although extensive information is known about type A, type B has recently become available; however, there is a limited clinical familiarity. Some of the remaining unknown distinctions between the two subtypes are the extent of toxin diffusion from the site of injection, the onset of action, the dose equivalency, and the duration of effect.
Objective:
The purpose of this preliminary double-blind study was to compare the duration of muscle paralysis and rhytid reduction of botulinum toxin types A and B. Additional relevant information was obtained, all of which can be useful in toxin selection.
Method:
Ten women, ages 28 through 60, voluntarily consented to undergo a double-blind trial and were randomly assigned to have botulinum toxin type A injected into one set of lateral canthal rhytides and toxin type B into the contralateral periocular region. Based on dose-ranging investigations performed in patients with cervical dystonia, participants received treatment at the lowest reported effective ratio of 1:50 (1 U of toxin type A to 50 U of toxin type B). Three injections of 5 U of type A (total 15 U) and three injections of 250 U of undiluted type B (total 750 U) were injected into the lateral fibers of the orbicularis oculi muscle.
Results:
Patients were evaluated at 7, 30, 60, and 90 days. Findings were compared by the treating physician, patient self-assessment, and photographic images.
Conclusion:
All patients noted rapid and satisfactory reduction in the rhytides in both periocular areas. However, upon unblinding of the solutions at the same volumes with a 1:50 ratio, type B toxin was found to be associated with slightly more discomfort upon injection, quicker onset of action, a sensation of "tightness" of the treated area, and a briefer duration of muscle paralysis.
Among factors that may affect the potency of botulinum toxin A (Botox), it is said that foam, together with bubbles, may cause surface denaturation of the toxin.
To determine whether the muscle relaxation effect of Botox is preserved and has the same duration when it is reconstituted in the presence of foam.
Six female volunteers, aged 42 to 56 years old, were treated for glabellar and periocular wrinkles. Each half of the face was treated with 16 U of Botox divided in four sites: three at the lateral orbital area and one at the medial brow, in the glabellar region. The right side received Botox gently reconstituted with saline to avoid foaming formation. The left side of the face was treated with Botox that was rapidly reconstituted in order to achieve as many bubbles as possible, even with shaking. Blinded observers compared pretreatment and posttreatment photographs and answered assessment-related questions. The results were analyzed clinically and statistically.
There was no difference in muscle paralysis between treated sides in all patients, neither in early (15 days) nor late (4 months) follow-up evaluations.
Botox maintains its potency even in the presence of foaming during the reconstitution process.